As women and as mothers we want to do everything right and we want to be prepared. Although we set out to breastfeed, appreciating all of the benefits of doing so, sometimes a little loving support and lactation expertise is needed to be successful breastfeeding. It is important for nursing mothers and those supporting them to know breastfeeding norms and reasonable expectations. It is important to know when to call the primary health care provider and/or Lactation professional.
Often times, when challenges present during the first weeks of breastfeeding, it is because the new parents did not have the support of those with breastfeeding experience and/or the fundamental information to navigate the unexpected. We all learn differently. For some, attending a class with peers and being able to listen, learn, and ask questions as they come to mind is the best way. For others, learning on ones own is best.
Stephanie wants nursing mothers and all those supporting the breastfeeding dyad to have fundamental information so as to navigate the early weeks of breastfeeding. The following are summary notes from the “Just the Essentials” class that Stephanie Moore, RN, BSN, IBCLC teaches at Becoming Mothers. By attending the class, one is able to participate in a dynamic exchange of information, questions, and anticipated concerns. Understanding that some prefer learning on their own, Stephanie shares these notes with you so that you will feel more confident as you nurture your baby at the breast.
Babies eat sleep, pee, and poop! (If they don’t do any of these things, notify the baby’s health care provider).
• Whereas it is important to know the baby’s elimination pattern, one doesn’t need to be too obsessive about it unless a concern is identified. It is a good idea to have some sort of Baby Log. Make one column Nursing/Feeding, one column Poop, one column Pee, one column Sleep. What we want to know is if the baby is doing all four of these essential jobs every day. There are a number of Apps that can be downloaded to Smart Phones that facilitate this recording.
• Should parents have any concerns about their baby, even if it is a gut feeling, the infant’s primary care provider should be contacted. The MD, CNM, or CM will refer to a Lactation professional when appropriate.
• During the first week, we expect the baby to wet the number of diapers equal to the baby’s age/days (=3 wet diapers on day 3) and 1 or two stools (at least the size of a US quarter) in 24 hours. The stool will transition from meconium (dark, sticky, and black) to a transitional stool (army green) to a breast milk stool (Dijon mustard with seeds). AFTER the first week, we expect a minimum of 6-8 wet diapers/24 hours and 2+ stools (“quarter-size” vs. “MBO=major blow out!). Many of the new disposable diapers have a urine-sensitive strip incorporated to facilitate urine counts. A baby’s bladder = wet diaper = 3 tablespoons.
Move the milk and Feed the Baby! (Baby’s job is to gain weight and Mom’s job is to make milk!)
• Babies need to be fed 8 – 12 times/24 hours during the first months (frequency depends of baby’s weight gain which is typically 1 ounce/day after the breast milk is fully “in”). This frequency of nursing translates to every 90 minutes (evening cluster feeding) to 3 hours. Newborn babies will also have one solid sleep between 4 to five hours in duration. Unfortunately, it will most likely NOT occur during adult preferred nighttime sleeping hours. Again, this, too, will pass!
Watch your baby and follow her lead! (Babies absolutely know what they need.)
• Don’t watch the clock; watch your baby at the breast. Each baby has a unique nursing pattern (“gourmet, picky” eater vs. “chow down, no manners” eater.) Once your milk production is established, nurse your baby until she falls from the breast or until she is sleeping at the breast rather than transferring milk.
Position, Position, Position….Latch, Latch, Latch! (Sore, cracked, blistered nipples are NOT the norm!)
• A common position for nursing is sitting in a chair, utilizing a footstool, and using a nursing pillow to support the back and mom’s arms. The nursing mother supports the baby in her arm. Supporting the breast is ideal as it stabilizes the latch for the baby. The cross-cradle position and the under-arm position are good ones for early nursing as the mother is able to visualize her baby at the breast.
• Biological Nurturing aka Laid-Back Breastfeeding allows the nursing mother to hold and cuddle her baby in a biological nurturing position that allows mom’s body to be supported by gravity, relaxed, and comfortable. There is no predetermined position for mom. Baby is always on top of mom. Gravity keeps baby’s body aligned with moms. OK for mom to gently guide baby to the breast. Baby to breast in any of the 3 sleep states (deep ~ light ~ drowsy sleep) as baby is more organized around nursing.
• The most common reason for sore, cracked, blistered nipples is due to incorrect latch of the baby at the breast and/or incorrect positioning of the baby in Mom’s arms. Baby should be in alignment to the Mom’s body.
• Baby needs to open the mouth WIDE and the breast is to be offered when the mouth is the widest. To initiate the gapping and open jaw, bring the nipple to baby’s nose. When the babe opens the mouth wide, bring the baby to the breast from below in the same way one would eat a thick sandwich. If the baby’s mouth is not fully opened, use a finger to gently open the jaw by gently pressing down on the lower chin.
• When in the hospital, a sock with the foot cut out can be used as an arm sleeve to cover the hospital bands and IVs.
~ A few simple analogies/images that help guide breastfeeding mothers during the first few weeks~
Breasts are NOT Utters!
• Mothers nursing newborn infants will swear their breasts are utters; they are not! When the baby latches and suckles at the breast, the infant is stimulating a complex neurological pathway that allows the mother to synthesize breast milk during the breastfeeding session. This physiology really makes sense to the mother nursing an older infant or toddler, not to the mother of a newborn.
The Sink Analogy ~ it summarizes breast milk production and mom-baby physiology!
• In order for the mother to produce milk, the breast needs to be emptied frequently (remember 8-12 times/24 hours for the first few months). The “milk production” threshold for ultimate milk production is between weeks 2 and 5. If milk accumulates in the breast (aka engorgement), the congestion of milk is the physiologic mechanism to slow down milk production and eventually (in 3-4 days), cease milk production all together. This is how mothers wean their babies from the breast (or wean their bodies from making milk.) If the milk is not being “moved”, engorged breasts can result and are very painful. Engorgement is NOT the norm
Babies invented Fast Food Restaurants (I’d eat a lot if my stomach was the size of a ping-pong ball!)
• Babies’ stomachs are small and therefore, they demand to be fed frequently. Breast milk is completely absorbed and babies are hungry frequently. Mothers and babies are intimately connected and Mom’s body establishes a pattern based upon the pattern established by the baby. In the professional experience of the LC, feeding schedules (delayed/postponed breastfeeding) do not support the physiologic needs of the newborn/infant.
The Magic Number and Long-term Milk Production
• The number of times in 24 hours mom empties her breasts during the first months when baby is gaining weight well and mom’s production is adequate is the same number of feedings/pumpings that are required when mom returns to work and /or when baby begins to sleep longer at night.
“She can’t be hungry again!” the mother exclaimed in disbelief. “Yes, she can”, said the LC. Remember to follow the baby’s lead.
• Babies go through growth spurts roughly around 3 weeks, 6 weeks, 3 months, and 6 months. Remember to follow the baby’s lead. The growth spurt will last up to 72 hours. Breastfeed the infant “on demand” and avoid supplementation. (Think…supply and demand)
“Babies sleep all day and play all night” ~ so what’s a parent to do?
• Babies take about 3 to 4 weeks to reverse their activity windows. Remember how your baby was a “rock n’ roller” before birth. The best thing to do is to relax expectations, take afternoon naps, have a “nursing station” in your bedroom/nursery, and ask family members to do the domestic and non-nursing baby care tasks. Mom’s job is to feed the baby and to take care of herself. Remember, this, too, will pass.
If my breasts are super engorged, what can I do to relieve the pressure and encourage the baby to nurse?
• Manually express milk after massaging the breasts and the application of moist-heat. Every nursing mother should know how to express her breast milk with her hands.
• Dr. Jane Morton, Pediatrician at Stanford University has a number of excellent videos online. Every nursing mother should review this one on hand-expression of breast milk.
IBCLC – The Gold Standard! Know who to call and when to call.
• Those mothers giving birth in the hospital, the perinatal RN staff is “on call” 24/7 during the postpartum stay. Those birthing at home will have the support of the Certified Midwife. In the community, one can arrange a home visit lactation consultation to address breastfeeding concerns or a well-baby visit just to review newborn behavior, etc. La Leche League is a community organization for nursing mothers to support each other. Becoming Mothers offers the Monday Morning Milk (& Cookies) Lactation Q&A. The “gold standard” for lactation expertise is the IBCLC and indicates that the lactation professional has met proficiency standards as established by the International Lactation Consultants Association (www.ilca.org).
~A few answers to frequently asked questions~
Breastfeeding mothers should maintain hydration so that the urine is dilute. Breastfeeding mothers should eat healthy, culturally akin diets.
• Babies have what I call “all American fussy baby syndrome” in the early evening hours. This is when babies will often “cluster feed” and only be calmed at mom’s breast. This is not colic. This is not reflux. If your baby has obvious GI distress, the first foods to eliminate from the mother’s diet are cow’s milk products and gluten. The list goes on and on and if food elimination is done in a cavalier fashion, the mother is restricted to very few items. Procreatin, papaya enzyme, prior to eating some foods, may allow the nursing mother to enjoy some foods that would otherwise be offensive to the nursling.
Is it okay to have an occasional alcoholic drink?
• Moderation is a good rule of thumb for life, in general. An occasional social drink with a meal is probably fine. If you feel the affect of the alcohol, it is probably best to pump and dump the milk and feed the baby with previously expressed breast milk.
The best time to introduce a bottle is between 3 and 6 weeks.
• The first bottles are occasional bottles, meaning 2-3 varied times/week. There are a lot of bottles available so just make certain that any plastic bottle is BPA-free.
• Sometimes there is an indication to use bottles before 3 weeks. If this is your baby’s case, do remember that the bottle should be continued even after the baby is fully at the breast.
• Also (!) remember that if bottles are substituted for a regular breastfeeding (think: mom wants to take a bath each evening at 8pm so Dad offers a bottle of expressed breast milk) and Mom doesn’t express her breast milk, in 3-5 days, milk production will be decreased because the milk was allowed to accumulate. (Remember the sink analogy.}
• The new bottle from Medela, Inc., the CALMA BOTTLE, only flows when the baby applies vacuum and the nipple. The Calma Bottle allows the baby to control the flow of milk.
Pacifiers are a subject of debate.
• During the first days/weeks, it is best to use the pacifier as the last resort so that mom and baby can learn to breastfeed and so the baby nurses often. Ideally, a pacifier is not introduced until milk production is established and baby is nursing at the breast with a proper latch and is gaining weight as expected.
• Babies have sucking needs. Some babies will suck their thumb, fingers, or wrist. Some babies will suck Daddy’s finger. Other babies will continuously suckle at Mom’s breast. Some babies prefer pacifiers. You will know your baby and will discover what is the best “sucking device” for your baby.
• The important thing about which to be mindful is that the pacifier should not being used in lieu of breastfeeding. Hungry babies are not thrilled with pacifiers and babies wanting to be pacified are annoyed with breasts being forced upon them!
What are baby’s feeding cues?
• Watch for rapid eye movement, hands being brought to the face, moving slightly after a deep sleep, stretching movements after sleeping, arm and leg cycling, stretching the fingers, arm and leg cycling, finger flexion/extension. Watch your baby and you’ll learn to identify his nursing cues. If you miss them, the baby’s cry will alert you!
• Recognize finding reflexes: head righting; head lifting; rooting; head bobbing
Safe Co-Sleeping Practice IS NOW the Safe-to-Sleep Campaign
It is not recommended by the AAP to sleep in the same bed with the baby. It is recommended to bring baby to bed to breastfeed and then put baby back onto a firm surface. A “co-sleeper” works nicely as the baby is immediately proximal to the nursing mother and the baby is not sleeping in the bed with the parents. The Safe-to-Sleep Campaign was launched in August 2013 as the research has indicated a significant decrease in SIDS when the baby does not sleep in the same bed as the parents. I encourage you to discuss this with your primary care provider, remembering that the co-sleeper is a nice compromise for many families.
The Breast Crawl Process: Not Just about Breastfeeding
If left undisturbed after birth, in skin-to-skin contact with the mother, the newborn – guided especially by her sense of smell and using her innate primitive reflexes -goes through a predictable sequence of behaviors during which:
- She rests and recovers from the birth,
- starts to orient to her surroundings,
- begins to interact with parents,
- moves about on her mother’s chest to seek the nipple,
- familiarizes herself with the nipple,
- latches to the nipple and suckles.
While the breast crawl, in most cases, culminates with the act of suckling at the breast, research indicates that much more than just feeding is going on. Skin-to-skin contact – and the rooting, crawling, massaging, and grasping movements of the baby on the mother’s abdomen and breast – leads to the release of high levels of maternal oxytocin, which has many positive physiological and psychological effects in the immediate postpartum period.
The intimacy of uninterrupted skin-to-skin contact immediately after birth creates the opportunity for rich sensory interaction and connection between mother and baby, which supports bonding.
It is hypothesized that when the infant is allowed to peacefully go through the stages of the breast crawl, skin-to-skin with his mother, this may result in patterning early optimal self-regulation.
Studies have shown between 70%-100% of babies are capable of self-latching without any outside help.
Safe Co-Sleeping Practice IS NOW Safe-to-Sleep Campaign
• It is not recommended by the AAP to sleep in the same bed with the baby. It is recommended to bring baby to bed to breastfeed and then put baby back onto a firm surface. A “co-sleeper” works nicely as the baby is immediately proximal to the nursing mother and the baby is not sleeping in the bed with the parents.
• The Safe-to-Sleep Campaign was launched in August 2013 as the research has indicated the significant decrease in SIDS when the baby does not sleep in the same bed as the parents. I encourage you to discuss this with your primary care provider, remembering that the co-sleeper is a nice compromise for many families.
• Prior to the launch of The Safe-to-Sleep Campaign in August 2013, safe co-sleeping with infants was encouraged. There is a controversy amongst “camps” about the safest sleep arrangement for infants. I encourage everyone to review safe co-sleeping as well as the Safe-to-Sleep Campaign as our families will ask.
• The seven steps for safe co-sleeping that I previously discussed were –
- 1) Breastfeeding Relationship
- 2) Infant is in sensory-awareness of mother
- 3) No mind-altering drugs or prescription medications, 4) Smoke free home
- 5) No siblings or pets in the bed, 6) Adults sharing the bed must be in agreement about co-sleeping with infant,
- 7) Do not nurse the baby on a couch or soft chair when sleepy.
Reference – Dr. James McKenna
Please contact Stephanie should a Home Visit Lactation Consultation be what is needed to help your breastfeeding experience be a positive one that supports your dreams and expectations AND supports the nutritional needs of your newborn. Stephanie can be reached at 720-297-6312 (telephone, office, and home-visit consultations)