Breastfeeding Information

Diaper Output and Milk Intake in the Early Weeks

Are counting wet and dirty diapers a reliable indication of whether a breastfed baby is getting enough milk? During the first six weeks of life, parents are often encouraged to track daily diaper output (number of wet and dirty diapers per day), but is this an accurate gauge? Science has taken a close look and the results may surprise you.

During the first day or two of life, breastfed babies receiving colostrum typically have one to two wet diapers and stools per day. After that, some health organizations suggest breastfeeding parents track daily diaper output to estimate milk intake. According to the International Lactation Consultant Association1 signs of effective breastfeeding are at least three stools per day after Day 1 and at least six wet diapers per day by Day 4. The Academy of Breastfeeding Medicine 2 considers indicators of adequate mother’s milk intake to be the transition from the first dark stools passed by the baby to yellow stools by Day 5 and three to four stools per day by the fourth day of life.

Two U.S. studies examined whether diaper output accurately reflects adequate milk intake. Both found that there was much room for error. One study 3 of 73 exclusively breastfeeding mother-baby couples monitored the babies’ weight loss and gain, breastfeeding patterns, and diaper output for the first 14 days. The researchers found that more stools during the first 5 days were associated with positive infant outcomes. More stools during the first 14 days were associated with the lowest weight loss and early transition to yellow stools. (Mean number of stools per day was four, but some babies had as many as eight.) The first day of yellow stools was a significant predictor of percentage of weight loss (the earlier the babies’ stools turned yellow, the less weight was lost). The average number of daily stools was not an accurate predictor of initial weight loss, but the more stools passed during the entire 14-day study period, the earlier birth weight was regained.

Because some newborns breastfed ineffectively, number of daily feedings at the breast were not related to initial weight loss, start of weight gain, regaining of birth weight, or weight at Day 14. (Mean number of daily feedings at the breast was 8.5, with a range of 6 to 11.) In fact, the researchers considered unusually frequent feeding with low stool output a red flag to check baby’s weight, as the study baby who breastfed the most times per day had the poorest weight outcomes. They found that frequent feedings with good stool output was a sign of effective breastfeeding, but frequent feedings without much stooling should be considered a red flag of breastfeeding ineffectiveness.

The second U.S. study 4 followed 242 exclusively breastfeeding mother-baby couples, also for the first 14 days of life. These researchers found that “diaper output measures, when applied in the home setting, show too much overlap between infants with adequate versus inadequate breast milk intake to serve as stand-alone indicators of breastfeeding adequacy.” The most reliable predictor of poor milk intake was fewer than four stools on Day 4, but only when paired with the mothers’ perception that their milk had not yet increased. But even when both of these criteria were true, there were many false positives, meaning that many of these babies’ weight was in the normal range.

So at best, diaper output can be considered a rough indicator of milk intake. While it can be helpful to track diaper output on a daily basis between regular checkups, diaper output alone cannot substitute for an accurate weight check. Other indicators of good milk intake, such as alertness, responsiveness, and growth in length and head circumference.

In its 2012 policy statement, the American Academy of Pediatrics recommends that “All breastfeeding newborn infants should be seen by a pediatrician at three to five days of age, which is within 48 to 72 hours after discharge from the hospital.”5 That early checkup can identify babies at risk of low milk intake. Most newborns lose weight after birth. In the womb, they float in amniotic fluid for nine months, becoming “waterlogged,” and after birth, these excess fluids are shed. On average, breastfed babies lose about 5% to 7% of their birth weight, with the lowest weight occurring on about Day 3 or 4. If baby has lost more weight than this, make sure the scale used was recently calibrated.

Regarding diaper output, it’s important to know, too, that stooling patterns change over time. Four stools per day are average during the early weeks, but after six weeks of age stooling frequency often decreases, sometimes dramatically. Some breastfed babies older than six weeks may go a week or more between stools, which is not a cause for concern from a breastfeeding perspective as long as the baby is gaining weight well.

References
1International Lactation Consultant Association. (2005). Clinical Guidelines for the Establishment of Exclusive Breastfeeding. Raleigh, NC: International Lactation Consultant Association.

2Academy of Breastfeeding Medicine. (2007). ABM Clinical Protocol #2 (2007 revision): guidelines for hospital discharge of the breastfeeding term newborn and mother: "the going home protocol Breastfeeding Medicine, 2(3), 158-165.

3Shrago, L. C., Reifsnider, E., & Insel, K. (2006). The Neonatal Bowel Output Study: indicators of adequate breast milk intake in neonates. Pediatric Nursing, 32(3), 195-201.

4Nommsen-Rivers, L. A., Heinig, M. J., Cohen, R. J., & Dewey, K. G. (2008). Newborn wet and soiled diaper counts and timing of onset of lactation as indicators of breastfeeding inadequacy. Journal of Human Lactation, 24(1), 27-33.

5American Academy of Pediatrics. (2012). Policy statement: Breastfeeding and the use of human milk. Pediatrics, 129(3), e827-841.

Copyright Nancy Mohrbacher. Used with Authors Permission.

Milk Sharing: Formal and Informal

For most of human history, the sharing of human milk has taken place in the form of one mother breastfeeding the baby of another. In most instances, the immediate benefit of this kind of milk sharing—the continued life of the baby—far outweighed any possible risks. Even today, during times of emergency or in remote areas, sharing human milk may be the only way to save the life of a child whose mother has been injured, killed or is gravely ill. There may be limited or no access to any other feeding alternatives. The World Health Organization lists “wet-nursing” and milk banks as being equal alternatives when mother’s own milk is not available.*

In the United States, mothers investigate multiple sources of human milk for their babies when they themselves are unable to provide their own milk. Some are able to obtain milk from established Human Milk Banking Association of North America (HMBANA) milk banks that have a standardized system of collecting milk and screening donors. Others turn to family members and close friends in a more informal milk sharing arrangement which may include breastfeeding the baby and/or sharing milk for breastmilk feeding. In this age of the internet, still others are using social networking tools to link up with mothers who may be willing to donate milk. There is much debate now on the advisability of informal milk sharing amongst friends or strangers.

Some in the lactation community are worried that informal milk-sharing will negatively impact the ability of HMBANA milk banks to find donors. While this has not been documented as yet, it is something to consider, and mothers may want to investigate the possibility of donating to one of these milk banks before entering a more informal arrangement. Much of the milk from these banks goes to ill or premature babies and thus their screening process for donors is fairly stringent. Mothers seeking milk for full-term, healthy babies may be unable to obtain milk from HMBANA banks or to afford the cost. Even for fragile babies, HMBANA milk may not be available due to lack of donors. It is a difficult situation. It would be wonderful if HMBANA banks were operating in every community and their milk was more available and affordable - a worthy project for any lactation group or hospital to undertake. It is unfortunate that access to formula is so much easier than finding a source for human milk.

The risks of formula feeding have been well-documented. Depending on the situation, they can range from immediate risk of mortality from infections or SIDS to more long-range risks of increased rates of obesity, diabetes and some kinds of cancer. Some risks are more likely to pose immediate harm than others; some risks have a higher statistical probability than others. But the risk exists, there is no doubt about that.

While the use of human-milk substitutes involves documented risks to the baby, milk sharing is not without risk, either. Human milk that is carelessly collected or stored may be contaminated by any number of potentially harmful microorganisms. Donor mothers may have diseases that could be transmitted through the milk; some may not even know that they are infected. Donor mothers may be taking drugs or herbs that could cause harm to the baby. It does seem that most donor mothers want to take all reasonable precautions to make sure that their milk poses no risk to the babies who receive it. Yet there is always the element of the unknown, even when using milk donated by friends or family.

As with any other health-related decision, mothers who choose to share milk informally need to weigh the risk versus the benefit to their babies. They need to take whatever measures they deem necessary to ensure the safety of the milk they are obtaining for their babies. Those measures could include having the donor fill out a questionnaire and/or submit to blood testing. Testing does not ensure that the milk will be “safe” for the baby. However, nobody can insure the safety of formula feeds, either, or the degree of risk if baby receives a human-milk substitute. There has been no research at this time comparing the risks of banked human milk versus informally shared human milk for babies in this country. There is no official place for mothers to report negative experiences they have had while engaging in informal milk sharing. It is a complex issue and one that deserves careful examination by anyone considering any kind of milk sharing.

Websites that advocate for informal milk-sharing, such as Eats on Feets, Milk Share, and Human Milk 4 Human Babies, contain lots of information on this topic. La Leche League International cautions against informal milk-sharing in its policy statement.

Again, mothers unable to nourish their babies with their own milk must decide for themselves, on a case by case basis, what is best for their situation. Parents are responsible for their own children and must live with the outcomes of their decisions. Mothers are encouraged to fully research the available options in order to make an informed decision.

For more information, see:
Use of Donor Human Milk from the FDA
Milk sharing: from private practice to public pursuitby James E Akre, Karleen D Gribble, and Maureen Minchin. International Breastfeeding Journal 2011, 6:8 (25 June 2011)
Biomedical ethics and peer-to-peer milk sharing by Karleen D. Gribble. Clinical Lactation, 3(3):109-112 (2012).

*From WHO: Global Strategy for Infant and Young Child Feeding, #18 (page 17):
“…..For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or human-milk bank, or a breast-milk substitute ……depends on individual circumstances.”

© Breastfeeding USA, all rights are reserved.

For Teen Mothers: What Breastfeeding Is Like in the First Days

No one can know what life is like with a newborn baby before having one. Many say, “No one ever tells you what it’s really like.” That’s very true, because it’s a story that can’t be told beforehand. It will be a story that you and your baby will tell together.
But some things we can tell you for certain. These things have been studied and understood for quite a while. One of the things we know is the normal way newborns eat and the natural food they are meant to have.

You already know without anyone telling you that one of the main jobs in your life with your baby is feeding her. Feeding this baby from your breast is the easiest, healthiest, cheapest, safest, least tiring, most fascinating and delightful way to give your baby food. Feeding your baby can be simple and satisfying and healthy and amazing for the both of you if you nurse your baby.

Your body already started preparing food for your baby by making colostrum, an early kind of milk, when you were about 16 weeks pregnant. Now that your baby is here, you will have the right amount of that milk available from the moment she finds your breast. And she can find your breast all by herself when you lie back, and she lies flat on your body, sort of tummy-to-tummy. She can do that when she’s less than an hour old. You will watch her cute efforts to wiggle around and come to your breast without much help at all. She knows where to go and what to do when she gets there! She knows more than you do about this, so let her show you.

Only you are the mother of this baby, and others should honor what you decide for him. If you know what the best scientific evidence says about nursing your baby, you can act in the healthiest and happiest way for both of you, and everyone in the hospital should listen to you and support your wishes. There may be times when the hospital wants to do things to you and your baby because of hospital routines that may not be in the best interests of you and your newborn. One example of that is taking your baby away from you and giving him a bath before he’s even 6 hours old. He may not be ready to keep his temperature steady yet, especially after a bath.1,2 You can request that they wait a few more hours before the bath, and do it when you are close by, so that he can go right back on your skin to keep his temperature nice and stable. An even temperature is very important for his health.

When you first meet this new baby, he is ready to adjust well to life outside your body. It’s going to be your delight to watch him while he is resting on you and getting ready to nurse for the first time. No one should rush him or rush you. Let him do it in his own time. Remember you are the mother, and you can tell the hospital staff to let this baby stay on your body for at least an hour. He must adjust and then nurse for the first time before they do anything at all to him. That means no eye ointment or he won’t be able to see you well; no weighing, no shots. Nothing at all should disturb you and your baby in the first hour or so. You can tell your caregiver that your baby should have no bottles, no pacifier, just you. You can insist and the staff should honor your wishes. You are now a mother and this is your baby.

Here’s what all baby doctors and scientists want you to know about how to begin feeding your baby with your milk. Keep your baby with you and as close as possible day and night. That means right next to you in your hospital room. And that also means keeping your baby on your chest, with his bare skin on your bare skin for good long periods of time. All of a baby’s body functions, temperature and heart rhythm and blood pressure and breathing are nicely regulated by being on your body. When your baby stays close, you will very quickly get very good at seeing your baby’s “feeding cues.” That means you’ll see your baby do the little movements of his hands and mouth and body that mean that he is ready to nurse. That’s his way of asking for food. That’s his language.

While your baby is on your chest, he may bob his head around and find your nipple and begin to nurse while he is still half asleep. It’s amazing to see. He’ll just be doing what comes naturally. Babies love to nurse and they are born to suck, so in the beginning of your life with him, he may want to nurse a lot. He knows what he needs, so just follow his “cues”, and feed him whenever he asks. Babies who spend lots of time on their mom’s bare skin in the first days and weeks after birth cry less, eat and digest better. They also sleep well, and that’s great for you. Newborns really are meant to spend their early days and weeks as close to you as they can get. Just keeping your baby close to you makes him healthier. As time goes by you will see that it’s really the easiest way to keep him fed and happy and to keep your breasts comfortable. Plus think of all the wonderful cuddling you and your babe get to do.

The more you know about all the good things that will happen to both of you when you decide to nurse your baby, the more you’ll understand how really important it is. You’ll see that your decision to breastfeed will mean a lot more than just the easiest way to feed, or good health or saving money. It will mean that you are able to enjoy the deep and special and lasting attachment that happens to you and your babe when you are a breastfeeding pair. Your baby needs and wants the special food only you can give him... your milk... and you’ll be amazed at how much he really does want it.

While you are in the hospital, you will be able to have a nurse or a lactation expert— someone who knows about nursing—show you how to find a comfortable position for nursing. The expert will explain what your baby needs and what you need for a good beginning. You’ll learn how your baby changes over the first weeks of his life with you, and how your milk changes along with him. In just the first few days of your life together, you will become an expert on the subject of your new baby. You’ll learn about her ways. You’ll be surprised at how easy and pleasant and just plain amazing it is to nurse your baby and how well you both will do it together.

1World Health Organization. (2009). Newborn Care Until the First Week of Life: Clinical Practice Pocket Guide. Geneva, Switzerland: World Health Organization, 19.

2World Health Organization. (1997). Thermal Protection of the Newborn: A Practical Guide. Geneva, Switzerland: World Health Organization, 14.

Breastfeeding USA. All Rights Reserved

Choosing a Breast Pump

Claire was excited. “My baby is due next month,” she said, “and I still have not decided which breast pump to buy. Does it really matter which one I choose?”

You may have noticed how almost all “must have” list for pregnant parents includes a breast pump. Here are some things to consider.

Who needs a pump?
You may need a pump if:

  • your baby is not able to directly breastfeed
  • you will be separated from your baby because of his prematurity, or your work or schooling
  • under certain circumstances, if you need to increase your milk production

If you are staying home to care for your healthy newborn, you may not need a pump at all. For the occasion when you may want to go out without your baby, hand expression is an effective and cost-saving option.

A word about hand expression.
Hand expression is a very useful skill and is easy to learn. Ask your Breastfeeding USA Counselor to show you how to do it. You can see a simple animation of hand expression here:
http://ammehjelpen.no/handmelking?id=907 (Scroll down for English text.)

When is the best time to buy a pump?
This will depend on your own circumstances, because there are different kinds of pumps for different situations.

If either you or your baby is unable to nurse after birth, you should use a special hospital-grade pump. Your hospital will have one available for you to use during your stay, and they will let you know where to rent one if your baby is still unable to nurse when you go home.

If you are sure that you will be returning to work, you might want to consider buying a personal pump before the baby is born. That way you will have it available if you need to pump to comfort in the early weeks. However, these personal pumps should not be confused with the previously-mentioned hospital grade pumps, which are designed to help you establish milk production.

Not all pumps are created equal!
Don’t waste your money on a cheap pump. They do not work very well, are noisy, break down often, and can even cause nipple damage.

Check the length of the pump's warranty, because that is the expected lifetime of the pump!
As a general rule, it is a good idea to avoid pumps made by companies whose main business is selling bottles, nipples and other supplies needed by mothers who are formula feeding. In the long run, it is much cheaper to rent or to buy a good pump than to buy formula.

When buying a pump, consider whether that brand offers different fit options. Pump fit is not about breast size; it’s about nipple size. It refers to how well your nipples fit into the pump opening or “nipple tunnel” that your nipple is pulled into during pumping. Pump nipple tunnels come in different sizes. Fit is an important aspect of pump comfort and efficiency.

If you need to rent or buy a pump, first check to see if you qualify for a free one from your local WIC agency.

There are so many breast pumps available today that it can be hard to decide which one is right for you. Here are some things to consider.

There are three kinds of pumps:

  • For occasional use.
  • For regular use.
  • For mothers who have not yet established a milk supply and/or whose baby is less than 8 weeks old.

Pumps for occasional use.
NOTE: These are all single user pumps that, like toothbrushes, should not be loaned or re-sold.

  • Manual pumps are designed for very occasional use - once or twice a week. They carry a 30-to-90 day warranty.
  • Small, motorized pumps are often chosen by mothers who are separated from their babies for about one or two feedings, once or twice a week. These pumps, which also have very short warranties, can be useful for emergencies. They are expensive to run on batteries, because the batteries need to be changed so frequently. Whenever possible, plug them into an electrical socket. They have a 90-day (3 months) warranty, and tend to be a bit noisy.

Pumps for regular use
Are you a mother who has already established a good milk supply and has a baby who is nursing well? If you will be separated from your baby because of work or school, you will need a dependable and efficient electric double pump. Some mothers find that pumping both breasts at once saves time and actually brings in more milk. See the Breastfeeding USA article To Pump More Milk, Use Hands-On Pumping for more ideas for bringing in more milk.

There are new multi-user electrical pumps in the $300 price range, which carry a three-year warranty. After you are finished with it, the pump can be loaned or sold to another mother who has her own personal accessory set, and even be recycled.

Some mothers prefer to rent the hospital-grade electric double pumps for the reasons below. Contact a Breastfeeding USA Counselor for the most current information on available breast pumps.

Pumps for mothers who have not yet established a milk supply and/or whose baby is less than 8 weeks old.
If this is your situation, you will probably need to rent a hospital-grade electric double pump:

Mothers of babies who:

  • are premature
  • are too sick to nurse
  • have physical anomalies (like a cleft palate) which may prevent breastfeeding
  • are having difficulties nursing for other reasons

Mothers who:

  • are exclusively pumping
  • have had breast reduction surgery
  • have medical conditions (like untreated low thyroid levels) which may make it difficult to produce a full milk supply
  • are relactating or inducing lactation for an adopted baby
  • are having difficulties nursing for other reasons

Hospital-grade electric pumps are specially designed to bring in and maintain a mother’s milk supply. They can be sanitized and used by more than one mother.

Previously used pumps.
Using a previously owned pump that has not been approved for multiple users is like using somebody else's toothbrush. Milk can get into the unsealed motor, even if you get new tubes and personal milk collection parts.

Remember that the average lifetime of a pump is about the same as the length of its warranty. Yes, the pump may work a bit longer than the length of the warranty, but you will have no recourse from the manufacturer if it no longer works efficiently..

There is an even more important aspect to consider. An older pump that is beginning to wear out may not work well. If the pump is not able to adequately stimulate your breasts, then your milk production will drop, and you may not be able to make enough milk to keep up with your baby's needs.

Nothing lasts forever. Pumps wear out. We are not surprised when a hairdryer or a microwave oven or a car fails to work properly after it has reached it's *expiration* date, and it is the same for pumps.

Need more information?
If you want to know more about choosing or using a pump, storing your milk, or if you have other breastfeeding concerns, FREE help is available from Breastfeeding USA Counselors.

All rights reserved by the author and Breastfeeding USA.

Does Your Older Baby Still Need Night Feedings?

Has somebody told you that your baby doesn't need to breastfeed at night past a certain age? This age often varies by advisor. However, science tells us that in many cases, this simply isn't true.

Why? Babies and mothers are different and these differences affect baby’s need for night feedings. Some babies really do need to breastfeed at night, at six months, eight months, and beyond. This is in part because if their mother has a small “breast storage capacity” and tries to sleep train her baby, her milk production will slow, along with her baby’s growth. To find out what this means and if this applies to you, you need to know the basics of how milk production works.

Degree of Breast Fullness
Two basic dynamics are major influencers of milk production. The first, “degree of breast fullness,” refers to a simple concept: Drained breasts make milk faster and full breasts make milk slower. Whenever your breasts contain enough milk to feel full, your milk production slows. 1The fuller your breasts become, the stronger the signal your body receives to slow milk production.

Breast Storage Capacity
This second basic dynamic refers to a physical characteristic known as breast storage capacity, which varies among mothers.2This physical difference explains why feeding patterns can vary so much among mothers and why one breastfed baby does not need to breastfeed at night while another one does.

Breast storage capacity is the amount of milk your breasts contain in your milk-making glands at their fullest point of the day. Storage capacity is not related to breast size, which varies mainly by how much fatty tissue is in your breasts. In other words, smaller-breasted mothers can have a large storage capacity and larger-breasted mothers can have a small capacity.

Both large-capacity and small-capacity mothers produce plenty of milk for their babies. But their babies feed differently to get the daily volume of milk they need. 3After baby’s first month, a mother with a large storage capacity may notice that her baby:
• Is satisfied with one breast at most or all feedings.
• Is finished breastfeeding much sooner than other babies (sometimes just five minutes).
• Gains weight well on fewer feedings per day than the average eight or so.
• Sleeps for longer-than-average stretches at night.

If this describes your breastfeeding experience, your baby may already be sleeping for longer stretches at night than other babies you know. But if after the first month of life your baby often takes both breasts at feedings, feeds on average longer than about 15 to 20 minutes total, typically takes eight or more feedings per day, and wakes at least twice a night to breastfeed, your breast storage capacity is likely to be small or average.

Again, what’s important to a baby’s healthy growth is not how much milk he receives at each feeding, but rather how much milk he consumes in a twenty-four-hour day. Breastfed babies of both large- and small-capacity mothers receive plenty of milk, but their breastfeeding patterns will necessarily differ to gain weight and thrive. 4For example, a baby whose mother’s breasts hold six ounces or more (180 mL) may grow well with as few as five feedings per day. But to get this same 30 ounces (900 mL) of milk, if a mother’s breasts hold only three ounces (90 mL), a baby with a small-capacity mother will need to feed ten times each day. (This may not apply in the same way to a mother who’s pumping.)

How These Dynamics Affect Night Feedings

How does this apply to night feedings? A mother with a large storage capacity has the room in her milk-making glands to comfortably store more milk at night before it exerts the amount of internal pressure needed to slow her milk production. On the other hand, if the baby of the small-capacity mother sleeps for too long at night, her breasts become so full that her milk production slows.

In other words, if you are a mother with an average or small breast storage capacity, night feedings may need to continue for many months in order for your milk production to stay stable and for your baby to thrive. Also, because your baby has access to less milk at each feeding, night feedings may be crucial for him to get enough milk overall. Again, what’s important is not how much milk a baby receives at each individual feeding, but how much milk he consumes in a twenty-four-hour day. If a mother with a small storage capacity uses sleep training strategies to force her baby to go for longer stretches between feedings, this may slow her milk production and compromise her baby’s weight gain.

Each mother-baby pair is unique. Babies will outgrow the need for night nursings at different ages, so a simple rule of thumb doesn't consider either the emotional needs of the baby or his physical need for milk.

References

1. Daly, S. E., Kent, J. C., Owens, R. A., & Hartmann, P. E. (1996). Frequency and degree of milk removal and the short-term control of human milk synthesis,, Experimental Physiology 81(5), 861-875

2. Cregan, M. D., & Hartmann, P. E. (1999). . Computerized breast measurement from conception to weaning: clinical implications. 89-96 Journal of Human Lact 15(2)

3. Kent, J. C., Mitoulas, L. R., Cregan, M. D., Ramsay, D. T., Doherty, D. A., & Hartmann, P. E. (2006). , Volume and frequency of breastfeedings and fat content of breast milk throughout the dayPediatrics, 117(3), e387-395

4. Kent, J. C. (2007). How breastfeeding works. Journal of Midwifery & Women's Health, 52(6), 564-570.

Used with permission. Copyright Nancy Mohrbacher, 2012

What About a Sleepy Baby?

All babies sleep a lot in the first days and weeks of life. Some babies certainly are sleepier than others, so how will you know if your baby is too sleepy? And what does “too sleepy” mean?

When you gave birth, there were probably health-care providers around you to help you make sure that your baby woke up often enough to get the milk he needed. Once you are on your own, you may not have anyone around who can help you know whether your baby is feeding well. Because every baby is different, sometimes even experienced mothers cannot always identify a baby who may need some help to feed often enough.

Normal Infant Behavior
First let’s take a brief look at newborns and their sleep patterns, which of course, vary from baby to baby. Newborn sleep has been studied and described for many years. Newborns move through several states: deep sleep, light sleep, a drowsy time, a quiet awake state, an active awake state, and, of course, crying is a “state” as well.1

Most newborns will sleep somewhere between 14 and 18 hours a day in the first weeks, waking frequently to nurse. There really aren’t regular patterns in the life of a new baby. Some babies will wake more frequently than others, with perhaps one longer sleep period. Some will sleep longer between wakings for part of the day, then wake more often to “cluster-feed.” That means that they may nurse several times in a row, even though only a half-hour or an hour has gone by. They may take little naps between those frequent feedings. There is no schedule, no predicting how often a baby will nurse, or how long each sleep period will be. Don’t be surprised if your baby has a longer sleep time of four to five hours every day, or from time to time. That’s also a normal part of an unpredictable schedule. Even a baby’s personality will affect eating and sleeping behavior. There are relaxed, slow feeders who take their fine time, and those who eat quickly and go back to sleep.

Does Your Baby Need to Breastfeed More?
So is your baby too sleepy? Most newborns need to nurse 8-to-12 times a day. (Even 14 or more is not unusual.) Some babies nurse less or more frequently than that, but frequent nursing is needed to establish and maintain your milk supply. 2 If your baby nurses fewer than eight times per day total, that may mean she is too sleepy and needs some helpful stimulation to nurse.

That number of 8-to-12 times a day is a good guide. And new mothers do need to know how to recognize their baby’s early feeding cues, such as any movements (including eye fluttering), hand-to-mouth, and rooting (head turning from side to side with an open mouth). Mothers also need to be aware of techniques they can use to help a sleepy baby feed more often. Your baby may be struggling with the effects of labor medication, a difficult birth, or may be just a little immature.

“Talk, stroke, and woo”3 your baby, says British author Sheila Kitzinger, to bring him closer to wakefulness. That may indeed be a natural and delightful thing for a mother to do. And here’s a list of other tips that have worked for many a mother:

  • Lie back with comfortable support, open your shirt in front, and open your baby’s clothing as well. Put your sleeping baby on your chest, front to front, talk to him, and let your baby rouse and find your breast as he moves from deep to light sleep. Even though he’s sleeping, your baby can nurse effectively.4 Keep your baby lying tummy down on your body as much as possible, as that triggers his inborn feeding reflexes more often. That position, whether in skin-to-skin contact or lightly dressed, helps both of you get ready.
  • Dim the lights or draw the shades so that she can open her eyes.
  • Massage his body or feet, and talk to him.
  • Hold her up vertically face to face and talk...let her hear your voice in that position.
  • Hand express some colostrum or milk onto his lips to stimulate suckling.
  • Put your newborn on his back on a flat surface, and very gently and slowly roll him from left side to right side a few times in a row.
  • Undress your baby a bit. You may have him dressed too warmly.

Even if your baby was wrapped up and “swaddled” in the hospital, it may be better for your baby not to be wrapped up to sleep. Wrapping him can stop his normal responses to nursing and keep him from having access to his own hands and the freedom to move his little body around as he feels like doing. Think about what it might feel like being wrapped up tightly when you needed to move about. It really wouldn’t be too comfortable, but while you could say something about your discomfort, your baby can’t tell you. Light clothing in layers...just one layer more than you are wearing, is a perfect way for him to sleep. And remember to spend time skin to skin with your baby to help his little growing brain mature.

Sometimes you may try to stimulate your baby to feed, but find he is in a deep sleep and unresponsive. He may be so totally relaxed that you can pick up his arm, let go, and it just drops. If that is the case, you may want to wait until his sleep state changes. In 20 minutes or so, try the stimulation techniques again, since newborns move in and out of deep sleep more often than adults. You may be able to rouse him more easily after some time has passed.5 He may be ready to eat the next time you try. You will learn how to stimulate your baby, as you watch him and learn more about him. As he matures, he will wake to nurse on his own unique schedule. You will find that once your sleepy baby takes a few good mouthfuls of your milk, she will become interested in getting more of that lovely, tasty stuff.

If, however, you have continuing concerns about getting your baby to feed, consider reviewing the signs that tell you that your baby is getting enough to eat. He should be having four yellow, seedy poopy diapers by Day 4 and your breasts should feel noticeably fuller.6 Your newborn should seem to be comfortable at your breast, relaxing body and hands as the feeding progresses, and let go of the breast by herself after a feed. If your baby is gaining an average of an ounce a day or more, he is doing well. Your care provider can reassure you that your baby is indeed getting a good amount of milk if his weight gain is within the normal range. If these signs are not there, no matter how long or briefly your baby sleeps, quickly get help from a board-certified lactation consultant or your health-care provider. An underfed or dehydrated baby can be very sleepy and not nurse well even when he wakes often.

Each baby is unique. While some mothers worry that their baby isn’t sleeping regularly enough during the early weeks and months, you may have concerns that your baby is too sleepy. Experience has shown, however, that most babies develop more of an established sleep pattern after the newborn period. Enjoy this special time with your baby.

References
1 Brazelton, T.B., & Nugent, J.K. (1995). Neonatal behavioral assessment scale. London, UK: MacKeith Press.
2 Mohrbacher, N. & Kendall-Tackett, K. (2010). Breastfeeding Made Simple: Seven Natural Laws for Nursing Mothers. Oakland, CA: New Harbinger Publications.
3 Kitzinger, S. (1989). Breastfeeding Your Baby, New York: Alfred A Knopf.
4 Colson, S., DeRooy, L., Hawdon, J. (2003). Biological Nurturing increases duration of breastfeeding for a vulnerable cohort. MIDIRS Midwifery Digest 13(1), 92-97.
5 Richardson, H.L., Walker, A.M. & Horne, R. S.C. (2010). Stimulus type does not affect infant arousal response patterns. Journal of Sleep Research, 19, 111-115.
6 Nommsen-Rivers, L. A., Heinig, M. J., Cohen, R. J., & Dewey, K. G. (2008). Newborn wet and soiled diaper counts and timing of onset of lactation as indicators of breastfeeding inadequacy. J Hum Lact, 24(1), 27-33.

To Pump More Milk, Use Hands-On Pumping

Would you like an effective method for pumping more milk? Until 2009, most of us assumed that when a mother used a breast pump, the pump should do all of the milk-removal work. But this changed when Jane Morton and her colleagues published a ground-breaking study in the Journal of Perinatology.1 The mothers in this study were pumping exclusively for premature babies in the hospital’s neonatal intensive care unit.

For premature babies, mother’s milk is like a medicine. Any infant formula these babies receive increases their risk of serious illness, so these mothers were under a lot of pressure to pump enough milk to meet their babies’ needs.

Amazingly, when these mothers used their hands as well as their pump to express milk, they pumped an average of 48 percent more milk than the pump alone could remove. This milk also contained twice as much fat as when mothers used only the pump.2 In most mothers exclusively pumping for premature babies, milk production falters after three to four weeks.3 But the mothers using this “hands-on” technique continued to increase their milk production throughout their babies’ entire first eight weeks, the entire length of the study .

Hands-on pumping is not just for mothers with babies in special care. Any mother who pumps can benefit from it. How does it work? To do hands-on pumping, follow these steps:

  1. First, massage both breasts.
  2. Double pump, compressing your breasts as much as you can while pumping. (Search “hands free pumping” online for pumping bras or bustiers that fit any brand of pump and allow you to double pump with both hands free.) Continue until milk flow slows to a trickle.
  3. Massage your breasts again, concentrating on any areas that feel full.
  4. Finish by either hand expressing your milk into the pump’s nipple tunnel or single pumping, whichever yields the most milk. Either way, during this step, do intensive breast compression on each breast, moving back and forth from breast to breast several times until you’ve drained both breasts as fully as possible.

This entire routine took the mothers in the study an average of about 25 minutes. For a demonstration of this technique, watch the online video “How to Use Your Hands When You Pump” at: http://newborns.stanford.edu/Breastfeeding/MaxProduction.html.

These three online videos are examples of three different hand-expression techniques that some mothers have found helpful and can be used as part of hands-on pumping: http://ammehjelpen.no/handmelking?id=907 (scroll down for the English version), http://video.about.com/breastfeeding/Hand-Expression-Technique.htm and http://newborns.stanford.edu/Breastfeeding/HandExpression.html. See also the article Hand Expression on the Breastfeeding USA website.

Hands-on pumping can be used by any mother who wants to improve her pumping milk yield or boost her milk production. Drained breasts make milk faster, and hands-on pumping helps drains your breasts more fully with each pumping.

References
1Morton, J., Hall, J. Y., Wong, R. J., Thairu, L., Benitz, W. E., & Rhine, W. D. (2009). Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. Journal of Perinatology, 29(11), 757-764.
2Morton, J., Wong, R. J., Hall, J. Y., Pang, W.W., Lai, C.T., Lui, J., Hartmann, P.E., & Rhine, W. D. (2012). Combining hand techniques with electric pumping increases the caloric content of milk in mothers of preterm infants. Journal of Perinatology, Jan 5. doi: 10.1038/jp.2011.195. [Epub ahead of print]
3 Hill, P. D., Aldag, J. C., Chatterton, R. T., & Zinaman, M. (2005). Primary and secondary mediators' influence on milk output in lactating mothers of preterm and term infants. J Hum Lact, 21(2), 138-150.

added links to references and studies.

Night Weaning of Older Babies and Toddlers: Mothers share their experiences

“When will my child sleep through the night?” is a question so many mothers ask. It is a question I have asked. When we hear that our friend’s infant started sleeping for 10 hours a night at five months of age, we sigh a little bit, knowing that very night we’ll be up with our two-year-old who has yet to do it. Some days we can go-go-go on little sleep while other days are not so easy, especially with the myriad responsibilities we have. We wonder if we should night wean, either partially or completely. We wonder what book will have the answer. We wonder if a sleep training method will solve our “problem.” And we wonder these most often when exhaustion and sleep deprivation don’t creep in, but rather pounce.

Why do some people use the expression “sleeps like a baby” to refer to a child or adult who sleeps soundly all night long? When I think of sleeping like a baby, I think of my own baby, who sleeps for 15 minutes and wakes up crying. Then she sleeps for 90 minutes and wakes up crying. Then she sleeps for two more hours and wakes up, you guessed it, crying. And so the night goes on. I want my 17-month-old to STOP sleeping like a baby and start sleeping the way some people interpret the expression: soundly and all night long.

Our story is like so many others. Many mothers have asked themselves and each other what they can do in order to get a full night’s rest. How can we get our children to not need us during these long, exhausting nights? We hear lots of well-intentioned advice: ‘Let your child cry it out.’ ‘Give him a bottle of formula before bed to fill him up so he won’t wake up hungry.’ ‘Have Dad go in and hold her so she gets some comfort, but not breast milk.’

We know that newborns and young babies need to feed at night to get the calories they need. Whether or not to wean or sleep train an older baby or toddler is in part a personal choice (for more on this, see the article on this website “Does Your Older Baby Still Need Night Feedings?”). We must do what is best for our families. Some of us choose to night wean and some of us choose to continue doing what we’ve been doing all along--meeting our child’s needs night after night.

I asked the mothers on the Breastfeeding USA Yahoo chat group for advice on night weaning when I was literally sick from being tired from getting up so often with my little one, who sleeps in her own room. I received both suggestions and support.

Breastfeeding USA provides evidence-based breastfeeding information and support. This article is not based on evidence, but is an example of the kind of support provided by Breastfeeding USA. It is a collection of mother-to-mother wisdom, comments, and suggestions on how to get through the nighttime hours. All comments come from Breastfeeding USA members.

"When [my daughter] hit three, I spent a few days with, ‘Well, mommy didn't get a lot of sleep, so we are playing at home instead of the park.' Sure caught on, since nights she didn't wake me I was little Miss Perky going to the park…"

"Key for us was that *daddy* stepped up to take on the primary ‘night time parenting role.’ Baby realized that daddy wasn't the milk source and was much better at accepting soothing back to sleep by daddy and not me. We waited for a time when baby was healthy and not teething. With one of the kids the first attempt was not good, so we waited and tried again a couple months later. Of course ... both kids continued to wake several times at night until they were two or three years old."

“I didn't night wean. Yes....I offered water instead of nursing sometimes, and when she was actually just thirsty, she was happy with the water and I was happy for the break! There were times when I asked her just to snuggle, and sometimes that was enough (which, I guess, could be considered night weaning). I didn't insist on having my way about it, though. If it was mutually okay, then fine. Most of the time she really just wanted the comfort of nursing. I would remind myself that this won't last forever (although, in my case, it did last for four years, but she is a particularly needy child). I'm very happy that I was able to do that, but not everyone is able to. You have to do what will work for you and your situation.”

“I never considered night weaning. The idea of having to actually become fully awake to deal with a fussy child was not what I wanted to deal with. Guess I am just lazy. I have been caring for kids my whole life, as the oldest of a large family and a frequent babysitter in our apartment buildings. Even those who were "sleep trained" woke at night. So to me, nursing at night was an easy way to get the most sleep. And some of mine nursed night and day even longer than four years. I did, however, always remove my nipple from the mouths of sleeping babies, so they did not get used to just holding it in their mouths.”

“A couple of quick ideas that have worked for moms I know:

  • Move baby IN the crib into your room (less up and down, less wide awake).
  • Move baby IN the crib and sidecar it to your bed (there are lots of safe ways to do this).
  • Make a bed in baby's room for you or your partner to sleep comfortably during the night, and plan on staying there (perhaps you sleep there from 9 pm to 2 am, and he takes over from 2 am to 6 am it'll be a temporary thing).”

“Sometimes, just going to sleep and getting more sleep can help you feel like you can cope longer. I would also add that if you are going to attempt a night weaning plan, first get more sleep, by taking naps and/or going to sleep earlier for a couple of weeks. Feeling centered before you approach something as tricky as changing nighttime behavior can make a person go a little crazy. I’ve heard it takes 21 days to make or break a habit. With persistent people (behaviors) it takes longer. To adequately and sensitively approach a new nighttime routine, you must think about the entire month and make sure that there won't be any visitors, planned vacations, surprise houseguests, etc. Also, I tend to think that spring is a good time to approach something like night weaning. During the winter, when there is the proclivity to catch colds and feel horrible, night nursing often saves everyone.”

"…many mothers will want to know, step by step, how to get a straight eight hours of sleep. I always like to start with smaller steps. So I shot for a straight five hours, understanding that was the definition of "sleeping through the night." I chose my five hours from 11 pm to 4 am. I would actively wake up my babies to nurse at 11 pm and bring them to bed with me so we could all get some sleep. That didn't work for my sister.”

“A friend used a night light on a timer to help manage night needs. In her case, the rule was nursing only when the light is on. I think her daughter was more two to three when that worked. It would probably be harder for a younger baby to get the reasoning, but maybe not.”

"Napping during the day or at least dozing were what helped me survive. I am a night owl, so sometimes flinging the baby at my partner the second he walked in the door and then napping until dinner (I'm blessed to have married a man who loves to cook) would help me get a second wind until my bedtime. And grudgingly for months at a time I would forgo my preferred bedtime and go to sleep with the kids at eight or nine in anticipation of interrupted sleep."

“…there is no single ‘right’ method that will work for everyone.”

“Some things I found that affected my children's frequency of night waking were: food allergies, teething (woke me up all the time when a wisdom tooth decided to erupt at age 40... so I get it now!), overstimulation, food additives, especially artificial colors and flavors, and my nemesis, caffeine, even decaf after 12 noon, kept our youngest awake half the night wanting to nurse every hour.. I think most of us consider (however briefly or not) night weaning when we are exhausted and finding it hard to function. It also helped me to pay attention to colds, changes in routine, etc."

“There is one thing that was also a lifesaver for me. My husband gave me Saturday mornings. When the baby woke for the first time on Saturday, I would nurse then he would take him and play, watch TV, go for a walk, whatever it took (with runs to me when nursing was really necessary), to continue until noon. This allowed me to sleep, bathe, or even grocery shop on my own. There were weeks when I was in countdown mode by Wednesday, but somehow knowing there was a break coming allowed me to cope. This can also be done with a friend if dad is not available or cooperative :)”

“I just came across an interesting piece in a Washington Post health section…It says that in the winter, lack of daytime sunlight makes it harder to sleep at night…They conclude that it is crucial in the winter months to get outside and soak in some natural light. Seems like something mothers and grandmothers have been saying for years--get outside and your child will have a better night's sleep!”

“A good friend had the most startling success story with night waking and food allergies. Her baby was eight months and nursing every hour. She read the book Tracking Down Hidden Food Allergies and put them all on an elimination diet. It turned out to be legumes--all kinds--that irritated her son's system.”

“I think that sometimes there can be anatomical obstructions that create sleep problems. Having a good physical from a qualified doctor who isn't going to peg breastfeeding as the problem is helpful.”

I took all of these suggestions to heart and gave some of them a try. Surprisingly, even though I was hoping to find an effective way to night wean my baby and thereby get more sleep, what helped me most were the comments of empathy, support, and affirmation that getting up to breastfeed was, for us, the right thing to do. Comments like these gave me the strength to regroup and re-energize.

"Now is not forever."

“Even as adults, we all wake at night. Just because you night wean your toddler doesn't mean you will necessarily get more sleep, and it takes away a valuable night parenting tool.”

“How often are new mothers asked, 'When do you plan to make him walk?' Sounds, silly, doesn't it, because we KNOW that babies will walk when their bodies are ready to do so. Same thing with talking. So why don't we believe that they will stop nursing when they are physically and mentally able to do so?”

“The following passage from the chapter 'Getting Enough Rest' of Norma Jane Bumgarner’s book, Mothering Your Nursing Toddler was very helpful to me: ‘First of all, nursing is not the cause of your losing sleep. That is hard to believe when the whole household is quietly asleep—that is everyone but you. The little one nods off, still clinging to your nipple, but like so many mothers who slept well while their small infants are nursing, you find it difficult to sleep while nursing a little child. So you, little one attached, lie grudgingly awake in the peaceful night. Every time you remove your nipple from his mouth, no matter how carefully, he starts kicking and crying. Under these circumstances you are not likely to be very receptive to my suggestion that it is not the nursing that is keeping you awake. Well, technically, you are awake because of the nursing. But I would suggest that in reality you are awake because of being the mother of your child at this time in her life. I would suggest that if you were not lying there half-awake nursing, you would probably be stumbling around fixing a bottle or an apple slice, or rocking and patting, or fumbling among the toys under the bed looking for a lost pacifier. . . .'"

“… if I were to attempt other forms of nighttime parenting (putting my partner on nighttime duty, offering a cup of water versus nursing, etc.), I would still be waking when my son needed me and it would be even harder to get back to sleep. Once I made my peace with these things, I no longer resented nursing at night. For me it was better than the alternative. And at around two-and-a-half years, my son started going all night without nursing all on his own.”

“Lucky for me, I had read Dr. Sears' The Fussy Baby Book about high-need babies and in there he says children aren't really neurologically developmentally ready to sleep through the night until age three…”

“We are all in this together…You have everything inside you that you need to be the best mama to this little person!”

“Most of all we trust one another to reach out, to share, and to ultimately decide what is best for our child, since it is only the family who lives 24/7 with its members that knows what will work.”

“…I just wanted to say I SO feel your pain!”

I am thankful for all of the Breastfeeding USA members who took the time to share their suggestions, their encouragement, and their stories. What I appreciated most was the lack of judgment. No one told me that I should night wean. No one told me that I would be in the wrong to do so. I will continue to turn to Breastfeeding USA members--smart, knowledgeable, experienced mothers.

One thing is certain: Our babies are only babies for a short time. As hard as it is for me sometimes to get up night after night, I keep telling myself that in a few short years she won’t want or need me like she does now. That knowledge reminds me to cherish our nighttime feedings. Currently I still get up when my little one needs me. We have not night weaned.

For those who are interested, the following list contains links to websites provided by Breastfeeding USA members about various methods of helping older babies and toddlers sleep:

Special thanks to the following Breastfeeding USA members, who gave me permission to share their posts: Karen Abraham, Genevieve Colvin, Kathleen Doerr, Celina Dykstra, Donna Gilbert, Ginger Gorrell, Cecily Harkins, Lynn Kutner, Beth Lichy, Penny Piercy, Norma Ritter, Krista Cornish Scott, Patty Spanjer, Ruth Tincoff, Lisa Wilkins.

References

Bumgarner, N.J. (2000). Mothering Your Nursing Toddler. Schaumburg, IL: La Leche League International.

Crook, W.G. (1980). Tracking Down Hidden Food Allergies. Professional Books: Jackson TN.

Sears, W. & Sears, M. (1996). The Fussy Baby Book: Parenting Your High-Need Child from Birth to Age Five. Boston, MA: Little Brown & Company

Copyright Breastfeeding USA, Inc.

Does Your Older Baby Still Need Night Feedings?

Has somebody told you that your baby doesn’t need to breastfeed at night past a certain age? This age often varies by advisor. However, science tells us that in many cases, this simply isn’t true.

Why? Babies and mothers are different and these differences affect baby’s need for night feedings. Some babies really do need to breastfeed at night, at six months, eight months, and beyond. This is in part because if their mother has a small “breast storage capacity” and tries to sleep train her baby, her milk production will slow, along with her baby’s growth. To find out what this means and if this applies to you, you need to know the basics of how milk production works.

Degree of Breast Fullness
Two basic dynamics are major influencers of milk production. The first, “degree of breast fullness,” refers to a simple concept: Drained breasts make milk faster and full breasts make milk slower. Whenever your breasts contain enough milk to feel full, your milk production slows.1 The fuller your breasts become, the stronger the signal your body receives to slow milk production.

Breast Storage Capacity
This second basic dynamic refers to a physical characteristic known as breast storage capacity, which varies among mothers.2 This physical difference explains why feeding patterns can vary so much among mothers and why one breastfed baby does not need to breastfeed at night while another one does.

Breast storage capacity is the amount of milk your breasts contain in your milk-making glands at their fullest point of the day. Storage capacity is not related to breast size, which varies mainly by how much fatty tissue is in your breasts. In other words, smaller-breasted mothers can have a large storage capacity and larger-breasted mothers can have a small capacity.

Both large-capacity and small-capacity mothers produce plenty of milk for their babies. But their babies feed differently to get the daily volume of milk they need.3 After baby’s first month, a mother with a large storage capacity may notice that her baby:

  • Is satisfied with one breast at most or all feedings.
  • Is finished breastfeeding much sooner than other babies (sometimes just five minutes).
  • Gains weight well on fewer feedings per day than the average eight or so.
  • Sleeps for longer-than-average stretches at night.

If this describes your breastfeeding experience, your baby may already be sleeping for longer stretches at night than other babies you know. But if after the first month of life your baby often takes both breasts at feedings, feeds on average longer than about 15 to 20 minutes total, typically takes eight or more feedings per day, and wakes at least twice a night to breastfeed, your breast storage capacity is likely to be small or average.

Again, what’s important to a baby’s healthy growth is not how much milk he receives at each feeding, but rather how much milk he consumes in a twenty-four-hour day. Breastfed babies of both large- and small-capacity mothers receive plenty of milk, but their breastfeeding patterns will necessarily differ to gain weight and thrive.4 For example, a baby whose mother’s breasts hold six ounces or more (180 mL) may grow well with as few as five feedings per day. But to get this same 30 ounces (900 mL) of milk, if a mother’s breasts hold only three ounces (90 mL), a baby with a small-capacity mother will need to feed ten times each day. (This may not apply in the same way to a mother who’s pumping.)

How These Dynamics Affect Night Feedings

How does this apply to night feedings? A mother with a large storage capacity has the room in her milk-making glands to comfortably store more milk at night before it exerts the amount of internal pressure needed to slow her milk production. On the other hand, if the baby of the small-capacity mother sleeps for too long at night, her breasts become so full that her milk production slows.

In other words, if you are a mother with an average or small breast storage capacity, night feedings may need to continue for many months in order for your milk production to stay stable and for your baby to thrive. Also, because your baby has access to less milk at each feeding, night feedings may be crucial for him to get enough milk overall. Again, what’s important is not how much milk a baby receives at each individual feeding, but how much milk he consumes in a twenty-four-hour day. If a mother with a small storage capacity uses sleep training strategies to force her baby to go for longer stretches between feedings, this may slow her milk production and compromise her baby’s weight gain.

Each mother-baby pair is unique. Babies will outgrow the need for night nursings at different ages, so a simple rule of thumb doesn’t consider either the emotional needs of the baby or his physical need for milk.

References

1Daly, S. E., Kent, J. C., Owens, R. A., & Hartmann, P. E. (1996). Frequency and degree of milk removal and the short-term control of human milk synthesis, Experimental Physiology, 81(5), 861-875.

2Cregan, M. D., & Hartmann, P. E. (1999). Computerized breast measurement from conception to weaning: clinical implications. J Hum Lact, 15(2), 89-96.

3Kent, J. C., Mitoulas, L. R., Cregan, M. D., Ramsay, D. T., Doherty, D. A., & Hartmann, P. E. (2006). Volume and frequency of breastfeedings and fat content of breast milk throughout the day, Pediatrics, 117(3), e387-395.

4Kent, J. C. (2007). How breastfeeding works. Journal of Midwifery & Women's Health, 52(6), 564-570.

2012 Breastfeeding USA, Inc.

Hand Expression

Hand expression is a useful skill for any nursing mother.  It can relieve breast fullness, stimulate milk production, and provide milk for your baby.

Getting Ready
First wash your hands well. Find a clean collection container with a wide mouth, like a cup. Or, you can express your milk into a spoon and feed it directly to the baby. Whenever possible, plan to express in a private, comfortable place where you can relax. Feeling relaxed enhances milk flow.

Find Your ‘Sweet Spot’
There are many ways to hand-express milk. Whichever technique you use, the most important part is finding your “sweet spot,” the area on your breast where milk flows fastest when your breast is compressed. Try different finger positions until you find it. If the dark area around your nipple (areola) is large, your “sweet spot” may be inside it. If it is small, it may be well outside it. When you find your “sweet spot,” you may want to put a small circle bandage on it to make it easier to find it next time.

Do What Works Best
Always do what feels best and expresses the most milk. The following technique combines recommendations from the World Health Organization with other methods:

  1. Before expressing, gently massage your breasts with your hands and fingertips or a soft baby brush or warm towel.
  2. Sit up and lean slightly forward, so gravity helps milk flow.
  3. To find your “sweet spot,” start with your thumb on top of the breast and fingers below it, both about 1.5 inches (4 cm) from the base of the nipple. Some mothers find it helpful to curl their hand and use just the tips of their fingers and thumb. Several times, apply steady pressure into the breast toward the chest wall.  If no milk comes, shift finger and thumb either closer to or farther from the nipple and compress again a few times.  Repeat, moving finger and thumb until you feel slightly firmer breast tissue, and gentle pressure yields milk.  After you’ve found your “sweet spot,” skip the “finding” phase and start with your fingers on this area.
  4. Apply steady pressure on areas of milk in the breast by pressing fingers toward the chest wall, not toward the nipple.
  5. While applying inward pressure on the breast, compress thumb and finger pads together (pushing in, not pulling out toward the nipple).  Find a good rhythm of press—compress—relax, like a baby’s suckling rhythm.
  6. Switch breasts every few minutes (five or six times in total at each expression) while rotating finger position around the breast. After expressing, all areas of the breast should feel soft. This process usually takes about 20 to 30 minutes.

If Needed, Adjust
Hand expression should feel comfortable. If not, you may be compressing too hard, sliding your fingers along the skin, or squeezing the nipple. If you feel discomfort, review the description above, and adjust your technique. It is important to find the method of hand expression that works best for you. This U.S. video shows a similar method of hand expression that works well for some mothers. This Norwegian video shows another simple hand-expression technique. (Disregard its suggestion you place your fingers on the “edge of your areola, as your “sweet spot” may be inside or outside of the areola.) If you need more information about hand expressing your milk, a Breastfeeding Counselor or International Board Certified Lactation Consultant (IBCLC) may be able to help.

Reference

WHO (2009) Infant and young child feeding: Model Chapter for textbooks for medical students and allied health professionals. Geneva, Switzerland: World Health Organization.

 

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