Breastfeeding Questions

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By Dr. Liji Thomas, MDReviewed by Dr. Jennifer Logan, MD, MPH

Breastfeeding is one of the most important natural provisions for the baby’s health and development. This process is regulated largely by nervous and hormonal signals.

How is breastfeeding regulated?

During the last month of pregnancy, the pituitary gland increases production of the hormone prolactin. Prior to birth, high levels of estrogen and progesterone inhibit prolactin so that milk is not secreted, however. Following childbirth, estrogen and progesterone levels fall, and releasing prolactin from inhibition, and thus inducing milk production.

The act of nursing a baby increases prolactin levels. This hormone signals the body to continue producing milk for subsequent feeding. If a woman stops nursing (or expressing milk by hand or using a breast pump), her milk supply will eventually dry up.

The posterior pituitary hormone called oxytocin causes the actual milk ejection or “let-down”. It causes the small muscle fibers surrounding the breast alveoli to contract, squeezing the milk out through the milk ducts and finally the nipple.

The breasts leak when one breast is being nursed, or when the mother hears or thinks of her baby. This is due to emotional stimuli triggering the let-down reflex. Nursing pads can be placed against the skin to absorb leaked milk and keep clothing dry, but should be changed when wet to irritation or local infection.

Prolactin and oxytocin also encourage normal mother-child bonding, as well as calming and destressing the mother and promoting relaxed sleep. Thus endocrine and nervous stimuli are involved in successful breastfeeding.

What are the benefits of breastfeeding?

Both mother and baby benefit hugely from breastfeeding.

Anti-infective action

Colostrum is the yellowish first milk produced in the hours to days immediately after birth. It helps protect the baby against infections. It contains white cells and antibodies, especially secretory immunoglobulin A, which provides local gut immunity against bacteria that the baby will be exposed to after birth. Epidermal growth factor also promotes maturation of the gut mucosa, aiding proper digestion and immune function.

Colostrum is yellow because of its rich vitamin A content, which aids in eye and epithelial development; it also has protein, minerals in bioavailable form, and vitamins E and K.

Mature milk, which is more white in color (or clear to white depending on the time of day) and arrives within a few days of childbirth, contains immunoglobulins (mainly immunoglobulin A), antimicrobial proteins like lysozyme and lactoferrin, and special sugars (oligosaccharides) to inhibit bacterial attachment to the gut. These provide unique immunity to each baby without causing harmful inflammation.

Breastfed children also have a reduced risk of many other illnesses, including;

Asthma
Childhood leukemia
Childhood obesity
Ear infections
Eczema
Diarrhea
Obesity
Pneumonia
Necrotizing enterocolitis which destroys the gut in some preterm babies
Sudden infant death syndrome (SIDS)
Type 2 diabetes in later life

Mothers who breastfeed experience many benefits, including lower risks of;

Breast cancer
Ovarian cancer
Diabetes
High blood pressure

Mothers who breastfeed often have an easier time losing pregnancy weight than those who do not breastfeed.

Nutrition

Mature milk is ideal in composition for the baby’s growth and development, and completely digestible. It contains about the appropriate proportions of fats, protein, sugars, and vitamins needed for a baby to thrive during the first 6 months of life. Breastfed babies do not require supplemental nutrition during the first 6 months of life. After that time, breastfeeding continues to supply the most important dietary components as babies begin to learn to eat solid foods. Breastfeeding continues to benefit infants throughout their first year and beyond.

Other advantages

It promotes mother-baby bonding; it provides the baby with nutrition, security and comfort, and calms the mother too. It is globally accessible, free, available instantly, and is clean and at the right temperature. It is also environmentally friendly, as money and supplies can be saved by not having to purchase packaging and baby bottles.

Preparing to breastfeed

In most cultures where breastfeeding is routine, and new mothers are familiar with it because of experience in observing other mothers. This is not the case for all women, however, so some information is provided to help mothers prepare.

Some good ways to prepare for it include:

Learning about breastfeeding and its benefits
Giving birth at a baby-friendly hospital that supports immediate breastfeeding and rooming-in (newborn and mother are in the same hospital room) which allows much more frequent feeds
Proper antenatal care to minimize the risk of low birth weight and prematurity which make breastfeeding more difficult
Finding a training/support group
Discussing it with your spouse and family beforehand
Getting help from a lactation consultant before or after birth to ease the transition to breastfeeding

Nipple hardening is unnecessary. Skin should be cared for with gentle soap and water. Breasts should be kept dry between nursing sessions to prevent irritation and infection. Nursing bras help support the growing breast weight and make breastfeeding easier.

Working mothers should encourage the family and caregivers to properly handle and store expressed breast milk and feed the baby when the mother is away. Bringing the baby to the workplace for feeding is ideal but often challenging.

Family members should also support the mother’s efforts to provide enough milk for the baby’s normal growth and development, whether she is working away from the home or staying home with the child. Breastfeeding can continue as long as mother and child are comfortable and if weaning is proceeding in tandem.

How should a breastfeeding mother eat?

Unless grossly malnourished, a breastfeeding mother doesn’t need to eat for two. An adequate healthy diet is sufficient, with plenty of water and clear fluids to stay hydrated. Poor nutrition must be corrected and supplemental minerals and vitamins taken as required.

Alcohol, tobacco, and illicit drugs should be avoided by breastfeeding mothers. Breastfeeding women should consult with their doctor or their baby’s doctor regarding any medications the mother may need, to determine whether they can be taken safely while breastfeeding.

Foods in the mother’s diet cannot cause gastrointestinal distress or colic in nursing babies the way they might in adults (for example, gas or bloating with cruciferous vegetable or bean consumption), as the foods themselves do not enter the baby’s gastrointestinal tract. However, some proteins from a mother’s diet can enter breastmilk and lead to allergic symptoms in a susceptible baby (changes in stool, fussiness, rash). Breastfed babies are much less likely to develop food allergies than those who are not breastfed, however.

A baby with these symptoms should be evaluated by a healthcare provider, but the mother should continue to breastfeed while sorting out the cause of the baby’s symptoms. In most cases, the breastmilk itself will provide far more benefit for the baby than formula.

When should I start breastfeeding?

Colostrum is produced by pregnancy week 26 and should be offered as soon as the baby is born. No other feed should be allowed, unless medically indicated and prescribed by the doctor.

If you need help, ask to work with a certified lactation consultant. Many hospitals and birthing centers have these experts on staff to educate new mothers about nursing and support her in techniques to optimize feeding for the mother and baby. Support groups such as La Leche, and peer counselors, are also often available.

How do I know I’m breastfeeding properly?

Breastfeeding begins with a good latching on to the breast by the baby. Most commonly, the baby is held upright or lying, against the mother’s chest, with the mother supporting the head and shoulders and the baby’s hips in a comfortable hold.

When the breast is offered, the hungry baby turns towards it with open mouth. The baby’s head should be positioned so that the nipple and surrounding areola are fully taken into the mouth. This is the latching position and lets the baby breathe freely while suckling.

Signs of good latching-on include:

The baby’s chin is pressed against the mother’s breast, and the lower lip curls out against the breast.
The top part of the areola is much more visible than the lower part, more of the latter being in the baby’s mouth, which is open wide and fully against the breast while suckling.
There is no pain or discomfort, apart from some minor discomfort during the first few days to weeks.

Avoid pacifier use with new babies. Whenever they have an urge to suck, they should be breastfed.

Within seconds to minutes of suckling, the milk ejection reflex or let-down occurs. There may be a tingling or gushing sensation in the breast. The baby suckles deeply and slowly, gulping about once a second. This indicates a normal swallowing reflex. Milk ejection may occur without these sensations too.

Persistent pain may mean poor latching on. The baby may be sucking the nipple using a too-shallow latch. If this occurs, try to re-latch. First, insert a finger gently between the side of the babies lips and the breast to break the suction. Remove the breast tissue from the baby’s mouth and try again. Good latches are often established when the baby takes in the lower part of the breast tissue with the lower part of the mouth first before closing his or her mouth over the nipple.

Oral thrush (white patches on the baby’s tongue or mucous membrane of the mouth that cannot be wiped off) can be spread to the breast and cause severe, prolonged pain while breastfeeding with other signs. It occurs typically after a course of antibiotics for either mother or baby, and is treated with topical antifungals.

How do I know when the baby wants to be fed?

The first sign is when the baby licks or smacks the lips, turning the head from side to side, searching for the breast with the mouth – the rooting reflex, seen in the turn of the baby’s head towards a finger stroking the cheek.

Other signs include sucking on an offered finger, or the baby’s own fingers, or cramming the fist into the mouth. However, most newborns do not have the muscle strength or coordination to get their hands to their mouths.

Finally, the baby begins to whimper and then cry. At this point the baby is often too upset to latch on properly. Therefore, it is always best to feed the hungry baby before this.

How do I know the baby is getting enough milk?

This question may be the single most commonly asked one by breastfeeding mothers.

Breast size has no relationship with milk production, if frequent feeding is continued.

In the first three days, only about 40-50 ml of colostrum is produced, with the baby getting a teaspoon or so with each feed to match the small stomach capacity. As breastfeeding continues and the baby’s stomach enlarges, within 3-5 days the mature or white milk “comes in”. The breasts become full and heavy.

In the first week, the baby typically wants to be fed 8-12 times in 24 hours (300-400 ml/day once the milk comes in). The intervals between feeds vary, but some experts recommend waking the baby to feed if it has been 4 hours without a feeding. On-demand breastfeeding promotes milk production and optimal feeding.

Over the next month or two, the baby drinks more, and faster. Feeds become shorter, while the intervals lengthen. The breasts may no longer feel heavy. Milk secretion is now adapted to your baby’s demands, but remains adequate. Babies go through several growth spurts that require increased feeding frequency; they may eat as often as every hour during these periods of time. A mother’s breasts will adapt to the increased demand and within days will be producing more milk.

The first milk to be secreted with each feed is thin and watery, quenching the thirst. This “fore milk” is followed towards the end by thicker fat-rich milk - the “hind milk”, which satisfies the baby’s hunger. With each feed both types should be emptied from each breast, typically over about 20 to 45 minutes.

Once full, the baby drops off to sleep, releases the nipple, or turns away.

Diaper counts help evaluate breastfeeding adequacy, as the following table shows. If your baby is growing normally, it is a good sign of adequate nutrition.

This chart shows the minimum number of diapers for most babies.
It is fine if your baby has more.

Baby's Age	Wet Diapers	Dirty Diapers Color and Texture
Day 1 (birth)	1	Thick, tarry and black
Day 2	2	Thick, tarry and black
Day 3	3	Greenish yellow
Day 4	5 - 6	Greenish yellow
Day 5	5 - 6	Seedy, watery mustard color
Day 6	5 - 6	Seedy, watery mustard color
Day 7	5 - 6	Seedy, watery mustard color

Another way to tell is doubling of the baby’s birth weight by five months. Standard growth charts are useful to confirm normal growth during this period, normally about 28 g a day after the first week.

Can I conceive while I’m breastfeeding?

While the sexual relationship may suffer because of the new demands upon the mother’s time and energy, this is best addressed by inviting the husband to help with the baby and other chores. The heightened emotional bonding and intimacy promotes sexual interest. Contraception must be discussed openly beforehand, to reach mutual agreement.

Ovulation and menstruation typically stop for several months (“lactational amenorrhea”) when the mother breastfeeds exclusively (breastmilk is the only form of nutrition for the baby), especially at night, when prolactin levels are highest. This is because prolactin inhibits normal reproductive hormones.

However, ovulation may occur without any warning, and cause conception without periods having been resumed. For this reason, dependable contraception is essential if the couple wants to defer the next pregnancy.

Lactational amenorrhea method (LAM) is about 98% effective at providing contraception if all of the following conditions are met:

A woman is within six months of childbirth
She has experienced no spotting or menstruation
She is exclusively breastfeeding her child (no other formula or food for the baby)
Breastfeeding is on-demand and at least every 4 hours during the day and 6 hours at night (baby has to suckle at these intervals, so if the baby is taking in expressed milk when the mother is not pumping or nursing, she does not meet this criterion)

The advantages of LAM include absence of artificial intervention, independence of coital timing, widespread acceptability, contribution to maternal and child health, and high efficacy.

After 6 months, other contraceptives are necessary. Combined oral contraceptive pills or injectables are unsuitable while breastfeeding, as estrogen may reduce milk production. Barrier contraception will not interfere with breastfeeding.

Why does my baby choke or vomit all the time after breastfeeding?

Some breastfed babies have a weak muscle guarding the opening to the stomach (the lower esophageal sphincter) which results in their vomiting up much of the milk they drink after each feed. This is called reflux, and may cause them to choke, cry, wake at night, refuse to feed, burp or regurgitate frequently, and sometimes develop chest infections or wheezing.

Positioning the baby upright, or face-down over the nipple, or walking around while feeding, may help keep the head higher than the nipple, preventing reflux. Keeping the baby upright for a period of time after nursing may also help with reflux. If the baby loses weight or is reluctant to feed, the pediatrician may prescribe medications to help with the reflux.

When should I not breastfeed?

Breastfeeding may need to be discontinued in a few situations, but mothers should ask their healthcare providers before stopping:

If the mother
Is on medicines which are secreted in breast milk and could endanger your baby’s health.
Has active tuberculosis
Has H1N1 or swine flu – expressed breast milk with clean hands and a clean container is fine if someone else can feed it to the baby. Avoid contact with the baby.
Is on certain types of radiation therapy
Is on medications containing bismuth subsalicylate (used in traveler’s diarrhea) as salicylate could be toxic to the baby
if the baby has galactosemia or milk intolerance which prevents milk digestion.

If a mother develops diarrhea or vomiting while breastfeeding, she should continue nursing the baby while drinking more fluids. This will protect the baby against the same infection. The germs do not usually enter the breast milk, but the mother should ensure that she is washing her hands frequently, particularly before close contact with the baby.

Breastfeeding in pregnancy

Breastfeeding may continue throughout a normal uncomplicated pregnancy. If you have pregnancy complications like strong uterine contractions, vaginal bleeding, history of preterm labor, poor maternal weight gain, or sore nipples, weaning may be advised.
After childbirth, the new baby must get the colostrum as well as sufficient milk thereafter for proper growth and development, even if the older child is also being breastfed.

How do I breastfeed if I have twins?

Your body will make enough milk for both babies, but you may need some help initially with feeding both simultaneously. Switch babies to alternate breasts with each feed to ensure both breasts produce equal amounts of milk despite different suckling styles and duration. Express milk if immediate breastfeeding is not possible, eat well and stay hydrated.

Can I breastfeed if I had breast surgery?

If the surgery spared the areola and nipple, or following a breast implant or augmentation surgery, breastfeeding is typically possible. If not, partial breastfeeding is often possible and should be strongly advised immediately after birth.

Can I breastfeed if my baby has a cleft lip/palate?

Babies with cleft lip or palate are quite common, and this may pose some difficulty with breastfeeding unless the cleft is small and very posterior. A semi-upright baby position, or filling the gap with the mother’s finger, may help when the cleft is small. A special obturator mouthpiece may be provided to seal the cleft palate and help the baby swallow the milk. A lactation consultant or pediatrician should be able to advise and assist mothers who have children with cleft palates. A third way to provide breast milk would be to express breast milk, beginning immediately after birth using electric pumps, and feeding to the baby using a bottle designed for use with a cleft palate.

How do I use expressed breast milk?

If breastfeeding is not possible, as for some working or sick mothers, milk is pumped manually or with an electric pump, and used to feed their babies. This not only promotes the baby’s health but ensures good milk production. Clean conditions are necessary, and the equipment should be sterilized with each use. The expressed milk must be chilled or frozen immediately, in glass or BPA-free bottles closed tightly, preferably in sizes suitable for one feed, and labeled with date and time.

Image Credit: Kseniia Perminova / Shutterstock

The milk should be thawed but not warmed to preserve the beneficial constituents. Cream will separate to the top of the milk during storage; it should be mixed in by gently swirling it around after thawing. It can be given at room temperature or cold. Once thawed, it must be used or discarded within 24 hours.

Can I induce lactation?

After adopting a baby, or when trying to restart breastfeeding after stopping for a while, induction of lactation may be necessary. One way involves using a combination of oral contraceptive pills with another pill that raises prolactin levels, while another relies on progesterone with the second drug. A third way relies on herbs that stimulate lactation. In all cases, expressing or pumping the breasts is also important in helping the milk to come in. The pharmacologic methods require six months of use prior to initiating nursing for best results.