- Passes immunity from the mother to the infant
- Provides optimal nutrition for the first 6 months of life, as it meets all the nutritional requirements
- Helps mature the gastro-intestinal tract and therefore decreases the risk of diarrhoea
- Decreases respiratory, ear and digestive tract infections
- Promotes better cognitive development, so babies have higher IQ’s
- Decreases the risk of the baby developing food allergies
- Plays an important role in jaw and speech development
- Breastfed infants are less likely to be overfed
- Provides endorphins which makes the infant happy and relaxed
- Acts as an analgesic
- Creates a special bond between the mother and infant
- Breastfeeding has many long term health benefits such as reduced risk of heart disease and diabetes
- Promotes the contraction of the uterus therefore helping it to return to pre-pregnancy size
- Breastfeeding is convenient and economical
- Increases the energy needs of the mother and aids in post-pregnancy weight loss
- Decreases the risk of ovarian and pre-menopausal breast cancer
- Decreases the risk of osteoporosis
- Releases prolactin which is a mothering hormone
- Creates a special bond between the mother and infant
Written by Jack Newman MD, FRCPC. © 2003 (www.breastfeedingonline.com). This handout may be copied and distributed without further permission, on the condition that it is not used in any context in which the WHO code on the marketing of breastmilk substitutes is violated.
Breastfeeding mothers frequently ask how to know their babies are getting enough milk. The breast is not the bottle, and it is not possible to hold the breast up to the light to see how many ounces or millilitres of milk the baby drank. Our number obsessed society makes it difficult for some mothers to accept not seeing exactly how much milk the baby receives. However, there are ways of knowing that the baby is getting enough. In the long run, weight gain is the best indication whether the baby is getting enough, but rules about weight gain appropriate for bottle fed babies may not be appropriate for breastfed babies.
Ways of Knowing
- Baby's nursing is characteristic. A baby who is obtaining good amounts of milk at the breast sucks in a very characteristic way. When a baby is getting milk (he is not getting milk just because he has the breast in his mouth and is making sucking movements), you will see a pause at the point of his chin after he opens to the maximum and before he closes his mouth, so that one suck is (open mouth wide-->pause-->close mouth). If you wish to demonstrate this to yourself, put your index or other finger in your mouth and suck as if you were sucking on a straw. As you draw in, your chin drops and stays down as long as you are drawing in. When you stop drawing in, your chin comes back up. This pause that is visible at the baby's chin represents a mouthful of milk when the baby does it at the breast. The longer the pause, the more the baby got. Once you know about the pause you can cut through so much of the nonsense breastfeeding mothers are being told—like feed the baby twenty minutes on each side. A baby who does this type of sucking (with the pauses) for twenty minutes straight might not even take the second side. A baby who nibbles (doesn't drink) for 20 hours will come off the breast hungry.
- Baby's bowel movements. For the first few days after delivery, the baby passes meconium, a dark green, almost black, substance. Meconium accumulates in the baby's gut during pregnancy. Meconium is passed during the first few days, and by the 3rd day, the bowel movements start becoming lighter, as more breastmilk is taken. Usually by the fifth day, the bowel movements have taken on the appearance of the normal breastmilk stool. The normal breastmilk stool is pasty to watery, mustard coloured, and usually has little odour. However, bowel movements may vary considerably from this description. They may be green or orange, may contain curds or mucus, or may resemble shaving cream in consistency (from air bubbles). The variation in colour does not mean something is wrong. A baby who is breastfeeding only, and is starting to have bowel movements that are becoming lighter by day 3 of life, is doing well. Without your becoming obsessive about it, monitoring the frequency and quantity of bowel motions is one of the best ways of knowing if the baby is getting enough milk (but not as good as observing the pause in the chin). After the first 3-4 days, the baby should have increasing bowel movements so that by the end of the first week he should be passing at least 2-3 substantial yellow stools each day. In addition, many infants have a stained diaper with almost each feeding. A baby who is still passing meconium on the fourth or fifth day of life, should be seen at the clinic the same day. A baby who is passing only brown bowel movements is probably not getting enough, but this is not very reliable. Some breastfed babies, after the first 3-4 weeks of life, may suddenly change their stool pattern from many each day, to one every 3 days or even less. Some babies have gone as long as 15 days or more without a bowel movement. As long as the baby is otherwise well, and the stool is the usual pasty or soft, yellow movement, this is not constipation and is of no concern. No treatment is necessary or desirable, because no treatment is necessary or desirable for something that is normal. Any baby between 5 and 21 days of age who does not pass at least one substantial bowel movement within a 24 hour period should be seen at the breastfeeding clinic the same day. Generally, small, infrequent bowel movements during this time period mean insufficient intake. There are definitely some exceptions and everything may be fine, but it is better to check.
- Urination. With six soaking wet (not just wet) diapers in a 24 hours hour period, after about 4-5 days of life, you can be sure that the baby is getting a lot of milk (if he is only breastfeeding). Unfortunately, the new super dry "disposable" diapers often do indeed feel dry even when full of urine, but when soaked with urine they are heavy. It should be obvious that this indication of milk intake does not apply if you are giving the baby extra water (which, in any case, is unnecessary for breastfed babies, and if given by bottle, may interfere with breastfeeding). The baby's urine should be almost colourless after the first few days, though an occasional darker urine is not of concern. During the first 2-3 days of life, some babies pass pink or red urine. This is not a reason to panic and does not mean the baby is dehydrated. No one knows what it means, or even if it is abnormal. It is undoubtedly associated with the lesser intake of the breastfed baby compared with the bottle fed baby during this time, but the bottle feeding baby is not the standard on which to judge breastfeeding. However, the appearance of this colour urine should result in attention to getting the baby well latched on and making sure the baby is drinking at the breast. During the first few days of life, only if the baby is well latched on can he get his mother's milk. Giving water by bottle or cup or finger feeding at this point does not fix the problem. It only gets the baby out of hospital with urine that is not red. Fixing the latch, using compression usually fix the problem. If re-latching and breast compression do not result in better intake, there are ways of giving extra fluid without giving a bottle directly (handout #5 Using a Lactation Aid). Limiting the duration or frequency of feedings can also contribute to decreased intake of milk.
The following are NOT good ways of judging:
- Your breasts do not feel full. After the first few days or weeks, it is usual for most mothers not to feel full. Your body adjusts to your baby's requirements. This change may occur quite suddenly. Some mothers breastfeeding perfectly well never feel engorged or full.
- The baby sleeps through the night. Not necessarily. A baby who is sleeping through the night at 10 days of age, for example, may, in fact, not be getting enough milk. A baby who is too sleepy and has to be awakened for feeds or who is "too good" may not be getting enough milk. There are many exceptions, but get help quickly.
- The baby cries after feeding. Although the baby may cry after feeding because of hunger, there are also many other reasons for crying. See also handout #2 Colic in the Breastfeeding Baby. Do not limit feeding times. “Finish” the first side before offering the other.
- The baby feeds often and/or for a long time. For one mother every 3 hours or so feedings may be often; for another, 3 hours or so may be a long period between feeds. For one, a feeding that lasts for 30 minutes is a long feeding; for another, it is a short one. There are no rules how often or for how long a baby should nurse. It is not true that the baby gets 90% of the feed in the first 10 minutes. Let the baby determine his own feeding schedule and things usually come right, if the baby is suckling and drinking at the breast and having at least 2-3 substantial yellow bowel movements each day. Remember, a baby may be on the breast for 2 hours, but if he is actually feeding (open wide—pause—close mouth type of sucking) for only 2 minutes, he will come off the breast hungry. If the baby falls asleep quickly at the breast, you can compress the breast to continue the flow of milk (handout #15 Breast Compression). Contact the breastfeeding clinic with any concerns, but wait to start supplementing. If supplementation is truly necessary, there are ways of supplementing which do not use an artificial nipple (handout #5 Using a Lactation Aid).
- "I can express only half an ounce of milk". This means nothing and should not influence you. Therefore, you should not pump your breasts "just to know". Most mothers have plenty of milk. The problem usually is that the baby is not getting the milk that is available, either because he is latched on poorly, or the suckle is ineffective or both. These problems can often be fixed easily.
- The baby will take a bottle after feeding. This does not necessarily mean that the baby is still hungry. This is not a good test, as bottles may interfere with breastfeeding.
- The 5 week old is suddenly pulling away from the breast but still seems hungry. This does not mean your milk has "dried up" or decreased. During the first few weeks of life, babies often fall asleep at the breast when the flow of milk slows down even if they have not had their fill. When they are older (4-6 weeks of age), they no longer are content to fall asleep, but rather start to pull away or get upset. The milk supply has not changed; the baby has. Compress the breast to increase flow.
- Breastfeed within an hour, or as soon as possible, after delivery. Starting as soon as possible helps to establish a good feeding pattern and the production of breast milk to ensure a good flow.
- Make sure the baby is positioned correctly at the breast and has a deep latch.
- Rooming-in (where the mother and infant are kept together at all times) this enables you to breastfeed on demand and get to know your baby’s feeding cues.
- Ensure that you are comfortable and relaxed when breastfeeding.
- Ensure that your baby is positioned and latching on correctly.
- Breastfeeding on demand. Due to its easy digestibility, breastmilk is digested much faster than artificial substitutes. So breastfeeding on demand may be anything from ½ an hour to 2 hours. Initially, breastfed babies need to be fed 8-12 times a day, which will provide adequate volumes of breast milk.
Each mother and infant pair is unique. What will work for one mother might not work for the next, therefore a mother needs to practice her positioning to find out which is more comfortable and suitable for her and her baby.
- Be as comfortable when breastfeeding.
- The mother should be sitting with her back straight, or lying on her side.
- The infant should be lying on its side and facing the breast “Mummy to Tummy”.
- The mother should not be hunched over to reach the infant but the infant should be lifted to reach the breast. It is sometimes more comfortable for mothers to use a pillow underneath the infant to support their weight.
- The infant’s head should be supported but free to move and extend backwards.
- Support the breast by making a C shape with the hand. The thumb at the top of the breast at the edge of the brown areola and the remaining four fingers on the chest wall.
The infant needs to pull the breast into the mouth in order to be able to suckle correctly. The steps and signs below should guide you to correct attachment:
- Bring the infant to the breast and hold the infant slightly below the nipple. Use a pillow to support the weight of the infant if this is more comfortable.
- The baby has to have a wide open mouth before being brought to the breast.
- To illicit a wide open mouth, bring the baby to the breast and gently touch the top lip against the nipple and wait until the baby has a wide open mouth with the tongue extended forward over the bottom lip.
- Then move the baby quickly on to the breast supporting the shoulders. The baby’s head will be slightly extended and the chin will touch the breast first. By keeping the bottom lip as far away from the nipple as possible, the baby will get a good mouthful of breast tissue into his mouth.
- Correct latching will show the top of the areola exposed with the nipple and the majority of the bottom of the areola in the mouth. The infant’s chin should touch the breast and the lower lip should be curled outwards.
- With correct latching one should be able to see the forward and backward movement of the infant’s jaw when suckling on the breast.
- After a feed the mother should observe that her nipple looks rounded, stretched or elongated (not squashed like the tip of a lipstick) This shows that the infants is pulling the breast into his/her mouth and is latching correctly.
This is often caused by poor attachment, which results from infant sucking on the tip of the nipple, or the mother pulling the infant off the breast without breaking the suction first. How to prevent sore nipples:
- Check positioning and attachment of the infant is correct.
- After feeding use some of the breast milk to coat the nipple as breast milk contains healing properties.
- Keep your nipples dry and expose them to the sunlight.
After the first 3 or 4 days breast milk production increases significantly. As a result breasts can become full, tender and even hot to touch. Engorgement is made worse by an overload of IV fluids given during labour and delivery. It normal passes in a few days. Management of engorgement:
- Before feeding, place a warm cloth over the breast or jump into a hot shower and gently massage them, this helps to increase the flow of the milk.
- If the breasts are very full and hard, it may help to express some breast milk before feeding as babies find it hard to latch to an engorged breast.
- Check the positioning and attachment of the infant.
- Express breast milk in between feeds to relieve the pain and build up of milk.
- Cold compresses after feeding are soothing, cabbage leaves may help, but should be changed 3-4 hourly.