Patient education: Breastfeeding guide (Beyond the Basics)

INTRODUCTION — Breast milk is the optimal source of nutrition for virtually all babies. It meets essentially all of the nutritional needs of full-term babies until approximately six months of age, when solid foods are usually added to the diet. Breast milk also has important health benefits for premature babies.

This topic discusses how to get started with breastfeeding, including tips to ensure that breastfeeding is comfortable and healthy for you and your baby. Other aspects of breastfeeding are discussed in more detail separately:

●(See "Patient education: Deciding to breastfeed (Beyond the Basics)".)

●(See "Patient education: Health and nutrition during breastfeeding (Beyond the Basics)".)

●(See "Patient education: Common breastfeeding problems (Beyond the Basics)".)

●(See "Patient education: Pumping breast milk (Beyond the Basics)".)

●(See "Patient education: Weaning from breastfeeding (Beyond the Basics)".)

In this article, we use the term "breastfeeding" to refer to feeding an infant at the breast or chest. Many of the benefits of breastfeeding can also be achieved by feeding expressed (pumped) human milk by bottle.

GETTING STARTED WITH BREASTFEEDING

Importance of early breastfeeding — You should start breastfeeding within the first few hours after birth, if at all possible. Early and frequent breastfeeding after the birth is important because:

●Colostrum benefits – During the first few days after birth, your breasts naturally produce colostrum, or "first milk," which is a gold or yellow liquid that is rich in nutrition and healthy antibodies that help protect your baby from infections. Although the quantity of colostrum is small, it provides all of the nutrition that the baby needs in the first few days as long as they are receiving it frequently. During this time, your breasts will not feel full or different, because the colostrum is concentrated in a small volume.

●Establishment of milk supply – Frequent breastfeeding (or pumping) signals the breasts to make more milk. This is a natural "demand and supply" system, in which your body adapts to meet your baby's needs. During the first few days after birth, frequent and effective suckling (at least 8 to 12 times in 24 hours) provides the needed signaling to your body. It's important to use good breastfeeding technique for your comfort and to protect your nipples from rubbing and compression, as discussed below. (See 'Breastfeeding technique' below.)

After a few days, your breasts will transition to making larger quantities of mature milk. This is sometimes called the "milk coming in," though that is a misnomer because colostrum is also breast milk, just in an early and concentrated form. This usually happens between three and five days after the birth. Frequent breastfeeding (or pumping) is important to helping this transition happen.

At birth — You can usually start breastfeeding right after birth as part of "skin-to-skin contact" (figure 1). Most babies will instinctively find the nipple and start sucking, which helps them practice feeding and gives them their first meal of colostrum.

If you need to be separated from your baby for medical reasons, you can still get started by expressing the colostrum or "first milk" from your breasts, either by hand or with a breast pump. The expressed milk can be fed to your baby. Hand expressing or pumping also provides the necessary signaling to your body to make more milk. You should start expressing milk as soon as possible, ideally within the first one to six hours after the birth. More information about expressing and storing milk is available separately. (See "Patient education: Pumping breast milk (Beyond the Basics)".)

The first few days

●Rooming-in – During the first few days after birth, most hospitals and birth centers will have your baby stay in the room with you (this is called "rooming-in"). Your baby will breastfeed frequently throughout the day and night; having them nearby will allow you to get to know them and notice the signs that they want to feed, so that you can respond promptly. Also, you and your baby will feel most comfortable and relaxed when you are together. (See 'Feed whenever your baby is hungry' below.)

●Safe sleep – When you are finished feeding, be sure to put your baby back into the bassinet before you fall asleep. Although you can breastfeed in a lying-down position, it's very important not to keep the baby in bed with you when you sleep (figure 2). Babies should always sleep on a separate sleep surface (bassinet, cradle, or crib) and on their back to reduce the risk of sudden infant death syndrome (SIDS). (See "Patient education: Sudden infant death syndrome (SIDS) (Beyond the Basics)".)

●Fatigue – Most parents will feel exhausted during the first few weeks after birth because healthy newborn babies feed frequently during the day and night. While this can be challenging, it is normal. Don't expect your baby to sleep for more than a few hours at a time at this age. Instead, aim to help your baby be a "good sleeper" by helping them feed effectively and settle after the feed. (See 'Breastfeeding technique' below.)

To cope with exhaustion, make sure that you nap or rest when you can to make up for interrupted sleep at night. It's also important to have physical and emotional support from your partner, family, or friends. Some tips for managing exhaustion during the early days of breastfeeding are provided in the table (table 1).

BREASTFEEDING TECHNIQUE — While breastfeeding is a natural process, it is normal for it to feel different or awkward at first. It is always helpful to keep some basic principles in mind and be prepared to handle common problems and/or seek help if they arise.

Positioning for comfort — You can breastfeed in many different positions (figure 3). The most important determinant of a good position is that you and your baby are comfortable. You will probably find a favorite position, but it's helpful to try different positions, especially if you are experiencing any discomfort or if your baby is having any problems feeding.

Helping your baby latch on — The key step in breastfeeding is when your baby "latches on" to your breast, so that their mouth forms a seal around the nipple, covering much of the areola near the baby's lower jaw (the areola is the dark area of skin around your nipple). Having a comfortable latch protects your nipple from pain or irritation during breastfeeding and allows for good milk flow by preventing nipple compression.

Signs that your baby has a good latch-on include (figure 4):

●You are completely comfortable during breastfeeding. You may feel some tugging, pressure, or tingling (especially during the first minute of the feeding), but you should not feel pain or rubbing of your nipple.

●Your baby is attached so that:

•The nipple is high and deep in their mouth

•Their top and bottom lips are wide open (like a big yawn), with the lower lip turned outward against the breast

•Their upper lip is very close to the nipple and the lower lip is near the border of the nipple and areola

•Their chin is touching the breast, and the nose is close to the breast

•Their cheeks are full

•Their tongue comes out over the lower lip during latch-on and stays below the areola during nursing

●After the feeding, your nipple looks normal and full, rather than creased, sloped, or compressed (figure 5).

Adjusting the latch — If you feel pain or rubbing of your nipple while breastfeeding, this is probably because your nipple is getting compressed. This will make it harder for your baby to get milk flow.

Any time you feel pain, it's important to adjust the baby's latch promptly to protect your nipple and allow good milk flow. To adjust the latch:

●Gently insert your finger in the side of your baby's mouth to break the suction.

●Help your baby reattach in a better position (figure 4). Try bringing your baby toward your breast from below, with their head tilted back so that they are looking up to the breast. Your baby's chin should touch near the bottom border of the areola.

Videos that show how to latch a baby correctly are available here and here. More information about nipple pain is available separately. (See "Patient education: Common breastfeeding problems (Beyond the Basics)", section on 'Nipple pain'.)

Suckling and swallowing — When your baby is feeding well, you can usually hear them swallow (a small "kuh" sound). During the first few days of breastfeeding, the swallowing sounds may be infrequent, such as a swallow after every three or four sucks. Then, as time goes on and your baby starts taking more milk, their swallows will become more obvious and frequent; you may hear bursts of swallowing, with one swallow for every suck, followed by a pause. At the beginning of the feed, they will suck rapidly without swallowing as they get the milk flow started.

WHEN TO FEED

Feed whenever your baby is hungry — In general, you should feed your baby whenever they show signs of hunger, rather than on a schedule. This is known as feeding "on cue" or "on demand," as well as "responsive feeding." However, you should make sure that they feed at least 8 to 12 times in 24 hours. Frequent feeding helps ensure that your baby is getting enough milk and also signals your breasts to produce more milk.

Signs that a baby is ready to feed (feeding cues) are:

●"Rooting" or turning of the head in search of the breast

●Bobbing head when you are holding them close to your chest

●Opening and closing the mouth or smacking the lips

●Sucking on the fingers or hands

Try to recognize these feeding cues so that you can offer the feed before your baby starts crying, which is a late sign of hunger. If your baby is crying, you may need to comfort and settle them before they are able to feed effectively.

Typical feeding patterns — A healthy baby's feeding pattern is often irregular. Sometimes, they feed in clusters, with an hour or less between feeds and, other times, they might go as long as three or four hours between feeds. It is important to watch your baby's cues and not the clock, as a baby will feed best when they are interested in eating. (See 'Feed whenever your baby is hungry' above.)

The length of each feed also varies (generally between 5 and 20 minutes). You should continue the feed as long as your baby is actively suckling and swallowing. If your baby seems sleepy at the breast, you can try to arouse them by taking "burp breaks"; changing the diaper; or rubbing their head, back, arms, or feet. You can also help your baby get more milk by gently compressing or massaging your breast during the feed. Most babies signal that they are finished by relaxing their face and hands and no longer showing any feeding cues when you hold them against your chest.

In the first few days, when your milk volume is relatively low, you can offer both breasts during each feeding. Once you are making ounces of milk, make sure your baby drains the first breast before switching sides. It is okay if they do not always feed on the second side. You should alternate which side you start on each time.

At first, babies do not distinguish day from night in their feeding pattern. After a few weeks, they often settle into a pattern where they sleep for three or four hours at a time during some parts of the night. The average four-month-old might be able to go six to eight hours in between feedings at night, but different babies have different sleep patterns.

Maintaining your milk supply — Throughout breastfeeding, the amount of milk that you produce depends on how often and how completely your breasts are emptied. This is a natural "demand and supply system," in which your body adapts to meet your baby's needs. Therefore, you can help maintain your milk supply by doing the following:

●Feed frequently, and try to have your baby empty at least one breast at each feed.

●Switch which breast you start with for each feed.

●If you need to be separated from your baby, empty your breasts by pumping or hand expressing milk each time your baby feeds in any way other than directly at your breast.

●Don't give your baby formula unless your health care provider advises that it is medically necessary to do so. Feeding your baby formula won't make them sleep better and can lead to a low milk supply.

Signs that your baby is getting enough milk — The most reliable sign that your baby is getting enough milk is their weight gain. Your health care provider will check your baby's weight and let you know if they are on track. Babies usually lose some weight during the first week after birth, then regain to reach their birth weight by two weeks of age.

These are signs that your baby is likely getting enough milk:

●They feed at least eight times in 24 hours

●They seem satisfied and relaxed after feeds

●They have at least one wet diaper per day of age until day 4 to 5 and then six to eight wet diapers a day thereafter

●You hear swallowing during the feeds

●Breastfeeding is comfortable for you both, without nipple pain, rubbing, or compression

If you or your health care provider are concerned that your baby is not getting enough milk, or your baby is not showing all of the above signs, make sure that your baby is checked and weighed.

Here are some ways that you can boost your milk supply:

●Feeding frequently, at least 10 times in 24 hours.

●Expressing milk after the feed, using a pump or hand expression to increase the "make more milk" signal to your body.

●Getting advice on breastfeeding technique from a lactation consultant or other health care provider with special expertise in breastfeeding. They can check to see if your baby is latching on, sucking and swallowing well. (See 'Finding a lactation consultant or other support' below.)

NUTRITIONAL CONTENT OF BREAST MILK — Breast milk is the best source of nutrition for your baby. Most babies do not need additional water, formula, or other foods until they are at least four to six months old. Also, giving formula or other foods might decrease your breast milk production and won't make a baby sleep longer.

Even so, they may need a vitamin or mineral supplement. Your baby's health care provider will tell you if your baby needs any supplements, but below are some general guidelines:

●Vitamin D – Most babies need extra vitamin D to ensure healthy bones. Babies with very low vitamin D can get rickets, a condition that causes bones to be soft and fragile. To be sure that your baby gets enough vitamin D, you should give them a supplement with 400 international units (10 micrograms) of vitamin D each day, starting soon after birth. You can buy liquid vitamin D drops for babies at your pharmacy. Although giving vitamin D drops to your baby is the recommended and most common approach, an alternative is to take a high dose of vitamin D yourself (approximately 6000 international units [150 micrograms]) every day. If you are interested in this option, talk to your health care provider first.

Vitamin D can also be made by the skin when exposed to sunlight. In the first year, babies often don't get enough vitamin D from this source, especially if they have darker skin tone, spend most of their time indoors, or wear clothing or sunscreens to protect them from sunburn.

●Vitamin B12 – If you follow a vegan or lactovegetarian diet (ie, if you do not eat meat or eggs) and do not take a vitamin B12 supplement, you should give your baby a multivitamin supplement that includes vitamin B12. Adequate vitamin B12 is available in most nonprescription infant vitamin drops. Low levels of vitamin B12 can lead to anemia, developmental delay, and serious neurologic problems. (See "Patient education: Health and nutrition during breastfeeding (Beyond the Basics)", section on 'Vitamin B12'.)

●Iron – Breast milk supplies sufficient iron for the first few months of a baby's life. After four months of age, they may need additional iron. Talk with your baby's health care provider about whether your baby needs this. (See "Patient education: Starting solid foods with babies (Beyond the Basics)", section on 'Vitamin and mineral supplements'.)

●Fluoride – No supplement is needed from birth to six months of age. After six months, exclusively breastfed infants should receive extra fluoride. Talk to your health care provider about supplementation. (See "Patient education: Starting solid foods with babies (Beyond the Basics)", section on 'Fluoride'.)

Some babies might need other supplements, including very premature babies or those with a liver, kidney, or digestive problem. Depending on their condition, these babies may need extra nutrients (calories, protein, calcium, phosphorus, and vitamins), in addition to their breast milk feeds. If your baby has a medical condition, talk with their health care provider about whether they need any additional supplements.

COMMON BREASTFEEDING QUESTIONS

What if I have nipple pain? — Nipple pain during breastfeeding is usually caused by an improper latch. If so, you should be able to fix this by unlatching your baby each time you feel pain, then relatching with special attention to positioning to finish the feed. (See 'Adjusting the latch' above.)

It is rare that nipple pain is related to any other causes or conditions. If you are not able to get comfortable by changing the positioning and latch-on, seek help from a lactation consultant or a specialist in breastfeeding medicine. They will help diagnose and manage the problem. (See "Patient education: Common breastfeeding problems (Beyond the Basics)", section on 'Nipple pain'.)

Should I offer my baby a pacifier? — For the first few weeks of breastfeeding, it's generally best not to give your baby a pacifier. Avoiding pacifiers might help establish healthy breastfeeding patterns. Once your baby is latching on comfortably and your milk supply is good, you can offer your baby a pacifier for sleep. This usually happens around two to four weeks after birth. Having a pacifier for sleep might decrease the risk of sudden infant death syndrome (SIDS), although this is not proven. (See "Patient education: Sudden infant death syndrome (SIDS) (Beyond the Basics)", section on 'After birth'.)

Do I need to change my diet during breastfeeding? — Your diet doesn't have to be perfect for your body to make good breast milk. Try to eat healthy and make sure you get enough nutrients and calories, but don't worry too much. (See "Patient education: Health and nutrition during breastfeeding (Beyond the Basics)", section on 'Nutrition and lactation'.)

What should I know about medications and breastfeeding? — Most medications are compatible with breastfeeding, but you should check with a health care provider before taking any new medications (either prescription or over-the-counter), herbs, or supplements. If you have questions about specific medications, talk with your health care provider.

More information about medications and other substances (including alcohol, caffeine, tobacco, and cannabis) is available separately. (See "Patient education: Health and nutrition during breastfeeding (Beyond the Basics)", section on 'Safety of medications and other substances during breastfeeding'.)

Will I need to pump or express my milk? — Most people who breastfeed also pump or express their milk at times. You might choose to pump if you are going to be separated from your baby, to boost your milk production, or to allow you to continue breastfeeding after returning to work or school.

During the first few days of breastfeeding, you may get little or no milk when you pump or try to express milk by hand. However, the process still helps to boost your milk supply because it signals your body to produce more milk. The strongest signal to make more milk is when your baby suckles at your breast or when you hand express or pump your breasts (even when they are mostly empty).

In the first few days after birth, hand expression may be the most effective way to express colostrum ("first milk") (figure 6). Thereafter, an electric pump will probably be the most efficient way to express milk. You should choose a pump to suit your needs and make sure that it fits well so that pumping is efficient and comfortable. More details about breast pumps and expressing milk by hand are provided in a separate topic. (See "Patient education: Pumping breast milk (Beyond the Basics)".)

Other questions — You may have other questions about breastfeeding. More detailed information about the benefits of breastfeeding, preparing to breastfeed, and preventing or managing problems is available separately. (See "Patient education: Deciding to breastfeed (Beyond the Basics)", section on 'Common questions' and "Patient education: Common breastfeeding problems (Beyond the Basics)".)

FINDING A LACTATION CONSULTANT OR OTHER SUPPORT — Resources for finding a lactation consultant, peer support (online or in person), and other types of support are listed in the table (table 2).

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Deciding to breastfeed (The Basics)
Patient education: Breastfeeding (The Basics)
Patient education: Health and nutrition during breastfeeding (The Basics)
Patient education: Common breastfeeding problems (The Basics)
Patient education: Jaundice in babies (The Basics)
Patient education: Pumping and storing breast milk (The Basics)
Patient education: What to expect in the NICU (The Basics)
Patient education: When a baby is born premature (The Basics)
Patient education: Weaning from breastfeeding (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Deciding to breastfeed (Beyond the Basics)
Patient education: Health and nutrition during breastfeeding (Beyond the Basics)
Patient education: Common breastfeeding problems (Beyond the Basics)
Patient education: Pumping breast milk (Beyond the Basics)
Patient education: Weaning from breastfeeding (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Breastfeeding: Parental education and support
Initiation of breastfeeding
Common problems of breastfeeding and weaning
Maternal nutrition during lactation
Infant benefits of breastfeeding
Maternal and economic benefits of breastfeeding
Contraception: Postpartum counseling and methods
Breast milk expression for the preterm infant
Breastfeeding the preterm infant

Websites — The following organizations also provide reliable health information:

●United States National Library of Medicine

(www.medlineplus.gov/breastfeeding.html)

●Centers for Disease Control and Prevention (CDC)

(www.cdc.gov/breastfeeding)

●American Academy of Pediatrics

•Professional website (www.aap.org/en/patient-care/breastfeeding)

•Parenting website (www.healthychildren.org/English/ages-stages/baby/breastfeeding)

●Academy of Breastfeeding Medicine

(www.bfmed.org/protocols)

●La Leche League International

(www.llli.org/resources)

●Office on Women's Health

(www.womenshealth.gov/patient-materials/health-topic/breastfeeding)