Patient education: Deciding to breastfeed (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 the benefits of breastfeeding and how to prepare for breastfeeding. Other aspects of breastfeeding are discussed separately:

●(See "Patient education: Breastfeeding guide (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.

WHY IS BREASTFEEDING IMPORTANT? — Exclusive breastfeeding (meaning giving only breast milk and no formula or other foods) is widely recommended for approximately the first six months of life. After this, experts recommend continuing to breastfeed for at least the first year, in addition to introducing complementary solid foods. Many people choose to breastfeed beyond the first year, and some of the benefits continue during this time.

Breastfeeding offers important benefits and protection for both you and your baby. Many families also benefit from the cost savings and convenience of breastfeeding:

Benefits for the baby — Some of the short-term benefits of breastfeeding for babies are:

●Better digestive tract (gastrointestinal) function and protection from digestive tract infections that can cause vomiting and diarrhea

●Reduced risk of respiratory infections, wheezing, ear infections, and urinary tract infections

●Reduced risk of sudden infant death syndrome (SIDS)

While not proven, evidence supports that there are multiple longer-term benefits of breastfeeding as well, including a reduced risk of type 1 diabetes, inflammatory bowel disease, wheezing, and certain dental problems and, possibly, a reduced risk for obesity, allergies, and certain childhood cancers. (See "Infant benefits of breastfeeding".)

Benefits for you — Compared with people who feed their babies formula, people who breastfeed experience:

●Reduced blood loss after childbirth – Breastfeeding helps the uterus to contract, which reduces uterine bleeding

●Decreased risk of breast cancer, ovarian cancer, hypertension, and type 2 diabetes

Benefits for the family — Families who breastfeed experience:

●Reduced cost for feeding the baby – In the United States, for those not receiving public assistance for their family via the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program, infant formula and bottle supplies typically cost approximately $1000 to $2000/year, which is two to three times the usual cost of breastfeeding supplies and nutrition for the mother. The cost savings from breastfeeding relative to family income are even higher for families living in low-income countries.

●Other savings – In addition to money saved by not buying formula, other savings come from having a healthier baby. This reduces the cost of health care as well as the amount of time parents need to take off from work to take care of a sick baby.

COMMON QUESTIONS

Is breastfeeding comfortable? — Most people can be completely comfortable while breastfeeding. You might experience pinching or pain in your nipples, but, in the vast majority of cases, this can be fixed immediately by adjusting the baby's "latch" on the nipple. Your health care provider or lactation consultant can show you how to adjust the latch by gently removing your baby's mouth from your nipple and having them latch on again, as shown in the figure (figure 1). It is important to adjust the latch until it is comfortable to avoid compressing or rubbing your nipple and also so that your milk will flow more easily. (See "Patient education: Breastfeeding guide (Beyond the Basics)", section on 'Helping your baby latch on'.)

Occasionally, you might feel pain in your breasts because of breast engorgement (milk oversupply). Enlargement or swelling and tenderness of your breasts approximately two to four days after giving birth is expected and is a sign that your body is transitioning to making ounces of milk instead of drops of colostrum. Some breast infections or conditions can also cause breast or nipple pain. Your health care provider can help determine the cause of the problem and its solution. (See "Patient education: Common breastfeeding problems (Beyond the Basics)".)

Do breastfed babies sleep well? — Healthy newborn babies wake easily and frequently to feed, regardless of whether they are breastfed or formula fed. Most babies feed 8 to 12 times in 24 hours, including several times during the night. Although this can be exhausting for you, remember that it is completely normal for a newborn to wake easily and feed frequently. Your baby will sleep for longer stretches as they get older. Some tips for dealing with exhaustion are shown in the table (table 1). Feeding your baby anything other than breast milk will not help your baby sleep more and might also decrease your milk supply.

Will I make enough milk?

●Normal milk production – Most people can make enough milk for their baby. Your breasts will produce more milk if they are "signaled" and emptied frequently, either by having the baby feed or by pumping; in other words, the milk supply responds to the demand.

•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 the nutrition that the baby needs in the first few days as long as they are receiving it frequently.

•Several days after giving birth, your breasts 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 considered breast milk, just in an early and concentrated form. You will recognize this transition because your breasts feel more full and firm, and some milk might leak out. This usually happens between three and five days after the birth but is sometimes delayed for seven or more days. The frequency and effectiveness of your baby's suckling (at least 8 to 12 times in 24 hours) helps trigger this transition and increases the milk volume. (See "Patient education: Breastfeeding guide (Beyond the Basics)", section on 'Getting started with breastfeeding'.)

●How can I tell if my baby is getting enough milk? – It is normal for a baby to lose some weight during the first week after birth, then start gaining weight after that. To make sure a baby is getting enough milk, health care providers will weigh the baby at least twice during the first two weeks of life and periodically after that. When there is concern about more weight loss than usual or poor feeding, your health care provider will weigh your baby more often in the first weeks of life to follow their weight closely and offer you breastfeeding support. They will also tell you how to look for signs that the baby is feeding well and is well hydrated.

If your baby is not getting enough milk, your health care provider will evaluate you and your baby and suggest solutions to help boost your milk supply and ensure that your baby is getting what they need. This is discussed separately. (See "Patient education: Common breastfeeding problems (Beyond the Basics)".)

Can everybody breastfeed? — Most people who give birth are able to breastfeed. For parents who did not give birth, there are ways to get some of the benefits of breastfeeding for both parent and baby; these are discussed below.

●Birthparent – Certain conditions and situations may interfere with breastfeeding, most of which can be addressed by extra support from a health care provider or lactation consultant. Examples include:

•Flat or inverted nipples – Flat or inverted nipples may sometimes interfere with the initiation of breastfeeding because the baby might have a harder time latching on to the breast (figure 2). If you have flat or inverted nipples, you might need to use special techniques to help the baby latch on, but that can be addressed once you start breastfeeding and see how it goes.

•Premature birth or another medical condition in the baby – In these cases, the baby may not be able to suck or swallow well until they approach their due date or are more medically stable. In these situations, pumping and/or hand expressing on a regular basis beginning right after birth can help preserve your milk supply until your baby is ready to breastfeed.

•Breast reduction surgery – If you have had a breast reduction, this may reduce your milk supply, although you may still be able to breastfeed. By contrast, breast enlargement surgery (breast implants) usually does not affect your milk supply or breastfeeding.

•Medications – Most medications are safe to take while breastfeeding, but a few are not. Check with your health care provider about any medications you take (including herbal medications or supplements) to make sure that they are safe for the baby. You can also look up your medications in the LactMed database, which is a free reference for lactation compatibility for prescription and over-the-counter drugs.

There are only a few situations in which breastfeeding is not recommended, including HIV infection (in most countries), use of illegal drugs, or classic galactosemia (a rare genetic condition) in the baby.

•Conditions for which breastfeeding is not recommended are listed here, from the Centers for Disease Control and Prevention (CDC) website (www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/contraindications-to-breastfeeding.html).

•People who are breastfeeding are advised not to use cannabis (marijuana) or cannabidiol (CBD) in any form, because the effects of the chemicals or contaminants on the baby are not known (CDC guidance: www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/vaccinations-medications-drugs/marijuana.html).

●Non-birthparents – Non-birthparents have several options to give their baby the benefits of breastfeeding. This may include the birthparent's partner or parents whose baby was adopted or born to a gestational carrier ("surrogate"). Options include:

•Allowing the baby to "comfort" suckle at the breast or chest without feeding – This can provide comfort and bonding even if the baby is getting their nutrition from bottle feeding. (See 'How can my partner or support people be involved with feeding the baby?' below.)

•Donor milk – If neither parent can breastfeed and you prefer to give the baby human milk rather than formula, you can use donor human milk, but this will be very expensive. If you choose this option, it is important to use milk from an established human milk bank because these organizations follow safety regulations for optimal milk collection, pasteurization, storage, and shipping. Do not use donor milk obtained over the internet and/or unpasteurized milk, because of risk of infection. Information about certified milk banks can be found online (through the Human Milk Banking Association of North America or other country-specific resources), or your health care provider can provide resources.

•Inducing lactation – If you feel strongly that you want to feed the baby directly from your breast or chest, you can ask your health care provider about the possibility of taking hormones that signal your body to "induce" lactation. However, this requires prescriptions and monitoring from a health care provider with special expertise in this technique, such as a breastfeeding medicine specialist. The amount of milk that people are able to produce after induced lactation varies, and supplementation with donor milk or infant formula may be necessary.

Can my baby get all their nutrients from breast milk alone? — Breast milk supplies almost all of the nutrients that your baby needs. It is recommended that they receive some extra vitamin D to support bone health, starting shortly after birth. The amount, options, and other considerations are discussed separately. (See "Patient education: Breastfeeding guide (Beyond the Basics)", section on 'Nutritional content of breast milk'.)

How can my partner or support people be involved with feeding the baby? — If you are breastfeeding, your partner or another caregiver can still be closely involved in other aspects of the baby's care. For example, they might change the baby's diaper or burp them after each feed. Once the baby is several weeks old and is breastfeeding well, you may want to start expressing (pumping) some milk from your breasts after the feed or between feeds, which your partner can use for some bottle feedings.

Providing some feeds by bottle allows your partner or others to be involved with feeding and helps prepare for whenever you might need to be away from your baby (for example, return to work or school). For bottle feeding, it may be helpful to use strategies to slow the milk flow so that it is more similar to what the baby experiences while breastfeeding. This might include making sure that your baby opens their mouth wide and is actively engaged in sucking, holding the bottle more horizontal to the ground rather than at a slant so that milk flow is triggered by sucking rather than gravity, and taking frequent breaks ("paced" bottle feeding). (See "Patient education: Pumping breast milk (Beyond the Basics)".)

Is breastfeeding convenient? — Most people find that breastfeeding is very convenient (and usually more convenient than formula feeding) once they get used to it. You have a constant supply of fresh milk, and you don't need to buy, store, prepare, or warm the milk.

Many people find that, with some practice, they can easily breastfeed when they are away from home. This allows more flexibility as you don't need to think about packing formula for outings with your baby or having supplies for mixing, cleaning, and storing. If you wish, you can use a cloth or thin scarf to cover your breast while feeding in public. Or, you may choose to find a private place to breastfeed, such as your car or a quiet room. You will quickly find a way of feeding your baby that you are comfortable with.

What if I need to go back to work or school? — Most people are able to continue breastfeeding after returning to work or school or if they are away from the baby for a few days. You can pump your milk while at work, store the milk in the refrigerator or freezer, and have another caregiver feed the milk to the baby while you are away by using a bottle. You can buy or rent an efficient electric breast pump for this purpose. In the United States, most commercial health insurance plans cover the cost of renting a hospital-grade breast pump and employers are required to provide a private place at your workplace for you to pump that is not a restroom. (See "Patient education: Pumping breast milk (Beyond the Basics)".)

How does breastfeeding affect my breasts and body?

●Breast shape and fullness – Most people's breasts enlarge during early pregnancy as the milk producing glands mature (figure 3). After birth, the breasts start to fill with milk, whether or not you breastfeed. If you breastfeed, your breasts will continue to fill with milk and will generally look and feel more full and firm as long as you continue to breastfeed. Once you stop breastfeeding, your breasts will usually return to their previous shape but may remain slightly larger than before breastfeeding. (See "Patient education: Weaning from breastfeeding (Beyond the Basics)".)

●Body weight – Bodies have a wide range of responses to pregnancy and delivery. Some people lose the weight that they gained during pregnancy easily, and others do not. You burn 300 to 500 more calories when you are breastfeeding, which may help you lose some of your pregnancy weight as long as you continue to eat a regular diet. This is also not a time for any special diets. The best way to reach a healthy body weight after pregnancy is to eat a healthy and balanced diet and get plenty of physical activity.

●Cancer and diabetes risk – Studies show that breastfeeding reduces your long-term risk for ovarian cancer, uterine cancer, breast cancer, and type 2 diabetes, even if you had gestational diabetes. (See 'Benefits for you' above.)

PREPARING TO BREASTFEED

What supplies will I need? — It is not necessary to buy any breastfeeding supplies before birth. Many people who breastfeed will rent or purchase a breast pump at some point, but many experts suggest waiting until after the baby is born to make the decision about when and how to do this. Most people only need the pump once they return to work or have to spend time away from the baby. If a pump is needed sooner (for example, to pump milk for a premature baby), a lactation consultant or health care provider can advise you about the type of pump to get and where to purchase or rent one. (See 'Where to get more information' below and "Patient education: Pumping breast milk (Beyond the Basics)".)

Do I need to prepare my nipples or breasts? — There is no need to do anything to prepare or condition your nipples for breastfeeding. You should not try to "toughen" the skin or stretch the nipple. This will not help with breastfeeding and might even injure the nipple. You can plan to bathe and wash your breasts with a gentle soap as you normally would with no other special care.

What to expect in the first few days — Most hospitals specifically encourage and support you to breastfeed with these steps:

●When to start breastfeeding – You should start breastfeeding within the first few hours after giving birth, if possible. This usually happens in the birthing room as part of "skin-to-skin contact" immediately after the baby is born (figure 4). Most babies will instinctively find the nipple and start sucking, which helps them practice feeding and gives them their first meal of colostrum, or concentrated breast milk that is packed with nutrition and protection for your baby.

●Rooming-in – During the first few days, the baby will breastfeed frequently throughout the day and night and will feel most comfortable and the least stressed with you and near you. It is recommended that your baby stay in the room with you ("rooming-in") so that you can respond to every cue. It is normal for your breasts to produce only small amounts of colostrum during the first few days, and this is all that your baby needs. With frequent feedings and effective emptying of the breast to signal your body that the baby is here, your milk supply will increase every day as your baby's needs increase. (See 'Will I make enough milk?' above.)

●Postpartum support – The nursing and medical staff in birth hospitals can observe you feeding your baby and provide general advice about breastfeeding, including how to help the baby latch on in a comfortable and effective manner. If you need more help, you can get more detailed guidance from a lactation consultant or peer counselor. (See 'Finding a lactation consultant or other support' below.)

More details on breastfeeding techniques are provided in a separate topic review. (See "Patient education: Breastfeeding guide (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: 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)

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: Breastfeeding guide (Beyond the Basics)
Patient education: Common breastfeeding problems (Beyond the Basics)
Patient education: Health and nutrition during breastfeeding (Beyond the Basics)
Patient education: Pumping breast milk (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
Infant benefits of breastfeeding
Maternal nutrition during lactation
Contraception: Postpartum counseling and methods
The impact of breastfeeding on the development of allergic disease
Safety of infant exposure to antidepressants and benzodiazepines through breastfeeding
Prevention of HIV transmission during breastfeeding in resource-limited settings

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/Pages/default.aspx)

●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)