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• React appropriate to how it feels. "Ouch!" you holler as you pry those little baby jaws apart with your fingers to preserve your precious, tender piece of flesh. Once you've rescued your nipple, watch baby's face. Sensitive babies will cry at mother's reaction. Calm her and immediately resume nursing. When she bites again, react the same way. Eventually, baby will associate biting with an undesirable reaction and will stop biting.
• End the feeding. When baby bites and you prematurely end the feeding, baby associates biting with the end of a feeding, which acts as another deterent for her continued biting.
• Pull baby close. Instead of the yank-and-yell response, which you may intuitively feel like doing, as soon as you sense baby's teeth coming down to bite, draw her in close to your breast and she will automatically let go in order to open her mouth more and uncover her nose to breathe. Don't try to disengage your nipple from the clenched teeth. Your baby will lessen her bite as she realized that she can't both bite and breathe. After several times of this counter-instinctive trick of pulling your baby in close to you when she bites, your baby will realize that biting triggers this uncomfortable response and she will stop biting. Remember, your goal is to discourage her from biting, not to frighten her.
• Reserve a protective finger. Once you know your baby is in the biting phase, keep a finger in the corner of her mouth, ready to break the suction if you sense her starting to clamp down.
• Try the pull-off-and-put-down technique. If baby bites, immediately disengage her from the breast and put her down, not in a punitive way, but with enough firmness that she makes the connection between biting and being put down.
• Provide an alternative. Teething creates the urge to chomp, and anything that enters her mouth is fair game. Keep some teething toys in the freezer, such as a frozen banana or a washcloth, and let her chomp on these before, or at the end of a feeding. If you know from experience that biting comes at the end of the feeding, let her finish her sucking on your finger or a cool substitute.

• Part or all of the breast is intensely painful, hot, tender, red, and swollen. Some mothers can pinpoint a definite area of inflammation, while at other times the entire breast is tender.
• You feel tired, run down, achy, have chills or think you have the flu. A breastfeeding mother who thinks she has the flu probably has mastitis. Mothers with mastitis will sometimes experience these flu-like symptoms, even before they get a fever or notice breast tenderness.
• You have chills or feel feverish, or your temperature is 101F or higher. These symptoms suggest that you have an infection.
• You are feeling progressively worse, your breasts are growing more tender, and your fever is becoming more pronounced. With simple engorgement, a plugged duct, or mastitis without infection, you gradually feel better instead of worse.
• Recent events have set you up for mastitis: cracked or bleeding nipples, stress or getting run down, missed feedings or longer intervals between feedings.

PREVENTING MASTITIS

The best way to prevent mastitis is to avoid the situations that set you up for it.

• Relieve engorgement promptly. Milk that doesn't flow gets thicker and clogs the ducts, which is a set-up for mastitis.
• Breastfeed frequently. Don't restrict the length of feedings.
• If you feel your breasts getting full, encourage your baby to nurse. You don't have to wait for baby to tell you he's hungry.
• Avoid sleeping on your stomach or so far over on your side that your breasts are compressed against the mattress.
• Take care of yourself and get plenty of rest (both of mind and body).

REPEATED EPISODES OF MASTITIS

Problems with recurrent mastitis are usually the result of irregular breastfeeding patterns: missing feedings, giving bottles in place of breastfeedings, or skipping pumping sessions when separated from the baby. Recurrent mastitis may also mean that mother's immune system is generally run down, because of fatigue and stress. Mastitis is a sign that you need to take a closer look at your lifestyle and breastfeeding relationship and make some adjustments.

TREATING MASTITIS

Treating mastitis is much like treating engorgement only more urgent. Try these suggestions in addition to those listed under engorgement.

• Rest, rest, rest. Mastitis is an illness, so take a medical leave from all responsibilities other than breastfeeding. Take your baby to bed with you and nurse. Rest relieves stress and replenishes your immune system.
• Alternate warm and cold compresses on your breasts. Cold compresses relieve pain; warmth increases circulation, which mobilizes infection-fighters in the inflamed area. Lean over a basin of warm water, stand in a warm shower, or soak in a warm bath. Warm water or a warm, wet towel is more effective than the dry heat of a heating pad. For cold compresses, use crushed ice in plastic bags or bags of frozen vegetables, covered with a thin dishtowel to protect your skin.
• Gently massage the area of tenderness. This increases circulation, helps to loosen any plugged ducts in the area, and mobilizes local immune factors. Try doing this while soaking the breast in a warm shower or bath.
• Breastfeed frequently on the affected side. If it hurts to nurse the baby, start the feeding on the breast that is not sore, and switch to the sore side after your milk lets down. Breastfeeding is usually more comfortable when the milk is flowing. It's important to empty the inflamed breast. As in other parts of the body, fluid that is trapped can get infected. Your baby can empty your breast more efficiently than a breast pump. However, if your baby is not nursing well, you may have to use a breast pump or hand expression to get the milk out.
• Vary the baby's position at the breast, so that all the ducts are emptied.
• Take analgesics for fever and pain. Acetaminophen and/or ibuprofen are safe to take while breastfeeding. Unrelieved pain not only decreases your ability to produce milk, but suppresses your body's ability to fight infection.
• Drink lots of fluids, as you would if you had the flu. Fever and inflammation increase your need for fluids.
• Boost your immune system with good nutrition.
• Sleep without a bra. At other times, wear a looser fitting bra that does not put pressure on the affected area. Or if possible, go without a bra.
• Don't quit nursing at this point. Weaning increases the risk of a breast infection turning into a breast abscess that requires surgical draining. Continuing to nurse your baby is the best treatment for engorgement, mastitis and breast infections.
• If baby refuses to nurse on the affected breast, it may be because inflammation of the milk glands increases the sodium content of your milk, giving it a salty taste. Most babies either don't notice or don't mind, and go right on nursing. Some may object to the change and fuss or refuse to nurse from that side. Try starting the feeding on the unaffected side and finishing on the salty side. As the inflammation subsides, your milk will soon return to its usual taste.

DO YOU NEED ANTIBIOTIC TREATMENT?

You can experience the pain and inflammation of mastitis without necessarily having a bacterial infection. Yet it is often difficult to tell whether mastitis has become a breast infection. Consult your healthcare provider as soon as you suspect mastitis. In our medical practice, we operate on the principle of better to treat mastitis earlier than later. Mothers who are given antibiotics too late in the course of mastitis are more likely to wean their babies from the breast, to have a more severe infection, and to have the infection recur.

The following guidelines can help you both determine whether or not you need an antibiotic.

You may not need an antibiotic in the following situations:

• You do not have a history of frequent episodes of mastitis.
• You don't feel that sick.
• You have not gotten progressively sicker over the last few hours.
• Your fever is not rising.
• The breast pain and tenderness is not increasing.
• You can easily correct whatever factors may have set you up for engorgement in the first place.

Signs suggesting you do need antibiotic treatment:

• A history of frequent mastitis
• A fever that is rising.
• You are feeling progressively sicker as the hours go by.
• Your nipples are cracked, which allows bacteria to get into your breast tissue more easily.

Which antibiotics are best? The type of bacteria involved in mastitis is usually staphylococcus, and the two safest and most effective classes of antibiotics against this organism are cloxacillins and cephalosporins. Other frequently prescribed antibiotics are Augmentin or erythromycin. All of these antibiotics are safe to take while breastfeeding. Even though you will feel better after a few days of taking antibiotics, be sure to complete the full course of antibiotics prescribed by your doctor (usually ten days); otherwise you run the risk of the mastitis returning. If you don't feel better after two or three days on antibiotics, call your doctor. He or she may wish to prescribe a different medication.

BREAST ABSCESS

Engorgement, mastitis, or a plugged duct can sometimes lead to a breast abscess. (This is unlikely if you continue to breastfeed your baby frequently during an episode of mastitis or when you have a plugged duct.) An abscess is a pus-filled area, like a boil under the skin. Your healthcare provider will suspect an abscess if the lump remains tender and does not go away with the treatment listed under plugged ducts and mastitis. An ultrasound of the breast may be necessary to locate an abscess deeper in the breast. An abscess often requires surgical drainage, plus antibiotic therapy. In addition to the medical treatment recommended by your doctor, it's important to continue to empty the breast with the abscess. Depending on the location and the extent of the abscess, you may or may not be able to nurse on the infected breast. Your healthcare provider can help you determine whether this will be possible. If you are temporarily unable to breastfeed on the breast with an abscess, use an electric breast pump to empty the breast and nurse baby more frequently on the other breast. Apply moist heat to the affected area before nursing or pumping to help the milk flow.

It used to be common practice to treat flat or inverted nipples prenatally with nipple-stretching exercises and/or breast shells (plastic cups worn inside the bra that press on the areola, forcing the nipple out). Yet studies comparing treated with untreated groups showed the treated groups actually were less successful at breastfeeding. Most breastfeeding specialists no longer recommend prenatal nipple treatment. They believe that all the attention given to nipples prenatally makes the mother feel that her breasts are inadequate, setting her up for breastfeeding failure.

GETTING BABY STARTED AT THE BREAST

An alert newborn who latches on and sucks well is the best remedy for flat or inverted nipples. It's easiest for baby to learn to latch on in the first day or two after birth, before your milk comes in. Engorgement tends to make flat nipples flatter, which makes learning to latch-on more difficult. Plan on rooming-in with your baby right from the start, so that the two of you can have lots of practice with breastfeeding.

If you are having difficulties latching your baby on because of flat or inverted nipples try these suggestions:

• Pay close attention to how baby takes the breast. Review Latch-on basics and get hands-on help from a lactation consultant. Baby should grasp the breast with a wide-open mouth.
• "Make" a nipple. Use the "breast-sandwich" technique to get more breast tissue into baby's mouth. Hold your breast well back on the areola, with your fingers underneath and thumb on top. Press in with thumb and fingers while at the same time pushing back toward your chest wall. This elongates and narrows the areola, which enables baby to latch on more easily.
• Use a breast pump to draw out your nipples before feedings. The high-quality electric pumps available on hospital maternity wards will do the best job of drawing out the nipple without damaging it. You can also purchase a device specially designed to draw out an inverted nipple before feeding the Evert-It Nipple Enhancer , or ask a nurse or LC to help you make your own with a 10 cc disposable syringe. Remove the plunger, and with a sharp knife cut off a half inch from the nozzle end. Insert the plunger into the cut end of the syringe. Place the uncut open end of the syringe over your nipple so it rests up against your areola. Gently pull on the plunger to draw out your nipple just before putting baby to the breast.
• Try wearing breast shells designed for flat or inverted nipples between feedings or for thirty minutes before feedings. Breast shells are made of plastic. They have two parts: a back with a hole through which the nipple can protrude and a rounded dome that fits inside your bra. Pressure on the shell from your bra against the areola gradually stretches out adhesions and allows the nipple to protrude. Be sure to wash these shells with soap and hot water between feedings and discard any milk that collects in them while you wear them in your bra. Note that shells come with two types of backs; the one with the larger hole is meant for treatment of sore nipples. Be sure to use the back with the small hole, which fits close to the nipple base.
• If baby continues to have difficulty latching on, try a nipple shield. You can get these from a lactation consultant who will also advise you on how to use the nipple shield without compromising your milk production.

No matter what animal it comes from, milk contains the basic nutritional elements of fats, proteins, carbohydrates, vitamins, and minerals. Let's look at each one of these nutrients in human milk, comparing them to the same nutrients in formula or cow milk, so you can further appreciate how your milk is custom-made to meet the needs of your baby.

Unique nutrition for unique humans. As hormones levels change in the days after birth, the mother's body starts to make more plentiful amounts of milk. Colostrum gradually changes into mature milk--the stuff babies have been thriving on for thousands of years. Milk's basic ingredients are fat, proteins, lactose, vitamins, minerals, and water. This is true of milk from all kinds of mammals. Yet, the proportions of these ingredients differ, as do the kinds of protein and fat. This is what makes each species' milk uniquely suited to its young. It's also why cow's milk and cow's milk-based formulas are not the ideal food for human infants.

HIGH QUALITY PROTEIN

Protein is a prime example of how human milk is unique nutrition for human babies. Human milk is low in protein, at least when compared with the milk of other species, especially cow's milk. This isn't a nutritional deficiency; there are good reasons for this. Human infants are designed to grow slowly. While it's important for humans to develop strong bodies, even more important is brain development and the learning of social skills. The experiences that shape the brain come from close contact between mother and baby when baby is held and carried. If human infants doubled their birthweight in less than 50 days the way baby calves do, and then continued growing, how could their mothers carry them and talk to them and keep them close? Baby cows need to learn where to find the best grass in the meadow; baby humans need to learn how to work with others so that everyone's needs get met.

Though the protein content of human milk is generally low, the types of amino acids that make up these proteins are important. One particular amino acid, taurine, is found in large amounts in human milk. Studies show that taurine has an important role in the development of the brain and the eyes. The body can't convert other kinds of amino acids into taurine, so its presence in human milk is significant--so significant that some formula manufacturers have begun adding it to artificial baby milks.

If you let milk stand out of the refrigerator and sour, you will see that milk proteins fall into two categories, curds and whey. (Remember Miss Muffet?) The curd portion, the casein proteins, are the white clots; the liquid is the whey. Cow's milk is mostly casein protein, which forms a rubbery, hard-to-digest curd in babies' tummies. Human milk has more whey than curd, and the curds that are formed are softer and more quickly digested. Breastfed babies get hungry sooner than babies who are formula-fed because human milk proteins are digested so efficiently. It doesn't take as much energy to digest human milk as it does to digest formula. Frequent feedings also ensure that human babies get lots of attention from their mothers.

SELF-DIGESTING FATS

There's another reason why babies digest human milk so quickly: the fat in human milk comes with an enzyme, lipase, that breaks the fat down into smaller globules so this important nutrient can be better absorbed into the bloodstream. Fat is a valuable source of energy for babies, so the presence of lipase makes the fat in human milk more available. This is one of the reasons human milk is so good for premature babies, who need lots of energy to grow but whose digestive systems are very immature.

A changing nutrient for changing needs. The fat content of human milk changes constantly. Typically, fat levels are low at the beginning of a feeding and high at the end. Babies nurse eagerly to get the low-fat, thirst-quenching foremilk, then slow down and linger over the high-fat dessert at the end of their meal. Babies who nurse again soon after the end of the last feeding get more high-fat milk, so babies who breastfeed more frequently during a growth spurt get more calories. Longer intervals between feedings bring down the fat content of the milk stored in the breast. This nutritional fact of human milk is one of the many reasons why the rigid 3 to 4 hour scheduled style of feeding is biologically incorrect.

Smarter fats. The special kind of fat in human milk is important to brain development. As newborn babies grow, the nerves are covered with a substance called myelin which helps the nerves transmit messages to other nerves throughout the brain and body. To develop high-quality myelin, the body needs certain types of fatty acids--linoleic and linolenic--which are found in large amounts in human milk.

VITAMINS AND MINERALS

The vitamins and minerals listed on the formula can are no match for those in the milk made by mom, even if milligram by milligram comparisions suggest otherwise. When formula researchers want to know how much of a particular vitamin or mineral babies need each day, they look first at how much of that nutrient is present in human milk and how much milk a baby of a given age takes in a day. But just doing the math doesn't tell the whole story. More important than the amounts of nutrients in the milk is the amount that is available for the infant to use, a nutrient principle called bioavailability. The bioavailability of a nutrient is influenced by many factors, including its chemical form and the presence of other substances.

The three important minerals calcium, phosphorus, and iron are present in breastmilk at lower levels than in formula, but in breastmilk these minerals are present in forms that have high bioavailability. For example, 50 to 75 percent of the iron in breastmilk is absorbed by the baby. With formula, as little as four percent of the iron is absorbed into baby's bloodstream. To make up for the low bioavailability of factory-added vitamins and minerals, formula manufactures raise the concentrations. Sounds reasonable, right? If only half gets absorbed by the body, put twice as much into the can. Yet, this nutrient manipulation may have a metabolic price.

Baby's immature intestines are required to dispose of the excess. Meanwhile, the excess unabsorbed minerals (especially iron) can upset the "ecology of the gut," interfering with the growth of healthful bacteria and allowing harmful bacteria to flourish. This is another reason formula-fed infants have harder, more unpleasant smelling stools.

To enhance the bioavailability of nutrients, breastmilk contains facilitators - substances that enhance the absorption of other nutrients. For example, vitamin C in human milk increases the absorption of iron. Zinc absorption is also enhanced by other factors in human milk. In an interesting experiment, researchers added equal amounts of iron and zinc to samples of human milk, formula, and cow'd milk, and fed them to adult volunteers. More of the nutrients in the human-milk sample got into the bloodstream compared to the formula and cow's milk. In essence, breastmilk puts nutrients where they belong - in baby's blood, not in baby's bowels.

HORMONES AND ENZYMES

Every year medical journal articles describe more valuable substances discovered in human milk. Scientists are only beginning to write the story on other factors in human milk that may be important to baby's growth and development. For example, other enzymes besides lipase are available to aid infant digestion. Epidermal growth factor, present in human milk in significant amounts, may promote the development of tissues in the digestive tract and elsewhere. Other hormones in milk may influence a baby's metabolism, growth, and physiology. The effects may be subtle, but they may also have far-reaching implications. Being breastfed has advantages that reach into adulthood. Science is only beginning to learn what these benefits are.

• Alcohol. Women who are breastfeeding should avoid consuming alcohol because it can enter the baby’s body through breast milk. The effects of the alcohol on the baby are linked to the amount of alcohol consumed by the mother. Moderate to heavy drinking (two or more alcoholic drinks per day) can impair the baby’s motor development and interfere with its weight gain. Moderate to heavy alcohol consumption can also interfere with the mother’s let-down reflex, or milk-ejection reflex.

  An occasional drink, however, may be safe as long as the mother avoids breastfeeding for two hours after the drink. Women planning to consume an alcoholic drink can pump their breast milk beforehand. This allows the mother to bottle-feed the baby with the breast milk. She should then express and discard the milk that is affected by the alcohol.

• Caffeine. Excessive amounts of caffeine (more than five 5-ounce cups of coffee per day) can cause fussiness and difficulty sleeping. Moderate caffeine intake (fewer than five 5-ounce cups of coffee), however, does not usually cause problems for a breastfeeding baby.
• Nicotine. The tobacco in cigarettes contains nicotine, an addictive substance that can be transferred to a baby through breast milk. Nicotine can also affect the amount of breast milk a woman produces. Women who smoke are encouraged to quit. For those who cannot quit, breastfeeding is still recommended because the benefits of breast milk outweigh the nicotine-related risks.
• Medication. Most medications can reach a baby through breast milk. As a result, women should discuss the safety of their medications with their physician, as well as their baby’s pediatrician. The effects of many medications have already been studied. A number of medications, including mood stabilizers and migraine medications, have been found to pass through the breast milk and cause harm to the baby. Many other medications (e.g., antibiotics, insulin, acetaminophen, progestin-only birth control pills), however, have been deemed safe. There are also many medications for which the safety status remains unknown.
  Physicians may be able to recommend alternative treatments that will not affect the baby. A woman using medication on a short-term basis may also be able to temporarily express and discard her breast milk while taking the medication. This will allow a mother to maintain her supply of breast milk while feeding her baby previously stored breast milk.
• Recreational drugs. Women who are breastfeeding should not use any form of illegal drug. Certain drugs, such as cocaine and PCP can intoxicate the baby through breastfeeding and cause serious side effects. Other drugs, such as heroine and marijuana, can cause irritability, difficulty sleeping, tremors and vomiting. In addition, the baby may become addicted to the drug.

In addition to limiting and avoiding certain substances, women who are breastfeeding should also follow a healthy diet. Breastfeeding mothers should take in about 2,700 calories a day because producing milk burns approximately 500 calories a day. Although fluid intake has no direct effect on breast milk production, women should drink a lot of fluids in order to stay hydrated.

Women who generally follow a healthy diet usually produce healthy breast milk, even if they fail to eat well at times. Women who have diets very low in vitamins and minerals may produce milk that is lower than normal in some vitamins. Undernourished women can improve the quality of their breast milk by improving their diets or taking vitamin supplements. Women following strict vegetarian diets may also need to increase their intake of vitamin B12 and be sure they are eating adequate amounts of protein.

Babies who are breastfeeding may have reactions to the foods their mothers eat (e.g., spicy foods, dairy products). Signs and symptoms of such reactions include diarrhea, rash, fussiness, gas, dry skin and green stools with mucus. In addition, the baby may also show signs of abdominal pain, such as pulling its knees up and screaming. Women can prevent these reactions by avoiding the foods that cause them. To help identify the foods that may be causing the problem, women can keep a record of what they eat and drink along with their baby’s reactions.

Increase feeding frequency. Breastfeed your baby at least every two hours during the day. If your baby has been napping for more than two hours, wake her up for a feeding. Consider waking your baby for at least one extra night feeding, too, especially if you have a baby who sleeps for more than a four or five hour stretch at night.

Don't wait for your breasts to "fill up" to determine when it's time for another feeding. There is always milk in your breasts for your baby, and more milk is made while you feed. Studies have shown that fat levels in milk are higher when the time between feedings is shorter. This means when you offer the breast again minutes after the last feeding (when your breasts may still feel "empty"), your baby is getting high-fat milk that will help him gain weight.

Offer the breast more often. The "law of supply and demand" that governs milk production implies that babies will demand the milk they need. Yet, this does not always work. Some babies, especially sleepy babies and those with mellow personalities, may not breastfeed as frequently as they need to without mother doing a bit of prodding. If this sounds like your baby, you need to take the lead and give your baby more frequent opportunities to nurse. Skin-to-skin contact, nap and night nursing, and sling feeding will help to stimulate longer, more frequent feedings.

Nurse longer. Don't limit the length of your baby's feedings to a predetermined number of minutes on each side. Allow your baby to finish the first breast before switching to the other side. This gives baby an opportunity to fill up on the high-fat hindmilk brought down by the milk-ejection reflex. If you switch your baby to the second side too soon, he'll fill up on the watery foremilk, which will make his tummy feel full but may not give him enough calories to grow.

Try switch nursing. The advice in the previous point about finishing the first breast first may not work well for babies who suck at a leisurely pace or who fall asleep a few minutes into a feeding. Switch nursing will encourage a baby to suck more vigorously for a longer period of time so that he gets more of the creamier, high-fat hindmilk. In switch nursing, you let the baby feed on the first breast until the intensity of his suck and swallow diminishes. Before he drifts off into comfort sucking, sit him up and switch him to the other breast and encourage him to nurse actively again. When his sucking slows, go back to the first breast, and finally, finish feeding on the other breast. Burp him or change his diaper between sides, if that will help to wake him.

Try double-nursing. This is an alternative to switch nursing. After you feed your baby and he seems finished, hold or carry him upright and awake for 10 to 20 minutes, allowing any trapped air bubbles to be burped up. This makes room for more milk. Then feed him again on both breasts before you let him go to sleep. Double nursing, like switch nursing, stimulates more milk ejection reflexes, thus increasing the volume and calorie content of your milk.

Undress baby during feedings. Skin-to-skin contact helps awaken sleepy babies and stimulates less enthusiastic feeders. Undress baby down to his diaper. To maximize skin contact, take off your bra and wear a shirt that you can unbutton all the way down the front. To prevent baby from getting chilled, place a blanket around his back.

Nap and night nurse. One of the most powerful ways to stimulate increased milk production is to "take your baby to bed and nurse." This relaxes both you and your baby and stimulates longer and more frequent nursings. It also increases your milk-producing hormones and reminds you that breastfeeding your baby is the most important thing you can do at this stage of your life together.

Sling feed. Naturally, keeping baby inches away from his favorite cuisine will entice him to eat more. Wear your baby in a baby sling between feedings, even when he is napping. In fact, some babies feed better and more often when on the move.

Get focused. Take inventory of your lifestyle. What activities and worries are draining away energy that could be better spent in caring for yourself and your baby? Are you trying to do too much, so that you're not taking enough time to sit down and feed and enjoy your baby? To make more milk for your baby, you have to make breastfeeding and taking care of yourself a priority. Let go of other responsibilities for a while. Have your partner share in non-feeding infant care, so that you can rest, take a walk, or take a shower.

Get household help. Get help with laundry, dishes, cooking, and cleaning. If you have a demanding toddler, hire a teen to come to your house after school to entertain your older child and give you a few hours of relief so you can sit and relax and nurse your baby.

No pacifiers, no bottles. When there are concerns about weight gain, all your baby's sucking should be done at the breast. Bottles of formula will interfere with the balance between your milk supply and baby's need, so will satisfying baby's sucking need with a pacifier. If it is medically necessary to give your baby supplementary feedings, try alternatives to bottles that don't involve artificial nipples.

Think baby, think milk. While you are feeding, stroke and calm your baby using a lot of skin-to-skin contact - a practice called grooming. Enjoy his sweet face and the feel of his skin. This will help your milk ejection reflex. The milk ejection reflex squeezes the milk you make out of the milk glands and down into the ducts and milk sinuses where it's available to the baby. Between breastfeedings and immediately before a feeding, imagine your infant nursing at your breast and your breasts pouring out milk to satisfy your baby.

Try herbs to increase your milk supply. There are no scientific studies that show that certain herbs will make you produce more milk, but some mothers and lactation consultants believe that certain herbs can stimulate your body to make more milk. Remember, though, that an herbal tea or other concoction can not substitute for more frequent nursing as a way to tell your body to make more milk.

Get professional help. Contact your local La Leche League Leader and/or a professional lactation consultant for tips on increasing your milk supply. A lactation consultant can help you evaluate your baby's latch-on and suck so you can be certain that baby is nursing effectively. Support from a La Leche League Leader or the other mothers in a La Leche League Group will help you feel more confident about your ability to nourish your baby.

Trust that nature's system works. If you're nursing often enough, and baby is sucking effectively, you will make enough milk. It's rare that a mother is unable to produce enough milk for her baby. And while it may seem that your life is stressful, mothers throughout history have breastfed their babies through war, famine, and personal tragedies. Your body nourished this baby through pregnancy. There's no reason to think that you won't succeed at breastfeeding.

Massaging your MER. Giving your breast just the right touch can help trigger your MER, especially if your breasts are engorged, your nipples are sore, or your baby is impatient

1. Apply a warm compress to your breast, such as a warm towel or cloth diaper soaked in warm water. Then, with your fingertips, stroke from the top of the breast down and over the nipple, using a light feather touch. This helps you relax and helps stimulate your oxytocin.

2. Using a motion similar to the one you use when examining your breasts, massage the milk-producing glands and ducts by pressing the breast firmly with the flat of the fingers into the chest wall, beginning at the top and working in a spiral down toward the areola. Massage in a circular motion a few strokes at a time before moving to another spot.

3. While leaning forward, gently shake your breasts, allowing gravity to encourage the stimulation to release milk.

1. Temporary Irritant or Sensitivity Common irritants include: chocolate (may also cause diarrhea), and "gassy" vegetables (for example, broccoli, cauliflower, bell peppers, and onions). If you suspect that your newborn is "fussy" or irritated by certain foods you're eating, one approach for determining the irritants, as well as providing useful information to your pediatrician, is to keep a food journal. Be sure to note each food, the quantity consumed, and both the time you ate it and the time you breastfed your baby. You may also want to note your infant's reaction and when it appeared to happen (during feeding, 1 hour later, etc.). If your baby is temporarily irritated by the foods you eat, it usually subsides as your baby grows and his/her gastro-intestinal track matures. Be sure to discuss possible irritants with your health care provider.
2. Allergic Reactions On rare occasions, newborns are allergic to foods (eggs, corn, dairy, soy, wheat, peanuts and tree nuts are the most common) passing through the breast milk. Symptoms of an allergic reaction may include vomiting, diarrhea, rash, irritability, gas, or blood in the stool. It can often take 2 weeks for an allergic irritant to clear out of your system, so eliminate a suspected food for two weeks, then try to monitor whether positive changes occur in your baby. Then, reintroduce foods one by one in order to isolate and determine a possible problem. Resume eating these foods in small amounts, and watch for symptoms to recur. Discuss your suspicions with your child's pediatrician.

• Cradle hold. This position requires the mother to hold her baby with its head on her forearm and its entire body facing hers. The baby’s head is supported in the crook of the mother’s arm. This position is comfortable for most mothers. Pillows can be used under the mother’s arm to support the baby.
• Cross-cradle hold. Also known as the transitional or crossover hold, this position requires a mother to hold her baby along the opposite arm of the breast she is using. The baby’s entire body should be facing hers. The baby’s head is then supported with the palm of the mother’s hand at the base of its neck. This position is recommended for mothers who are just beginning to breastfeed. It is also an ideal position for premature babies, or babies who are having difficulty latching-on.
• Clutch or “football” hold. This position requires the mother to hold her baby in her arm while nestling the baby close to her side. The baby should be lying on its back with its head at the level of the mother’s nipple. The baby’s head is then supported with the palm of the mother’s hand at the base of its head. This position is recommended for mothers with large breasts, inverted nipples and premature or small babies. It is also ideal for women who have had a C-section, and those with multiple infants who need to nurse two babies at a time.
• Side-lying position. This position requires a mother to lie on her side with the baby facing her. The baby is then pulled toward the breast. The mother’s lower arm can be used to cradle the baby’s back. This position is ideal for women who have had a C-section. It also allows the mother to rest or sleep while the baby nurses.

Women can receive instructions for these positions from a lactation consultant or other expert at the hospital. No matter what position a woman chooses, the baby’s mouth needs to be near the nipple and it should not have to turn its head in order to breastfeed. For most positions, the baby should be on its side, with its entire body facing the mother. Pillows can also be used under the arms, elbows, neck or back for support. Pillows can also be placed under the baby to help with positioning.

After the baby is positioned correctly near the nipple, the mother will need to ensure that it latches on (take the breast into his or her mouth) properly. This may be difficult if the breast is engorged, requiring the mother to press back the breast tissue for easier access to the nipple. A good latch-on is necessary to ensure that the baby is nursing successfully and without causing pain to the mother. During the first few weeks of breastfeeding, a mother will require practice and patience for a baby to latch-on well. It can become frustrating for both the hungry baby and mother if the baby is unable to latch-on to the breast and successfully nurse.

To properly latch on a baby, a mother should:

1. Support the breast with her hand by positioning her thumb on top and her other four fingers on the bottom. The fingers should be kept far back enough so that it leaves enough of the nipple and areola (the darker skin around the nipple) for the baby to latch on to. The mother may need to support her breast for the entire feeding.

2. Gently slide the nipple from the middle of the baby’s bottom lip, down to its chin. This will encourage the baby to open its mouth. The baby’s mouth should be opened wide with its tongue down. Then quickly bring the baby to the breast, chin first.

3. Make sure the baby has taken in as much of the areola as possible, with more areola showing at the top lip then at the bottom lip. The baby should not be latched on to the nipple only as this will not stimulate milk production. In addition, latching on to the nipple only will cause pain to the mother.

4. Make sure the baby’s nose is nearly touching the breast and not pressed against it. The baby’s lips should be turned out (flanged), not tucked in or under. If the positioning of the baby’s lips is unclear, gently press on the lower chin to pull the lower lip out. The baby’s tongue should be cupped under the breast. Then, listen for sounds of swallowing and look for movement along the baby’s lower jaw. There may also be visible movement at the junction of the baby’s temples and ears.

Once the baby has latched on properly, there may be 30 to 60 seconds of pain while the milk is “let down.” Often, the mother will feel a tingling sensation indicating the milk has reached the nipple and will be released with nursing. After this initial period, the pain should subside and the mother will only feel a tugging sensation as the baby sucks on the breast. If the pain continues, the baby is most likely latched on improperly. It may feel like the breast is being pinched. The mother should stop feeding and reposition the baby on the breast.

When the milk is first released from the nipple, it may come out in a quick burst. This amount may be difficult for the baby to handle and can cause the baby to cough. Some mothers find it helpful to hand express the first release of milk and begin nursing when the milk is produced in a slow, steady stream.

As it begins to nurse, a baby should give four or five sucks, followed by a five- to 10-second pause. As the amount of milk increases, so will the baby’s sucking. Once the flow of milk begins to slow, the baby may only give three or four sucks with pauses that last more than 10 seconds.

Babies usually release the breast on their own. When a baby does not release the breast, but its sucking appears limited to the front of its mouth, a mother can take the baby off by slipping her finger in the side of the baby’s mouth. The finger should be placed between the gums, then turned a quarter turn in order to break the suction. The suction may also be released by gently pressing down on the top of the breast near the areola. When it is latched on properly, a baby should not easily come off the breast.

Once the baby has finished nursing, the mother should try to burp the baby. The baby should then be placed on the other breast. A mother should also switch the baby to the other breast any time it no longer seems interested in eating or has difficulty with one breast. After the baby is finished with the second breast, the mother should make another attempt to burp the baby if the first try was unsuccessful. After nursing, the mother’s nipple should not appear flattened or creased. This may be a sign of an incorrect latch.

Newborn babies require frequent feedings, especially when being fed breast milk which is easily digested. Mothers will have to breastfeed at least every two hours. However, feedings should not be based on a schedule. A baby should be fed whenever it shows signs of hunger. Common signs of hunger include:

• Being more alert or active
• Mouthing (putting its hands or fists to its mouth and making a sucking motion with the mouth)
• Rooting (turning its head in search of a nipple)

In the later stages of hunger, a baby may also begin to cry. During the first few days, however, the baby will be sleepy and may not be awake to demonstrate any of these signs. For this period, the mother will need to wake the baby every one to two hours for feedings. In addition, the baby may fall asleep during feeding and may need to be awakened to continue nursing. With time, the baby will begin to establish a regular feeding schedule and nurse for a sustained period of time.

Most newborn babies want to breastfeed approximately eight to 12 times every 24 hours. This frequent feeding stimulates the breasts to produce a large amount of milk. Babies will begin to nurse less often as they get older, and begin to eat solid foods.

Mothers may wonder if their babies are consuming enough milk. A common method used to determine if a baby is eating enough is counting the number of wet and dirty diapers. In the first couple of days after birth, the baby should only have one to two wet diapers a day. By the third or fourth day after birth, the mother’s milk supply will increase. As a result, a baby should have at least five to six wet disposable diapers or six to eight wet cloth diapers. There should also be at least three to four bowel movements. With breastfeeding, the bowel movements are not formed but rather tan to brown liquid.

Although some weight loss is normal after birth, a healthy baby should not lose a lot of weight. A baby who loses more than seven to 10 percent of its birth weight during the first three to five days of life may not be getting enough nourishment. After the first week of life, there should be a steady weight gain of approximately four to eight ounces a week for the first three months. A baby’s weight will be monitored on well-baby visits, however, if a mother is concerned about growth, she should contact her baby’s pediatrician.

In general, a woman can feel confident that her baby is receiving enough milk because the breasts regulate the amount of milk the baby receives. For a baby who requires more frequent feedings, the breasts will increase the amount of milk they produce.

• Breast milk is custom made, the perfect nutrition, and therefore the best food for your baby. Because of its chemical makeup, your baby can easily digest and absorb the nutrients.
• The antibodies found in breast milk help to fight many infections, including: respiratory, urinary tract, ear, and blood infections. It also improves your child's immune system.
• Breast milk helps to prevent food allergies and sensitivities.
• Breastfed babies are almost never constipated. They rarely have diarrhea or gas.
• Because nursing requires more effort than sucking on a bottle, breastfeeding encourages better, jaw, tooth and palate development. Babies who are breastfed are less likely to get cavities later in childhood.
• Breast milk helps to prevent jaundice.
• There is a decreased risk of sudden infant death syndrome (SIDS), meningitis, ulcerative colitis, Crohn's disease, leukemia, lymphoma, obesity, and juvenile diabetes in breastfed babies.
• Breastfeeding appears to increase a child's IQ.

Benefits for Mom

• Breastfeeding helps to return your uterus to its normal size and it uses up fat stores.
• Breastfeeding burns calories and helps mom to lose weight and get back into shape.
• Breastfeeding is convenient. There is no mixing, measuring, and cleaning. There is no advanced planning or packing.
• Breastfeeding is economical since there are no bottles, nipples, or formula to buy. And half-emptied bottles or opened cans of formula are never wasted.
• There is less odor in baby's spit up and bowel movements.
• When mom breastfeeds, she experiences a decreased risk of breast cancer, ovarian cancer, and osteoporosis.
• Breastfeeding protects iron stores because it suppresses ovulation and menstruation. But it should NEVER be relied on for birth control.

When it comes to breastfeeding, preparation is the key. Talk with family and friends who have successfully breastfed. Check out breastfeeding books at your local library. And definitely sign up to take a breastfeeding class at a local hospital, taught by a certified lactation consultant. During this class you will learn the breastfeeding basics…the tips and techniques…the do's and don'ts. With hands-on instruction you will be exposed to different holding techniques, basic nipple and breast care, how to store breast milk, ways to determine if your infant is getting enough milk, and how and when to use a breast pump. You'll learn what to do if problems should arise, and know when it is necessary to call your doctor or the pediatrician.

So if you are among the growing number of women who have decided to breastfeed…CONGRATULATIONS! And it you are still undecided, here is one suggestion: try it---you may like it. Because best of all, you and your baby will have reaped many, many benefits…if only for 2 weeks or for 2 years.

• Wash your hands before expressing breast milk.
• Make sure all equipment used to store breast milk is properly cleaned.
• If you use a breast pump, review and follow the operation and cleaning instructions.
• Breast milk can be stored in glass bottles, hard plastic bottles or freezer bags. If using plastic freezer bags, use the bags that are designed specifically for storing breast milk. For breast milk stored in the refrigerator, use plastic bottles. The protective properties of breast milk are better retained in plastic. Breast milk can be frozen in either plastic or glass containers. However, glass is less likely to crack under freezer conditions. To allow for expansion, do not completely fill bottles when freezing.

Freshly pumped breast milk can be kept:

• 10 hours at room temperature below 72 degrees Fahrenheit.
• 4-8 hours at room temperature below 79 degrees Fahrenheit.
• 5-8 days in the refrigerator at 39 degrees Fahrenheit or below.
• 2 weeks in a freezer compartment inside the refrigerator.
• 3-4 months in a refrigerator-freezer with a separate door.
• 6-12 months in a deep freezer at temperatures below 0 degrees Fahrenheit.

Remember to date the expressed breast milk. Then use a rotating system of first-in, first-out. Also remember:

• Breast milk should be stored in small amounts. For infants 1-3 months old, store in 2 to 4 ounce portions. For older infants, 4 to 6 ounce portions can be used. This will help avoid wasting unused breast milk after feedings.
• Never pour body-temperature milk on the top of frozen milk. This could partially thaw the frozen milk and allow bacteria to grow. Instead, chill the breast milk and then add it to a container of already-frozen milk.
• Frozen breast milk can be thawed in the refrigerator, under warm running water from the faucet, or in a bowl of warm water.
• To warm breast milk, run lukewarm tap water over the bottle of milk or place it in a bowl of warm water. This will take the chill off the milk. Before feeding the breast milk, gently shake the container to ensure an even temperature and to mix the layers. It is common for breast milk to separate during storage. Use the breast milk within 24 hours and never refreeze it.
• Do not thaw or heat breast milk in a pan on the stove or in the microwave. Do not boil the breast milk. High heating temperatures (over 100 degrees Fahrenheit) can destroy nutrients and protective properties of the milk.
• Because bacteria from the baby's mouth can get into the milk, NEVER store and reuse a bottle of breast milk once your baby has been fed from that bottle. The bacteria can multiply and then make your baby sick.

Use the weight of the baby to estimate the amount of breast milk to leave for each feeding.

• Round the baby's weight to the nearest half pound.
• Multiply this weight in pounds by 3.
• Divide by 8 to get the number of ounces of breast milk to leave for each bottle-feeding.
• For example, if a baby weighs 12 pounds, 2 ounces: 12 X 3 = 36 36 divided by 8 = 4.5 Therefore leave 4-5 ounces of breast milk for each feeding.

I have small breasts, can I still breastfeed?

Breast size, small or large, makes no difference in the success of breastfeeding or the volume of milk production. Breast size depends on the amount of fat and fibrous tissue, not the amount of glandular tissue.

Will the bonding process with my baby be stronger if I breastfeed?

When done properly, either method, breast or bottle, can provide the adequate nourishment and strong emotional bond that growing babies need. The decision to breastfeed is a personal one. It takes into account the mother's lifestyle, economic situation, and cultural beliefs. If you aren't sure which approach to use, start with breastfeeding. If it isn't right for you, then switch to bottle-feeding. Starting with a bottle, and then trying to breastfeed later is very difficult.

How long will my child be on breast milk or formula?

The American Academy of Pediatrics and most health experts recommend breast milk or iron-fortified infant formula until the first birthday is reached. After that, it is OK to start cow's milk, but use whole cow's milk until age two.

Does my newborn baby need extra bottles of water?

Newborns need little or no extra water. Breast milk or infant formula usually supplies enough fluid. The exceptions are being exposed to hot weather and no air-conditioning. Your baby will lose body fluids by perspiring. Then offer 1-2 ounces of plain water after a feeding. Water should never take the place of breast milk or formula. When your baby begins eating solid food, you can also offer a little plain water, along with the meal.

How often will my baby nurse?

Be prepared to nurse very frequently during the first few months. A newborn will nurse every 2-4 hours, 24 hours a day. That adds up to 8-12 feedings each day. A newborn's stomach is small, and nutrient needs are high during this period of rapid growth and development.

Should I offer both breasts each time I feed?

Yes, the last portion of milk your baby drinks from each breast is called "hind milk". This milk is higher in fat and helps the baby to feel full and satisfied. Then release your baby from the breast by gently putting your finger into the corner of his mouth. This will break the suction without discomfort. Burp the baby and offer your other breast. Burp your baby again at the end of the feeding. Clip a safety pin to your bra as a reminder of which breast to offer first at the next feeding. This ensures that both breasts are emptied regularly.

How will I know when my baby is full?

When babies feel full and satisfied, they may close their lips, turn away, or even fall asleep.

Is it normal for a breast fed baby to have yellow stools?

Yes, a breastfed baby will have loose, yellowish stools, which may resemble watery "mustard seeds".

How will I know if my baby is getting enough milk when I breastfeed?

Following the third or fourth day after birth, your baby will have 6 or more wet, soppy diapers, soiled with light colored urine, every 24 hours. Your baby should be nursing 8-12 times, every 24 hours, during the first month. And your baby's weight will steadily increase.

Can I return to work and still breastfeed?

Many mothers continue to breastfeed after they return to work, but it will require an adjustment for mom and the baby. Some moms express milk during their workday so baby receives bottles of expressed breast milk when mom is away. Others moms decide to continue to breastfeed when they can be with the baby and have caregivers offer bottles of formula when they are away. And some babies may receive both bottles of expressed breast milk and formula. Choose the option that works best for you and your baby. And discuss your plan with your lactation consultant.

• Select a caregiver for your baby who is supportive of breastfeeding.

• Plan to nurse before work, soon after work, and during the evening to keep your milk supply strong.

• Before you return to work, help your baby to learn to take expressed breast milk or formula from a bottle. Begin this at about 3-4 weeks. Experiment with different types of nipples to find a type that your baby prefers. This is the perfect time for dad to get involved in the feedings.

Can I breastfeed if I had a breast reduction?

Many women who have had breast reductions are able to breastfeed, though most do not produce enough milk to nurse exclusively. It will depend in part on how extensive the reduction was, where the incision was made, and how the procedure was preformed. If care was taken to preserve milk ducts and nerve pathways, chances are good that you will be able to produce at least some milk. Check with your surgeon. You should also work with a lactation consultant who has experience in this area. You will also want to monitor closely the baby's growth and development, the number of wet diapers, and the number of dirty diapers each day. Work closely with your pediatrician to make sure your baby's needs are being met. Even if you have to supplement your baby's diet with formula, remember that your baby is still getting some of the extra benefits of breast milk.

Can I breastfeed if I had breast implants?

Breast augmentation is far less likely to interfere with breastfeeding than a breast reduction. Most women are able to produce sufficient milk to feed the baby. However, some women may not produce enough milk and will need to supplement with formula. Monitor closely your baby's growth and development, number of wet diapers, and the number of dirty diapers each day. Work closely with your pediatrician to make sure your baby's needs are being met.

My doctor says that I will have a cesarean birth, can I still breastfeed?

Yes, you can. You may find breastfeeding after a cesarean birth to be uncomfortable at first. There will be less pain if you try to avoid putting pressure on the incision area. One of these positions may help: place a pillow on your lap under the baby, lie on your side, or use the football hold (supported with a pillow). While at the hospital, work with the lactation consultant to find a position that feels best for you.

Can I have an occasionally glass of wine while breastfeeding?

Yes, you can, but alcohol should be limited. Have a single drink only on occasion. Heavy drinking or binge drinking should always be avoided. It can make the baby drowsy and depress the nervous system. It will also slow motor development and reduce your milk supply. If you do have a drink, have it right after nursing and try not to nurse again for at least two hours.

Do I need to avoid any foods if I breastfeed?

Your breastfeeding diet is very important to the health of your baby. Eat a nutritious diet and continue to take your prenatal supplements. Avoid foods in your diet that irritate your baby by causing gas. This is very individualized. Garlic, onions, cabbage, broccoli, cauliflower, chocolate, and certain spices are sometimes common offenders. However, many babies are not bothered by these foods at all. Remember to limit or avoid alcohol. If possible, do not smoke. Do not take any medications without first checking with your doctor and your baby's pediatrician. Cut down on caffeine. Limit yourself to 1 or 2 caffeinated beverages a day. Caffeine is stored in the baby's body and not eliminated quickly. This can cause your baby to be jittery, irritable, or have difficulty sleeping.

Can I get pregnant while breastfeeding?

Yes you can. Although breastfeeding women resume normal menstrual cycles later than those who do not breastfeed, it is not a reliable form of birth control. There is no way to predict when you will ovulate and have your first post-baby period. Therefore, contraceptive caution is highly advisable.

By Becky Hand, Registered and Licensed Dietician