Companion Information to the Video, "Breastfeeding, a Guide to Getting Started"

by Jane Morton, MD

This material was developed by Jane Morton, MD and produced for educational purposes only.  Reproduction for commercial purposes is prohibited.  Utilization and copying of the materials to improve care of pregnant women and their newborns is encouraged with proper citation of source.

 

The ABCs of Breastfeeding

Getting Started - Position and Latch

Checklist for Latching On

Hand Expression of Breast Milk

How You Know If You Have Enough Milk

Common Breastfeeding Mistakes

When Breastfeeding is Not Successful

Breastfeeding Resources

The ABCs of Breastfeeding

A

Assistance.   Your baby will need to learn how to position your breast far back in his (or her) mouth, so that he can feed effectively, not just use the nipple as a pacifier.                         

B

Breastmilk.   The small amount of colostrum, (or early milk) less than a teaspoon is about what a baby takes with each good breastfeeding in the first couple of days. That amount is exactly right to meet his needs.

C

Contact.    Research shows the following benefits of holding your baby skin-to-skin:

• helps your baby sleep more
• helps you sleep more 
• helps your baby learn to breastfeed sooner
• keeps your baby at the perfect body temperature
• increases your milk production

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Getting Started -- Position and Latch

HOW DOES A BABY BREASTFEED?

When a baby uses a bottle, he uses his cheeks to create suction to remove the milk. (Try sucking on your thumb and notice how your lips become pursed and your cheeks cave in.) However, when a baby breastfeeds, his cheeks are relaxed and his mouth is wide open while his tongue and lower jaw massage the milk from the breast. (Try sucking on your forearm and notice how your jaw moves and your cheeks relax.)

As the baby nurses, a muscular wave starts at the tip of the baby’s tongue and moves backward. This rhythmical rolling action of the tongue and jaw massages the breast, squeezing the milk that lies in tiny pools beneath the areola into the nipple.                                                             

To be effective, the baby needs to take more than the nipple into his mouth. He needs to get far enough onto the breast so that his lower jaw and tongue can massage the pools of milk that lie in the lower part of the areola. If he is on well, less of the areola will be visible below the lower lip than above his top lip.

Poor Latch -- lips are <90° angle, lower lip is just below nipple.

Good latch -- lips are >120° angle, lower lip covers more areola.

If the baby sucks on the nipple only, he will suck on the nipple like a pacifier without drawing out milk. Sucking on the breast as on a bottle does not really work because the pools of milk are not being massaged into the nipple.  Also, when the baby sucks on the nipple only, it may be painful for the mother because the tongue and jaw, instead of massaging the breast, are rubbing the nipple and making it sore. (photo of typical nipple trauma from poor latch). Remember that pain is really a sign that something is wrong. Nature would not design a system where it hurts to feed a baby.

THE FIRST FEW DAYS AFTER BIRTH:  TWO REASONS TO NURSE RIGHT AWAY

There are two reasons to give a baby lots of practice during these first three days. The first reason is that it will be easier for him to learn how to latch on when the breasts are soft; secondly, because the breasts need to be stimulated by his nursing to produce enough milk for later.

The system nature has designed for learning breastfeeding makes a lot of sense. A baby is born with extra protective stores of water and nutrition, so that he will only need the small amount of colostrum (early milk) that his mother has available for him during the first few days. Since her milk production is not fully established, a mother’s breasts are still soft and the baby can easily learn to latch on correctly. A typical baby will need a little hands-on help at first.

A GOOD POSITION FOR YOU AND YOUR BABY

1. Sit straight up in your (comfortable) chair. Place the pillow on your lap.  Have the glass of water within easy reach. Put on some relaxing music.
2. Put your baby on the pillow. Take off his wraps so he’s easier to manage and stays awake.
3. When nursing with your right breast, hold your baby with your left arm. With his bottom tucked under your elbow, place your left arm along his back.  With the palm of your hand on the baby’s upper back and shoulders, your thumb and index finger should make a comfortable “C” around the base of his skull.
4. Lying horizontally on the pillow, with his head at the same level as his bottom, your baby should be tummy to tummy with you with his nose opposite your nipple. (Any higher up and you will be forcing him to flex his neck to nurse.)

Holding baby with fingers in "C" shape

THE PERFECT POINT FOR A PERFECT LATCH-ON

Here’s a valuable tip! When a baby is latched onto the breast perfectly, the tip of your nipple will be at the PERFECT POINT.  Imagine a line from the tip of your baby’s nose to his ear lobe.  Right at the midpoint of that line, far back towards the root of the baby’s mouth, is the PERFECT POINT:

When your nipple is at the PERFECT POINT, your baby will have latched on to the right part of the breast, the lower areola. A further benefit is that your nipple will be protected from the rubbing motion of the tongue.

Correct Latch: With his head tipped up, the baby reshapes the breast in his mouth.The baby’s tongue can now massage the area of the breast below the nipple, which is drawn back to the perfect point.

Nipple trauma resulting from a poor latch, where baby is sucking on the nipple instead of massaging the breast below the nipple.

HOLDING AND SHAPING THE BREAST FOR EASY LATCH ON

1. To shape the breast for easy latch on, place your left hand below your left breast with your thumb at the 3 o’clock position and your index finger at the 3 o’clock position. You will be compressing your breast in a “U” hold. (You may find it helpful to place band aid markers so that you can feel as well as see the right placement spots — make sure the markers are at least one or two inches away from the areola.)

A “U” hold to sandwich the breast to fit easily into the baby’s mouth.

2. Keep your index finger and thumb at least one or two inches back from the areola and the rest of your hand close to your body. That way your fingers and hand won’t be in the way of your baby.

3. Compress (gently squeeze) your breast with these two fingers, making a shape that will fit in the baby’s mouth.  You will be narrowing the width of the areola, making it an oval shape.  When the areola is deeply wrinkled, there will be more “give” to the nipple. A partner can help you shape the breast by holding the breast (far back from the areola) from above, with fingers parallel to the baby’s lips.  This works well for even a tiny baby.

4. Your fingers should be parallel with the baby’s lips. In this way, the oval shape of the breast should be parallel and not at an angle to the baby’s lips.  Think of how you hold a sandwich parallel to your lips before you take a bite.

"U" hold with a partner helping shape the breast from above. The mother uses this same position, but from below.

NOTE: If you shape your breast incorrectly by making a “C” instead of a “U”, the shape of the breast will not fit the baby’s mouth. This would be like trying to take a bite of a sandwich held vertically rather than horizontally.

LATCHING ON

1. Gently touch your baby’s upper lip with the nipple.
2. Wait for him to drop his jaw and tip his head up as he searches for the nipple.
3. Bring him to the breast at the moment his mouth is wide open. (Bring the baby to the breast, not the breast to the baby.)
4. Bring him to the breast in such a way that his lower jaw is far below the nipple, NOT at the base of the nipple.
5. Get the nipple far back in the mouth, right at the PERFECT POINT.  His chin, not his nose, should be pressed into the breast.

ONCE HE LATCHES ON

1. Continue to hold onto the compressed breast until your baby has started sucking.
2. After the baby begins nursing and seems to be latched on the right way, you can relax your fingers on the breast.
3. If your baby is holding the breast in his mouth without a problem, you can slide your left hand out from below the breast and bring your arm to a comfortable place under his head.
4. Holding your baby close to you, sit back and put your feet on the stool.

CAUTION: If at any time your nipple starts hurting, that probably means he has slipped off the right latch on position and has started sucking on the nipple only. Take your baby off by pulling the corner of his mouth to break the suction, and try again.

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Hand Expression of Breastmilk

There are many reasons to learn hand expression. In the first couple of days, if you are having trouble helping your baby latch on to your breast, hand express small amounts of colostrum onto a plastic spoon and give it to your baby. If your breasts become engorged, you will need to lessen this hardness by expressing milk. By expressing, you will soften the breasts and make it easier for the milk to flow.  If your breasts are hard, your baby may try to latch on and fail, or may try to start the flow of milk without success, causing him to fuss and cry or just give up and go to sleep. In order to make it easier for him, this is how you can soften the breast before you begin nursing.

To express milk, place your fingers, with your thumb and index finger one to two inches back from the areola (the dark-skinned area).  As you bring your fingers together, bring your hand backward and inward toward your
chest, instead of outward toward your nipple. Keep in mind that what you are doing is applying pressure in back of the pools of milk that lie underneath the areola.  Your milk will take a minute or so before it begins dripping.  After you have expressed enough milk so that the breasts have softened, compress the breast with the “U” hold described above so that your baby can latch on. If your baby becomes fussy or sleepy as you are trying to nurse him, squeeze some milk onto his lips or into his mouth to remind him of what he’s supposed to be doing.

 
Bring the pads of the thumb and index finger together as you pull in towards your chest, not pulling out towards your nipple. Repeat the motion rhythmically until the drops appear.

HOW OFTEN AND HOW LONG TO NURSE

Since every mother and baby are different, there are no hard and fast rules for how often and how long to nurse.  However, here are some general guidelines.

1. Try to nurse your baby (using both breasts) at least eight times a day starting from day one. This is the best way to stimulate milk production.
2. Nursing for longer periods of time (over 40 minutes) less often is not as effective for stimulating milk production as nursing for shorter periods of time more frequently.
3. In the first two to three days, a baby will “cluster” his nursing sessions by nursing very often for several hours in the day and then sleeping for a long time. This is normal. However, nurse at least eight times a day in order to stimulate milk production.  By the third to fourth day after your milk has come in, nursing will fall into a pattern.  Although all babies don’t follow the same pattern, a common one would be the baby who nurses eight to 12 times per day for about 30 minute sessions. Nurse your baby until he seems to be full and relaxed.
   

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How You Know If You Have Enough Milk

Remember that milk production increases by the end of the third or fourth day. Some signs that you are producing enough milk are:

1. You will hear your baby swallowing fairly often.
2. Your baby will have a sustained rhythm of suck-swallow, suck-swallow  . . . with a few pauses here and there.
3. By the fifth to sixth day, your baby will have several liquid or curdled BRIGHT YELLOW bowel movements and many wet diapers.
4. By the fifth day, your baby will nurse vigorously and then fall asleep without fussing. (If he is still sucking on his fists or needing a pacifier, he is still hungry.)
5. Babies normally lose weight during the first week and regain their birth weight by about day ten.
   
   CAUTION: If you are not seeing these signs, your baby may not be getting enough milk. See your primary care provider right away.

FOUR COMMONLY USED DRUGS MAY REDUCE YOUR MILK PRODUCTION.

• Birth contol pills
• Pseudoephedrine (found in many over the counter cold and allergy medicines)
• Nicotine
• Alchol

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Common Mistakes

Believing a baby doesn’t like breastfeeding because he cries or falls asleep after one or two sucks.

ANSWER: It is common for a baby to act like this, and it usually means he needs more “hands-on” help to position the nipple far back in his mouth and get the milk flow started. Some babies stop after two to three sucks if they are not latched on well. If he easily slips off the breast and does not have a secure suction, he was not latched on well to begin with. Some babies give up too soon because they can’t easily get milk to flow from the engorged breast. Help him by getting the milk flowing before he gets on and make sure he is securely latched onto the breast.

Holding the breast at an angle.

ANSWER: Make sure your fingers are parallel with your baby’s lips so that the shape of the breast will be the same as the shape of his mouth. If your fingers are not parallel, the shape of the breast will not comfortably fit in the baby’s mouth. This would make his nursing as difficult as your trying to eat a sandwich held at an angle. If he is lying horizontally across your chest, hold the breast so the areola looks like

This. . .

     

       

Not This …

Remember: don’t relax your fingers until your baby has drawn the nipple far back to the PERFECT POINT and has started sucking.

 

Trying to get all the areola into your baby’s mouth.

ANSWER: You might be positioning the baby’s upper lip so high that the lower lip just fits below the base of the nipple. Instead, keeping your eye on your baby’s lower lip, bring him to the breast, making sure that you get him to latch onto the area below the nipple more than the area above.

 

Holding the baby in such a way that he is flexing his neck (tipping his head down).

ANSWER: If the baby has his head bent down, it will be harder to get your nipple back to that PERFECT POINT.  More likely, your nipple will only be angled downward toward the baby’s tongue and jaw.  Instead, start off with the baby looking straight ahead with his nose pointing toward your nipple. Now, when he tips his head up slightly, the nipple will be much closer and angled toward the PERFECT POINT. His chin will be pressing into your breast more than his nose when you bring him to the breast.

 

Bringing your baby to the breast before his mouth is wide open.

ANSWER: Encourage your baby to open his mouth by touching your nipple to his upper lip or by expressing a few drops of milk onto his lip. When his mouth opens wide, quickly bring him to the breast.  But if he has taken only the nipple, take him off the breast and start again.  Attempts to push more breast into his mouth by moving him closer or moving his lower lip are not likely to work.  Start over and wait for him to drop his jaw before bringing him to you.

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If Breastfeeding is Not Successful

If your baby is not able to latch on well in the first few days, it is very important to pump eight times each day until your baby is able to nurse. For many reasons, some babies get a slow or late start and still go on to breastfeed effectively – but only if your production is good. If your baby is unable to nurse from the first day, ask for help and begin to pump, ideally with an electric pump.  Do not worry if you get nothing in the first couple of days with pumping.  You are encouraging your milk supply for the future.

SUPPLEMENTATION
There are medical reasons babies’ diets need to be supplemented. Perhaps you have a small (less than six pounds) or preterm baby, who is too small to stimulate your milk supply and needs more calories before your milk comes in.  Perhaps your baby has low blood sugar.  Perhaps you are separated from your baby. 

In the case of the small or preterm baby, you and your baby’s doctor may want to supplement the baby after breastfeeding to increase his calories.  The goal is to give your baby the opportunity to learn to breastfeed, while providing extra calories from expressed milk or formula.  You may also decide to pump after every breastfeeding (eight times a day).  The purpose is to provide extra stimulation to your breasts, so your milk supply will be generous enough for a small baby to feed easily exclusively at the breast, once your milk “comes in,” around the third day. The sooner you begin pumping, and the more frequently you pump, the better.

The average, healthy term baby without a medical problem should not need supplementation. If there are reasons that make you and your baby’s doctor think formula supplementation is appropriate, consider these four points:

1. Offer the smallest amount needed to settle your baby, usually less than an ounce.
2. Offering it by spoon, medicine cup, syringe or tube, rather than bottle, may be less likely to interfere with his
learning to breastfeed.
3. Choose a low-allergenic formula, if you have a strong family history of allergy.
4. Pump at least eight times a day, to make up for the stimulation your baby would otherwise be giving
with nursing.

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Breastfeeding Resources

Nursing Mother’s Council (650) 327-6455

La Leche League International (650) 363-1470

WIC (650) 573-2168

800-994-WOMAN….
this toll-free number offers trained lactation specialists to answer any question regarding breastfeeding

Up to date health news and breastfeeding information: www.4woman.gov

The American Academy of Pediatrics’ reference book:
“New Mother’s Guide to Breastfeeding, American Academy of Pediatrics.” Meeks JY. Tippins S. Bantam Books,
New York, 2002.

National Library of Medicine information on drugs and breastfeeding

The video "Breastfeeding, A Guide to Getting Started" can be purchased at www.breastmilksolutions.com

JMortonMD, reviewed 6/06 

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