The vast majority of mothers are perfectly capable of breastfeeding their babies exclusively for four to six months. In fact, most mothers produce more than enough milk. Unfortunately, outdated hospital routines based on bottle feeding still predominate in many health care institutions and make breastfeeding difficult, even impossible, for some mothers and babies. For breastfeeding to be well and properly established, a good early few days can be crucial. Admittedly, even with a terrible start, many mothers and babies manage.

The trick to breastfeeding is getting the baby to latch on well. A baby who latches on well, gets milk well. A baby who latches on poorly has difficulty getting milk, especially if the supply is low. A poor latch is similar to giving a baby a bottle with a nipple hole which is too small—the bottle is full of milk, but the baby will not get much. When a baby is latching on poorly, he may also cause the mother nipple pain. And if he does not get milk well, he will usually stay on the breast for long periods, thus aggravating the pain. Here are a few ways breastfeeding can be made easy:

1. The baby should be at the breast immediately after birth. The vast majority of newborns can be put to breast within minutes of birth. Indeed, research has shown that, given the chance, babies only minutes old will often crawl up to the breast from the mother’s abdomen, and start breastfeeding all by themselves. This process may take up to an hour or longer, but the mother and baby should be given this time together to start learning about each other. Babies who "self-attach" run into far fewer breastfeeding problems. Incidentally, studies have also shown that skin to skin contact between mothers and babies keeps the baby as warm as an incubator.
   
   
2. There is no evidence that mothers who are separated from their babies are better rested. On the contrary, they are more rested and less stressed when they are with their babies. Mothers and babies learn how to sleep in the same rhythm. Thus, when the baby starts waking for a feed, the mother is also starting to wake up naturally. This is not as tiring for the mother as being awakened from deep sleep, as she often is if the baby is elsewhere when he wakes up.
   
   The baby shows long before he starts crying that he is ready to feed. His breathing may change, for example. Or he may start to stretch. The mother, being in light sleep, will awaken, her milk will start to flow and the calm baby will be content to nurse. A baby who has been crying for some time before being tried on the breast may refuse to take the breast even if he is ravenous. Mothers and babies should be encouraged to sleep side by side in hospital. This is a great way for mothers to rest while the baby nurses. Breastfeeding should be relaxing, not tiring.
   
   
3. Artificial nipples should not be given to the baby. There seems to be some controversy about whether "nipple confusion" exists. Babies will take whatever method gives them a rapid flow of fluid and may refuse others that do not. Thus, in the first few days, when the mother is producing only a little milk (as nature intended), and the baby gets a bottle (as nature intended?) from which he gets rapid flow, he will tend to prefer the rapid flow method. Nipple confusion includes not just the baby refusing the breast, but also the baby not taking the breast as well as he could and thus not getting milk well and /or the mother getting sore nipples. Just because a baby will "take both" does not mean that the bottle is not having a negative effect. Since there are now alternatives available if the baby needs to be supplemented (see handout #5 Using a Lactation Aid, and handout #8 Finger Feeding) why use an artificial nipple?
   
   
4. No restriction on length or frequency of breastfeedings. A baby who drinks well will not be on the breast for hours at a time. Thus, if he is, it is usually because he is not latching on well and not getting the milk which is available. Get help to fix the baby’s latch, and use compression to get the baby more milk (handout #15 Breast Compression). This, not a pacifier, not a bottle, not taking the baby to the nursery, will help.
   
   
5. Supplements of water, sugar water, or formula are rarely needed. Most supplements could be avoided by getting the baby to take the breast properly and get the milk that is available. If you are being told you need to supplement without someone having observed you breastfeeding, ask for someone to help who knows what they are doing.
   
   
6. A proper latch is crucial to success. This is the key to successful breastfeeding. Unfortunately, too many mothers are being "helped" by people who don’t know what a proper latch is. If you are being told your two day old’s latch is good despite your having very sore nipples, be skeptical, and ask for help from someone who knows.
   
   Before you leave the hospital, you should be shown that your baby is latched on properly, and that he is actually getting milk from the breast and that you know how to know he is getting milk from the breast (open—pause—close type of suck). If you and the baby are leaving hospital not knowing this, get help quickly.
   

Handout #1. Breastfeeding Starting Out Right. Revised January 1998

Written by Jack Newman, MD, FRCPC

Colic in the Breastfed Baby

Colic is one of the mysteries of nature. Nobody knows what it really is, but everyone has an opinion. In the typical situation, the baby starts to have crying periods about two to three weeks after birth. These occur mainly in the evening, and finally stop when the baby is about 3 months of age (occasionally older ). When the baby cries, he is often inconsolable, though if he is walked, rocked or taken for a drive, he may settle temporarily. For a baby to be called colicky, it is necessary that he be gaining weight well and be otherwise healthy.

The notion of colic has been extended to include almost any fussiness or crying in the baby, and this may be valid, since we do not really know what colic is. There is no treatment for colic, though many medications and behaviour strategies have been tried, without any proved benefit. It is admitted that everyone knows someone whose baby was cured of colic by a particular treatment. It is also admitted that almost every treatment seems to work—for a short time, anyhow.

The Breastfeeding Baby with Colic

Aside from the colic that any baby may have, there are three known situations in the breastfed baby which may result in fussiness or colic. Once again, it is assumed that the baby is gaining adequately and that the baby is healthy.

1. Feeding Both Breasts at Each Feeding
   
   Human milk changes during a feeding. One of the ways in which it changes is that the amount of fat increases as the baby nurses longer at the breast. If the mother automatically switches the baby from one breast to the other during the feed, before the baby has "finished" the first side, the baby may get a relatively low amount of fat during the feeding. This may result in the baby getting fewer calories, and thus feeding more frequently. If the baby takes in a lot of milk (to make up for the reduced concentration of calories), he may spit up. Because of the relatively low fat content of the milk, the stomach empties quickly, and a large load of milk sugar (lactose) arrives in the intestine all at once. The protein which digests the sugar (lactase) may not be able to handle so much milk sugar at one time and the baby will have the symptoms of lactose intolerance--crying, gas, and explosive, watery, greenish bowel movements. This may occur even during the feeding. These babies are not lactose intolerant. They have problems with lactose because of the sort of information women get about breastfeeding. This is not a reason to switch to lactose free formula.
   
   
   • Do not time feedings. Mothers all over the world have breastfed babies successfully without being able to tell time. Breastfeeding problems are greatest in societies where everyone has a watch and least where no one has a watch.
     
     
   • The mother should feed the baby on one breast, as long as the baby breastfeeds, until the baby comes off himself, or is asleep at the breast. If the baby feeds for only a short time only, the mother can compress the breast (handout #15 Breast Compression) to keep the baby nursing. Please note that a baby may be on the breast for two hours, but may actually feed for only a few minutes. In that case the milk taken by the baby may still be relatively low in fat. This is the rationale for compressing the breast. If, after "finishing" on the first side, the baby still wants to feed, offer the other side.
     
     
   • The next feeding, the mother should start the baby on the other breast in the same way.
     
     
   • The mother's body will adjust quickly to the new method, and she will not become engorged or lop sided.
     
     
   • Just as there should be no "rule" for feeding both breasts at each feeding, there should be no rule for one breast per feeding. Let the baby finish on one breast (compress milk into his mouth if necessary to keep him swallowing longer) but if he wants more, then offer the other side.
     
     
   • In some cases, it may be helpful to feed the baby two or more feedings on one side before switching over to the other side for two or more feedings.
     
     
   • This problem is made worse if the baby is not well latched on to the breast. A proper latch is the key to easy breastfeeding.
   
   
2. Overactive Letdown Reflex
   
   A baby who gets too much milk too quickly, may become very fussy, very irritable at the breast and may be considered "colicky". Typically, the baby is gaining very well. Typically, also, the baby starts nursing, and after a few seconds or minutes, starts to cough, choke or struggle at the breast. He may come off, and often, the mother's milk will spray. After this, the baby frequently returns to the breast, but may be fussy and repeat the performance. He may be unhappy with the rapid flow, and impatient when the flow slows. This can be a very trying time for everyone. On rare occasions, a baby may even start refusing to take the breast after several weeks, typically around three months of age.
   
   What can be done?
   
   
   • If you have not already done so, try feeding the baby one breast/feed. In some situations, feeding even two or three feedings on one breast before changing to the other breast may be helpful. If you experience engorgement on the unused breast, express just enough to feel comfortable.
     
     
   • Feed the baby before he is ravenous. Do not hold off the feeding by giving water (a breastfeeding baby does not need water even in very hot weather) or a pacifier. A ravenous baby will "attack" the breast and cause a very active letdown reflex. Feed the baby as soon as he shows any sign of hunger. If he is still half asleep, all the better.
     
     
   • Feed the baby in a calm, relaxed atmosphere, if possible. Loud music, bright lights and lots of action are not conducive to a successful feeding.
     
     
   • Lying down to nurse sometimes works very well. If lying sideways to feed does not help, try lying flat on your back with the baby lying on top of you to nurse. Gravity helps decrease the flow rate.
     
     
   • If you have time, express some milk (an ounce or so) before you feed the baby.
     
     
   • The baby may dislike the rapid flow, but also become fussy when the flow slows too much. If you think the baby is fussy because the flow is too slow, it will help to compress the breast to keep up the flow (handout #15 Breast Compression).
     
     
   • This problem is made worse if the baby is not well latched on to the breast. A good latch is the key to easy breastfeeding.
     
     
   • On occasion giving the baby commercial lactase (the enzyme that metabolizes lactose), 2-4 drops before each feeding, relieves the symptoms. It is available without prescription, but fairly expensive, and works only occasionally.
     
     
   • A nipple shield may help, but use this only if nothing else has helped and only if you have gotten good help without any relief.
     
     
   • As a last resort, rather than switching to formula, give the baby your expressed milk by bottle.
     

Handout #2 Colic in the breastfed baby. Revised January 1998

Written by Jack Newman MD, FRCPC

Sore Nipples

Introduction

The best treatment of sore nipples is prevention. The best prevention is latching the baby on properly from the first day.

Sore nipples are usually due to one or both of two causes. Either the baby is not positioned and latched properly, or the baby is not suckling properly, or both. Incidentally, babies learn to suck properly by getting milk from the breast when they are latched on well. (They learn by doing). Fungal infection (due to Candida albicans), may also cause sore nipples. The soreness caused by poor latching and ineffective suckle hurts most as you latch the baby on and usually improves as the baby nurses. The pain from the fungal infection goes on throughout the feed and may continue even after the feed is over. Women describe knifelike pain from the first two causes. The pain of the fungal infection is often described as burning, but may not have this character. Sudden, unexplained onset of nipple pain when feedings had previously been painless is a tipoff that the pain may be due to a yeast infection, but the pain may come on gradually or may be superimposed on pain due to other causes. Cracks may be due to a yeast infection.

Proper Positioning and Latching

It is not uncommon for women to experience difficulty positioning and latching the baby on. Proper positioning facilitates a good latch and good latching reduces the baby's chances of becoming "gassy", and also allows the baby to control the flow of milk. Thus, poor latching may also result in the baby not gaining adequately, or feeding frequently, or being colicky (handout #2 "Colic in the Breastfed Baby).

Positioning—For the purposes of explanation, let us assume that you are feeding on the left breast.

Good positioning facilitates a good latch. A lot of what follows under latching comes automatically if the baby is well positioned in the first place.

At first, it may be easiest to use the cross Fortis La Femme hold to position your baby for latching on. Hold the baby in your right arm, the web between your thumb and index finger behind the nape of his neck (not behind his head) with your fingers (except for the thumb) supporting the baby's face from underneath, and your forearm supporting his back and buttocks. Hold the baby's buttocks between your chest and your forearm—this should give you good control. The baby should be almost horizontal across your body and should be turned so that his chest, belly and thighs are against you with a slight tilt so the baby can look at you. Hold the breast with your left hand, with the thumb on top and the other fingers underneath, fairly far back from the nipple and areola.

The baby should be approaching the breast with the head just slightly tilted backwards. The nipple then automatically points to the roof of the baby's mouth. (See handout on positioning and latching on)

Latching

1. Now, get the baby to open up his mouth wide. The way to do this is to run your nipple, still pointing to the roof of the baby's mouth, along the baby's mouth, very lightly, from one corner of the mouth to the other. Or you can run the baby along your nipple, something some mothers find easier. Wait for the baby to open up as if yawning. WAIT FOR HIM. As you bring the baby toward the breast, his chin should touch your breast first.
   
   
2. When the baby opens up his mouth, use the arm that is holding him to bring him onto the breast. Don't worry about the baby's breathing. If he is properly positioned and latched on, he will breathe without any problem. If he cannot breathe, he will pull away from the breast. Don't be afraid to be vigorous.
   
   
3. If the nipple still hurts, use your index finger to pull down on the baby's chin in order to bring the lower lip out. You may have to do this for the duration of the feed, but this is usually not necessary.
   
   
4. The same principles apply whether you are sitting or lying down with the baby or using the football hold. Get the baby to open wide, don't let the baby latch onto the nipple, but get as much of the areola (brown part of breast) into the mouth as possible (not necessarily the whole areola).
   
   
5. There is no "normal" length of feeding time. If you have questions, call the clinic.
   
   
6. A baby properly latched on will be covering more of the areola with his lower lip than with the upper lip.

Improving the baby's suckle

The baby learns to suckle properly by nursing and by getting milk into his mouth. The baby's suckle may be made ineffective or not appropriate for breastfeeding by the early use of artificial nipples or from poor latching on from the beginning. Some babies just seem to take their time developing an effective suckle. Suck training and/or finger feeding (handout #8 Finger Feeding) may help.

"My nipple turns white after the baby comes off the breast"

The pain associated with this blanching of the nipple is frequently described by mothers as "burning", but generally begins only after the feeding is over. It may last several minutes or more, after which the nipple returns to its normal colour, but then a new pain develops which is usually described by mothers as "throbbing". The throbbing part of the pain may last for seconds or minutes and may even blanch again. The cause would seem to be a spasm of the blood vessels in the nipple (when the nipple is white), followed by relaxation of these blood vessels (when the nipple returns to its normal colour). Sometimes this pain continues even after the nipple pain during the feeding no longer is a problem, so that the mother has pain only after the feeding, but not during it. What can be done?

1. Pay careful attention to getting the baby to latch onto the breast properly. This type of pain is almost always associated with, and probably caused by whatever is causing your pain during the feeding. The best treatment is the treatment of the other causes of nipple pain.
   
   
2. Heat (hot washcloth, hot water bottle, hair dryer) applied to the nipple immediately after nursing may prevent or decrease the reaction. Dry heat is usually better than wet heat, because wet heat may cause further damage to the nipples.
   
   
3. On occasion, we have had to use a medicated paste (nitroglycerine) or an oral medication (nifedipine) to prevent this type of reaction.

General Measures

1. Nipples can be warmed for short periods of time after each feeding, using a hair dryer on low setting.
   
   
2. Nipples should be exposed to air as much as possible.
   
   
3. When it is not possible to expose nipples to air, plastic dome-shaped breast shells (not nipple shields) can be worn to protect your nipples from rubbing by your clothing. Nursing pads keep moisture against the nipple and may cause damage that way. They also tend to stick to damaged nipples. If you leak a lot you can wear the pad over the breast shell.
   
   
4. Ointments can sometimes be helpful. If you do use an ointment, use just a very small amount after nursing and do not wash it off.
   
   
5. Do not wash your nipples frequently. Daily bathing is more than enough.
   
   
6. If your baby is gaining weight well, there is no good reason the baby must be fed on both breasts at each feeding. It may save you pain, and speed healing if you feed your baby on only one breast each feed. It will help to compress the breast (handout #15 Breast Compression), once the baby is no longer swallowing on his own in order to continue his getting milk. You may be able to manage this some feedings, but not others. In very difficult situations, a lactation aid (handout #5 Using a Lactation Aid) can be used to supplement (preferably expressed milk), so that the baby will finish the feeding on the first side.
   
   If you are unable to put the baby to the breast because of pain, in spite of trying all the above measures, it may still be possible to continue breastfeeding after a temporary (3-5 days) cessation to allow the nipples to heal. During this time, it would be better that the baby not be fed with a rubber nipple. Of course it is also best for you and the baby if the baby is fed your expressed milk. Use the technique called "finger feeding" (handout #8 Finger Feeding) or cup feeding.
   
   Nipples shields are not recommended for sore nipples, because, although they may help temporarily, they usually do not. They may also cut down the milk supply dramatically, and the baby may become fussy and not gain weight well. Once the baby is used to them, it may be impossible to get the baby back onto the breast. In fact, many women who have tried nipple shields find that they do not help with soreness. Use as a last resort only, but get help first.

Handout #3 Sore nipples. Revised January 1998

Written by Jack Newman, MD, FRCPC

Is My Baby Getting Enough Milk?

Breastfeeding mothers frequently ask how to know their babies are getting enough milk. The breast is not the bottle, and it is not possible to hold the breast up to the light to see how many ounces or milliliters of milk the baby drank. Our number obsessed society makes it difficult for some mothers to accept not seeing exactly how much milk the baby receives. However, there are ways of knowing that the baby is getting enough. In the long run, weight gain is the best indication whether the baby is getting enough, but rules about weight gain appropriate for bottle fed babies may not be appropriate for breastfed babies.

Ways of Knowing

1. Baby's nursing is characteristic. A baby who is obtaining lots of milk at the breast sucks in a very characteristic way. The baby generally opens his mouth fairly wide as he sucks and the rhythm is slow and steady. His lips are turned out. At the maximum opening of his mouth, there is a perceptible pause which you can see if you watch his chin. Then, the baby closes his mouth again. This pause does not refer to the pause between suckles, but rather to the pause during one suckle as the baby opens his mouth to its maximum. Each one of these pauses corresponds to a mouthful of milk and the longer the pause, the more milk the baby got. At times, the baby can even be heard to be swallowing, and this is perhaps reassuring, but the baby can be getting lots of milk without making noise. Usually, the baby's suckle will change during the feeding, so that the above type of suck will alternate with sucks that could be described as "nibbling". This is normal. The baby who suckles as described above, with several minutes of pausing type sucks at each feeding, and then comes off the breast satisfied, is getting enough. The baby who nibbles only, or has the drinking type of suckle for a short period of time only, is probably not. This is the best way of knowing the baby is getting enough. This type of suckling can be seen on the very first day of life, though it is not as obvious as later when the mother has lots more milk.
   
   
2. Baby's bowel movements. For the first few days after delivery, the baby passes meconium, a dark green, almost black, substance. Meconium accumulates in the baby's gut during pregnancy. Meconium is passed during the first few days, and by the 3rd day, the bowel movements start becoming lighter, as more breastmilk is taken. Usually by the fifth day, the bowel movements have taken on the appearance of the normal breastmilk stool. The normal breastmilk stool is pasty to watery, mustard coloured, and usually has little odour. However, bowel movements may vary considerably from this description. They may be green or orange, may contain curds or mucus, or may resemble shaving lotion in consistency (from air bubbles). The variation in colour does not mean something is wrong. A baby who is breastfeeding only, and is starting to have bowel movements which are becoming lighter by day 3 of life, is doing well.
   
   Without your becoming obsessive about it, monitoring the frequency and quantity of bowel motions is one of the best ways of knowing if the baby is getting enough milk. After the first 3-4 days, the baby should have increasing bowel movements so that by the end of the first week he should be passing at least 2-3 substantial yellow stools each day. In addition, many infants have a stained diaper with almost each feeding. A baby who is still passing meconium on the fifth day should be seen at the clinic the same day. A baby who is passing only brown bowel movements is probably not getting enough, but this is not yet definite.
   
   Some breastfed babies, after the first 3-4 weeks of life, may suddenly change their stool pattern from many each day, to one every 3 days or even less. Some babies have gone as long as 15 days or more without a bowel movement. As long as the baby is otherwise well, and the stool is the usual pasty or soft, yellow movement, this is not constipation and is of no concern. No treatment is necessary or desirable, because no treatment is necessary or desirable for something that is normal.
   
   Any baby between 5 and 21 days of age who does not pass at least one substantial bowel movement within a 24 hour period should be seen at the breastfeeding clinic the same day. Generally, small infrequent bowel movements during this time period means insufficient intake. There are definite exceptions and everything may be fine, but it is better to check.
   
   
3. Urination. With six soaking wet (not just wet) diapers in a 24 hours hour period, after about 4-5 days of life, you can be sure that the baby is getting a lot of milk. Unfortunately, the new super dry "disposable" diapers often do indeed feel dry even when full of urine, but when soaked with urine they are heavy. It should be obvious that this indication of milk intake does not apply if you are giving the baby extra water (which, in any case, is unnecessary for breastfed babies, and if given by bottle, may interfere with breastfeeding). The baby's urine should be clear as water after the first few days, though an occasional darker urine is not of concern.
   
   During the first 2-3 days of life, some babies pass pink or red urine. This is not a reason to panic and does not mean the baby is dehydrated. No one knows what it means, or even if it is abnormal. It is undoubtedly associated with the lesser intake of the breastfed baby compared with the bottle fed baby during this time, but the bottle feeding baby is not the standard on which to measure breastfeeding. However, the appearance of this colour urine should result in attention to getting the baby well latched on and making sure the baby is drinking at the breast. During the first few days of life, only if the baby is well latched on can he get his mother's milk. Giving water by bottle or cup or finger feeding at this point does not fix the problem. It only gets the baby out of hospital with urine which is not red. If relatching and breast compression do not result in better intake, there are ways of giving extra fluid without giving a bottle directly (handout #5 Using a Lactation Aid). Limiting the duration or frequency of feedings can also contribute to decreased intake of milk.

The following are NOT good ways of judging

1. Your breasts do not feel full. After the first few days or weeks, it is usual for most mothers not to feel full. Your body adjusts to your baby's requirements. This change may occur quite suddenly. Some mothers breastfeeding perfectly well never feel engorged or full.
   
   
2. The baby sleeps through the night. Not necessarily. A baby who is sleeping through the night at 10 days of age, for example, may, in fact, not be getting enough milk. A baby who is too sleepy and has to be awakened for feeds or who is "too good" may not be getting enough milk. There are many exceptions, but get help quickly.
   
   
3. The baby cries after feeding. Although the baby may cry after feeding because of hunger, there are also many other reasons for crying. See also handout #2 Colic in the Breastfeeding Baby. Do not limit feeding times.
   
   
4. The baby feeds often and/or for a long time. For one mother every 3 hours or so feedings may be often; for another, 3 hours or so may be a long period between feeds. For one a feeding that lasts for 30 minutes is a long feeding; for another it is a short one. There are no rules how often or for how long a baby should nurse. It is not true that the baby gets 90% of the feed in the first 10 minutes. Let the baby determine his own feeding schedule and things usually come right, if the baby is suckling and drinking at the breast and having at least 2-3 substantial yellow bowel movements each day. If that is the case, feeding on one breast each feeding (or at least finishing on one breast before switching over) will often lengthen the time between feedings. Remember, a baby may be on the breast for 2 hours, but if he is actually breastfeeding (open—pause—close type of sucking) for only 2 minutes, he will come off the breast hungry. If the baby falls asleep quickly at the breast, you can compress the breast to continue the flow of milk (handout #15 Breast Compression). Contact the breastfeeding clinic with any concerns, but wait to start supplementing. If supplementation is truly necessary, there are ways of supplementing which do not use an artificial nipple (handout #5 Using a Lactation Aid).
   
   
5. "I can express only half an ounce of milk". This means nothing and should not influence you. Therefore, you should not pump your breasts "just to know". Most mothers have plenty of milk. The problem usually is that the baby is not getting the milk that is there, either because he is latched on poorly, or the suckle is ineffective or both. These problems can often be fixed easily.
   
   
6. The baby will take a bottle after feeding. This does not necessarily mean that the baby is still hungry. This is not a good test, as bottles may interfere with breastfeeding.
   
   
7. The 5 week old is suddenly pulling away from the breast but still seems hungry. This does not mean your milk has "dried up" or decreased. During the first few weeks of life, babies often fall asleep at the breast when the flow of milk slows down even if they have not had their fill. When they are older (4-6 weeks of age), they no longer are content to fall asleep, but rather start to pull away or get upset. The milk supply has not changed; the baby has. Compress the breast (handout #15 Breast Compression) to increase flow.

Please Note: On occasion, it may be necessary to supplement a baby who is breastfeeding. If this is done by bottle, a bad situation may become worse. A lactation aid is a method of supplementing without giving a bottle and may allow you to supplement temporarily and get back to exclusive breastfeeding. It is generally easy to use. In an "emergency" situation, extra fluid can be given by spoon, cup or eyedropper until a lactation aid can be started.

Notes on scales and weights

1. Scales are all different. We have documented significant differences from one scale to another. Weights have often been written down wrong. A soaked cloth diaper may weigh several hundred grams (half a pound or more), so babies should be weighed naked.
   
   
2. Many rules about weight gain are taken from observations of growth of formula feeding babies. They do not necessarily apply to breastfeeding babies. A slow start may be compensated for later, by fixing the breastfeeding. Growth charts are guidelines only.

Handout #4. Is My Baby Getting Enough? Revised January 1998

Written by Jack Newman, MD, FRCP


Breastfeeding and Jaundice

Jaundice is due to a buildup in the blood of bilirubin, a yellow pigment which comes from the breakdown of old red blood cells. It is normal for red blood cells to break down, but the bilirubin formed does not usually cause jaundice because the liver metabolizes it and gets rid of it into the gut. The newborn baby, however, often becomes jaundiced during the first few days because the liver enzyme which metabolizes bilirubin is relatively immature. Furthermore, newborn babies have more red blood cells than adults, and thus more are breaking down at any one time. If the baby is premature, or stressed from a difficult birth, or the infant of a diabetic mother, or more than the usual number of red blood cells are breaking down (as happens in blood incompatibility), the level of bilirubin in the blood may rise higher than what is usual.

Two Types of Jaundice

The liver changes bilirubin so that it can be eliminated from the body. If, however, the liver is functioning poorly, as occurs during some infections, or the tubes which transport the bilirubin to the gut are blocked, this changed bilirubin may accumulate in the blood and also cause jaundice. When this occurs, the changed bilirubin (called conjugated bilirubin), appears in the urine and turns the urine brown. This brown urine is an important clue that the jaundice is not "ordinary". Jaundice due to conjugated bilirubin is always abnormal, frequently serious and needs to be investigated thoroughly and immediately. Except in the case of a few extremely rare metabolic diseases, breastfeeding can and should continue.

Accumulation of bilirubin before it has been changed by the enzyme of the liver may be normal"physiologic jaundice". Physiologic jaundice begins on the 2nd or 3rd day, peaks on the 3rd or 4th day and then begins to disappear. However, there may be other conditions which cause an exaggeration of this type of jaundice, such as a more rapid than normal breakdown of red blood cells. Because these conditions have no association with breastfeeding, breastfeeding should continue. If, for example, the baby has severe jaundice due to rapid breakdown of red blood cells, this is not a reason to take the baby off the breast. Breastfeeding should continue.

Breastmilk Jaundice

There is a condition commonly called breastmilk jaundice. No one knows what the cause of breastmilk jaundice is. In order to make this diagnosis, the baby should be at least a week old, though interestingly, many of the babies with breastmilk jaundice also have had physiologic jaundice, sometimes to levels higher than usual. The baby should be gaining well, with breastfeeding alone, having lots of bowel movements, passing plentiful, clear urine and be generally well (handout #4 Is my baby getting enough milk?). In such a setting, the baby has what some call breastmilk jaundice, though, on occasion, infections of the urine or an under functioning of the baby's thyroid gland may cause the same picture. Breastmilk jaundice peaks at 10-21 days, but may last for 2-3 months. Breastmilk jaundice is normal. Rarely, if ever, does breastfeeding need to be discontinued even for a short time. There is not one bit of evidence that this jaundice causes any problem at all for the baby. Breastfeeding should not be discontinued "in order to make a diagnosis". If, however, your doctor feels that discontinuing breastfeeding is appropriate, it would be worth trying a lactation aid with formula (handout #5 Using a Lactation Device) rather than taking the baby off the breast altogether, since this may result in difficulties with breastfeeding afterwards. If the baby is truly doing well on breast only, there is no reason, none, to stop breastfeeding or supplement with a lactation aid, for that matter. The notion that there is something wrong with the baby being jaundiced comes from the assumption that the formula feeding baby is the standard by which we should determine how the breastfed baby should be. This manner of thinking, almost universal amongst health professionals, truly turns logic upside down. Thus, the formula feeding baby is rarely jaundiced after the first week of life, and when he is, there is usually something wrong. Therefore, the baby with breastmilk jaundice is a concern and "something must be done". However, in our experience, most exclusively breastfed babies who are perfectly healthy and gaining weight well are still jaundiced at 5-6 weeks of life and even later. The question, in fact, should be whether it is normal not to be jaundiced and is this absence of jaundice something we should worry about? Do not stop breastfeeding for jaundice.

Not-enough-breastmilk Jaundice

Higher than usual levels of bilirubin or longer than usual jaundice may occur because the baby is not getting enough milk. This may be due to the fact that the mother's milk takes a longer than average time to "come in", or because hospital routines limit breastfeeding or because, most importantly, the baby is poorly latched on and thus not getting the milk which is available (handout #4 Is my baby getting enough milk?). When the baby is getting little milk, bowel movements tend to be scanty and infrequent so that the bilirubin that was in the baby's gut gets reabsorbed into the blood instead of leaving the body with the bowel movements. Obviously, the best way to avoid "not-enough-breastmilk jaundice" is to get breastfeeding started properly (handout #1 Breastfeeding—Starting Out Right). However, the answer to not-enough-breastmilk jaundice, is not to take the baby off the breast or to give bottles. If the baby is nursing well, more frequent feedings may be enough to bring the bilirubin down more quickly, though, in fact, nothing needs be done. If the baby is nursing poorly, helping the baby latch on better may allow him to nurse more effectively and thus receive more milk. Compressing the breast to get more milk into the baby may help (handout #15 Breast Compression). If latching and breast compression alone do not work, a lactation aid would be appropriate to supplement feedings (handout #5 Using a Lactation Aid).

Phototherapy (Bilirubin Lights)

Phototherapy increases the fluid requirements of the baby. If the baby is nursing well, more frequent feeding can usually make up this increased requirement. However, if it is felt that the baby needs more fluids, use a lactation aid to supplement, preferably expressed breastmilk, expressed milk with sugar water or sugar water alone rather than formula.

Handout #7. Jaundice Revised January 1998

Written by Jack Newman, MD, FRCPC

Breast Compression

The purpose of breast compression is to continue the flow of milk to the baby once the baby no longer drinks (open—pause—close type of suck) on his own. Breast compression simulates a letdown reflex and often stimulates a natural letdown reflex to occur. The technique may be useful for:

1. Poor weight gain in the baby
   
   
2. Colic in the breastfed baby
   
   
3. Frequent feedings and/or long feedings
   
   
4. Sore nipples in the mother
   
   
5. Recurrent blocked ducts and/or mastitis
   
   
6. Encouraging the baby who falls asleep quickly to continue drinking

Breast compression is not necessary if everything is going well. When all is going well, the mother should allow the baby to "finish" feeding on the first side and, if the baby wants more, should offer the other side. How do you know the baby is finished? When he no longer drinks at the breast (open—pause—close type of suck).

It may be useful to know that:

1. A baby who is well latched on gets milk more easily than one who is not. A baby who is poorly latched on can get milk only when the flow of milk is rapid. Thus, many mothers and babies do well with breastfeeding in spite of a poor latch, because most mothers produce an abundance of milk.
   
   
2. In the first 3-6 weeks of life, babies fall asleep at the breast when the flow of milk is slow, not necessarily when they have had enough to eat. After this age, they may start to pull away at the breast when the flow of milk slows down.
   
   
3. Unfortunately many babies are latching on poorly. If the mother’s supply is abundant the baby often does well as far as weight gain is concerned, but the mother may pay a price—sore nipples, a "colicky" baby, a baby who is constantly on the breast (but feeding only a small part of the time).

Breast compression continues the flow of milk once the baby starts falling asleep at the breast and results in the baby:

1. Getting more milk.
   
   
2. Getting more milk that is high in fat.

Breast Compression How to do it

1. Hold the baby with one arm.
   
   
2. Hold the breast with the other, thumb on one side of the breast, your other fingers on the other, fairly far back from the nipple.
   
   
3. Watch for the baby’s drinking, though there is no need to be obsessive about catching every suck. The baby gets substantial amounts of milk when he is drinking with an open—pause—close type of suck. (open—pause—close is one suck, the pause is not a pause between sucks).
   
   
4. When the baby is nibbling or no longer drinking with the open—pause—close type of suck, compress the breast. Not so hard that it hurts and try not to change the shape of the areola (the part of the breast near the baby’s mouth). With the compression, the baby should start drinking again with the open—pause—close type of suck.
   
   
5. Keep the pressure up until the baby no longer drinks even with the compression, then release the pressure. Often the baby will stop sucking altogether when the pressure is released, but will start again shortly as milk starts to flow again. If the baby does not stop sucking with the release of pressure, wait a short time before compressing again.
   
   
6. The reason to release the pressure is to allow your hand to rest, and to allow milk to start flowing to the baby again. The baby, if he stops sucking when you release the pressure, will start again when he starts to taste milk.
   
   
7. When the baby starts sucking again, he may drink (open—pause—close). If not compress again as above.
   
   
8. Continue on the first side until the baby does not drink even with the compression. You should allow the baby to stay on the side for a short time longer, as you may occasionally get another letdown reflex and the baby will start drinking again, on his own. If the baby no longer drinks, however, allow him to come off or take him off the breast.
   
   
9. If the baby wants more, offer the other side and repeat the process.
   
   
10. You may wish, unless you have sore nipples, to switch sides back and forth in this way several times.
    
    
11. Work on improving the baby’s latch.

The above works best, in our experience in the clinic, but if you find a way which works better at keeping the baby sucking with an open—pause—close type of suck, use whatever works best for you and your baby. As long as it does not hurt your breast to compress, and as long as the baby is "drinking" (open—pause—close type of suck), breast compression is working.

You will not always need to do this. As breastfeeding improves, you will able to let things happen naturally.

Handout #15. Breast Compression. Revised January 1998

Written by Jack Newman, MD, FRCPC

Fingerfeeding

Finger feeding is a technique which allows you to feed the baby without giving the baby an artificial nipple. Finger feeding is also a method which helps train the baby to take the breast. If you want to breastfeed successfully, it is better to avoid the use of artificial nipples before your milk supply is well established. Finger feeding may be used if:

1. The baby refuses the breast for whatever reason, or if the baby is too sleepy at the breast to nurse well. It is also a very good way to wake up a sleepy baby.
   
   
2. The baby does not seem to be able to latch on to the breast properly, and thus does not get milk well. (If a lactation aid can be used at the breast, why use finger feeding?).
   
   
3. The baby is separated from the mother, for whatever reason. However, in such a situation, a cup is probably a better method of feeding the baby.
   
   
4. Breastfeeding is stopped temporarily (there are very few legitimate reasons to stop breastfeeding. See handout #9 You Can Still Breastfeed).
   
   
5. Your nipples are so sore that you cannot put the baby to the breast. Finger feeding for several days may allow your nipples to heal without causing more problems by getting the baby used to an artificial nipple. Cup feeding is also more appropriate in this situation and takes less time. This is only a last resort. Proper positioning and a good latch help sore nipples far more frequently than finger feeding (Handout #3 Sore Nipples).

Finger feeding is much more similar to breastfeeding than bottle feeding is. In order to finger feed, the baby must keep his tongue down and forward over the gums, the mouth wide open (the larger the finger used, the better), and the jaw forward. Furthermore, the motion of the tongue and jaw is similar to what the baby does while feeding at the breast. Finger feeding is best used to prepare the baby to take the breast. Cup feeding is usually easier and faster when the mother is not present to feed the baby.

Please Note: If the baby is taking the breast, it is better by far to use the lactation at the breast, if supplementation is truly necessary (Handout #5 Using a Lactation Aid).

Finger Feeding (best learned by watching and doing)

1. Wash your hands. It is better if the finger nail on the finger you will use has been cut short, but this is not necessary.
   
   
2. It is best to position yourself and the baby comfortably. The baby's head should be supported with one hand behind his shoulders and neck, the baby should be on your lap, half seated, and facing you. Any position which is comfortable, however, will do.
   
   
3. You will need a lactation aid, made up of a feeding tube (#5F, 36" long), and a feeding bottle with expressed breast milk, sugar water, or, if necessary, formula, depending on the circumstances. The feeding tube is passed through the enlarged nipple hole into the fluid.
   
   
4. Line up the tube so that it sits on the soft part of your index (or other) finger. The end of the tube should line up no further than the end of your finger. It is easiest to grip the tube, about where it makes a gentle curve, between your thumb and middle finger and then position your index finger under the tube. If this is done properly, there is no need to tape the tube to your finger.
   
   
5. Using the finger with the tube, tickle the baby's lips lightly, until the baby opens up his mouth enough to allow your finger to enter. If the baby is very sleepy, but needs to be fed, the finger may be gently insinuated into his mouth. Generally, the baby will begin to suckle even if asleep, and receiving liquids will then awaken him.
   
   
6. Insert your finger with the tube so that the soft part of your finger remains upwards. Keep your finger as flat as possible. Usually the baby will begin sucking on the finger, and allow the finger to enter quite far. The baby will not usually gag on your finger even if it is in his mouth quite far, unless the baby is full or used to bottles.
   
   
7. Pull down the baby's chin, if his lower lip is sucked in.
   
   
8. The technique is working if the baby is drinking. If feeding is very slow, you may raise the bottle above the baby's head. Try to keep your finger straight, flattening the baby's tongue. Try not to point your finger up, but keep it flat, thus keeping down the baby's tongue, and working the lower jaw forward.
   
   
9. The use of finger feeding with a syringe to push milk into the baby's mouth, is, in my opinion, too difficult and definitely not more effective than simply using a bottle with the nipple hole enlarged and the tube coming from it.

If you are having trouble getting the baby to latch on to or to suckle at the breast, remember that a ravenous baby can make the going very difficult. Take the edge of his hunger by using the finger feeding technique for a minute or so. Once the baby has settled a little, and sucks well on your finger (usually only a minute or so), try offering the breast again. If you still encounter difficulty, do not be discouraged. Go back to finger feeding and try again later in the feed or next feeding. This technique usually works. Sometimes several days, or on occasion a week or more, of finger feeding are necessary, however.

If you are leaving the hospital finger feeding the baby, make an appointment with the clinic within a day or so of discharge. The earlier the better.

Once the baby is taking the breast, he may still require the lactation aid to supplement for a period of time. Although the baby may take the breast, the latch can still be less than ideal, and the suckle may still not be efficient enough to ensure adequate intake.

Handout #8.Finger Feeding. Revised January 1998

Written by Jack Newman, MD, FRCPC


What to Feed the Baby when the Mother is Working Outside the Home

This is not an information sheet on all the ins and outs of working outside the home and breastfeeding. This sheet provides information on how your baby can be fed when you are not with him. It is addressed in particular to the mother who is returning to paid work when the baby is about 6 months of age. New mothers should stay home with their babies for as long as practical and take full advantage of the 26 weeks maternity leave to which mothers have a right in Canada. Your baby will never be this age again.

Some Myths:

1. Babies must learn to take a bottle so that they can be fed when the mother is not there. Not true. Some exclusively breastfed babies will not take a bottle by 2 or 3 months of age. Most, who have not taken a bottle, and even some who did accept a bottle in the first weeks of life will not take one by the time they are 4 or 5 months of age. This is no tragedy, and there is no reason to give a bottle early so that the baby knows how. If your baby is refusing to take a bottle, do not try to force him; you and he may become very frustrated and there is just no need to go through all this. If the baby is 6 months of age when you start back at outside work, the baby quite simply does not need to take a bottle. He can be fed solids off a spoon just as any other 6 month old and by 6 months of age he can be taking enough so that he will not be hungry during the day. Furthermore, he can start learning to drink from a cup even by 5 or 6 months of age. The cup can be an open cup and does not need to have a spout. Start with water as your baby may spill a fair amount at first. If, however, he has not gotten the hang of the cup by the time you must leave him, do not worry, he can take fluids off a spoon, or the solid foods can be mixed with more liquid (expressed milk, juice). Obviously, if the baby is to be taking a fair amount of a variety of