Establishing breastfeeding
Reviewed by Dr. Laurie Jones
Breastfeeding is not all or nothing: Any amount you can do carries benefits for both you and your baby. There are many ways to breastfeed, including breastfeeding exclusively, pumping exclusively, supplementing with formula, and applying any combination of any of these methods, which is known as “inclusive breastfeeding.”
If you’ve chosen to breastfeed to any extent, there are a few practical tips and tools that can go a long way in helping you establish a good routine, mechanics, supply, and knowledge around when to get certain kinds of support. We’re here to help you learn and practice these.
A golden first hour
In the immediate hour after birth, any time when babies are both skin-to-skin with and connecting their mouths to the mother’s nipple is shown to promote breastfeeding. This is known as the Golden Hour1, though really the first five days of a baby’s life are crucial in establishing breastfeeding.
When babies are born, especially following an unmedicated delivery, if they’re placed on your stomach, they may do the “breast crawl” and find your nipple. They don’t even need to have a successful latch to help kickstart your breastfeeding journey. Expressing colostrum, often referred to as “liquid gold,” by hand while your baby licks will do the trick. But babies do have a suckling instinct, and many are able to latch (though not necessarily perfectly or even strongly) right after birth.
As valuable as the golden hour and first few days after birth are in promoting breastfeeding, it’s important to know that if you are unable to have this experience for whatever reason—including your baby being in the NICU—you can still do your best to stimulate your baby’s presence and sucking needs. You can, for example, try to stimulate your senses by hearing a recording or watching a video of your baby crying, or by smelling a hat your baby wore just after birth, to encourage your letdown.
If at any point in your early postpartum hours and days, you feel that you need support—anything from establishing a good latch with your baby to counseling over a traumatic birthing experience to grieving the loss of this golden hour—reach out to your provider, and ask for the help you need.
The mechanics of breastfeeding
Babies are born with a sucking reflex. When their mouth touches a nipple, they open it, then squeeze their gums, jaws, and cheek muscles. Once their mouth is fully over a nipple, they move their tongue from front to back in a wave-like motion, pressing the nipple against the roof of their mouth, while their jaw holds the breast and creates a vacuum that pulls the milk from the breast into their mouth and toward their throat.
In order for babies to compress a nipple between their tongue and the roof of their mouth, they need a good amount of the nipple areolar complex in their mouth. There isn’t a textbook amount that’s just right—many factors, including the baby’s palate and cheek strength, work together to make this possible for all body types. It can help to visualize pointing a nipple to the roof of your baby’s mouth so that it reaches back to the roof of your baby’s soft palate.
A good latch stimulates the nerve endings in the nipple and areola, which signal the pituitary gland in your brain to release two hormones: prolactin and oxytocin.
Prolactin prompts your alveoli to turn proteins and sugars from your blood supply into breast milk. Meanwhile, the number of prolactin receptors on milk-making cells increase as a baby, pump, or hand stimulates the breast2.
This is why, in the first few weeks after birth, if your goal is to increase your milk production, you should let your baby feed or suckle on your breast on demand, rather than on a pacifier, says Dr. Laurie Jones, a pediatrician and founder of Dr. MILK (Mothers Interested in Lactation Knowledge).
Oxytocin, meanwhile, triggers your breasts’ small clusters of alveoli sacs, called lobules, to release the milk stored in them, and it widens the milk ducts for easier flow to the nipple. You might feel tingling, fullness, or a tightening in your breasts, followed by a sense of calm and love as your baby suckles. In the days following delivery, it’s also common to feel cramping while breastfeeding as your uterus contracts. Learn more about the mechanics of breastfeeding.
Positioning
How you hold your baby to your breast can help establish a good latch. It can also help establish good posture for your own back, neck, and shoulders. (A breastfeeding pillow, such as a Boppy or My Brest Friend, can help support your arms and lower back while bringing your baby’s head higher up toward your chest, so you don’t need to hunch over.)
Some breastfeeding positions over time have acquired nicknames. This includes the laid-back hold3, which encourages a newborn baby to crawl to the breast (in moves known as the breast crawl) for the first feed. A few factors can affect the positions you try, including milk flow, your baby favoring one side or position (sometimes due to torticollis), and any injuries you might have sustained to your wrist, back, or shoulder.
Latch
Ensuring a good latch is crucial for good flow and will help ensure your baby’s ease of breastfeeding, as well as your own breast comfort. (Dr. Jones describes a shallow latch as being akin to drinking through a bent straw.) Start by creating a calm environment where you can focus on your baby while being skin to skin, as this helps both your baby’s latch and your milk letdown4.
Other tips encourage your baby’s sucking and swallowing reflexes, from expressing a little milk on to your nipple at the beginning of a feeding session, to pointing your nipple up and back toward your baby’s nose, to keeping your baby’s arms open and neck pointed directly toward your breast.
Securing a good breastfeeding latch
Dr. Laurie Jones
Pediatrician
Learning the art of the latch can take time and patience. It’s a partnered dance you’re doing with a brand-new partner! Follow these steps to help your baby latch properly:
Find a safe and comfortable place to breastfeed where you can relax, and your baby is calm. Recline on a bed, couch, or comfy chair, use pillows to support your arms and lower back, if you find this helpful, and have water nearby to drink.
If you are drowsy or concerned about falling asleep while your baby is in a vulnerable position, ask a nearby loved one to stay close, or set alarms on your phone to stay alert until you and your baby can transition to safe sleeping spots.
Put your baby in only a diaper belly-down on your bare chest. (Add a blanket for warmth—or a fan for coolness, if you are in a hot or muggy place.) Being skin-to-skin can calm you and your baby, and can improve both your baby’s latch and your milk let-down.
It’s ideal for your baby’s whole body to face yours. (It’s difficult to swallow with your neck turned!) If only your baby’s head is turned toward your breast, adjust her whole body to face you. She’ll be more comfortable if her ear, shoulders, and hips are in alignment.
Because mammary tissue is behind the areola, the more breast tissue your baby can latch on to, the easier the flow. Quick tips:
- Hand-express milk onto your nipple, and touch it to your baby’s lips.
- Press the palm of your hand under your baby’s shoulder blades to jut out his chest and naturally flex his head back.
- Aim your nipple to your baby’s nose so that it hits the roof of his mouth; this is called the “flipple technique,” and it encourages a wider latch and deeper suction.
- Check that your baby’s bottom lip is flipped out, and that there’s more areola above his mouth than below it.
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Your baby is used to being fully supported in the womb. You can provide that sense of security by placing her tummy on yours and cradling her head, shoulders, and upper back with one of your hands and arms. If you want to bring your baby closer to your breast, gently press her upper back toward you—but not her head, as doing so can force her mouth to close.
There are a few things you can watch for to ensure a proper latch:
- When your baby latches, you feel a comfortable pulling and tugging sensation.
- Your baby’s jaw moves rhythmically up and down while swallowing.
- Your nipple looks round and extended after feeding (unless you have flat or inverted nipples).
- Your breast feels softer after a feed, because your baby has successfully transferred milk.
If the latch doesn’t feel right, try to reset it by gently inserting a clean finger into the corner of your baby’s mouth to break the suction. This will help you avoid sore nipples and engorgement.
Duration
If you’re wondering how long to feed your baby, just remember that as you’re establishing your supply, there’s no textbook number of minutes per feeding session. It takes as long as it takes. And as your baby grows and becomes more efficient during the first few months, what initially took 20 minutes could eventually take 5. If your feeding sessions are lasting more than an hour, talk to your provider.
While the general rule of thumb is to put your baby on each breast for a roughly equal set of minutes, it’s also common for one breast to produce more milk (or simply to be more efficient) than the other. Think of it this way: One breast might make a meal, while the other might make a snack. Just offer both breasts, aim for softness in each, and don’t worry about establishing an equal amount of minutes on each breast.
“In the early days, you want your baby on your body as much as possible to allow your body to make exactly what your baby needs,” Dr. Jones advises. “We can't quantify it in ounces or minutes. And early on, some [babies] take only one side per feed, and as the days go on, they take both. Just always offer both, and let your baby decide when the feed is finished. Clenched fists usually indicate [that babies are] not done, while loose hands usually means they are.”
Engaged breastfeeding is better than calculated breastfeeding, Dr. Jones says. Tracking the minutes and times of day of feedings can cause stress and anxiety, she says, while simply focusing on and responding to your baby’s cues can help relax you and make feeding sessions go more smoothly. Babies communicate when they’re hungry and when they’re full through behaviors like crying, rooting for the breast, rhythmically swallowing, and turning away from the breast.
Sometimes babies also seek to latch and suck to fulfill a biological need for security, attachment, and comfort, rather than nutrition. This is valid time together that promotes bonding, but it can look and feel different from breastfeeding, as your baby seeks your scent and proximity—which alongside your nipple can engage the sucking reflex—more than your milk.
Instead of worrying about whether your baby is always getting milk from suckling on your breast, Dr. Jones advises, consider your baby’s separate needs for hunger, thirst, and security that time at the breast can fulfill, understanding and accepting their differences.
The basics of supply
Every time your baby sucks on your nipple, it sends a message to your brain to make milk. The more your baby sucks and removes milk, the more your body is stimulated to replace the milk that’s removed. One of the marvels of breastfeeding is that your breasts naturally adjust to your infant’s demands. This is because your hormones are linked to your baby’s feeding times and hunger cues5.
While you can control how frequently you feed your baby, which in turn can increase your supply (even though your output for each session may remain the same), there’s not much you can do about your breast storage capacity. In the first four to six weeks, however, if you give your baby liberal access to your breasts, you’ll most likely make enough milk for your baby’s growth to track well, with respect to your baby’s unique growth chart.
Pumping
There are many reasons people choose to pump. Pumping can mitigate the difficulties of latch or supply, can help you get back to work while maintaining your supply, and if you are separated from your baby for any length of time after giving birth, is actually a precondition to breastfeeding. Some people, of course, choose to exclusively pump.
Breastfeeding tools
Ideally, you’ll have people and tools to support your entire breastfeeding journey. In fact, promoting the very notion of “natural breastfeeding” can hinder more than help. It’s completely normal to rely on support from both people and tools to start and maintain breastfeeding. And your experience is completely unique to you, your goals, and your circumstances.
If you seek out help in the form of equipment, you might want and/or need:
- heat or ice packs
- nipple balms
- breastfeeding or standard pillows
- pumping devices such as breast pumps, pumping bra, bottles, and freezer bags
- a supplemental nursing system like SNS or LactAid (if recommended by your provider)
When to seek professional help
It can be helpful to take note of things that are going well. You can pay attention to your baby’s latch and position while breastfeeding, your own breast health, and how frequently your baby is feeding.
Your providers, including your child’s pediatrician, should also track several things, including weight gain (which is actually weight loss in the first 24 hours), bowel movements (which start off as a pasty substance called meconium) and wet diapers, and a metabolic screening6 to test for genetic conditions that are critical to identify in the first weeks.
There are also certain signs that things aren’t going well—and might even need urgent medical attention—so it’s important to closely watch your newborn. Babies are at higher risk for infections, especially in the first week of life, that can very quickly make them very sick. With tiny stomachs that can handle only a tiny bit of milk at a time, they are feeding machines, so be on the lookout for any abrupt changes in feeding habits.
Call 911 immediately if your newborn:
- won’t wake up
- isn’t moving or appears to be very weak
- has bluish or gray-colored lips, tongue, or face
- is making moaning or grunting noises with every breath
Call your infant’s provider immediately if your newborn:
- needs to be woken to feed or won’t finish feeds
- has yellowish skin indicating jaundice
- has pale, bluish, or gray arms and legs
- sweats during feedings
- exhibits symptoms of illness, including coughing, diarrhea, or vomiting
- suddenly sleeps more than usual
- has a swollen fontanel, the soft spot on top of the head
- has a fever of 100.4 degrees Fahrenheit at less than 8 weeks of age (take the temperature rectally in the first three months, and do NOT give your newborn fever medication)
- has a body temperature (again, taken rectally during your baby’s first three months) that is below 96.8 degrees Fahrenheit
- exhibits other symptoms or behaviors you believe require urgent attention
Contact your infant’s provider within 24 hours if your newborn:
- has pink, orange, or peach-colored urine, or is not stooling as frequently as expected
- still is releasing meconium in stools after day 4
- exhibits other symptoms or behaviors you believe need medical attention but are not urgent
- exhibits other symptoms or behaviors you are simply concerned about
References
1 https://mhnpjournal.biomedcentral.com/articles/10.1186/s40748-017-0057-x
2 https://www.ncbi.nlm.nih.gov/books/NBK148970/
3 https://lllusa.org/lie-back-and-relax-a-look-at-laid-back-breastfeeding/
4 https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/1746-4358-8-1
5 https://www.ncbi.nlm.nih.gov/books/NBK148970/
6 https://www.stanfordchildrens.org/en/topic/default?id=newborn-metabolic-screening-160-57
Additional resources
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