Health Topic

Breastfeeding Questions

BREASTFEEDING QUESTIONS

Definition

This guideline covers common questions asked about breastfeeding. If your infant is healthy, go directly to the number of the topic that relates to your child for care advice.

  1. Frequency of feedings to bring in the milk supply
  2. Length of feedings to bring in the milk supply
  3. Signs of adequate milk supply (Do I have enough milk?)
  4. How to increase milk supply
  5. Supplemental formula
  6. Extra water
  7. Severe engorgement (swelling and pain) of the breast
  8. Sore or cracked nipples
  9. Mother's medicines
  10. Sick infants
  11. Sick mother (with acute illness)
  12. Normal stools
  13. Leaking breastmilk
  14. Vitamin D and fluoride for breastfed baby

See More Appropriate Topic (instead of this one) If

WHEN TO CALL YOUR DOCTOR FOR BREASTFEEDING QUESTIONS

Call 911 Now (your child may need an ambulance)

  • Unresponsive or difficult to awaken
  • Not moving or very weak

Call Your Doctor Now (night or day) If

  • Your child looks or acts very sick.
  • Age less than 1 month old and starts to look or act sick in any way.
  • Signs of dehydration (less than 3 wet diapers/day, pink-colored urine, sunken soft spot, very dry mouth).
  • Age less than 1 month old and refuses to breastfeed for more than 6 hours.
  • Refuses to drink anything for more than 8 hours
  • Looks deep yellow or orange
  • Age < 12 weeks with fever > 100.4 F (38.0 C) rectally

Call Your Doctor Within 24 Hours (between 9am and 4pm) If

  • You think your child needs to be seen.
  • Doesn't seem to be gaining weight by day 5.
  • < 3 normal-sized, yellow-colored, seedy stools/day (during first 6 weeks) (EXCEPTION: may not be present while milk is coming in during 1-4 days of life.)
  • < 6 wet diapers/day.
    (EXCEPTION: 2 wet diapers/day can be normal while milk is coming in during 1-4 days of life.)
  • The mother has signs of breast infection (red, tender area on breast). (EXCEPTION: localized engorgement.)

Call Your Doctor During Weekday Office Hours If

  • You have other questions or concerns.
  • Seems hungry after feedings (Reason: needs a weight check).
  • Needs a formula supplement during first month (reason: breastfeeding not going well.)

Parent Care at Home If

  • Breastfeeding question about healthy child and you don't think your child needs to be seen.
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Breastfeeding Advice (Topics 1-14)

  1. Frequency of Feedings to bring in the milk supply:
    • Every 1½ to 2½ hours for the first month (8 or more times/day).
    • During the day, wake her up if more than 3 hours have passed since the last feeding.
    • During the night, wake your baby if more than 4 hours pass without a feeding. After 1 month of age, allow your baby to sleep longer. If your baby is gaining weight well, feed on demand and don't need to awaken for feedings.
  2. Length of Feedings to bring in the milk supply:
    • Offer both breasts with each feeding.
    • 10 min. on first breast and up to 15 min. on second breast if your baby is actively suckling.
    • Alternate which breast you start on.
    • Needing to stimulate your baby to take the second breast is normal.
  3. Length of Feedings after milk supply is in: (by day 8 at the latest):
    • Allow your baby to nurse as long as she wants to on the first breast (up to 20 minutes) (reason: to get the high-fat, calorie-rich hind milk).
    • You can tell your baby has finished the first breast when the sucking slows down and your breast becomes soft. Then offer the 2nd breast if she's interested.
    • Alternate breasts at the start of each feeding.
  4. Signs of Adequate Milk Supply: (i.e. your baby is receiving enough breast milk):
    • 3 or more good-sized, yellow-colored, seedy BMs (bowel movements)/day (EXCEPTION: may not be present while the milk is coming in until day 5 of life) (Caution: infrequent BMs are not normal in breastfed babies until age 6 to 8 weeks)
    • 6 or more wet diapers/day (EXCEPTION: 2 wet diapers/day can be normal while milk is coming in - until day 5 of life)
    • (Note: if uncertain about diaper being wet, place tissue in diaper)
    • Satisfied (not hungry) after feedings
    • Breasts feel full before feedings and soft after feedings
    • The let-down reflex is the automatic release of breastmilk into the milk ducts just before feeding. It develops after 2 to 3 weeks of nursing. Initially, milk letdown may require 60 to 90 seconds of sucking.
  5. How to Increase Milk Supply:
    • Adequate sleep (extra naps), reduced stress (ask for help), relaxed environment, adequate fluids (1 quart of milk and 1 quart of water per day). (Minimum: one 8 oz. glass of fluid every 4 hours while awake.)
    • Increase the frequency of nursing and minimize the use of the pacifier.
    • Pump the breasts for 10 minutes after each feeding (see lactation consultant).
  6. Supplemental Formula:
    • Don't offer your baby any bottles of formula before 3 to 4 weeks old (Reason: it will interfere with establishing a good milk supply).
    • EXCEPTION: medical indications to prevent dehydration or severe jaundice to prevent dehydration or severe jaundice include the following: The milk is not in (day 2-4) AND your baby is very hungry (especially preterms), inadequate number of wet or soiled diapers or the baby is quite jaundiced (reason: prevent dehydration). Method: give 1 oz. of formula after every breastfeeding for 1 or 2 days. Also see your doctor within 24 hours for a weight check.
    • After your baby is 3 to 4 weeks old and nursing is well established, give a bottle of pumped breast milk or 1 oz. of formula once daily (reason: so your baby will accept bottle feedings if need to leave with a sitter). If you wait until 6 weeks of age, your baby may be unwilling to try the bottle.
  7. Extra Water:
    • Never needed (reason: breast milk contains 88% water).
    • Until the milk comes in (day 3 - 5), a few need supplemental formula, but
      not water.
  8. Engorgement: (swelling and pain) of the breast (most common 48-72 hours after birth)
    • Nurse your baby more frequently (avoid the use of pacifiers).
    • Express a little milk before nursing your baby.
    • Compress the areola with your fingers or use a manual pump at the start of each feeding to soften the nipple area (reason: for milk release, your baby must be able to latch on to the areola).
    • Pump your breasts, whenever they hurt, whenever you must miss a feeding or whenever a feeding doesn't relieve the pain.
    • Localized Engorgement: For localized hard areas or swelling or tenderness due to blocked milk ducts, apply moist heat or take a hot shower and massage the affected area toward the nipple.
    • Call your doctor if not improved after 24 hours of treatment.
  9. Sore or Cracked Nipples: (usually due to friction from improper latching on or non-areola grasp)
    • Clean with warm water after each feeding (avoid soap which dries out the skin).
    • Then coat and lubricate nipple and areola with breast milk for sore nipples.
    • For cracked nipples, apply 100% lanolin (no prescription) after feedings.
    • Help your baby latch on to as much of the areola as possible by compressing areola.
    • Prevent the breast from pulling out of your baby's mouth by supporting the breast from below.
    • Start feedings on the side that is least sore.
    • Limit feedings to less than 10 minutes on the sore side.
    • Don't pull your baby off the nipple until she has released her grip. You can break the seal by placing your finger in baby's mouth between the gums.
    • Call back if: not improved after 24 hours of treatment.
  10. Mother's Medicines (it's best to take your drug at the end of a feeding):
    • Most commonly used drugs are safe: e.g., acetaminophen, ibuprofen, penicillins, erythromycin, cephalosporins, stool softeners, antihistamines, cough drops, nose drops, eyedrops, and skin creams. Avoid pseudoephedrine because it reduces milk production in some
      mothers. Avoid aspirin because of a small risk for Reyes's syndrome. Aspirin sulfa drugs until baby is 4 weeks old. For all other drugs, call your doctor.
    • Caffeine and alcohol can cause some symptoms. A high intake of caffeine-containing beverages can cause restlessness, crying or even diarrhea. Excessive alcohol can cause drowsiness. Limit beer or wine to 1 drink per day.
  11. Sick Infants: Do not discontinue breastfeeding for vomiting, spitting up, diarrhea, cough, jaundice, etc. See the appropriate guideline for that symptom. Continue breastfeeding whenever possible.
  12. The Mother is Sick (has an acute illness):
    • Continue breastfeeding, even if you have a fever (reason: breast milk carries your antibodies which can protect your baby from the full-blown infection).
    • Try to prevent the spread of infection by good hand rinsing, especially after blowing your nose (for colds) or after stools (for diarrhea).
    • Contraindications to breastfeeding are rare: AIDS, Herpes simplex rash (fever blisters) on the nipple/areola, substance abuse and tuberculosis. Talk with your doctor.
  13. Breastfed Stools, Normal:
    • Meconium stools are dark greenish-black, thick and sticky. They normally are passed during the first 3 days of life.
    • Transitional stools (a mix of meconium and milk stools) are greenish-brown and more loose. They are passed day 4 to 5 of life.
    • Milk stools without any meconium present are seen from day 6 onward.
    • Breastfed babies pass from 4 stools per day to 1 after each feeding during the first months. The stools are runny, mustard-colored and contain seedy particles.
    • Normal breastfed stools can even become green or have a water ring around them during the first month.
    • Between 4 and 8 weeks of age, most breastfed babies change to infrequent stools. They pass 1 soft stool every 1 to 7 days (reason: complete absorption).
    • Breastfed stools have changed to true diarrhea if:
      • They contain blood or mucus.
      • Develop a bad odor or abruptly increase in number.
      • Your baby feeds poorly, acts sick, or develops a fever.
  14. Leaking Breastmilk: Leaking milk is a common problem that nursing mothers experience during the first months of nursing. Usually, the leaking decreases as a balance is established between what the baby drinks and what the breasts make. WHAT YOU CAN DO:
    • Maintain a regular nursing pattern. Try to avoid skipping or postponing feedings. (Reason: more milk leaks from over-full breast)
    • Use disposable nursing pads under your bra. Change pads frequently to keep your nipples dry.
    • Tops (shirts) with patterns hide milk spots better.
  15. Vitamin D and Fluoride for the Baby:
    • Breastmilk contains all the necessary vitamins and minerals except Vitamin D and fluoride. Starting at 4-8 weeks of age, all breastfed babies need to receive 200 IU per day of vitamin D (AAP Committee on Nutrition 2003). Until separate Vitamin D drops become available, use Vitamin ADC drops (OTC) in a dosage of 0.5 ml. Continue Vitamin D supplements until the child receives at least 16 oz (500 ml) of formula or cow’s milk per day. Starting at 6 months of age, children who are breastfeeding and not drinking any water (with fluoride) need 0.25 mg of fluoride drops each day to prevent tooth decay. This is a prescription item that you can obtain from your child’s physician.

Consultants: Lisbeth Gabrielski, RN and Marianne Neifert, M.D.

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Disclaimer: This information is not intended be a substitute for professional medical advice. It is provided for educational purposes only. You assume full responsibility for how you choose to use this information.

Pediatric HouseCalls Online. Copyright © 2000-2005 Barton Schmitt, M.D. FAAP

Reviewed 8/2005

Revised 8/2005

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