Best first foods for baby led weaning

For most babies, it does not matter what the first solid foods are. By tradition, single-grain cereals are usually introduced first. However, there is no medical evidence that introducing solid foods in any particular order has an advantage for your baby. Although many pediatricians will recommend starting vegetables before fruits, there is no evidence that your baby will develop a dislike for vegetables if fruit is given first. Babies are born with a preference for sweets, and the order of introducing foods does not change this. If your baby has been mostly breastfeeding, he may benefit from baby food made with meat, which contains more easily absorbed sources of iron and zinc that are needed by 4 to 6 months of age. Check with your child’s doctor.

Baby cereals are available premixed in individual containers or dry, to which you can add breast milk, formula, or water. Whichever type of cereal you use, make sure that it is made for babies and iron fortified.

Iron-rich foods

• You need iron in your diet to prevent anemia. Certain foods are very good sources of iron. Red meats, fish, and poultry are best.
• Lunch meats are also a good choice. Children may eat ham or turkey slices if they won’t eat other meats.
• Other good iron sources are iron-enriched cereals and beans of all types. Egg yolks and peanut butter are iron-rich. Other good foods are plum juice and dark leafy greens. After age 4, raisins and other dried fruits can be offered.

Since most breastfeeding babies’ iron stores begin to diminish at about six months, good first choices for solids are those rich in iron. Current recommendations are that meats, such as turkey, chicken, and beef, should be added as one of the first solids to the breastfed infant’s diet. Meats are good sources of high-quality protein, iron, and zinc and provide greater nutritional value than cereals, fruits, or vegetables.

Iron-fortified infant cereal (such as rice cereal or oatmeal) is another good solid food to complement breast milk. When first starting infant cereal, check the label to make sure that the cereal is a single- ingredient product—that is, rice cereal or oatmeal—and does not contain added fruit, milk or yogurt solids, or infant formula. This will decrease the likelihood of an allergic reaction with the initial cereal feedings. You can mix the cereal with your breast milk, water, or formula (if you’ve already introduced formula to your baby) until it is a thin consistency. As your baby gets used to the taste and texture, you can gradually make it thicker and increase the amount.

Once your child has grown accustomed to these new tastes, gradually expand her choices with applesauce, pears, peaches, bananas, or other mashed or strained fruit, and such vegetables as cooked carrots, peas, and sweet potatoes. Introduce only one new food at a time and wait several days before you add another new food, to make sure your child does not have a negative reaction.

As you learn which foods your baby enjoys and which ones she clearly dislikes, your feeding relationship will grow beyond nursing to a more complex interaction— not a replacement for breastfeeding, certainly, but an interesting addition to it. Remember to keep exposing your baby to a wide variety of foods. Research indicates that some babies need multiple exposures to a new taste before they learn to enjoy it. The breastfed baby has already been experiencing different flavors in the mother’s breast milk, based upon her diet, so solid foods often have a familiar taste when introduced to the breastfed baby.

Babies need only a few spoonfuls as they begin solids. Since these first foods are intended as complements and not replacements for your breast milk, it’s best to offer them after a late afternoon or evening feeding, when your milk supply is apt to be at its lowest and your baby may still be hungry.

Some pediatricians recommend an iron supplement. If this is the case, be careful to give the exact dose prescribed by your doctor. Always store iron and vitamin preparations out of the reach of young children in the household, since overdoses can be toxic.

You may find that the number of breastfeedings will gradually decrease as her consumption of solid food increases. A baby who nursed every two to three hours during early infancy may enjoy three or four meals of breast milk per day (along with several snacks) by her twelfth month.

Unless you intend to wean her soon, be sure to continue breastfeeding whenever she desires, to ensure your continuing milk supply. To ease breast discomfort, it may become necessary to express a small amount of milk manually on occasion, if her decreasing demand leaves you with an oversupply. Breast comfort is another reason why a gradual introduction of solid foods is advisable, since it allows your body time to adapt to changing demands. Over the span of several months, a readjustment in the supply-and-demand relationship can take place smoothly and painlessly.

Vitamins

• Formula-fed babies get all the vitamins they need from formula.
• Breast-fed babies need extra vitamin D. Start 400 units per day at 2 weeks of age. Vitamin D drops can be found in most drug stores.
• After your child is 1 and eating a balanced diet, added vitamins are usually not needed.
• If your child is a picky eater, give him 1 chewable vitamin pill. Do this at least twice a week. Gummy vitamins are not as helpful. Reason: they have all the vitamins, but not the minerals.

Weaning is the journey for a child between being fully breastfed or breastmilk-fed, if you feed pumped breast milk and when the child stops nursing for comfort and nutrition. Often, weaning happens gradually and without any conscious effort or action. But you may need to wean before your child would have naturally stopped nursing or receiving your milk. If you need or want to actively wean before it happens on its own, it is best for you and your child to go slowly. Weaning suddenly can be physically painful for you and emotionally hard on you and your baby.

In cultures where there is no social pressure to wean, children usually stop breastfeeding or receiving their mother’s milk between 2½ and 7 years old.

In families that let it happen on its own, weaning happens very gradually, often without any fuss, process, or effort.

Breast milk is the best food for your baby during the first year of life. Feed your baby only breast milk for at least 6 months. At about this time, your baby may be ready to start eating solid foods. These are foods that your baby eats other than breast milk or formula. They’re usually soft, liquid or mashed.

The American Academy of Pediatrics recommends the following schedule as a guide to weaning:

• Breastfeed exclusively (no other foods or drinks) for the first 6 months of your baby’s life
• After 6 months of age, continue to breastfeed and begin to add solid foods (this is when weaning begins)
• After your baby’s first birthday, continue to breastfeed for as long as both you and your baby are comfortable. Some mothers and babies continue to nurse into the toddler years and beyond.
• Breastfeeding is good for mother and child at any age, and no evidence has been found of developmental harm from breastfeeding an older child.

Baby foods are strained or pureed foods. Baby foods are called solid foods only because they are not liquids.

Breast milk or formula meet all of your baby’s diet needs until 6 months or longer. Starting strained foods earlier just makes feeding harder.

The American Academy of Pediatrics recommends feeding only breast milk for 6 months.

For formula-fed infants, the American Academy of Pediatrics recommends starting baby foods around 6 months.

Which baby foods you start first is not important. Just start one new food at a time.

Try to wait 3 days in between starting a new baby food. That way if your baby has diarrhea or a rash, you might know what caused it.

Baby led weaning first foods key points

• Your baby gives you cues (signs) that she’s ready to start solid foods.
• Keep feeding your baby breast milk even when you start giving her solid foods.
• See your baby’s doctor if you think your baby is allergic to a solid food.

Foods to avoid for babies

• Honey. Never give your child honey during the first year of life. Reason: rarely, it can cause infant botulism, a muscle weakness disease.
• Cow’s milk (whole milk). Do not give during the first year of life. Reason: in some babies, it can cause a low iron level (anemia). Cow’s milk formulas are fine.
• High-risk Foods for Choking. Do not give any foods your child might choke on. Some high-risk foods are grapes and hot dogs. These may block the airway and cause sudden death. Raw vegetables (like carrots) and peanuts should also be avoided until 4 years old. Reason: Young children can’t chew them and they could be inhaled into the lungs. Also, avoid large pieces of any sticky food (such as peanut butter).

How do I know if my baby’s ready for solid foods?

Your baby needs only breast milk for about 6 months. When she’s ready to start solid foods, she gives you cues (signs) to let you know.

Signs that the older baby is ready for solids include sitting up with minimal support, showing good head control, trying to grab food off your plate, or turning her head to refuse food when she is not hungry. Your baby may be ready for solids if she continues to act hungry after breastfeeding. The loss of the tongue thrusting reflex that causes food to be pushed out of her mouth is another indication that she’s ready to expand her taste experience.

Starting to eat solid foods (like baby cereal and baby food) is an important part of your baby’s development. But starting solid foods too early could lead to problems with overweight or obesity later. Here are some signs that she’s ready for solids:

At about 6 months

• Cues:
  • She can hold her head up.
  • She stops pushing things out of her mouth with her tongue.
  • She doubles her birthweight or weighs more than 13 pounds.
  • She opens her mouth, drools or leans forward when she sees food.
• What you can feed your baby:
  • Breast milk
  • Baby cereal (like rice or oatmeal) mixed with breast milk

At 6 to 8 months

• Cues:
  • She can sit up without support.
  • She starts to feed herself and brings food to her mouth.
• What you can feed your baby:
  • Breast milk
  • Cooked, softened fruits and vegetables that are mashed or pureed (blended into a paste or thick liquid)
  • Pureed meats
  • Baby food from a jar

8 to 12 months

• Cues:
  • She can sit up without support.
  • She can hold food between her fingers and thumb (also called a pincer grasp).
  • She can hold objects (like a spoon) in her hand.
  • She starts to chew food.
• What you can feed your baby:
  • Breast milk
  • Finger foods, like breakfast cereal, small pieces of bread and well-cooked (until soft) vegetables, pasta and meat
  • Fruits that are soft (like bananas) or cut up
  • Small pieces of table food. This is food that you make for your family, but cut up small for your baby.

How to help your baby try different foods and explore new tastes

Introducing your baby to new foods can be both fun and frustrating. Some parents worry about wasting food and money if their babies don’t like a lot of foods at first. Good news: a new eater only needs 1-2 tablespoons of each food and will gradually increase to 3-4 tablespoons as she gets older. By getting your baby used to lots of different foods, you’ll help him build a healthy diet for life.

Be patient and try, try again.

When your baby is ready to start eating solid foods (around 6 months), her tastes will change from day to day. A baby may have to try a new food 10 to 15 times over several months before she’ll eat it!

Yes, 10 to 15 times sounds like a lot, but you only need to offer her a spoonful each time —not a whole bowl. Try giving her a new food once or twice a week along with foods she regularly eats.

Let your baby try small portions (1 to 2 tablespoons) of many different kinds of healthy foods, including those with different feels and flavors. This will help your child learn to eat healthy.

Make snack time fun with healthy foods.

Snacks are a regular part of life for growing babies. It’s also a great time to try new healthy foods. Starting at 9 months, you can give your child healthy snacks 2 to 3 times a day.

What changes can I expect after my baby starts solids?

When your baby starts eating solid foods, his stools will become more solid and variable in color. Because of the added sugars and fats, they will have a much stronger odor too. Peas and other green vegetables may turn the stool a deep-green color; beets may make it red. (Beets sometimes make urine red as well.) If your baby’s meals are not strained, his stools may contain undigested pieces of food, especially hulls of peas or corn, and the skin of tomatoes or other vegetables. All of this is normal. Your baby’s digestive system is still immature and needs time before it can fully process these new foods. If the stools are extremely loose, watery, or full of mucus, however, it may mean the digestive tract is irritated. In this case, reduce the amount of solids and introduce them more slowly. If the stools continue to be loose, watery, or full of mucus, consult your child’s doctor to find the reason.

Should I give my baby juice?

Babies do not need juice. Babies younger than 12 months should not be given juice. Breast milk and formula are the best choices for your baby. When it’s time for him to start using a cup (around 6 to 9 months), give him breast milk, formula, or water. After 12 months of age (up to 3 years of age), give only 100% fruit juice and no more than 4 ounces a day. Offer it only in a cup, not in a bottle. To help prevent tooth decay, do not put your child to bed with a bottle. If you do, make sure it contains only water. Juice reduces the appetite for other, more nutritious, foods, including breast milk, formula, or both. Too much juice can also cause diaper rash, diarrhea, or excessive weight gain.

Does my baby need water?

Healthy babies do not need extra water. Breast milk, formula, or both provide all the fluids they need. However, with the introduction of solid foods, water can be added to your baby’s diet. Also, a small amount of water may be needed in very hot weather. If you live in an area where the water is fluoridated, drinking water will also help prevent future tooth decay.

When to start foods for baby

Here are some helpful tips on starting your baby on solid foods. Remember that each child’s readiness depends on his own rate of development.

Other things to keep in mind:

• Can she hold her head up? Your baby should be able to sit in a high chair, a feeding seat, or an infant seat with good head control.
• Does she open her mouth when food comes her way? Babies may be ready if they watch you eating, reach for your food, and seem eager to be fed.
• Can he move food from a spoon into his throat? If you offer a spoon of rice cereal, he pushes it out of his mouth, and it dribbles onto his chin, he may not have the ability to move it to the back of his mouth to swallow it. That’s normal. Remember, he’s never had anything thicker than breast milk or formula before, and this may take some getting used to. Try diluting it the first few times; then, gradually thicken the texture. You may also want to wait a week or two and try again.
• Is he big enough? Generally, when infants double their birth weight (typically at about 4 months of age) and weigh about 13 pounds or more, they may be ready for solid foods.

Solid baby foods

• Baby foods are strained or pureed foods.
• They are called solid foods only because they are not liquids.
• Breast milk or formula meet all of your baby’s diet needs until 6 months or longer. Starting strained foods earlier just makes feeding harder.
• The American Academy of Pediatrics recommends feeding only breast milk for 6 months.
• For formula-fed infants, the American Academy of Pediatrics recommends starting baby foods around 6 months.
• Which baby foods you start first is not important. Just start one new food at a time.
• Try to wait 3 days in between starting a new baby food. That way if your baby has diarrhea or a rash, you might know what caused it.

Start new foods one at a time

• The order of which baby foods you start first is not that important.
• Try to wait 3 days in between before starting a new food. That way if your baby has diarrhea or a rash, you might know what caused it.
• Most parents start with rice, barley or oatmeal cereal. A mixed cereal should be added to your baby’s diet later. (Note: Add only after each cereal type in the mixed cereal has been tried by itself.)
• Next, give strained or pureed vegetables and fruits to your baby.
• After that, give strained or pureed protein-rich foods. Do this by 8 months at the latest. Other protein-rich foods include eggs, beans and peas. These solids can add to your infant’s iron intake.
• Between 8 and 12 months of age, start mashed table foods. They can have small chunks of food in them. They are also called stage 3 foods or junior foods.

Spoon feeding

• Do not start spoon feeding until your baby has the following physical skills:
  • Can sit with some support in a high chair or feeding seat.
  • Can hold his head steady.
  • Has strong neck muscles and good head support.
  • Knows to open the mouth at the sight of food.

How to spoon feed:

• Teaching your baby to take food off a spoon and swallow takes time.
• Use a small baby spoon.
• Put the spoon just inside the mouth. Wait for your baby to close his mouth around it.
• Then slowly pull the spoon straight out while he sucks the food off the spoon. The upper lip and sucking will keep most of the food inside.
• You can add a little milk to make it thinner and easier to suck.
• Some babies need to drink a little milk first if acting really hungry.
• Some children will grab at the spoon. Others try to hold it while you are trying to feed them. These children need to be distracted. Use finger foods or give them another spoon to play with.
• By 15 to 18 months of age, most children can use a spoon on their own. They no longer need your help to eat. The spoon now belongs to them.

Avoid gagging

• Gagging means you need to slow down. Give smoother foods or smaller amounts. It may mean that you need to delay starting solids.
• Most babies need to be 6 months old before they can easily swallow purees.
• Gagging is a good body reflex. It keeps food from getting into the airway. It also prevents choking.

How much to give

• Start with a small amount on the spoon. At first, your baby may just want a taste. Slowly work up to larger portions after your baby wants more.
• During the first year, 2 to 4 tablespoons (1 to 2 ounces) is a normal amount for each kind of food.
• If your child is still hungry after eating that amount, serve them more.
• If your baby doesn’t like a new food, stop. You can tell because they spit it out. They may also refuse to open their mouth after a taste. Don’t offer that food again for a few weeks.

Finger foods

• Finger foods are small, bite-size pieces of soft foods.
• They can be started when your child develops a pincer grip. That means your child can pick objects up between the thumb and first finger. A pincer grip most often starts between 9 and 10 months.
• Most babies love to feed themselves. Most babies will not be able to feed themselves with a spoon until 15 months. Finger foods keep your baby actively involved in the feeding process.
• Favorite finger foods are dry cereals (Cheerios, Rice Krispies, etc.). Others are small pieces of soft cheese or scrambled eggs. Canned fruit (peaches or pears) or bananas are also good if cut into small pieces. Other choices are crackers, cookies, and breads. Be sure to include peanut-flavored Cheerios or puffs.

To prevent choking, make sure anything you give your baby is soft, easy to swallow, and cut into small pieces. Some examples include small pieces of banana, wafer-type cookies, or crackers; scrambled eggs; well-cooked pasta; well-cooked, finely chopped chicken; and well-cooked, cut-up potatoes or peas.

At each of your baby’s daily meals, she should be eating about 4 ounces, or the amount in one small jar of strained baby food. Limit giving your baby processed foods that are made for adults and older children. These foods often contain more salt and other preservatives.

If you want to give your baby fresh food, use a blender or food processor, or just mash softer foods with a fork. All fresh foods should be cooked with no added salt or seasoning. Although you can feed your baby raw bananas (mashed), most other fruits and vegetables should be cooked until they are soft. Refrigerate any food you do not use, and look for any signs of spoilage before giving it to your baby. Fresh foods are not bacteria-free, so they will spoil more quickly than food from a can or jar.

NOTE: Do not give your baby any food that requires chewing at this age. Do not give your baby any food that can be a choking hazard, including hot dogs (including meat sticks, or baby food “hot dogs”); nuts and seeds; chunks of meat or cheese; whole grapes; popcorn; chunks of peanut butter; raw vegetables; fruit chunks, such as apple chunks; and hard, gooey, or sticky candy.

Snacks

• Once your baby goes to 3 main meals a day, offer a small snack. This will help tide them over between meals.
• Most babies begin this pattern between 6 and 9 months of age.
• The midmorning and midafternoon snack should be a healthy non-milk food.
• Fruits and dry cereals are good choices.
• If your child is not hungry at mealtime, cut back on snacks or stop them.

Table foods

• Your child should be eating the same meals you eat by about 1 year.
• This assumes that your diet is a well-balanced one. Avoid added salt.
• Carefully chop up any foods that would be hard for your baby to chew.
• Mash up some foods with a fork.
• Avoid foods that he could choke on. Examples are raw carrots, candy, peanuts, and popcorn. These foods should not be given.

Encourage family meals from the first feeding. When you can, the whole family should eat together. Research suggests that having dinner together, as a family, on a regular basis has positive effects on the development of children.

Remember to offer a good variety of healthy foods that are rich in the nutrients your child needs. Watch your child for cues that he has had enough to eat. Do not overfeed.

If you have any questions about your child’s nutrition, including concerns about your child eating too much or too little, talk with your child’s doctor.

When can my baby try other food?

Once your baby learns to eat one food, gradually give him other foods. Give your baby one new food at a time. Generally, meats and vegetables contain more nutrients per serving than fruits or cereals.

There is no evidence that waiting to introduce baby-safe (soft), allergy-causing foods, such as eggs, dairy, soy, peanuts, or fish, beyond 4 to 6 months of age prevents food allergy. If you believe your baby has an allergic reaction to a food, such as diarrhea, rash, or vomiting, talk with your child’s doctor about the best choices for the diet.

Within a few months of starting solid foods, your baby’s daily diet should include a variety of foods, such as breast milk, formula, or both; meats; cereal; vegetables; fruits; eggs; and fish.

How do I start my baby on solid foods?

Start with half a spoonful or less and talk to your baby through the process (“Mmm, see how good this is?”). Your baby may not know what to do at first. She may look confused, wrinkle her nose, roll the food around inside her mouth, or reject it altogether.

Use these steps when your baby’s first starting on solid foods:

1. Give your baby a little breast milk.
2. Switch to solid foods, like baby cereal mixed with breast milk. Use a spoon to feed your baby.
3. Finish with more breast milk.

One way to make eating solids for the first time easier is to give your baby a little breast milk, formula, or both first; then switch to very small half-spoonfuls of food; and finish with more breast milk or formula. Breastfeeding before and after feeding your baby solid food can help keep her from getting really hungry at mealtime and prevent your baby from getting frustrated or fussy when she is very hungry when trying to eat solids. It’s OK if most of her solid foods don’t make it into her mouth at first. She can still get the nutrients her needs from your breast milk.

Your baby may get frustrated as he’s learning how to eat from a spoon and swallow solids. If your baby cries or turns away from solid foods, don’t force it. Go back to breastfeeding for a week or 2 and try solid foods again later.

Do not be surprised if most of the first few solid-food feedings wind up on your baby’s face, hands, and bib. Increase the amount of food gradually, with just a teaspoonful or two to start. This allows your baby time to learn how to swallow solids.

Do not make your baby eat if she cries or turns away when you feed her. Go back to breastfeeding or bottle-feeding exclusively for a time before trying again. Remember that starting solid foods is a gradual process; at first, your baby will still be getting most of her nutrition from breast milk, formula, or both. Also, each baby is different, so readiness to start solid foods will vary.

Don’t feed your baby solid foods through a bottle. This can cause your baby to gain too much weight or to choke. However, cereal in a bottle may be recommended if your baby has reflux. Check with your child’s doctor first.

Other foods that may cause choking are:

• Candy
• Chunks of peanut butter, meat, cheese or hard fruit (like apples)
• Hot dogs
• Nuts and seeds
• Popcorn
• Raw vegetables
• Whole grapes

Food allergies prevention

A food allergy is a reaction to a food you touch, eat or breathe in. If you have a close family member with a food allergy, tell your baby’s doctor. Food allergies are common in children whose family members have them.

You can prevent food allergies by an early start of high-risk foods. The advice for preventing food allergies has changed in recent years.
Older bad advice: Avoid high risk foods such as eggs until 2 years. Avoid peanut butter and fish/shellfish until 3 years. Research has shown that was bad advice. Recent research found that the late introduction of certain foods may actually increase your baby’s risk for food allergies and inhaled allergies. You should discuss any concerns with your pediatrician.

• Current advice: An early start of these foods lowers the risk of food allergies. For example, early start of peanut butter puffs reduces peanut allergy by 90%.
• Current advice: High-risk foods can be started after 6 months of age. Eggs and fish can be mashed up. A small amount of smooth peanut butter can be mixed with normal baby foods. Better yet, give them as peanut butter puffs.
• Start other solid foods like cereals first for a few weeks.
• Add new foods one at a time. Try to wait 3 days in between before the start of a new baby food.
• Avoiding high-risk foods does not prevent allergic disease:
  • Most allergic diseases such as food allergies, eczema, and asthma cannot be prevented by diet.
  • Probably helpful: Breast milk only for 6 months or longer
  • Not helpful: Diet limits on any foods for pregnant or breastfeeding women
  • Not helpful: Soy formulas instead of cow’s milk formula
  • Not helpful: Delaying the start of solids past 6 months
  • Not helpful: Delaying the start of high-risk foods (such as peanut butter or eggs).

If no allergies are present, simply observe your baby for indications that she is interested in trying new foods and then start to introduce them gradually, one by one.

How do I know if my baby has a food allergy?

Common foods allergies include being allergic to:

• Eggs
• Soy
• Fish, like tuna, salmon and cod
• Shellfish, like lobster, shrimp or crab

Your baby may have a food allergy if he has:

• Rash or hives (red, itchy bumps on the skin)
• Coughing, wheezing or trouble breathing
• Vomiting
• Diarrhea

To help you spot a possible food allergy, give your baby one new food at a time for a few days. Watch for any signs of a food allergy. Then try another new food. Don’t mix new foods together until your baby has tried each one alone.

If your baby has an allergic reaction, stop feeding her that food and tell your baby’s health care provider. If your baby has a severe allergic reaction call your local emergency services number right away.

Signs of a severe reaction include:

• Swollen tongue or throat
• Turning blue
• Trouble breathing
• Passing out.

New guidelines on the introduction of allergenic foods

For many years, experts thought that the best way to fight peanut allergy was to avoid peanut products in the first years of life. At the time, it was thought that delaying introduction would possibly prevent the development of other allergic conditions, especially eczema (atopic dermatitis). However, more recent guidelines ¹⁾ show that there is no benefit to delaying the introduction of allergenic foods. In 2015, an important study showed that early introduction and regular feeding of peanut prevented the development of peanut allergy in infants at “high risk” for peanut allergy (meaning infants who had severe eczema and/or an egg allergy) ²⁾.

Current advice to parents:

• Start solids with a few foods that are of low allergy risk—for example, infant cereal, puréed bananas, or puréed prunes. Give your baby one new food at a time, and wait at least 2 to 3 days before starting another. After each new food, watch for any allergic reactions such as diarrhea, rash, or vomiting. If any of these occur, stop using the new food and consult with your child’s pediatrician.
• If there is no special reason to be concerned that your baby is at increased risk for food allergies, after a few first foods have been tolerated, you can start to introduce the more highly allergenic foods (milk, egg, soy, wheat, peanut, tree nuts, fish, and shellfish). It is important that these—and all foods—are in forms and textures appropriate for infants. For instance, while whole cow’s milk is not recommended before 1 year of age; you may introduce processed dairy products such as whole milk yogurt or Greek yogurt mixed with a fruit that your baby has already had in his or her diet.
• If your baby has or had severe, persistent eczema or an immediate allergic reaction to any food— especially if it is a highly allergenic food such as egg—he or she is considered “high risk for peanut allergy.” You should talk to your child’s pediatrician first to best determine how and when to introduce the highly allergenic complementary foods. Ideally peanut-containing products should be introduced to these babies as early as 4 to 6 months. It is strongly advised that these babies have an allergy evaluation or allergy testing prior to trying any peanut-containing product. Your doctor may also require the introduction of peanuts be in a supervised setting (e.g., in the doctor’s office).
• Babies with mild to moderate eczema are also at increased risk of developing peanut allergy. These babies should be introduced to peanut-containing products around 6 months of age; peanut-containing products should be maintained as part of their diet to prevent a peanut allergy from developing. These infants may have peanut introduced at home (after other complementary foods are introduced), although your pediatrician may recommend an allergy evaluation prior to introducing peanut.
• Babies without eczema or other food allergies, who are not at increased risk for developing an allergy, may start having peanut-containing products and other highly allergenic foods freely after a few solid foods have already been introduced and tolerated without any signs of allergy. As with all infant foods, allergenic foods should be given in age- and developmentally-appropriate safe forms and serving sizes.

Choking prevention:

• Whole peanuts themselves are choking hazards and should not be fed to babies. They can block the air passages, and if whole or partially chewed peanuts are inhaled into the lungs, they can cause a severe and possibly fatal chemical pneumonia. Avoid whole peanuts until your child is old enough to be counted on to chew them well (usually at least 4 years and up). ​
• A good way to introduce peanut in infancy would be mixing and thinning-out a small amount of peanut butter in cereal or yogurt. Dissolving peanut butter puffs with breast milk or formula and feeding it by spoon is another good option.

Remember:

The highly allergenic foods should initially be given to your baby in small tastes at home, and the amount can gradually be increased in a developmentally appropriate manner if there are no signs of intolerance or allergic symptoms.

How to produce more breast milk

Most mothers make plenty of breast milk for their babies. The best way to establish a normal supply of breast milk is to start breastfeeding early, breastfeed frequently and making sure your baby is latching on correctly. The fluid your breasts produce in the first few days after birth is called colostrum (the thick golden liquid that your breasts produce). It’s thick and usually a golden yellow color that provides all the nutrients your baby needs. It’s a very concentrated food, so your baby will only need a small amount, about a teaspoonful, at each feed. Your baby may want to feed quite often, perhaps every hour to begin with. They’ll begin to have fewer, but longer feeds once your breasts start to produce more “mature” milk in three to five days after birth. The more you breastfeed, the more your baby’s sucking will stimulate your supply and the more milk you’ll make. You’ll be able to feed your baby with only breast milk for the next six months. Even if you get sick, your body will make antibodies that go into your breast milk. The antibodies will help your baby fight off any colds or infections. And the amount of your breast milk grows along with your baby in the following weeks and months. It’s very rare that a mom doesn’t make enough milk to feed her baby, so trust your body. Unlike formula, your breast milk adjusts according to your baby’s needs and is easy to digest.

Your baby’s sucking causes muscles in your breasts to squeeze milk towards your nipples. This is called the let-down reflex. Some women get a tingling feeling, which can be quite strong. Others feel nothing at all. You’ll see your baby respond when your milk lets down. Their quick sucks will change to deep rhythmic swallows as the milk begins to flow. Babies often pause after the initial quick sucks while they wait for more milk to be delivered. Occasionally this let-down reflex can be so strong that your baby coughs and splutters.

Your milk supply is considered low when there is not enough breast milk being produced to meet your baby’s growth needs. Some women have low supply, particularly during the early weeks of breastfeeding. This is the main reason some mothers start weaning or move to formula feeding. However, it’s rare for a mother to produce less milk than her baby needs. If your baby is having a good number of wet nappies each day, low milk supply is not a likely cause. Breast milk supply is considered to be low if you are not producing enough milk to meet your baby’s normal growth and development needs. Low milk supply is usually a temporary situation that will improve with appropriate breastfeeding support and management. Making more breast milk is all about supply and demand — the more milk is removed from the breast, the more milk is made. The less milk removed, the less breast milk is made.

If the breast milk supply is genuinely low it is usually a temporary situation and can be improved with appropriate support. If you are concerned about your milk supply it is important to seek advice from your lactation consultant or doctor.

The following may help increase your breast milk supply:

• Make sure your baby is latching well, positioned well and removing milk efficiently from the breast. Breastfeeding is a skill that you and your baby learn together, and it can take time to get used to. Read our post on how to breastfeed
• Breastfeed often and let your baby decide when to end the feeding. Be prepared to feed your baby more frequently — breastfeed on demand at least 8 times in 24 hours
• Switch your baby from one breast to the other at each feeding; offer each breast twice at each feeding. Have your baby stay at the first breast as long as he or she is still sucking and swallowing. Offer the second breast when the baby slows down or stops.
• Ensure your breasts are emptied well at each feed or pumping session; you can express after breastfeeds to make sure
• Do not go longer than 5 hours without breast milk removal — your baby at the breast sucking is the most effective way to do this, but otherwise use a hand or electric pump
• When your baby is feeding, compress your breast to aid milk flow as this will also encourage more effective sucking
• Make sure you are drinking a lot of water, eating a healthy balanced diet and not missing any meals
• Also ensure you are resting as much as possible between feeds

Other options that can assist with a low supply include:

• a supplemental nursing system or ‘supply line’
• herbal and pharmacological remedies that are known to increase milk supply

Talk to your doctor, lactation consultant, breastfeeding counselor or child health nurse about these options.

Although breastfeeding is different for every woman, the following do NOT mean that you have a low supply:

• your breasts suddenly seem softer — this is normal as your milk supply adjusts to your baby’s needs
• your breasts do not leak milk, stop leaking or only leak a little
• you don’t feel a ‘let-down‘ when milk pushes out of the breast
• you are unable to pump very much with an electric pump — remember the baby is much more efficient and will always get more than a pump
• how much you pump decreases over time
• when your baby is around 6 weeks to 2 months old, your breasts may no longer feel full. This is normal. At the same time, your baby may nurse for only five minutes at a time. This can mean that you and your baby are just getting used to breastfeeding and getting good at it.
• growth spurts can make your baby nurse longer and more often. These growth spurts often happen around 2 to 3 weeks, 6 weeks, and 3 months of age. Growth spurts can also happen at any time. Don’t be worried that your supply is too low to satisfy your baby. Follow your baby’s lead. Nursing more and more often will help increase your milk supply. Once your supply increases, you will probably be back to your usual routine.

There are many different reasons why some women have low supply including:

• Delays in breastfeeding after delivery or separations of mother and baby such as if the baby needs to be admitted to the special care nursery or if the mother is unwell after delivery
• Poor attachment to the breast, which can be caused by flat or inverted nipples, a tongue or lip tie, a sleepy baby because of jaundice, or a difficult or prolonged delivery
• If the mother is unwell due to problems like mastitis, retained placental tissue or large blood loss after the baby is born
• Scheduled or timed feeding, rather than feeding baby on demand. Nearly all babies need to feed at least 8 to 12 times in 24 hours.
• Your baby does not feed effectively at the breast.
• You have started using formula milk as well as breastfeeding.
• You are taking oral contraceptive pill that contains estrogen
• Skipping breast feeds and offering a supplement formula feed but not expressing breast milk at that time to ensure that supply continues to meet baby’s demand
• Long-term use of dummies or nipple shields
• You smoke cigarettes
• You have had breast surgery that is effecting your milk supply.
• You take some medications, including over-the-counter and herbal preparations such as cold/flu tablets, may reduce your milk supply.
• Rarely, there may be reduced or no milk production because of a medical condition. This occurs in less than five per cent of mothers.

Breast milk supply can be low if the woman has medical problems such as polycystic ovarian syndrome (PCOS), hypothyroidism (underactive thyroid), diabetes and pre-diabetes, or takes some blood pressure medications and cold and flu preparations, or has taken the contraceptive pill or has been infertile.

In some women, breast or nipple surgery makes breastfeeding difficult. In a few women, the breasts did not change during puberty and early pregnancy in a way that makes breastfeeding easier.

Some issues with breastfeeding include:

• wanting to be fed often — breast milk is digested in about 1.5 to 2 hours, whereas formula takes longer to digest
• being more fussy in the evening; you might produce less milk at this time and your baby will request fewer feeds or will ‘cluster feed‘ (feed frequently at certain times of the day)
• having a fussy or unsettled time in the day that may last for a few hours
• liking to suck even if they have had a good breastfeed — sucking comforts them
• wanting lots of cuddles and skin to skin contact — this makes them feel secure and ensures that baby’s needs are being met
• wanting to feed more frequently, which will happen when a baby is having a growth spurt — increased feeding will increase your supply
• reduces the amount of sucking time at the breast — this often happens after 2 or 3 months as your baby becomes more efficient at the breast.

Tips for breastfeeding success:

• Learn your baby’s hunger signs. Signs your baby may be hungry include:
  • Becoming more alert and active
  • Putting hands or fists to the mouth
  • Making sucking motions with the mouth
  • Turning the head to look for the breast
  • Crying can be a late sign of hunger, and it may be harder for the baby to latch if he or she is upset. Over time, you will be able to learn your baby’s cues for when to start feeding.
• Follow your baby’s lead. Some babies will feed from (or “take”) both breasts, one after the other, at each feeding. Other babies take only one breast at each feeding. Help your baby finish the first breast as long as he or she is still sucking and swallowing. Your baby will let go of your breast when he or she is finished. Offer your baby the other breast if he or she seems to want more. If your baby falls asleep while nursing and you are worried he or she did not get enough milk, try switching to the other breast or squeeze your breast to encourage more milk to flow and wake up your baby.
• Keep your baby close to you. Skin-to-skin contact between you and baby will soothe his or her crying and also will help keep your baby’s heart and breathing rates stable. A soft carrier, such as a wrap, can help you “wear” your baby.
• Avoid nipple confusion. Do not use pacifiers and bottles in the first few weeks after birth unless there is a medical reason. If you need to use supplements, work with a lactation consultant. She can show you ways to give supplements that help you and your baby continue breastfeeding. These include feeding your baby with a syringe, a tiny tube taped beside your nipple, or a small, flexible cup. Try to give your baby expressed or pumped milk first.
• Make sure your baby sleeps safely and close by. Have your baby sleep in a crib or bassinet in your bedroom so that you can breastfeed more easily at night. Research has found that when a baby shares a bedroom with his or her parents, the baby has a lower risk of sudden infant death syndrome (called SIDS) ¹⁾.

Figure 1. Normal breast

Common reasons why women may think their milk supply is low

My baby feeds too often.

Babies naturally feed frequently (normally 8 to 12 times in 24 hours), and in the early days babies can be very unsettled. This does not mean that there is not enough milk. In fact, frequent feeding is necessary to establish a good breast milk supply.

My breasts feel soft.

When your milk supply adjusts to your baby’s needs your breasts may not feel as full (this may occur anywhere between 3 to 12 weeks following birth). As long as your baby continues to feed well, your breasts will produce enough milk for your baby.

My baby has suddenly started to feed more frequently.

Your baby may want to feed more during a ‘growth spurt’, but this increased feeding over a couple of days will help you to increase your supply.

My baby only feeds for a short time.

This is no cause for concern as long as your baby continues to grow. After two or three months your baby becomes more efficient at feeding and therefore will take less time at the breast.

How can I produce more breast milk?

The best way to make more breast milk is to breastfeed often and to empty your breasts completely at each feeding. Breastfeed frequently, two to three hourly – a total of at least eight feeds in 24 hours. Your baby may need to be woken for some feeds, or may wake to feed even more often. After emptying your breasts at each feeding, less milk builds up in your breasts between feedings.

To better empty your breasts, follow these tips:

• Make sure that attachment is good and that your baby is both sucking and swallowing (you may need to seek help with this).
• Use breast massage and compression.
• Offer your baby both breasts at each nursing, offer each breast twice. When you notice your baby is becoming tired or not swallowing very frequently anymore, take your baby off that breast and ‘switch’ to the next side. Repeat on both breasts. This will ensure your baby is draining the breast more efficiently.
• Pump after breastfeeds if your baby does not remove all the milk from your breasts. Your breasts will soften when the milk is removed. If the baby empties your breasts, then you can pump to remove milk and increase milk production between nursing sessions.
• Hold your baby skin-to-skin at the breast (baby dressed in a nappy only, so that there is direct skin contact between you and your baby). This will help to keep your baby awake and also to increase the release of hormones involved in breast milk production.
• If your baby is sleepy at the breast and not feeding well you may need to cut short the feed and use the time to express each breast twice, for example, five minutes left side, five minutes right side and then repeat. The expressed breast milk should then be fed to your baby.
• When breastfeeding or expressing, compress or massage your breasts to assist with milk flow and drainage.
• If you need to give your baby extra milk, give expressed breast milk separately and before any infant formula. Seek advice from a lactation consultant or other health professional before commencing infant formula.

Sometimes prescription medicines are used to assist with increasing milk supply; these are available from your doctor.

What can affect how much breast milk I make?

You may make more or less breast milk, depending on:

• How completely milk is removed each time you breastfeed. An empty breast means better milk production.
• How often you nurse or pump to remove milk. The more often you empty your breasts, the more milk your breasts will make.
• The amount of milk your breasts store between feedings. If your breast stores too much milk between feedings (because your baby doesn’t empty the breast), your breast will make less milk. If your breast is emptied, it will make more milk. It is common for one breast to make more milk than the other, and it is normal for babies to prefer one breast over the other. This can affect how much milk you make in that breast.

How do I know if I will make enough breast milk?

Many mothers worry about making enough milk to feed their babies. Some women worry that their small breast size will make it harder to feed their babies enough milk. But women of all sizes can make plenty of milk for their baby. The more often your baby breastfeeds, the more milk your breasts will make.

Your baby’s weight should double in the first few months. Because babies’ tummies are small, they need many feedings to grow and be healthy. You can tell if your baby is getting enough milk by the number of wet diapers he has in a day and if he is gaining weight.

If you think you have or will have a low milk supply, talk to a lactation consultant.

What if my breastmilk supply goes down?

If you don’t feel as “full” as you did in the first few weeks of breastfeeding, you may worry that you are not making enough milk for your baby. But know that the milk is still there and flowing to your baby. Usually, after a few months of breastfeeding, your body learns to make the right amount of milk for your baby.

Also, your baby may only nurse for short periods, such as five minutes at each feeding. These are not signs of lower milk supply. Your body adjusts to meet the needs of your baby, and your baby gets very good at getting milk from the breast. It’s also normal for your baby to continue to nurse longer on each breast at each feeding.

How often should I feed my baby?

You should breastfeed as soon as possible after giving birth. Then, breastfeed your baby every 2 to 3 hours each day so that you will make plenty of milk. This means that in the first few days after birth, your baby will probably need to breastfeed about every one to two hours during the day and a few times at night.

Healthy babies develop their own feeding patterns. Follow your baby’s cues for when he or she is ready to eat.

In the first week, your baby may want to feed very often. It could be every hour in the first few days.

Feed your baby as often as they want and for as long as they want. They’ll begin to have fewer, but longer feeds after a few days.

As a very rough guide, your baby should feed at least 8 to 12 times, or more, every 24 hours during the first few weeks.

It’s fine to feed your baby whenever they are hungry, when your breasts feel full or if you just want to have a cuddle.

It’s not possible to overfeed a breastfed baby.

When your baby is hungry they may:

• get restless
• suck their fist or fingers
• make murmuring sounds
• turn their head and open their mouth (rooting)

It’s best to try and feed your baby during these early feeding cues as a crying baby is difficult to feed.

How long should I breastfeed my baby?

The American Academy of Pediatrics recommends breastfeeding as the only source of food for the first 6 months of your baby’s life. The American Academy of Pediatrics also recommends continuing breastfeeding (after starting solid food) beyond your baby’s first birthday and for as long as both you and your baby would like.3 The easiest and most natural time to wean is when your child leads the process. But how you feel is also very important in deciding when to wean.

Your decision may depend on several factors, such as returning to work, your or your baby’s health, or a feeling that the time is right.

What is the let-down reflex during breastfeeding?

The let-down reflex also called just “let-down” or the milk ejection reflex, happens when your baby begins to nurse. The nerves in your breast send signals that release the milk into your milk ducts. Let-down happens a few seconds to several minutes after you start breastfeeding your baby. It also can happen a few times during a feeding. You may feel a tingle in your breast or you may feel a little uncomfortable. You also may not feel anything.

Let-down can happen at other times, too, such as when you hear your baby cry or when you’re just thinking about your baby. If your milk lets down as more of a gush and it bothers your baby, try expressing some milk by hand before you start breastfeeding.

Many factors affect let-down, including anxiety, pain, embarrassment, stress, cold, too much caffeine, smoking, alcohol, and some medicines. Mothers who have had breast surgery may have nerve damage that interferes with let-down.

How long should breast feedings be?

There is no set time for feedings. They may be 15 to 20 minutes per breast, or they may be shorter or longer. Your baby will let you know when he or she is finished feeding. If you worry that your baby is not getting enough milk, talk to your baby’s doctor.

Breastmilk changes throughout the feed:

• Early in the feed, the milk has a lower fat content. This helps to quench the baby’s thirst.
• As the feed goes on, the fat content of the milk rises which satisfies the baby’s hunger.
• A baby who is allowed to finish the first breast, so that he feeds until he comes off by himself before being offered the second breast, receives the higher fat milk.
• At times your baby may be satisfied with just one breast, at others he may also want the second side, or even a third.
• By switching which breast you feed from first, you will ensure each breast keeps making a good amount of milk.

Will my breastmilk change as my baby grows?

Yes. Your breast milk changes in the days after birth and continues to change as your baby grows. Learn what will happen with your milk, your baby, and you in the first few weeks.

Birth

• Milk: Your body makes colostrum (a rich, thick, yellowish milk) in small amounts. It gives your baby early protection against diseases.
• Baby: Your baby will probably be awake in the first hour after birth. This is a good time to breastfeed your baby.
• You (Mom): Let your baby begin the process of searching for your nipple. This baby-led way of breastfeeding can help your baby get a good latch.

First 12 to 24 hours

• Milk: Your baby will drink about 1 teaspoon of colostrum at each feeding. You may not see the colostrum, but it has what your baby needs and in the right amount.
• Baby: It is normal for the baby to sleep heavily. Labor and delivery are hard work! Some babies like to nuzzle and may be too sleepy to latch at first. Feedings may be short and disorganized.
• You (Mom): Your body is still making colostrum. Take advantage of your baby’s strong instinct to suck and feed upon waking every couple of hours to help your milk come in faster.

Next 3 to 5 days

• Milk: Your mature (white) milk takes the place of colostrum. It is normal for mature milk to have a yellow or golden tint at first.
• Baby: Your baby will feed a lot, at least 8 to 12 times or more in 24 hours. Very young breastfed babies do not eat on a schedule. It is okay if your baby eats every 2 to 3 hours for several hours, then sleeps for 3 to 4 hours. Feedings may take about 15 to 20 minutes on each breast. The baby’s sucking rhythm will be slow and long. The baby might make gulping sounds.
• You (Mom): Your breasts may feel full and leak. (You can use disposable or cloth pads in your bra to help with leaking.)

First 4 to 6 weeks

• Milk: White breastmilk continues.
• Baby: Your baby will now likely be better at breastfeeding and have a larger stomach to hold more milk. Feedings may take less time and may be farther apart.
• You (Mom): Your body gets used to breastfeeding. Your breasts may become softer and the leaking may slow down.

Dealing with leaking breasts

Sometimes, breast milk may leak unexpectedly from your nipples. Wearing breast pads will stop your clothes becoming wet with breast milk. Remember to change them frequently to prevent an infection.

Expressing some milk may also help. Only express enough to feel comfortable as you do not want to overstimulate your supply.

If your baby has not fed recently, you could offer them a feed as breastfeeding is also about you being comfortable.

When can I start using a breast pump?

Talk to your health care provider about when you can start pumping your breast milk. You may want to start pumping soon after your baby is born. This can help build up your milk supply, and you can freeze the expressed breast milk to use later. Your milk supply is the amount of breast milk you make for each feeding. Pumping your breasts after your baby breastfeeds can help you increase your milk supply.

Wait until your baby is breastfeeding well before you start feeding him pumped breast milk from a bottle. Starting your baby on a bottle (or giving him a pacifier) too early can cause nipple confusion. This is when your baby has trouble latching on and sucking after being given a bottle or pacifier. Your baby forgets how to latch on to your breast, so he doesn’t feed well or doesn’t want to breastfeed.

If you’re going back to work or school:

• Start pumping at least 2 weeks before you go back.
• Try to pump as often as your baby usually feeds. This may be every 3 to 4 hours for about 15 minutes each time.
• Find a private place to pump. Talk to your employer before you go back to work so she/he knows what you need.

Breast pumping tips

Pumping while away from your baby can be tricky. Finding the time and space to do it, as well as relaxing while you do it can be easier said than done.

Mothers who have successfully pumped are a great resource and can provide many suggestions to make the process easier. Here are some of those suggestions:

• Find a quiet place where you are not likely to be interrupted. You may want to look around your work area before you go out on leave to find the best place. It does not have to be fancy, but it should be private. The restroom is not an acceptable place to be asked to pump. Be aware that there are laws in place in some countries to protect you.
• Relaxing is important. Many mothers look at pictures of their babies, listen to music, drink water or have a snack. Some use their phones to watch videos of their babies or face time the baby and caregiver.
• Some mothers find that hand expressing for 1-2 minutes before using the pump gives them better results. The warmth of their hands and “Skin on skin” first provides good stimulation so that their milk is released better.
• Stay hydrated. Drink plenty of fluids so that you do not become overly thirsty. If you can snack as well as get a good meal break, this is helpful as well.
• Invest in a hands free pumping bra. There are several on the market or you can make your own. If you make your own, simply use a sports bra and cut holes where the flanges will go through. You can use duct tape to seal the edges so they don’t fray.
• Invest in a good pump. It will be cheaper than formula in the long run and it will be more comfortable for you. Most manufacturer’s have various sizes of flanges. Be sure your flange is not too tight, nor too loose.

How often will I have to pump my breast when I go back to work or school?

How long you are apart from you baby influences this decision. Ideally, you would pump as often as your baby would nurse. This may not be possible with your work/ school schedule. Most mothers find that pumping every 2-3 hours maintains their milk supply and does not cause them to become uncomfortably full.

For example, if a mother worked an 8 hour work day, she would nurse her child before coming to work, then pump mid-morning, at lunchtime and then mid-afternoon. She would nurse her baby when she returned home.

Should I single or double pump?

Using a pump that can express milk from both breasts at the same time will save the most time. It may take about 15 minutes to pump both breasts instead of 30 minutes or more to pump each breast separately. Double pumping also provides very strong stimulation to keep a good milk supply. Prolactin, which is an important hormone for making milk, becomes very elevated when mothers double pump.

Is there any way to decrease the number of times I have to pump at work?

If it is possible for you to go home at lunch, or have someone meet you on your break with your baby, you can breastfeed instead of pump. Some employers have onsite child care and this could allow you to take your breaks with your baby.

Some babies develop a pattern known as “reverse cycle breastfeeding.” This means that your baby will sleep more while you away and breastfeed more when you are together. If this happens, you may find you need to pump less when you are away from your baby. Keep your baby near you at night, so that you may nurse easily and get as much sleep as possible.

How do I choose a breast pump?

They type of breast pump you need depends very much on your situation. Your ability to pump well will depend on matching your specific needs to the best pumping system that meets those needs.

If you do need to leave your baby because you are returning to work or school, a good pump will be needed. There are many options to choose from. It is important to choose one that will meet your specific needs. Some things to consider are cost, efficiency, how easy it is to transport and how much noise it makes.

If you only need to pump occasionally, a hand operated pump may be the right one. They are small, easy to carry and use and are not very expensive (for example they may cost $20-50 in the US). One pump that is no longer recommended is the “bicycle horn” style manual pump. This pump did not work well and many mothers found it to be uncomfortable to use.

If you will only be away a few hours a day and only need to pump once or twice, a small electric pump may be appropriate. The cost of these range from about $50 to $150 in the US. Some are double pumping styles, others will pump one breast at a time. Some of them are fairly quiet, but some are rather noisy. These can be plugged into the wall or use batteries. Some have AC adapters.

If you will be away for 8 or more hours, a double electric pump is likely the best choice. These are recommended if the time you have to pump is limited and/or you will be pumping 3 or more times per day. These pumps are automatic and they have a suck release cycle that mimics the pattern of a baby nursing. They can be fairly large, and come in carrying cases that resemble a large handbag. These cases hold all of the accessories needed. They are usually quiet. They cost between $200 – 300 in the US and are classified as single user pumps by the manufacturers.

The last option is the hospital grade pump, also called the multi user pump. This is a very strong pump and is used when mother and baby are separated, such as pumping milk for a premature baby in the hospital, or if mother needs strong stimulation to increase her milk supply. These are rarely purchased. Most mothers rent them from a hospital or from a Durable Medical Equipment Company.

Many mothers find it helpful to talk with their friends about whether or not a pump is needed, and if so, what kind worked best. Be sure to ask what features worked well and what didn’t.

My friend no longer needs her pump and said I can use it. Is this okay?

It is important to know that most breast pumps are considered single user. Milk can flow backwards into the pump mechanism and cause contamination. For this reason, sharing or borrowing single user pumps is not recommended.

How breastmilk is made

Breasts often become fuller and more tender during pregnancy. This is a sign that the alveoli, cells that make breastmilk, are getting ready to work. Some women do not feel these changes in their breasts. Other women may feel these changes after their baby is born.

The alveoli make milk in response to the hormone prolactin. Prolactin levels go up when the baby suckles. Levels of another hormone, oxytocin, also go up when the baby suckles. This causes small muscles in the breast to contract and move the milk through the milk ducts. This moving of the milk is called the “let-down reflex.”

The release of prolactin and oxytocin may make you feel a strong sense of needing to be with your baby.

How your breasts make and give milk

• The onset of breastmilk production is triggered by delivery of the placenta which results in a sudden drop in progesterone levels.
• The skin covering the nipple contains many nerves that are triggered by the baby’s sucking. This causes hormones to be released into the mother’s bloodstream.
• One of these hormones (prolactin) acts on the milk-making tissue, building up the milk supply.
• The other hormone (oxytocin) causes the breast to push out or release the milk already there.
• This release of milk is known as the let-down reflex (sometimes called the milk ejection reflex).
• The more often your baby’s sucking causes a let-down and the more milk that is removed from your breasts, the more milk will be made.
• Respond to your baby’s feeding cues. Crying is a late sign of hunger.
• Breastfeed your baby often.
• Don’t limit time at the breast or delay the time between feeds. A well drained breast ensures more milk is made quickly.
• The breasts are never completely empty.
• Babies stop feeding when they have had enough, while at the same time, your breasts are already at work making more milk.
• Whatever your baby drinks is automatically replaced, producing a constant supply, perfectly matched to her need, whenever she needs it.

Building up your milk supply

Around 2 to 4 days after birth you may notice that your breasts become fuller. This is often referred to as your milk “coming in”.

Your milk will vary according to your baby’s needs. Each time your baby feeds, your body knows to make more milk for the next feed. The amount of milk you make will increase or decrease depending on how often your baby feeds.

Feed your baby as often as they want and for as long as they want. This is called responsive feeding. In other words, responding to your baby’s needs. It’s also known as on-demand or baby-led feeding.

In the beginning, it can feel like you’re doing nothing but feeding. But gradually you and your baby will get into a pattern and the amount of milk you produce will settle down.

It’s important to breastfeed at night because this is when you produce more hormones (prolactin) to build up your milk supply.

In the early weeks, before you and your baby have become comfortable with breastfeeding, “topping up” with formula milk or giving your baby a dummy can lower your milk supply.

Speak to a midwife or doctor if you are worried about breastfeeding or you think your baby is not getting enough milk.

They might suggest giving your baby some expressed breast milk along with breastfeeding.

How do I know that baby is getting enough milk?

When you first start breastfeeding, you may wonder if your baby is getting enough milk. It may take a little while before you feel confident your baby is getting what they need.

Always look at the whole picture to ensure that baby’s growth and development is with normal limits.

Signs your baby is getting enough milk if your baby:

• go through 6 to 8 wet nappies in a 24-hour period including at least a few dirty nappies
• from the fourth day, they should do at least 2 soft, yellow poos the size of a $2 coin every day for the first few weeks.
• from day 5 onwards, wet nappies should start to become more frequent, with at least 6 heavy, wet nappies every 24 hours. In the first 48 hours, your baby is likely to have only 2 or 3 wet nappies.
• after about 5 to 6 days, your baby’s poop should stop looking black and thick and they should also have at least 2 soft or runny yellow poops.
• wake for feeds by themselves and feed vigorously at the breast
• has 8 to 12 breastfeeds in 24 hours
• pass a soft yellow stool
• settle and sleep fairly well after most feeds
• when your baby is 3-4 days old and beyond you should be able to hear your baby swallowing frequently during the feed
• is back to birth weight in about 2 weeks. Your baby gains weight steadily after the first 2 weeks – it’s normal for babies to lose some of their birth weight in the first 2 weeks.
• gain on average 150 grams or more every week for the first 3 months.

Other signs your baby is feeding well:

• Your baby starts feeds with a few rapid sucks followed by long, rhythmic sucks and swallows with occasional pauses.
• You can hear and see your baby swallowing.
• Your baby’s cheeks stay rounded, not hollow, during sucking.
• They seem calm and relaxed during feeds.
• Your baby comes off the breast on their own at the end of feeds.
• Their mouth looks moist after feeds.
• Your baby appears content and satisfied after most feeds.
• Your baby appears healthy and alert when they’re awake.
• Your breasts feel softer after feeds.
• Your nipple looks more or less the same after feeds – not flattened, pinched or white.
• You may feel sleepy and relaxed after feeds.

Nappies

The contents of your baby’s nappies will change during the first week. These changes will help you know if feeding is going well. It can be hard to tell if disposable nappies are wet. To get an idea, take an unused nappy and add 2 to 4 tablespoons of water. This will give you an idea of what to look and feel for. Speak to your doctor if you have any concerns.

Baby’s age	Wet nappies	Dirty nappies
1-2 days old	1-2 or more per day urates may be present*	1 or more dark green/black ‘tar like’ called meconium
3-4 days old	3 or more per day nappies feel heavier	At least 2, changing in color and consistency –brown/green/yellow, becoming looser (‘changing stool’)
5-6 days old	5 or more heavy wet**	At least 2, yellow; maybe quite watery
7 days to 28 days old	6 or more heavy wet	At least 2, at least the size of a $2 coin yellow and watery,‘seedy’ appearance

Footnotes: *Urates are a dark pink/red substance that many babies pass in the first couple of days.At this age they are not a problem, however if they go beyond the first couple of days you should tell your midwife as that maybe a sign that your baby is not getting enough milk.

** With new disposable nappies it is often hard to tell if they are wet,so to get an idea if there is enough urine, take a nappy and add 2-4tablespoons of water. This will give you an idea of what to look/feel for.

When to stop breastfeeding

Stopping breastfeeding also called weaning, is when you stop breastfeeding your baby or toddler, when your baby no longer has any breastmilk. Weaning is the process of stopping breastfeeding and replacing it with either expressed breast milk, formula or milk. Stopping breastfeeding is a natural process, and all growing children go through it, but it can sometimes be a difficult time for mother and baby. Your breast milk contains everything your baby needs for the first 6 months of their life. Weaning usually starts when your baby has any food other than your breast milk at times during the day and weaning ends when your child no longer has any breastmilk. Breastfeeding is recommended when your baby starts eating solid foods at around six months. It’s best for your baby if you keep breastfeeding while giving your baby solids until at least 12 months. Your baby might even start weaning before you’re ready, but this is less common. For example, you might need to wean, because you’re going back to or starting work.

Weaning is going to be different for every mother and baby. It’s important to remember that it is a process, not an event, and the time involved varies from person to person. Some children are more attached to breastfeeding than other children are. They’ll all wean in their own time. But if you don’t want to wait for your child to wean herself, weaning can happen when you’re ready.

Weaning can occur in 3 different ways:

1. Mutual decision – the easiest and most comfortable way to wean for both of you, this is when your baby starts to show an interest in food
2. Mother-led weaning – there could several reasons why you want to wean your baby, such as returning to work, problems with breastfeeding, another pregnancy, medical issues or just deciding it’s the right time
3. Baby-led weaning – this is when your baby stops showing an interest in breastfeeding

You might decide to stop breastfeeding when or before your baby reaches 6 or 12 months. For example, you might find that you start thinking about weaning when you’re getting ready to return to work. If your baby is older than six months and developing well, you might decide to try night weaning while still breastfeeding during the day. On the other hand, if you’re comfortable with feeding your baby during the night, there’s no hurry to phase out night feeds. You can choose what works best for you and your baby.

To wean an older baby or toddler, you might want to go slowly, changing your child’s routine gradually.

It’s also quite common to feel a bit down after your last feed, even if you were looking forward to weaning. If you’re feeling a bit sad about the last breastfeed, that’s pretty normal. It might help to remind yourself that you’ve done a great job giving your child a healthy start to life.

Your hormones might take some time to return to normal. Some women begin ovulating as soon as they reduce night feeds or begin to wean, while others find that the return of ovulation and menstruation takes several months.

There is no need to wean because of the return of menstruation. Some mothers notice their babies seem fussy a few days before their period starts and for the first couple of days of the cycle. Some mothers notice their nipples can be tender at this time too.

If you need to wean quickly, here are some suggestions that will make weaning more comfortable for you and less upsetting for you and your child. Your milk supply will gradually decrease as milk is removed less often.

• Depending on your child’s age and how much she needs to suck, you can wean on to a cup or a bottle. Babies younger than 7 months should use a bottle, but if older than 7 months, they can start to use a cup.
• Slow weaning is best, both emotionally and physically, for you and your baby. For you, it will be more comfortable because your breast milk will decrease gradually. This will reduce the risk of blocked ducts and mastitis. You will also avoid a sudden hormonal change. If it is slow, your baby will remain secure and more settled as they adjust to the change.
• Start dropping the breastfeed that your child seems least interested in. Then cut out one breastfeed every few days, or one each week, depending on your own comfort, and how willing to cooperate she is.
  • Slowly tapering off how long and how often you breast-feed each day — over the course of weeks or months — will cause your milk supply to gradually diminish and prevent engorgement. It might be easiest to drop a midday breast-feeding session first. After a lunch of solid food, your child might become interested in an activity and naturally give up this session. Once you’ve dropped one feeding, you can work on dropping another.
• Cow’s milk is not suitable for babies under 12 months, so until they reach that age you should continue with expressed breast milk or formula.
• Whether you replace the missed feeds with formula, cows’ milk or water, will depend on the age of your child and the other food and drinks she is having. If your child is less than 12 months of age and is being weaned from breastfeeding or breastmilk feeding, she will need to have breastfeeds replaced with formula. If your child is older than 12 months of age, she can have cows’ milk as a drink. Ask your child health nurse to help you with this.
• Make sure you still spend plenty of time with your child and give her lots of cuddles.
• If your breasts become engorged, hand express or use a hand pump until you are comfortable. Do not try to empty your breasts. You do not want your supply to build up again.
• If your baby is unwilling to follow your lead, here are some more ideas, which will help stimulate your breasts less, and therefore reduce your milk supply
  • Offer your baby a pacifier (dummy) for extra sucking if she needs it;
  • Give your baby formula before breastmilk, if doing both at the same feed;
  • Offer one breast only at each feed, and ensure that your baby has plenty of other drinks; and/or
  • Feed your baby according to a fixed routine, if possible.
• If your baby is finding weaning difficult, try:
  • lots of extra cuddles
  • offering a dummy for extra sucking
  • offering formula before breast milk (if weaning on to formula)
  • making sure that your baby is being offered lots of extra drinks
  • offering only one breast at each feed
  • changing your routine – go out when your baby is due for a breastfeed
  • having your partner, a friend or a relative offer a cup or bottle to your baby
  • having your partner get up to the baby when they wake at night

Mutual weaning

The natural weaning process begins once your baby starts to have anything other than breast milk, including water, juices, solid food and other milks. However, most of us think of weaning as the time during which our babies start having fewer and fewer breastfeeds until they are completely replaced by other food and drinks.

Baby-led weaning

Sometimes your baby will decide for herself that she has had enough. This can make your feel disappointed, sad or even rejected. This may be especially so if you were looking forward to many more months of leisurely feeding. Sometimes a baby’s refusal may be temporary.

Mother-led weaning

• You have had enough. Mothers of older babies and toddlers sometimes feel like this, especially if your baby loves to feed frequently, especially during the night.
• You wish to become pregnant and breastfeeding could be preventing ovulation.

You have been advised to wean for medical reasons. If you are not keen to wean, let your doctor know how you feel. Sometimes weaning is not the only option.

Weaning, pregnancy and contraception

Breastfeeding gives you some protection from getting pregnant, especially if:

• you’ve been exclusively breastfeeding
• your periods haven’t started again
• your baby is less than six months old and doesn’t sleep for long periods between feeds.

When you start to wean your baby, breastfeeding might give you less protection from getting pregnant, so it’s a good idea to consider other forms of contraception.

If you’re thinking about oral contraception – either the combined pill or the minipill – there are a couple of things to bear in mind:

• It’s safe to start the combined pill (estrogen and progesterone) while your baby is still having some breastfeeds. The combined pill helps reduce your supply of breastmilk.
• You need to take greater care with the minipill (progesterone only pill) if it’s your only contraception in addition to breastfeeding. For example, you must take it within three hours of the same time every day.

The contraceptive pill is prescription medicine, so you’ll need to see your doctor or obstetrician to get it. Your doctor will talk you through how to use it properly so you’re protected from getting pregnant.

How to wean from breastfeeding

When you’re stopping breastfeeding, it’s a good idea to take it slowly. This way your baby can get used to the change in routine and diet, and your body can get used to no longer making milk. If the decision to wean is yours rather than your baby’s, you might need to offer some extra comfort as you and your baby make the transition to bottle-feeding or drinking from a cup. Plenty of cuddles and time with you can help your baby feel secure and loved without relying on the breast.

Weaning for baby

You can wean baby to a cup or a bottle. This decision depends on your baby’s age – if your baby is around 7-8 months, he could learn to drink straight from a cup.

The age of your baby also determines whether to replace breastfeeds with infant formula or cow’s milk – babies younger than 12 months shouldn’t be offered cow’s milk, so they need to be weaned onto formula.

When you start the weaning process, the first step is to replace the breastfeed your baby seems least keen on with expressed breastmilk, infant formula or cow’s milk, from a cup or bottle. Drop one breastfeed at a time, and wait a few days or a week before you drop the next one.

Weaning off breastfeeding for older children

Breastmilk continues to provide both nutrition and immune benefits for toddlers and older children. Many mothers find that breastfeeding provides their child with the emotional security that ends up being one of the most important parts of their feeding relationship. It lets their child outgrow infancy at their own pace.

Weaning can be stressful for a toddler or preschooler so take it slowly. Give your child comfort and cuddles to make the change easier.

Weaning is likely to be a big change for your child. For many older children, breastfeeding is more about security and comfort than about food, so weaning can be quite stressful.

This means it’s probably best to avoid weaning when there are other major changes in your child’s life – for example, toilet training, starting child care or moving house.

A few weeks or months before you start weaning, it’s a good idea to start talking with your child about what will happen. This will give your child time to get used to the idea and can help to make the change easier.

When you are breastfeeding a toddler or older child, it is okay to set limits on feeding that are realistic for you and your child.

When you’re weaning older children off breastfeeding, a good way to start is to never offer a breastfeed, but never refuse.

Here are more tips that can help. You can start with the tip you think will suit your child best, or use a few if that suits you both:

• Drop one breastfeed at a time, and wait a few days before you drop the next one. This will also be easier on your breasts, which might get engorged if you stop too suddenly.
• Consider dropping daytime breastfeeds first, then gradually drop any bedtime or night-time feeds – these are the ones your child probably feels most needy about.
• Introduce a few limits, like not breastfeeding when you’re out, or feeding only after lunch during the day.
• Introduce lots of activities and outings into your daily routine so your child is too busy and distracted to think about breastfeeding.
• Occasionally replace a breastfeed with a ‘grown-up’ alternative. Your child might be excited about having a special but healthy drink like a babyccino at a café when he’d normally be at home having a breastfeed.
• Try the ‘out of sight, out of mind’ principle. This involves leaving your child with someone she’s comfortable with at times when she’d normally have a breastfeed, because she’ll be less likely to miss it if you’re not around. A child usually reacts differently with people they know well and will take other drinks and food and forget about a breastfeed.
• Avoid dressing and undressing while your child is around, and wear clothes that make it hard for your child to get to your breasts – for example, dresses rather than separates.
• If your child wakes in the night for a breastfeed, try to let your partner or someone else settle him with a cup of milk or water.
• Consider your child’s sucking need. If your child really seems to need to suck, weaning onto a bottle may be better than going straight to a cup. Offer a short breastfeed, then the bottle.

Remember that children over 12 months of age can be weaned to cow’s milk from a cup. You don’t need to wean an older child onto formula.

Weaning off morning and night feeds

Your child’s last remaining breastfeeds might be at bedtime and when she wakes in the morning.

• To drop the morning feed, try to be up and dressed before your child wakes, then offer him a cup of milk and breakfast.
• To drop the bedtime feed, a change of routine can help break the old routine. You could try a sleepover with grandparents, or your partner could read stories to your child instead of a breastfeed.

If your child is used to being fed to sleep, change the routine by offering a story after the feed, as an incentive to stay awake.

Feeding in another room, and not just before bed, can also help break the association between feeding and sleeping. Once you’ve broken the association, over time you can drop the feed.

When weaning your child off night feeds, make sure her bedtime still involves a relaxed, warm routine with lots of cuddles.

Weaning for mum

If you stop breastfeeding quickly, your breasts might fill with milk (engorge) and get very uncomfortable. To prevent engorged breasts, you might need to express your milk sometimes. Express just enough for comfort – if you express too much you’ll actually stimulate an increase in supply.

As you reduce the number of breastfeeds, your milk supply will also slowly decrease. This reduces the risk of blocked ducts and mastitis. Weaning slowly also gives your baby time to adjust.

Some mothers need to go from one feed a day to one feed every few days to avoid engorged breasts, before stopping breastfeeding altogether.

Watch out for lumpy breasts. After your baby has stopped breastfeeding, you might have lumpy breasts for 5-10 days. A lump might indicate a blocked duct or the beginnings of mastitis. If this happens, try massaging the lumps or expressing a small amount of milk. This might help reduce the lumpiness.

If any lump is persistent or painful or you start feeling flu-like symptoms, see your doctor as soon as possible.

Your feelings about weaning

You may feel sad, weepy, or even depressed after the last feed, even if you really wanted to wean and it went smoothly and calmly. These are very natural feelings. Your hormones take time to get back to normal, especially if you had to wean quickly. Some women do not begin to menstruate immediately and some even find the return of their ovulation and menstruation is delayed for some months. Some find that they still have a little bit of milk in their breasts for weeks, or even months, after they wean.

Should I refuse feedings during the weaning process?

Refusing to breast-feed when your child wants to nurse can increase your child’s focus on the activity. If your child wants to nurse, go ahead. Then, continue working to distract him or her with new foods, activities and sources of reassurance — such as a favorite stuffed animal — around the times of your typical breast-feeding sessions.

What about nutrition after weaning?

If you wean your child from breast-feeding before age 1, use expressed breast milk or iron-fortified formula. Don’t give your child cow’s milk until after his or her first birthday.

You can wean your child to a bottle and then a cup or directly to a cup. When introducing your child to a bottle, choose a time when he or she isn’t extremely hungry and might have more patience. Use a bottle nipple with a slow flow at first. If you use a bottle nipple with a fast flow, your child might become accustomed to that and get frustrated with the pacing and different flow rate of milk during breast-feeding.

How long does weaning take?

Weaning could take days, weeks or months. Even after you successfully wean your child from day feedings, you might continue to breast-feed in the morning and before your child’s bedtime to keep up that feeling of closeness.

Breast-feeding is an intimate experience. You might have mixed emotions about letting go. But by taking a gradual approach to weaning and offering lots of affection you can help your child make a smooth transition to a bottle or cup.

When do you stop breastfeeding?

The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months after birth and breastfeeding in combination with solids foods until at least age 1. Breastfeeding is recommended as long as you and your baby wish to continue.

When to start weaning your child is a personal decision. It’s often easiest to begin weaning when your baby starts the process. Changes in breast-feeding patterns leading to eventual weaning often begin naturally at age 6 months, when solid foods are typically introduced. Some children begin to seek other forms of nutrition and comfort at around age 1. By this age, children typically eat a variety of solid foods and are able to drink from a cup. Other children might not initiate weaning until they become toddlers, when they’re less willing to sit still during breast-feeding.

You might also decide when to start the weaning process yourself. This might be more difficult than following your child’s lead — but can be done with extra care and sensitivity.

Whenever you start weaning your baby from the breast, focus on your child’s needs as well as your own. Resist comparing your situation with that of other families, and consider rethinking any deadlines you might have set for weaning when you were pregnant or when your baby was a newborn.

Are there certain times when it wouldn’t be smart to start weaning?

Consider delaying weaning if:

• You’re concerned about allergens. If you or your child’s father has food allergies, consider delaying weaning until after your child turns age 1. Research suggests that exposing a child to potential allergens while breast-feeding might decrease his or her risk of developing allergies. Talk to your child’s doctor.
• Your child isn’t feeling well. If your child is ill or teething, postpone weaning until he or she feels better. You might also postpone weaning if you’re not feeling well. You’re both more likely to handle the transition well if you’re in good health.
• A major change has occurred. Avoid initiating weaning during a time of major change. If your family has recently moved or your child care situation has changed, for example, postpone weaning until a less stressful time.

If your baby is struggling with the weaning process, consider trying again in a month or two.

Caffeine and breastfeeding

Breastfed babies generally do not suffer ill effects from mother’s moderate caffeine consumption. However, you may want to take the following into consideration:

• Babies who are under six months or have other health issues may be more likely to show symptoms ¹⁾.
• A baby who is showing signs of caffeine intake may be unusually irritable, fussy, or wakeful. They may have a harder time staying asleep ²⁾.

It’s wiser to cut caffeine out while breastfeeding as it’s a stimulant which can make your baby restless. If you do drink caffeine, try not to have more than 300 mg of caffeine a day ³⁾. According to the Mayo Clinic ⁴⁾, an average 8 oz cup of coffee contains 95 – 165 mg of caffeine and an 8oz cup of black tea can contain 25-48 mg however, strength of coffee/other caffeinated beverage may be different for each individual so it may be helpful to review serving size and nutritional labels prior to drinking. Most breastfeeding mothers can consume a moderate amount of caffeine (2-3 cups of coffee or tea each day) without it affecting their babies. If a mother smokes, this can compound the effect of caffeine on her baby, so mothers who smoke should limit their caffeine intake further ⁵⁾. Newborn babies however can be particularly sensitive to caffeine. This is because it can take a newborn baby a long time (i.e., half-life of 50–100 hours) to process caffeine. By 3–4 months, however, it takes a baby only about 3–7 hours ⁶⁾.

The amount of caffeine that gets into a mother’s breastmilk is about 1% of what she takes in and the caffeine level in her breastmilk usually reaches a peak about 60 minutes after she has consumed it ⁷⁾.

Some mothers find that their baby becomes unhappy, jittery, colicky and/or sleeps poorly if she consumes too much caffeine ⁸⁾. Too much caffeine is different for every mother and depends on various things such as how well a mother’s body processes caffeine. The only way to know if you are taking in too much caffeine is to observe your baby.

If you suspect your baby might have an effect from your caffeine intake, try going without for a week or two ⁹⁾. This will give enough time for the caffeine to clear your system. It is best to reduce your caffeine slowly, as you may experience headaches if you stop too quickly.

If a breastfeeding mother has nipple vasospasm she may find caffeine consumption aggravates it.

It’s not just tea and coffee that contains caffeine, it’s in chocolate and various energy drinks and soft drinks. Check the tables below for an idea of the caffeine content in popular beverages. Drink sizes are in fluid ounces (oz.) and milliliters (mL). Caffeine is shown in milligrams (mg).

Keep in mind that the actual caffeine content of a cup of coffee or tea can vary quite a bit. Factors such as processing and brewing time affect the caffeine level. So use these numbers as a guide.

To give you an idea of what that looks like:

• 1 mug of filter coffee = 140mg
• 1 mug of instant coffee = 100mg
• 1 (250ml) can of energy drink = 80mg (larger cans may contain up to 160mg caffeine)
• 1 mug of tea = 75mg
• 1 (50g) plain chocolate bar = up to 50mg
• 1 (354mls) cola drink = 40mg

Table 1. Coffee drinks

Coffee drinks	Size in oz. (mL)	Caffeine (mg)
Brewed	8 (237)	96
Brewed, decaf	8 (237)	2
Espresso	1 (30)	64
Espresso, decaf	1 (30)	0
Instant	8 (237)	62
Instant, decaf	8 (237)	2

Table 2. Tea drinks

Teas	Size in oz. (mL)	Caffeine (mg)
Brewed black	8 (237)	47
Brewed black, decaf	8 (237)	2
Brewed green	8 (237)	28
Ready-to-drink, bottled	8 (237)	19

Table 3. Sodas

Sodas	Size in oz. (mL)	Caffeine (mg)
Citrus (most brands)	8 (237)	0
Cola	8 (237)	22
Root beer (most brands)	8 (237)	0

Table 4. Energy drinks

	Ounces per bottle or can	Caffeine Concentration (mg/oz)	Total Caffeine (mg)
Top Selling Energy Drinksb
Red Bull	8.3	9.6	80
Monster	16	10	160
Rockstar	16	10	160
Full throttle	16	9	144
No Fear	16	10.9	174
Amp	8.4	8.9	75
SoBe Adrenaline Rush	8.3	9.5	79
Tab Energy	10.5	9.1	95
Higher Caffeine Energy drinksc
Wired X505	24	21	505
Fixx	20	25	500
BooKoo Energy	24	15	360
Wired X344	16	21.5	344
SPIKE Shooter	8.4	35.7	300
Viso Energy Vigor	20	15	300
Cocaine Energy Drink	8.4	33.3	280
Jolt Cola	23.5	11.9	280
NOS	16	16.3	250
Redline RTD	8	31.3	250
Blow (energy Drink Mix)	8	30	240
Lower Caffeine Energy Drinksc
Bomba Energy	8.4	8.9	75
HiBall Energy	10	7.5	75
Airforce Nutrisoda Energize	8.5	5.9	50
Whoop Ass	8.5	5.9	50
Vitamin Water (Energy Citrus)	20	2.5	50
High Concentration Energy Drinksc
RedLine Power Rush	2.5	140	350
Ammo	1	171	171
Powershot	1	100	100
Fuel Cell	2	90	180
Classic Soft Drinks
Coca-Cola Classic	12	2.9	34.5
Pepsi Cola	12	3.2	38
Dr. Pepper	12	3.4	41
Mountain Dew	12	4.5	54

Footnote: ^a Data on drink volume and caffeine content were obtained from the manufacturer via product label, website, or personal communication with manufacturer representatives. The one exception was that the caffeine content for BooKoo Energy was obtained from the CaffeinInformer website ¹⁰⁾ which indicates the information was obtained from a Boo-Koo representative. When the authors contacted the BooKoo company directly, a BooKoo representative refused to disclose the drink’s caffeine content but did indicate that accurate information for the caffeine content of BooKoo Energy was available online.

^b Top selling energy drinks in the U.S. 2006, listed sequentially as a percentage of market share (Packaged Facts, 2007 ^11)
c Examples of energy drinks drawn from the hundreds of energy drink products currently marketed in the U.S., listed sequentially on total caffeine content

[Source ¹²⁾]

How to breastfeed

Breastfeeding takes practice. It takes time to work out which feeding and burping positions feel best. There aren’t ‘correct’ positions – it’s about what feels most comfortable for you both, so try them all out to see which feels best. Remember to offer both breasts and switch breasts after each feed.

Latching on (see the steps below)

1. Hold your baby’s whole body close with their nose level with your nipple.
2. Let your baby’s head tip back a little so that their top lip can brush against your nipple. This should help your baby to make a wide, open mouth.
3. When your baby’s mouth opens wide, their chin should be able to touch your breast first, with their head tipped back so that their tongue can reach as much breast as possible.
4. With your baby’s chin firmly touching your breast and their nose clear, their mouth should be wide open. You should see much more of the darker nipple skin above your baby’s top lip than below their bottom lip. Your baby’s cheeks will look full and rounded as they feed.

With breastfeeding, a latch refers to how the baby fastens onto the breast. Getting a good latch is important. In fact, how your baby latches is actually more important than how you hold your baby. Getting your baby to “latch on” properly can take some practice. You can try different breastfeeding holds to help your baby get a good latch. Learn signs of a good latch. Get tips to help your baby have a good latch.

Signs of a good latch include the following:

• The latch feels comfortable to you and does not hurt or pinch.
• Your baby’s chest rests against your body. Your baby does not have to turn his or her head while drinking.
• You see little or no areola (the darker skin around the nipple), depending on the size of your areola and the size of your baby’s mouth.
• When your baby is positioned well, his or her mouth will be filled with breast.
• The baby’s tongue is cupped under the breast, so you might not see the baby’s tongue.
• You hear or see your baby swallow. Some babies swallow so quietly that a pause in their breathing may be the only sign of swallowing.
• You see the baby’s ears “wiggle” slightly.
• Your baby’s lips turn outward like fish lips, not inward. You may not even be able to see the baby’s bottom lip.
• Your baby’s chin touches your breast.

Step 1. Hold your baby’s whole body close with their nose level with your nipple.

Step 2. Let your baby’s head tip back a little so that their top lip can brush against your nipple. This should help your baby to make a wide, open mouth.

Step 3. When your baby’s mouth opens wide, their chin should be able to touch your breast first, with their head tipped back so that their tongue can reach as much breast as possible.

Step 4. With your baby’s chin firmly touching your breast and their nose clear, their mouth should be wide open. You should see much more of the darker nipple skin above your baby’s top lip than below their bottom lip. Your baby’s cheeks will look full and rounded as they feed.

How to breastfeed twins, triplets or more

What does it mean to have a good latch?

A good latch means that the bottom of your areola (the darker area around the nipple) is in your baby’s mouth and your nipple is back inside his or her mouth, where it’s soft and flexible. A shallow latch happens when your baby does not have enough of your breast in his/her mouth or is too close to the end of your nipple. A shallow latch can make the nipple sore, cracked, and bleeding.

Check your nipples

The sensitivity of the skin on your nipples and breasts helps your breasts respond to your baby and know how much milk to make. When the baby is latched correctly, the bottom part of the areola is also in his or her mouth. But a shallow latch, even if it doesn’t hurt right away, will start to hurt soon. And your baby has to work harder to get the milk out.

Not sure if baby’s latch is too shallow?

Ask yourself:

• Are you in pain? If the pain lasts longer than a few seconds, the latch is probably too shallow. Gently break the suction by placing a clean finger into your baby’s mouth and help your baby latch on again.
• How’s your nipple? When the baby unlatches, look down. Your nipple should look the same or slightly longer than usual. Pain or pinching is a sign of a poor latch.

Check your comfort

Both you and your baby should be comfortable both during and after feedings.

• During feeds. A little bit of discomfort at first is okay, but if your baby has been at the breast more than a few seconds and it still hurts, or if you find yourself using the breathing they taught you for labor and delivery to get through pain, that’s not good. Take your baby off, look at how you’re positioned, and try again. Your baby needs a good latch to get maximum milk, and you need a good latch for comfort.
• Between feeds. You might sometimes feel your breasts getting fuller when it’s time for a feeding. Some moms can feel a tingling sensation in their breasts just by thinking about their baby or hearing another baby cry. You may even leak a little milk between feedings. These are normal signs. But if your breasts feel painful, achy, itchy, hot, or burning, or you feel a hard lump that can’t be massaged out, call a doctor or nurse right away. These can be signs of an infection. Regardless of the diagnosis, even if you’re prescribed medicine, keep breastfeeding if the doctor or nurse tells you to. Why? Continued breastfeeding keeps the milk moving through the breast, which helps the healing process and speeds recovery.

Sometimes, even when you do everything right and the latch looks good, you may still experience pain. Remember, pain is a red flag. So get help from a breastfeeding expert, doctor, or nurse.

How can I help my baby get a good latch while learning to breastfeed?

The steps below can help your newborn latch on to the breast to start sucking when he or she is ready. Letting your baby begin the process of searching for the breast may take some of the pressure off you and keeps the baby calm and relaxed. This approach to learning to breastfeeding is a more relaxed, baby-led latch. Sometimes called biological nurturing, laid-back breastfeeding, or baby-led breastfeeding, this style of breastfeeding allows your baby to lead and follow his or her instincts to suck.

Keep in mind that there is no one way to start breastfeeding. As long as the baby is latched on well, how you get there is up to you.

• Create a calm environment first. Recline on pillows or other comfortable area. Be in a place where you can be relaxed and calm.
• Hold your baby skin-to-skin. Hold your baby, wearing only a diaper, against your bare chest. Hold the baby upright between your breasts and just enjoy your baby for a while with no thoughts of breastfeeding yet.
• Let your baby lead. If your baby is not hungry, she will stay curled up against your chest. If your baby is hungry, she will bob her head against you, try to make eye contact, and squirm around. Learn how to read your baby’s hunger signs.
• Support your baby, but don’t force the latch. Support her head and shoulders as she searches for your breast. Avoid the temptation to help her latch on.
• Allow your breast to hang naturally. When your baby’s chin hits your breast, the firm pressure makes her open her mouth wide and reach up and over the nipple. As she presses her chin into the breast and opens her mouth, she should get a deep latch. Keep in mind that your baby can breathe at the breast. The nostrils flare to allow air in.

If you have tried the “baby-led” approach and your baby is still having problems latching on, try these tips:

• Tickle the baby’s lips with your nipple to encourage him or her to open wide.
• Pull your baby close so that the baby’s chin and lower jaw moves in to your breast.
• Watch the baby’s lower lip and aim it as far from the base of the nipple as possible so that the baby takes a large mouthful of breast.

What are some common breastfeeding latch problems?

Below are some common latch problems and how to deal with them.

• You’re in pain. Many moms say their breasts feel tender when they first start breastfeeding. A mother and her baby need time to find comfortable breastfeeding positions and a good latch. If breastfeeding hurts, your baby may be sucking on only the nipple, and not also on the areola (the darker skin around the nipple). Gently break your baby’s suction to your breast by placing a clean finger in the corner of your baby’s mouth. Then try again to get your baby to latch on. To find out if your baby is sucking only on your nipple, check what your nipple looks like when it comes out of your baby’s mouth. Your nipple should not look flat or compressed. It should look round and long or the same shape as it was before the feeding.
• You or your baby feels frustrated. Take a short break and hold your baby in an upright position. Try holding your baby between your breasts with your skin touching his or her skin (called skin-to-skin). Talk or sing to your baby, or give your baby one of your fingers to suck on for comfort. Try to breastfeed again in a little while.
• Your baby has a weak suck or makes tiny sucking movements. Your baby may not have a deep enough latch to suck the milk from your breast. Gently break your baby’s suction to your breast by placing a clean finger in the corner of your baby’s mouth. Then try to get your baby to latch on again. Talk with a lactation consultant or pediatrician if you are not sure if your baby is getting enough milk. But don’t worry. A weak suck is rarely caused by a health problem.
• Your baby may be tongue-tied (ankyloglossia). Babies with a tight or short lingual frenulum (the piece of tissue attaching the tongue to the floor of the mouth) are described as “tongue-tied.” These babies often find it hard to nurse. They may be unable to extend their tongue past their lower gum line or properly cup the breast during a feed. This can cause slow weight gain in the baby and nipple pain in the mother. If you think your baby may be tongue-tied, talk to your doctor.

When can I start breastfeeding?

Most women can start breastfeeding within 1 hour after their baby is born. A nurse or lactation consultant can help you get started:

• Tell the nurses that you want to breastfeed.
• Ask to have your baby stay in the room with you so you can breastfeed him when he needs to eat.
• Ask your nurses, the lactation consultant and your baby’s provider to help make sure breastfeeding is going well before you leave the hospital.

Is breastfeeding good for babies with special needs?

Yes. Some babies are born premature (before 37 weeks of pregnancy) or with birth defects or other medical conditions. Breastfeeding a baby with special needs like these can help her grow and protect her from illness. But you may need help to make breastfeeding work for you and your baby.

Talk to your health care provider or lactation consultant about breastfeeding your baby with special needs. A lactation consultant is a person with special training in helping women breastfeed.

Is any amount of breastfeeding good?

Yes. It’s best to feed your baby only breast milk for at least 6 months. This means no water, formula, other liquids or solid food—just breast milk. But any amount of breastfeeding is good for your baby’s health and development. Even breastfeeding for a short time is good for your baby.

How do you know when your baby’s ready to eat?

Look for her feeding cues. Feeding cues are ways that your baby tells you that she’s hungry. Examples are:

• Rooting (turning her head toward anything that strokes her cheek or mouth)
• Sucking movements or sounds
• Putting her hand to her mouth
• Crying — This is a late feeding cue. Try to breastfeed your baby before she starts to cry.

How often do you breastfeed?

Feed your baby when she’s hungry. This is called on-demand feeding. Most newborns eat about eight to 12 times over 24 hours, which is about once every 2 to 3 hours. But each baby is different. Your baby may want to feed more often or less often. As your baby grows, her feeding patterns may change, and she may go longer between feedings.

To make nighttime feedings easier, put the baby’s crib in your room. Just don’t sleep with the baby in your bed.

How long does each feeding last?

Let your baby feed as long as she wants at one breast. This is called feeding unlimited at the breast. This usually takes about 15 to 30 minutes. Your baby may take more or less time. When she is finished with one breast, burp her. Then switch her to feed from the other breast. It’s OK if she only wants to nurse from one breast. Just be sure to start her on the other breast at the next feeding. Let your baby end breastfeeding on her own.

How do you know if your baby is getting enough milk?

Lots of new moms ask this question. Your body is pretty amazing. As you breastfeed, your body learns when your baby needs more milk. Your body makes exactly the right amount for your baby. But what if you’re still not sure he’s eating enough? Your baby is probably getting enough milk if he:

• Is gaining weight
• Is making six to eight wet diapers a day by the time he’s 5 to 7 days old

Is breastfeeding good for the mother?

Yes. Breastfeeding your baby helps you because:

• It increases the amount of a hormone in your body called oxytocin. This helps your uterus (womb) go back to the size it was before you got pregnant. It also helps stop bleeding that you have after giving birth.
• It burns extra calories. This helps you get back to your pre-pregnancy weight (your weight before pregnancy).
• It may help lower your risk for diabetes, breast cancer and ovarian cancer.
• It can help you bond with your baby.

Breastfeeding also delays the return of your period. But this can make it hard to know when your body can get pregnant again. Use birth control when you start having sex again. Talk to your provider about birth control that’s safe to use when you’re breastfeeding.

Can breastfeeding help me lose weight?

Besides giving your baby nourishment and helping to keep your baby from becoming sick, breastfeeding may help you lose weight. Many women who breastfed their babies said it helped them get back to their pre-pregnancy weight more quickly, but experts are still looking at the effects of breastfeeding on weight loss.

Is breastfeeding safe for all moms and babies?

No. Breastfeeding may not be safe for your baby if you have certain medical conditions, take certain medicines or have other problems, like using street drugs or abusing prescription drugs. You can pass some infections, medicines and drugs to your baby through breast milk. Some can be very harmful to your baby. Talk to your provider if you think you have a condition that may make breastfeeding unsafe for your baby.

How long should a mother breastfeed?

The American Academy of Pediatrics recommends that breastfeeding continue for at least 12 months, and thereafter for as long as mother and baby desire. The World Health Organization recommends continued breastfeeding up to 2 years of age or beyond.

What can happen if someone else’s breast milk is given to another child?

HIV and other serious infectious diseases can be transmitted through breast milk. However, the risk of infection from a single bottle of breast milk, even if the mother is HIV positive, is extremely small. For women who do not have HIV or other serious infectious diseases, there is little risk to the child who receives her breast milk.

Should mothers who smoke breastfeed?

Mothers who smoke are encouraged to quit, however, breast milk remains the ideal food for a baby even if the mother smokes. Although nicotine may be present in breast milk, adverse effects on the infant during breastfeeding have not been reported. American Academy of Pediatrics recognizes pregnancy and lactation as two ideal times to promote smoking cessation, but does not indicate that mothers who smoke should not breastfeed.

When should a baby start eating solid foods such as cereals, vegetables, and fruits?

Breast milk alone is sufficient to support optimal growth and development for approximately the first 6 months after birth. For these very young infants, the American Academy of Pediatrics ¹⁾ states that water, juice, and other foods are generally unnecessary. Even when babies enjoy discovering new tastes and textures, solid foods should not replace breastfeeding, but merely complement breast milk as the infant’s main source of nutrients throughout the first year. Beyond one year, as the variety and volume of solid foods gradually increase, breast milk remains an ideal addition to the child’s diet.

How to stop breastfeeding?

You can breastfeed your baby for as long as you want. When you stop breastfeeding, it’s called weaning your baby. Some babies begin weaning on their own between 6 and 12 months as they start eating solid food and become more active. Weaning is a slow process that doesn’t happen in a few days. Taking your time can make weaning easier for you and your baby.

If you wean your baby off breast milk before she’s 12 months old, feed her formula. She can stay on formula until she’s ready to drink regular milk after she turns 1.

Does your baby need vitamin supplements if you breastfeed?

Yes. A supplement is a product you take to make up for certain nutrients that you don’t get enough of in the foods you eat.

Breast milk doesn’t have enough vitamin D for your baby. Vitamin D helps make bones and teeth strong and helps prevent a bone disease called rickets. Give your baby vitamin D drops starting in the first few days of life. Talk to your baby’s provider about vitamin D drops for your baby.

If you’re a vegan or if you’ve had gastric bypass surgery, you need extra vitamin B12. A vegan is someone who doesn’t eat meat or anything made with animal products, like eggs or milk. Gastric bypass is surgery on the stomach and intestines to help a person lose weight. Ask your provider about taking a vitamin B12 supplement to make sure you and your baby get the right amount.

How does breastfeeding help in an emergency?

During an emergency, such as a natural disaster, breastfeeding can save your baby’s life:

• Breastfeeding protects your baby from the risks of an unclean water supply.
• Breastfeeding can help protect your baby against respiratory illnesses and diarrhea.
• Your breast milk is always at the right temperature for your baby. It helps to keep your baby’s body temperature from dropping too low.
• Your breast milk is always available without needing other supplies.

Do you need special clothes to breastfeed?

No, but nursing bras have flaps that make breastfeeding easier than if you’re wearing your regular bra. You may want to get one or two while you’re pregnant so you have them when your baby is born. Get a nursing bra that is one size larger than your regular bra size so it will fit when your breasts get larger when your breast milk comes in.

You may find it easier to breastfeed in shirts that pull up, rather than shirts that button. Sometimes it’s hard to get buttons undone quickly when you’ve got a hungry baby wanting to eat.

How to hold baby when breastfeeding

Before you breastfeed your baby, have a drink beside you – something thirst quenching like a big glass of water. There are a few different breastfeeding positions you can try, some moms find that the following positions are helpful ways to get comfortable and support their babies while breastfeeding. You can also use pillows under your arms, elbows, neck, or back to give you added comfort and support. Keep trying different positions until you are comfortable. What works for one feeding may not work for the next feeding.

• Clutch or “football” hold: useful if you had a C-section, or if you have large breasts, flat or inverted nipples, or a strong let-down reflex. This hold is also helpful for babies who like to be in a more upright position when they feed. Hold your baby at your side with the baby lying on his or her back and with his or her head at the level of your nipple. Support your baby’s head by placing the palm of your hand at the base of his or her head.
• Cross-cradle or transitional hold: useful for premature babies or babies with a weak suck because this hold gives extra head support and may help the baby stay latched. Hold your baby along the area opposite from the breast you are using. Support your baby’s head at the base of his or her neck with the palm of your hand.
• Cradle hold: an easy, common hold that is comfortable for most mothers and babies. Hold your baby with his or her head on your forearm and his or her body facing yours.
• Laid-back hold (straddle hold): a more relaxed, baby-led approach. Lie back on a pillow. Lay your baby against your body with your baby’s head just above and between your breasts. Gravity and an instinct to nurse will guide your baby to your breast. As your baby searches for your breast, support your baby’s head and shoulders but don’t force the latch.
• Side-lying position: useful if you had a C-section, but also allows you to rest while the baby breastfeeds. Lie on your side with your baby facing you. Pull your baby close so your baby faces your body.

The following are 3 of the most popular breastfeeding positions:

1. Cradle hold
2. Lying on your side
3. Clutch or “football” hold

Figure 1. Breastfeeding positions

Cradle hold

This is the probably the most popular breastfeeding position. However, if you’ve had a caesarean, this may be uncomfortable as your baby lies across your tummy near the scar (try lying on your side or the rugby hold instead). For the cradle hold, sit in a comfy chair with arm rests, or a bed with cushions or pillows around you.

Positioning:

1. Lie your baby across your lap, facing you.
2. Place your baby’s head on your forearm – nose towards your nipple. Your hand should support the length of their body.
3. Place your baby’s lower arm under yours.
4. Check to make sure your baby’s ear, shoulder and hip are in a straight line.

If you’re sitting on a chair, rest your feet on a stool or small table – this will stop you from leaning forward which can make your back ache.

Figure 2. Cradle hold

Lying on your side

This is a good position if you’ve had a caesarean or difficult delivery, or if you’re breastfeeding in the middle of the night.

Positioning:

1. Start by getting comfy lying on your side. Your baby lies facing you, so you are tummy to tummy. Check to make sure your baby’s ear, shoulder and hip are in a straight line – not twisted.
2. Put some cushions or pillows behind you for support. A rolled up baby blanket placed behind your baby will help support them. If you’ve got a pillow under your head, make sure it’s not too close to your baby’s head or face.
3. Tuck the arm you’re lying on under your head or pillow (ensuring your baby’s position isn’t altered by the pillow) and use your free arm to support and guide your baby’s head to your breast.

Figure 3. Lying on your side

Football hold (Clutch)

The football hold is a good position for twins as you can feed them at the same time, as well as caesarean babies as there’s no pressure on the tummy and scar area.

Positioning

1. Sit in a chair with a cushion or pillow along your side.
2. Position your baby at your side (the side you want to feed from), under your arm, with their hips close to your hips.
3. Your baby’s nose should be level with your nipple.
4. Support your baby’s neck with the palm of your hand.
5. Gently guide your baby to your nipple.

Figure 4. Football hold

Checking your position

Both you and your baby need to be comfortable. Although it takes practice to get a good latch, you should never have to work hard to stay in the right position while your baby is breastfeeding. You can only know which nursing hold works best for you and your baby through trial and error. But whatever the position, you should be relaxed with your baby snuggled close, belly-to-belly with you, so your baby doesn’t have to turn his or her head to the side.

Not sure if your baby is positioned right?

Here are two easy tricks:

1. Look for your baby’s belly button. If you can see the belly button while your baby’s latched, the baby’s not comfortable enough to latch well. Scoot your baby’s body inward a little so that the belly button is facing toward you.
2. Look around. If you can chat and use your hands without concentrating on holding your position, that’s a good position for a latch.

Burping your baby

Burping your baby also known as winding, is an important part of feeding. Newborns might have wind if they swallow air when crying or feeding. When your baby swallows, air bubbles can become trapped in their tummy and cause a lot of discomfort. Some babies find it easy to burp, while others need a helping hand. Some babies might be unsettled during and after a feed until they’ve been burped. Burping your baby part way through a feed might help. Use the position that works best for your baby.

There are no rules on when you should burp your baby, some babies need burping during their feed, some after. Look for clues – if your baby seems uncomfortable while feeding, have a little burping break. If they seem fine while feeding, wait until they’ve finished. Your baby will let you know.

To burp a baby support your baby’s head and neck, make sure their tummy and back is nice and straight (not curled up), and repeated gentle patting on your baby’s back should do the trick. Cup your hand while patting — this is gentler on the baby than a flat palm. To prevent messy cleanups when your baby spits up or has a “wet burp,” you might want to place a towel or bib under your baby’s chin or on your shoulder.

You don’t need to spend ages burping your baby, a couple of minutes should be enough.

There are a few ways to burp your baby. Try them all out and see which works best or use a combination.

Try different positions for burping that are comfortable for you and your baby. Many parents use one of these three methods:

1. Sit upright and hold your baby against your chest. Your baby’s chin should rest on your shoulder as you support the baby with one hand. With the other hand, gently pat your baby’s back. Sitting in a rocking chair and gently rocking with your baby while you do this may also help.
2. Hold your baby sitting up, in your lap or across your knee. Support your baby’s chest and head with one hand by cradling your baby’s chin in the palm of your hand. Rest the heel of your hand on your baby’s chest, but be careful to grip your baby’s chin, not the throat. Use the other hand to pat your baby’s back.
3. Lay your baby on your lap on his or her belly. Support your baby’s head and make sure it’s higher than his or her chest. Gently pat your baby’s back.

If your baby seems fussy while feeding, stop the session, burp your baby, and then begin feeding again. Try burping your baby every 2 to 3 ounces (60 to 90 milliliters) if you bottle-feed and each time you switch breasts if you breastfeed.

Try burping your baby every ounce during bottle-feeding or every 5 minutes during breastfeeding if your baby:

• tends to be gassy
• spits a lot
• has gastroesophageal reflux disease (GERD)
• seems fussy during feeding

If your baby doesn’t burp after a few minutes, change the baby’s position and try burping for another few minutes before feeding again. Always burp your baby when feeding time is over.

To help prevent the milk from coming back up, keep your baby upright after feeding for 10 to 15 minutes, or longer if your baby spits up or has GERD. But don’t worry if your baby spits sometimes. It’s probably more unpleasant for you than it is for your baby.

Sometimes your baby may awaken because of gas. Picking your little one up to burp might put him or her back to sleep. As your baby gets older, don’t worry if your child doesn’t burp during or after every feeding. Usually, it means that your baby has learned to eat without swallowing excess air.

Babies with colic (3 or more hours a day of continued crying) might have gas from swallowing too much air during crying spells, which can make the baby even more uncomfortable. Using anti-gas drops has not proven to be an effective way to treat colic or gas, and some of these medicines can be dangerous.

If your newborn is often unsettled after feeding and burping, or you’re worried for any other reason, see your doctor.

How long to burp a baby?

You don’t need to spend ages burping your baby, a couple of minutes should be enough.

Over your shoulder

Put a cloth over your shoulder. Put baby over your shoulder and support baby with your hand on the same side. With your baby’s chin resting on your shoulder, support the head and shoulder area with one hand, and gently rub and pat your baby’s back. It might help to walk around as you are doing this.

Your baby might vomit up some milk during burping. This is normal.

After burping, your baby will give you baby cues about what to do next. If baby is comfortable, it might be time for play and activities with you.

If your baby is still upset after being burped, the problem might be something other than wind. Is your baby still hungry? Does baby have a dirty nappy? Is baby unwell?

Figure 5. Over your shoulder to burp a baby

Sitting on your lap

Sit your baby upright on your lap facing away from you. Place the palm of your hand flat against their chest and support their chin and jaw (don’t put any pressure on the throat area). Lean your baby forwards slightly with baby’s tummy against your hand and with your free hand, gently rub or pat your baby’s back. The pressure of your hand on baby’s tummy might bring up wind.

Your baby may bring some milk up while burping, so have a burp cloth or muslin square ready (this is perfectly normal and nothing to worry about).

After burping, your baby will give you baby cues about what to do next. If baby is comfortable, it might be time for play and activities with you.

If your baby is still upset after being burped, the problem might be something other than wind. Is your baby still hungry? Does baby have a dirty nappy? Is baby unwell?

Figure 6. Sitting on your lap to burp a baby

Lying across your lap

Lie your baby across your lap or your forearm face down so baby is looking sideways and is supported by your knee or hand. Supporting their chin (don’t put any pressure on the throat area), use your free hand to gently rub or pat your baby’s back with your other hand.

Your baby may bring some milk up while burping, so have a burp cloth or muslin square ready (this is perfectly normal and nothing to worry about).

After burping, your baby will give you baby cues about what to do next. If baby is comfortable, it might be time for play and activities with you.

If your baby is still upset after being burped, the problem might be something other than wind. Is your baby still hungry? Does baby have a dirty nappy? Is baby unwell?

Figure 7. Lying across your lap to burp a baby

What if my baby won’t burp?

If these methods don’t work and your baby shows signs of trapped wind (crying, arched back, drawing legs into tummy, clenched fists), try lying them on their back and gently massaging their tummy. Also move your baby’s legs back and forth – like they’re riding a bicycle. If this doesn’t work, talk to your health care provider, they’ll be able to advise you on the best thing to do.

Breastfeeding benefits

Why breastfeeding is good for your baby

• Breast milk has hormones and the right amount of protein, sugar, fat and most vitamins to help your baby grow and develop. Breast milk has antibodies that help protect your baby from many illnesses. Antibodies are cells in the body that fight off infection. Breastfed babies have fewer health problems than babies who aren’t breastfed. Breastfed babies don’t have as many ear, lung or urinary tract infections. And they’re less likely to have asthma, certain cancers and diabetes (having too much sugar in your blood) later in life. They’re also less likely to be overweight.
• Breast milk has fatty acids, like DHA (docosahexaenoic acid), that may help your baby’s brain and eyes develop. It may lower the chances of sudden infant death syndrome (SIDS). SIDS is the unexplained death of a baby younger than 1 year old.
• Breast milk is easy to digest. A breastfed baby may have less gas and belly pain than a baby who is fed formula. Formula is a man-made product that you buy and feed your baby.
• Breast milk changes as your baby grows so he gets exactly what he needs at the right time. For example, for the first few days after giving birth, your breasts make a thick, yellowish form of breast milk called colostrum. Colostrum has nutrients and antibodies that your baby needs in the first few days of life. It changes to breast milk in 3 to 4 days. Breast milk is always ready when your baby wants to eat. The more you breastfeed, the more milk you make. Most breastfeeding moms make as much breast milk as their babies need.

In the United States, most new moms (about 4 in 5 or 80 percent) breastfeed their babies. About half of these moms breastfeed their babies for at least 6 months.

Breastfeeding benefits for infants

Infants who are breastfed have reduced risks of ²⁾:

• Asthma
• Obesity (during childhood)
• Type 2 diabetes
• Ear and respiratory infections
• Sudden infant death syndrome (SIDS)
• Leukemia (during childhood)
• Ear infections
• Eczema (atopic dermatitis)
• Diarrhea and vomiting
• Lower respiratory infections
• Necrotizing enterocolitis, a disease that affects the gastrointestinal tract in premature babies, or babies born before 37 weeks of pregnancy

Your breastmilk helps your baby grow healthy and strong from day one.

Your first milk is liquid gold. Called liquid gold for its deep yellow color, colostrum is the thick first milk that you make during pregnancy and just after birth. This milk is very rich in nutrients and includes antibodies to protect your baby from infections.

1. Colostrum also helps your newborn’s digestive system to grow and function. Your baby gets only a small amount of colostrum at each feeding, because the stomach of a newborn infant is tiny and can hold only a small amount. (Read How do I know if my baby is getting enough breastmilk? to see just how small your newborn’s tummy is!)
2. Your milk changes as your baby grows. Colostrum changes into mature milk by the third to fifth day after birth. This mature milk has just the right amount of fat, sugar, water, and protein to help your baby continue to grow. It looks thinner than colostrum, but it has the nutrients and antibodies your baby needs for healthy growth.

Breastfeeding benefits for mothers

Breastfeeding helps a mother’s health and healing following childbirth. Breastfeeding leads to a lower risk of these health problems in mothers ³⁾:

• Heart disease
• Type 2 diabetes
• Ovarian cancer
• Breast cancer

According to a report by the Centers for Disease Control and Prevention ⁴⁾, the proportion of mothers who breastfed their infants rose from 70.3 percent to 83 percent between 2004 and 2014. Babies are also breastfeeding for longer; 55% of U.S. babies born in 2014 were being breastfed at 6 months, up from 42% in 2004. Despite these overall increases, racial disparities between black and white infants persist ⁵⁾.

A recent Centers for Disease Control and Prevention study, published in the Morbidity and Mortality Weekly Report ⁶⁾, describes how breastfeeding rates continue to differ between African American and white infants within states.

• Among infants born during 2010–2013, 64.3% of African American infants started breastfeeding, compared to 81.5% of non-Hispanic white infants, a gap of 17.2 percentage points.
• Most of the 34 states included in the study reported lower rates of breastfeeding initiation rates among African American infants than among non-Hispanic white infants. Among low-income mothers (participants in the Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]), the breastfeeding initiation rate was 67.5%, but in those with a higher income ineligible for Women, Infants, and Children, it was 84.6% ⁷⁾. Breastfeeding initiation rate was 37% for low-income African American mothers ⁸⁾. Similar disparities are age-related; mothers younger than 20 years initiated breastfeeding at a rate of 59.7% compared with the rate of 79.3% in mothers older than 30 years. The lowest rates of initiation were seen among African American mothers younger than 20 years, in whom the breastfeeding initiation rate was 30%
• ⁹⁾.
• In 14 states (primarily in the South and Midwest) the percentage of African American infants who ever breastfed was at least 15 percentage points lower than among non-Hispanic white infants.
• African American infants also had significantly lower rates than non-Hispanic white infants of exclusive breastfeeding at 6 months and breastfeeding for 12 months.

Many factors influence a woman’s decision to start and continue breastfeeding. Some barriers disproportionately affect African American women, such as:

• Returning earlier to work.
• Not receiving enough information about breastfeeding from providers.
• Lack of access to professional breastfeeding support.

Diet for breastfeeding

A ‘perfect’ diet is not required for breastfeeding. You don’t need to eat anything special while you’re breastfeeding. But it’s a good idea for you, just like everyone else, to eat a healthy diet. In general, your diet is important for your own health and energy levels, rather than affecting your breastmilk and your baby. Even in countries where food is scarce, mothers are able to breastfeed and their babies thrive. However, there are a few nutrients a baby needs that may be affected if the mother’s intake is too low, such as iodine and vitamin B12.

When you are breastfeeding, your body is able to partly compensate for the extra demand on nutrients by using them more efficiently and there is usually an increase in your appetite as well. You can obtain the extra energy and nutrients needed by eating slightly more of the same foods you would normally eat, using up some of your fat stores laid down while you were pregnant and by reducing the amount of energy you use.

For mothers eating a normal American diet, the most common nutrients of concern are iodine, iron and calcium. Talk to your medical adviser or a dietitian to find out if you have enough of these in your diet. Particularly in the case of iodine, you may be advised to take a supplement, as the amounts recommended for pregnant and breastfeeding mothers are hard to obtain from a normal American diet.

A healthy diet includes:

• At least 5 portions of a variety of fruit and vegetables a day, including fresh, frozen, tinned and dried fruit and vegetables, and no more than one 150ml glass of 100% unsweetened juice
  starchy foods, such as wholemeal bread, pasta, rice and potatoes
• Plenty of fiber from wholemeal bread and pasta, breakfast cereals, rice, pulses such as beans and lentils, and fruit and vegetables – after having a baby, some women have bowel problems and constipation, and fiber helps with both of these
• Protein, such as lean meat and chicken, fish, eggs, nuts, seeds, soya foods and pulses – at least 2 portions of fish a week is recommended, including some oily fish
• Dairy foods, such as milk, cheese and yogurt – these contain calcium and are a source of protein
• Non-dairy sources of calcium suitable for vegans include tofu, brown bread, pulses and dried fruit
• Drinking plenty of fluids – have a drink beside you when you settle down to breastfeed: water and skimmed or semi-skimmed milk are all good choices

Eating a healthy, balanced diet is an important part of maintaining good health, and can help you feel your best. This means eating a wide variety of foods in the right proportions, and consuming the right amount of food and drink to achieve and maintain a healthy body weight.

The following table shows the recommendations for food groups and average serve sizes. This is only a guide showing the relative numbers of serves of food types. You should use your common sense, your appetite and any changes in your body weight to determine what is right for you. If you have any concerns that you may not be getting the proper amount of nutrients, talk to your doctor or nutritionist about improving your diet or the possibility of taking supplements.

Small amounts of what you’re eating and drinking can pass to your baby through your breast milk. If you think a food you’re eating is affecting your baby and they’re unsettled, talk to your doctor or nutritionist.

Table 1. Balanced diet sample daily food patterns

Food Group	Serves per day			What is a serve?
	Women 19-50 years	Pregnant	Breastfeeding
Grain (cereal) foods, mostly wholegrain and/or high-fiber cereal varieties	6	8½	9	1 slice (40 g) bread ½ (40 g) medium roll or flat bread ½ cup (75–120 g) cooked rice, pasta, noodles, barley, buckwheat, semolina, polenta, bulgur, quinoa ½ cup (120 g) cooked porridge 2/3 cup (30 g) wheat cereal flakes ¼ cup (30 g) muesli 3 (35 g) crispbreads 1 (60 g) crumpet 1 small (35 g) English muffin or scone
Vegetables and legumes/beans	5	5	7½	About 75 g: ½ cup cooked green or orange vegetables ½ cup cooked dried or canned beans, peas, lentils 1 cup green leafy or raw salad vegetables ½ cup sweet corn ½ medium potato or other starchy vegetable (sweet potato, taro, cassava) 1 medium tomato
Fruit	2	2	2	About 150 g: 1 medium apple, banana, orange, pear 2 small apricots, kiwi fruit, plums 1 cup dried or canned fruit Occasionally: ½ cup (125 mL) fruit juice with no added sugar 30 g dried fruit (4 dried apricot halves, 1½ tbsp sultanas)
Milk, yogurt, cheese and/or alternatives (mostly reduced fat)	2½	2½	2½	1 cup (250 mL) fresh, UHT long-life, reconstituted powdered milk or buttermilk ½ cup (120 mL) evaporated milk 2 slices (40 g) or 4x3x2 cm cube (40 g) hard cheese ½ cup (120 g) ricotta cheese ¾ cup (200 g) yogurt 1 cup (250 mL) soy, rice or other cereal drink with at least 100 mg/100 mL calcium 100 g almonds with skin 60 g sardines, canned in water ½ cup (100 g) canned pink salmon with bones 100 g firm tofu (check label for calcium content)
Lean meats and poultry, fish, eggs, tofu, nuts and seeds, legumes/beans	2½	3½	2½	65 g cooked lean red meat such as beef, lamb, veal, pork or goat (90–100 g raw) 80 g cooked lean poultry (100 g raw) 100 g cooked fish fillet (115 g raw) 1 small can fish 2 large (120 g) eggs 1 cup (150 g) cooked or canned legumes/beans such as lentils, chickpeas or split peas 170 g tofu 30 g nuts, seeds, or nut or seed paste
Additional serves for taller or more active people. More from above food groups or unsaturated spreads and oils or discretionary choices*	0-2½	0-2½	0-2½	10 g poly/monounsaturated spread 7 g polyunsaturated oil such as olive, canola 10 g nuts or nut paste   Discretionary choices: 2 scoops (75 g) ice cream 2 slices (50–60 g) processed meats, salami, mettwurst 2 thin (50–70 g) sausages ½ snack-size packet (30 g) salty crackers or crisps 2-3 (35 g) sweet plain biscuits 1 (40 g) doughnut 1 slice (40 g) plain cake/muffin 5–6 (40 g) small lollies 1 tbsp (60 g) jam or honey ½ bar (25 g) chocolate 2 tbsp (40 g) cream 1 tbsp (20 g) butter 1 can (375 mL) soft-drink (sugar-sweetened) ¼ (60 g) commercial pie or pastie (individual size) 12 (60 g) hot chips

Footnote: * Discretionary foods only provide energy and very little nutrition, so are not good choices.

Healthy snack ideas for breastfeeding mums

The following snacks are quick and simple to make, and will give you energy and strength:

• fresh fruit
• sandwiches filled with salad, grated cheese, mashed salmon or cold meat
• yogurts and fromage frais
• hummus with bread or vegetable sticks
• ready-to-eat dried apricots, figs or prunes
• vegetable and bean soups
• fortified unsweetened breakfast cereals, muesli and other wholegrain cereals with milk
• milky drinks or a 150ml glass of 100% unsweetened fruit juice
• baked beans on toast or a baked potato.

Eating fish while breastfeeding

Eating fish is good for your and your baby’s health, but while you are breastfeeding you should have no more than 2 portions of oily fish a week. A portion is around 140g.

Oily fish includes fresh mackerel, sardines, trout and salmon.

All adults should also eat no more than 1 portion a week of shark, swordfish or marlin.

Peanuts and breastfeeding

Unless you’re allergic to peanuts, there’s no evidence to suggest you should avoid them (or any peanut based foods like peanut butter) while breastfeeding. If you’re worried about it, or concerned about your baby developing a food allergy, speak to your doctor.

If you’d like to eat peanuts or foods containing peanuts, such as peanut butter, while breastfeeding, you can do so as part of a healthy, balanced diet (unless, of course, you are allergic to them).

There’s no clear evidence that eating peanuts while breastfeeding affects your baby’s chances of developing a peanut allergy. If you have any questions or concerns, you can talk to your doctor, midwife or health visitor.

Mothers with medical conditions

Mothers may have conditions such as celiac disease, food allergies or another medical condition that requires a special diet. Provided these conditions are well managed, there should be no reason why these mothers cannot breastfeed. Breastfeeding may help to protect babies against also developing these conditions as they grow up. The diet can be well balanced and nutritionally complete for both the mother and her baby. If you are unsure if your diet is adequate, you can consult a dietitian for assessment and advice.

Food allergy or intolerance in baby

Some babies can be food-sensitive and react to traces of foods that come through their mother’s breastmilk. This can include allergies and food intolerances. The most common food allergies in babies are those to cow’s milk, eggs, peanuts and tree nuts. A baby can also have food intolerance (along with an allergy or alone) and react to a range of other foods in the mother’s diet. Since peanuts are one of the foods most likely to cause an allergic response in both children and adults, be sure to monitor your baby’s response when you eat foods containing peanuts, especially if there is a family history of food allergies.

However, there are many reasons a baby may be unsettled or have other symptoms that are like those of food intolerance. Seek professional advice to help you determine if your baby is food-sensitive. Each mother and baby pair is different. Even if you are sure that it is something in your diet, it can often be very difficult to identify which foods are causing problems. Avoiding a whole food group, such as dairy products, may make it more difficult for you to eat a balanced diet. A dietitian will be able to help you sort out what the problem foods are and ensure that your diet contains all the nutrients you need.

Cows’ milk allergy

Cows’ milk allergy is one of the most common childhood food allergies. While it’s more common when first infant formula milk is introduced or when your baby starts eating solids, it can happen while breastfeeding.

Symptoms include:

• skin reactions: such as a red itchy rash
• swelling: lips, face and around the eyes
• tummy ache, vomiting, colic, diarrhea or constipation
• runny or blocked nose
• eczema

Some babies are lactose intolerant (lactose is the natural sugar in milk). This means they can’t digest it – but this not an allergy and may only be temporary. Symptoms include:

• diarrhea
• vomiting
• tummy pain or rumbling
• wind

If you’re worried that your baby is showing signs of an allergic reaction, or intolerance, speak to your doctor. They’ll assess your baby and advise you on the best course of action.

Foods to eat while breastfeeding

The most important thing is to include a wide variety of fresh, healthy foods in your breastfeeding diet. If you think something you’re eating is affecting your baby through your breast milk, talk to your doctor or nutritionist.

Remember that you don’t need a special diet while you’re breastfeeding, just try to include a well-balanced, healthy variety of the following:

• Fruits and vegetables: Aim to eat at least 5 portions of fruit and veg a day. Fresh, frozen, tinned, dried or juiced can be part of your daily allowance – avoid anything with added salt or sugar.
• Starchy foods: Starchy foods are an important source of energy, certain vitamins and fiber. This includes bread, potatoes, breakfast cereals, rice, pasta and noodles. Go for wholemeal, instead of refined starchy (white) versions, as much as possible.
• Protein: Foods in this group include meat, fish, poultry, eggs, beans, pulses and nuts. Aim to have 2 portions of fish each week, make one of them an oily fish like salmon, sardines or mackerel. Shark, swordfish and marlin can contain more mercury than other types of fish, so avoid eating more than 1 portion per week.
• Dairy: Dairy includes milk, cheese and yogurt. It contains calcium and other essential nutrients. When possible, choose low-fat varieties, such as semi-skimmed, one per cent fat or skimmed milk, low-fat yogurt and reduced-fat hard cheese. If you prefer dairy-free alternatives, such as soy drinks and yogurts, go for the unsweetened, calcium-fortified versions.

Fish

It’s good to include 2 portions of fish per week, but when you are breastfeeding:

• Limit swordfish, marlin or shark to one portion a week. This is because of the high levels of mercury found in them
• Don’t eat more than 2 portions of oily fish a week (such as fresh tuna – tinned tuna is fine, salmon, trout, mackerel, herring, sardines, pilchards).

Calcium

Calcium is among the most important minerals in your diet. Your body stores of calcium (primarily from your bones) supply much of the calcium in your breast milk to meet your baby’s calcium needs. Studies show that women lose 3 to 5 percent of their bone mass when they are breastfeeding. After you finish breastfeeding, your body must replenish the calcium that was used to produce your milk. Making sure you consume the recommended amount of calcium in a normal diet—1,000 milligrams daily for all women ages eighteen to fifty and 1,300 milligrams for teenage mothers—helps ensure that your bones will remain strong after you have weaned your baby. The good news is that you recover the bone lost during breastfeeding within the six-month period after you wean your baby.

By consuming three servings of dairy products—8 ounces of milk is one serving—per day, you should receive the calcium you need. If you dislike milk, you can get the calcium you need from cheese and yogurt. If you are allergic to dairy products, try calcium-fortified juice, tofu, dark leafy greens such as spinach and kale, broccoli, or dried beans. You can also get calcium in fortified foods such as breakfast cereal. Contrary to popular myth, it is not necessary to drink milk to make milk.

If you do not routinely consume 1,000 milligrams of calcium in your diet, talk to your doctor or nutritionist about a dietary supplement of calcium. Avoid supplements made from crushed oyster shells, though, because of concern about lead from these sources. Consuming 1,000 milligrams of calcium daily—not only while breastfeeding but throughout life until you reach menopause—will decrease your risk of osteoporosis in later life.

Vitamin D

Everyone, including pregnant and breastfeeding women, should consider taking a daily supplement containing 10 mcg of vitamin D. If your baby is only having breast milk (no first infant formula top-ups), you should give them a daily vitamin D supplement of 8.5 to 10mcg.

Keep in mind, though, that your baby still needs vitamin D supplementation, even if you’re taking a supplement. Breast milk does not provide babies with enough vitamin D. Exclusively breastfed infants or those getting less than 32 ounces of vitamin D-fortified formula per day need 400 IU of vitamin D per day, because sunlight exposure can no longer be safely recommended as their primary source of vitamin D. Babies exclusively breastfed may develop a condition called rickets when adequate vitamin D is not provided. Make sure to talk to your baby’s doctor about the need for vitamin D supplementation.

Vitamin D is found in certain foods (including oily fish like salmon, sardines, and mackerel; red meat; and some breakfast cereals) but it’s hard to get enough from food alone. It’s sometimes referred to as the ‘sunshine vitamin’ as we get most of our vitamin D from sunlight (from late March to the end of September).

From late March/April to the end of September, the majority of people aged 5 years and above will probably get enough vitamin D from sunlight when they are outdoors. So you might choose not to take a vitamin D supplement during these months. However, exposure to sunlight it’s not the safest, given concerns about skin cancer. It’s also unreliable and depends a great deal on where you live. Instead, you should look to get vitamin D from foods such as salmon, mackerel, fortified milk or orange juice, and yogurt. Some ready-to-eat breakfast cereals are fortified with vitamin D.

You can get all the other vitamins and minerals you need by eating a varied and balanced diet.

Protein

Protein is another component of a healthy diet that demands your attention while you are breastfeeding. Protein builds, repairs, and maintains body tissues. You need 6 to 6½ ounces a day when you’re nursing. You can get it best by eating two or three servings of lean meat, poultry, or fish, usually about 3 ounces (the size of a deck of cards) in a serving. You can also get 1-ounce equivalents of protein from 1 egg, 1 tablespoon of peanut butter, nuts (12 almonds or 24 pistachios, for instance), or dried beans (¼ cup cooked). It’s also a good idea to include fish in your weekly diet as one source of protein, especially fatty fish such as salmon, tuna, and mackerel. These types of fish are rich sources of DHA (docosahexaenoic acid), an omega-3 fatty acid that is found in breast milk and contributes to growth and development of an infant’s brain and eyes. In addition, DHA content of milk declines with breastfeeding and can be replenished by eating fatty fish. As always, it’s best to vary your choices as much as possible, while keeping saturated fat intake to moderate levels. To do that, choose lean meats or low-fat varieties whenever possible.

Iron

Iron helps breastfeeding mothers (and everyone else) maintain their energy level, so be sure to get enough of this important mineral in your diet. Lean meats and dark leafy green vegetables are good sources of iron. Other sources of iron include fish, iron fortified cereals, and the dark meat in poultry.

When it comes to meeting your iron needs, it’s important to eat the best sources of iron and to pair them with the right foods. Iron from animal sources, for instance, is generally better absorbed than iron from plant sources. Tea may interfere with iron absorption, so you may want to avoid drinking tea when you eat iron-rich foods or take iron supplements. On the other hand, foods that are rich in vitamin C can enhance iron absorption. So consider pairing ground beef with spinach, or take your multivitamin/mineral supplement with a glass of orange juice.

Folic acid

Nursing mothers (along with all women of childbearing age) should get at least 400 micrograms of folate, or folic acid, daily toprevent birth defects in future children and ensure their babies’ continued normal development. Spinach and other green vegetables are excellent sources of folic acid, as are citrus fruits or juices, many kinds of beans, and meat or poultry liver. You can also get folic acid from breads, cereal, and grains, which are enriched with folate in the United States. All women in their reproductive years are encouraged to take a multivitamin supplement that provides 400 micrograms of folate daily.

Foods to avoid while breastfeeding

If your baby is sensitive to certain foods or drinks, you may need to avoid them. This is because traces of what you eat and drink can pass through to your breast milk. If you have any concerns, talk to your nutritionist or doctor.

Caffeine

Caffeine is a stimulant and can make your baby restless. Caffeine can reach your baby through your breast milk and may keep them awake. Caffeine occurs naturally in lots of foods and drinks, including coffee, tea and chocolate. It’s also added to some soft drinks and energy drinks, as well as some cold and flu remedies.

It’s wiser to cut caffeine out while breastfeeding as it’s a stimulant which can make your baby restless. If you do drink caffeine, try not to have more than 200mg a day. To give you an idea of what that looks like:

• 1 mug of filter coffee = 140mg
• 1 mug of instant coffee = 100mg
• 1 (250ml) can of energy drink = 80mg (larger cans may contain up to 160mg caffeine)
• 1 mug of tea = 75mg
• 1 (50g) plain chocolate bar = up to 50mg
• 1 cola drink (354mls): 40mg

Try decaffeinated tea and coffee, herbal teas, 100% fruit juice (but no more than one 150ml glass per day) or mineral water. Avoid energy drinks, which can be very high in caffeine.

Alcohol

Obviously, it’s better not to drink any alcohol while breastfeeding, but an occasional drink is unlikely to harm your baby. One or two units of alcohol, once or twice a week, should be fine.

If possible, allow two to three hours in between drinking and breastfeeding (you should only do this after breastfeeding is well established). This allows time for the alcohol to leave your breast milk. An alternative option is to express before drinking any alcohol, then your baby can be bottle fed and you can skip a feed. But if you do miss a feed, make sure your breasts don’t become uncomfortably full.

It’s very important that you never share a bed, or sleep on the sofa with your baby if you’ve been drinking. This is linked to the risk of sudden infant death syndrome (SIDS).

What is a unit of alcohol?

• a small glass of wine (125ml)
• half a pint of beer
• single measure of a spirit (25ml)

After drinking alcohol, how long should I wait to breastfeed?

On average, it takes about 2 to 3 hours for a glass of wine or beer to leave your system, so it’s best to wait a few hours to breastfeed. Obviously the more you drink, the longer it takes. If your baby is under 3 months old, it will take them longer to process the alcohol, as their liver is still developing.

If you express before drinking alcohol, your baby can be bottle-fed with your breast milk. If you need to miss a feed, don’t let your breasts become uncomfortably full as this can lead to mastitis. It’s best to express your breast milk rather than be uncomfortable.

What affects the content of my breastmilk?

Pregnant women usually pay close attention to their diet, since every food, beverage, and drug they ingest may make its way to their baby. Fortunately, this is not exactly the case with breastmilk.

Breastmilk is produced from the mammary glands in your breasts, not directly from the substances you ingest. These glands draw on the resources available in the form of nutrients from your diet and from your body’s stores of nutrients. If your diet contains insufficient calories or nutrients to fully sustain both you and your nursing child, your mammary glands will have “first shot” at your body’s available nutrients to produce highly nutritious breastmilk, leaving you to rely on whatever is left over. So a less-than-ideal diet will probably not affect your breastfeeding child, but it may leave your body at nutritional risk.

The mammary glands and cells that produce milk also help regulate how much of what you eat and drink actually reaches your baby. Moderate consumption of coffee, tea, caffeinated sodas, and an occasional glass of wine or other alcoholic beverage are fine when you are breastfeeding. However, some babies are more sensitive than others, so keep a close eye on your baby to see how she reacts. It is also reassuring to know that the drugs injected for epidural blocks and other types of regional anesthesia during childbirth do not pass into breast milk sufficiently to cause longterm harm, though they may make your baby a little sleepy at first. In cases when general anesthesia is used, your anesthesiologist or obstetrician should be informed in advance of your plans to breastfeed.

Most medications are safe to take during breastfeeding, but there are a few—including some nonprescription substances— that may be harmful to the baby. These are not always the same medications that are dangerous for pregnant women to take, so be sure to get approval for all medications from your doctor and your baby’s pediatrician. Excessive alcohol or any kind of recreational drug or medication that has not been approved by your pediatrician should not be indulged in, since enough of it could be passed on to your baby and cause serious harm.

Weight loss

It is normal to store extra fat during pregnancy to be used up while breastfeeding. Mothers vary in when they lose this extra weight – some in the early weeks, some later and some not until after they have stopped breastfeeding. It is important that you do lose this extra weight at some point, however, and not carry it through to another pregnancy or later life. If this happens, it makes it much harder to return to a healthy weight later on. Even though making breastmilk uses kilojoules, research is unclear whether breastfeeding actually increases weight loss after childbirth.

While breastfeeding, it is best to lose the extra weight gradually, using healthy eating principles and adding in some extra exercise. A loss of up to about half a kilo per week is safe for breastfeeding mothers. Don’t use crash or fad diets, where you lose weight quickly, either during pregnancy or breastfeeding. These diets don’t have a good balance of important nutrients needed for both you and your baby.

If you feel that you need to lose a lot of weight and more quickly, consult your medical adviser or a dietitian for advice on a balanced weight-reducing diet.

Some tips if you are trying to lose weight:

• Avoid shopping when you are hungry. Write a shopping list and stick to it. Don’t be tempted to buy high-fat or high-sugar snack foods or processed foods.
• Use smaller plates for your meals.
• Eat slowly. Don’t put more food on your fork until you’ve eaten the last mouthful. This gives you time to feel full.
• Don’t eat on the run – sit down at the table and relax.
• Choose snacks of wholegrain products, vegetables and fruits.
• Cut down on fat and calories intake by choosing low-fat or fat-free dairy products, cutting off all visible fat from meat before cooking and using only a small amount of oil during cooking.
• Choose foods that contain little or no added sugar. Note that foods labelled ‘low-fat’ are often very high in sugar. Foods with added fruit or fruit juice concentrate, but labelled ‘no added sugar’, can be just as high in calories as some others with added sugar. Check labels for energy (calories) content.
• Increase the amount of exercise you do.

Weight gain

Some breastfeeding mothers have the opposite problem and find that they lose too much weight, too quickly. In this case, try to increase the number of serves of food you eat across all food groups. Avoid the temptation to eat foods high in saturated fats or added sugar – the ‘discretionary choices’ listed in the table above. These foods might help you gain weight, but are not good sources of the extra nutrients you need. Try having frequent, small meals or at least have snacks between each regular meal. Consult your medical adviser or a dietitian if you are concerned about your weight loss.

Thirst

Making breastmilk uses extra fluid, so breastfeeding mothers are often more thirsty than usual. There is no one figure for how much you need to drink, as it depends on the weather conditions, your activity level and the foods you eat. Be guided by your thirst; don’t be tempted to ignore it because you are busy. Perhaps make it part of your breastfeeding routine to have a glass of water or a water bottle next to you each time you give your baby a feed. Carrying a water bottle with you when out and about also makes it easy to have a drink when you need it.

Special diets

Vegetarian

There are two types of vegetarian diets:

1. those that include some animal products, such as dairy products and/or eggs, and in some cases fish or some other animal products
2. those that do not contain any animal products (vegan)

The nutrients of most concern when animal products are not eaten or only in small amounts are protein, iron, calcium, vitamin B12 and omega-3 fatty acids. While breastfeeding, well-planned vegetarian diets are able to satisfy these needs, with the possible exception of vitamin B12 in a vegan diet. If you have followed a vegan diet for a long period of time prior to having your baby, it would be wise to have your vitamin B12 levels checked and you may require a vitamin B12 supplement. If you are unsure at all, check with your medical adviser or a dietitian regarding nutritional adequacy of your diet for both yourself and your baby.

Dairy-free diets

Some mothers follow dairy-free diets for either cultural reasons or because they or their babies have an intolerance to cow’s milk. Some cultural groups don’t traditionally eat dairy products and need to get their calcium from other foods. Dairy products primarily supply calcium in the Western diet, but they are also a valuable source of protein and some vitamins like A, B2 (riboflavin) and B12. When dairy products are avoided, consideration has to be given to replacing all of these from other sources in the diet. A dietitian is able to advise on this on an individual basis and take into account a mother’s cultural background.

Alcohol and breastfeeding

Alcohol passes through your breast milk to your baby, so the American Academy of Pediatrics recommends avoiding drinking alcohol while breastfeeding ¹⁾. The concentration of alcohol in your blood is the concentration of alcohol in your milk. Alcohol includes beer, wine, wine coolers and liquor. If you do drink alcohol, don’t have more than two drinks a week. Wait at least 2 hours after each drink before you breastfeed.

The effects of repeated alcohol exposure to your breastfed baby:

• There are increasing concerns about long-term, repeated exposure of infants to alcohol via the mother’s breast milk, so moderation is advised. Chronic consumption of alcohol may also reduce milk production.

If you choose to have an alcoholic drink:

• If you are going to have an alcohol containing beverage, it is best to do so just after you nurse or pump milk rather than before.
• Breastfeeding or pumping breast milk is okay 4 hours after your last drink. That way, your body will have as much time as possible to rid itself of the alcohol before the next feeding and less will reach your infant.

Drinking alcohol while breastfeeding what you should know:

• Drinking beer does not increase your milk supply, as urban myth(s) suggests.
• Consuming alcohol of any kind may decrease the amount of milk your baby drinks.
• Alcohol can change the taste of your milk, and some babies may not like it.
• Breastfeeding your baby while consuming alcohol can pose a risk to your infant if he or she consumes breast milk with alcohol.
• Expressing or pumping milk after drinking alcohol, and then discarding it (“pumping and dumping”), does NOT reduce the amount of alcohol present in your milk quicker. As your alcohol blood level falls over time, the level of alcohol in your breast milk will also decrease. Breast milk continues to contain alcohol if alcohol is still in your bloodstream.
• Drinking alcohol could impair your judgement and your ability to safely care for your baby. If you drink excessively, arrange for a sober adult to care for your baby during this time.

Drinking alcohol while breastfeeding key points

• Breastfeeding is important for your baby’s physical growth and emotional and mental development.
• You can have up to 2 standard drinks, but not every day, once your baby is a month old.
• Breastfeed before you have alcohol.
• Eat before and while you are drinking.
• Plan ahead if you think you may occasionally have more than 2 standard drinks.
• It is better to give a breastfeed with a small amount of alcohol than to feed artificial baby milk.
• There are risks in feeding your baby artificial baby milk.

You also can pass street drugs, like heroin and cocaine, to your baby through breast milk. If you’re breastfeeding, don’t use marijuana. It’s not safe for your baby. You may pass THC and other chemicals from marijuana to your baby through breast milk. If you breastfeed your baby and smoke marijuana, your baby may be at increased risk for problems with brain development. Marijuana also may affect the amount and quality of breast milk you make. Even if marijuana is legal to use in your state, don’t use it when you’re breastfeeding.

How does alcohol get into my breastmilk?

Alcohol gets into your breastmilk from your blood, moving freely from your blood to your breast milk and back out again. Alcohol will be in your breastmilk 30–60 minutes after you start drinking.

How much alcohol gets into my breastmilk?

A number of factors affect how much alcohol gets into your breastmilk, including:

• the strength and amount of alcohol in your drink
• what and how much you’ve eaten
• how much you weigh
• how quickly you are drinking.

It is important to know that the amount of alcohol in your blood is the amount of alcohol in your milk.

Can I reduce the amount of alcohol in my breastmilk?

Only time will reduce the amount of alcohol in your breastmilk.

Once you stop drinking, and the amount of alcohol in your blood drops, the amount in your milk will too. ‘Pumping and dumping’ (expressing breastmilk and throwing it away) will not reduce the amount of alcohol in your breastmilk.

How much can I drink?

It is best to avoid alcohol in the first month after the birth, until breastfeeding is going well and there is some sort of pattern to your baby’s feeding.

When your baby is very young, life can be busy. Your baby may have frequent breastfeeds without any pattern. You may not be able to tell when the next feed will be so you need to be aware that your baby could need another feed while there is still alcohol in your milk.As babies get older they fall into a more regular feeding pattern. You can often tell when their next feed will be. This makes it easier to enjoy a drink knowing that the next feed will contain little or no alcohol. However, sometimes babies don’t always stick to their routine. Be aware if your baby is a bit ‘out of sorts’ or ‘not their usual self’ and allow for this.

Will stout improve my milk supply?

No. You may have heard that black beers like stout are good for your milk supply. What is actually happening is that the alcohol stops the milk flowing as freely. Milk stays in the breasts, giving the false impression that the breasts are making more milk.

Can drinking an alcoholic beverage help me relax and stimulate milk production?

Alcohol consumption has not been shown to stimulate milk production. Studies have found that babies nurse more frequently, but consume less milk in the 3-4 hours after an alcoholic beverage is consumed.

Do I have to pump and dump after drinking an alcoholic beverage?

As alcohol leaves your bloodstream, it leaves your breastmilk. Since alcohol is not “trapped” in breastmilk (it returns to the bloodstream as mother’s blood alcohol level declines), pumping and dumping will not remove it. Pumping and dumping, drinking a lot of water, resting, or drinking coffee will not speed up the rate of the elimination of alcohol from your body.

What if I get drunk?

Mothers who are intoxicated should not breastfeed until they are completely sober, at which time most of the alcohol will have left the mother’s blood. Drinking to the point of intoxication, or binge drinking, by breastfeeding mothers has not been adequately studied. Since all of the risks are not understood, drinking to the point of intoxication is not advised.

Can alcohol abuse affect a breastfed baby?

Yes. Alcohol abuse (excessive drinking) by the mother can result in slow weight gain or failure to thrive in her baby. The let-down of a mother who abuses alcohol may be affected by her alcohol consumption, and she may not breastfeed enough. The baby may sleep excessively, or may not suck effectively leading to decreased milk intake. The baby may even suffer from delayed motor development. If you are concerned that you or someone you know is drinking alcohol excessively, contact your healthcare professional.

Can you drink alcohol while breastfeeding?

The short answer is no. Alcohol passes through your breast milk to your baby. The concentration of alcohol in your blood is the concentration of alcohol in your milk. Alcohol gets into your breastmilk from your blood, moving freely from the blood to the breast milk and back out again. Alcohol will be in your breastmilk 30–60 minutes after you start drinking. Alcohol transfers into human milk readily, with an average plasma to milk ratio of about 1. This does not necessarily mean the dose of alcohol in milk is high, only that the alcohol levels in plasma correspond closely with those in milk. The absolute amount (dose) of alcohol transferred into milk is generally low and is a function of the maternal level. Older studies, some in animals, suggested that beer (or more likely barley) may stimulate prolactin levels. Significant amounts of alcohol are secreted into breastmilk although it is not considered harmful to the infant if the amount and duration are limited. The absolute amount of alcohol transferred into milk is generally low.

The effects of alcohol on the breastfeeding baby are directly related to the amount the mother ingests. When the breastfeeding mother drinks occasionally or limits her consumption to one drink or less per day, the amount of alcohol her baby receives has not been proven to be harmful. If consumed in large amounts alcohol can cause drowsiness, deep sleep, weakness, and abnormal weight gain in the infant, and the possibility of decreased milk-ejection reflex in the mother. Mothers who have been drinking should not bed-share with their babies as their natural reflexes will be affected.

A number of factors affect how much alcohol gets into your breastmilk, including:

• The strength and amount of alcohol in your drink
  • The effect of alcohol on the baby is directly related to the amount of alcohol that is consumed
  • The more alcohol consumed, the longer it takes to clear the body
• What and how much you’ve eaten
  • An alcoholic drink consumed with food decreases absorption.
• How much you weigh
  • A person’s size has an impact on how quickly they metabolize alcohol
  • A heavier person can metabolize alcohol more quickly than a lighter person
• How quickly you are drinking.

Your baby’s age

• A newborn has an immature liver, and will be more affected by alcohol
• Up until around three months of age, infants metabolize alcohol at about half the rate of adults
• An older baby can metabolize alcohol more quickly than a young infant

As a general rule, it takes 2 hours for an average woman to get rid of the alcohol from 1 standard alcoholic drink and therefore 4 hours for 2 drinks, 6 hours for 3 drinks and so on. The time is taken from the start of drinking.

Only time will reduce the amount of alcohol in the milk in your breasts.

Once you stop drinking, and the amount of alcohol in your blood drops, the amount in the milk in your breasts will too.

‘Pumping and dumping’ (expressing breastmilk and throwing it away) will not reduce the amount of alcohol in your breastmilk. You also do not need to do this once the alcohol has passed through your system – alcohol is not ‘stored’ in the milk in your breasts, just as it doesn’t remain in your blood. Once the alcohol is out of your blood, it will be out of your breastmilk.

When breastmilk with alcohol is expressed, that expressed breastmilk will contain and continue to contain alcohol.

The safest option when breastfeeding is to avoid drinking alcohol altogether.

However, planning ahead can allow you to express some milk for your baby ahead of time. Your baby can have this milk if you miss a feed while drinking, or while you are waiting for the amount of alcohol in your milk to drop.

If you are breastfeeding and plan to consume alcohol, it is best to plan ahead. However, if, on a single occasion, you have a little more alcohol than you had planned to or if your baby needs to feed sooner than you had anticipated it is OK to breastfeed your baby.

Carers who are under the influence of alcohol may make less safe decisions about where their baby sleeps, so it is important to plan ahead and ensure safe sleeping arrangements have been made and never to sleep with your baby if you have been consuming alcohol.

Weighing the risks and benefits

Many mothers find themselves in a situation where they may want to drink. Maybe you are going to an event where wine will be served. Or perhaps you are going out with friends, or on a date. No matter the reason, you may have concerns about drinking and any possible effects on your baby. It is a good idea to weigh the benefits of breastfeeding against the benefits and possible risks of consuming alcohol. You might find the following suggestions helpful.

• Plan Ahead
  • If you want to drink, but are concerned about the effect on your baby, you can store some expressed breastmilk for the occasion
  • You can choose to wait for the alcohol to clear your system before nursing
    If your breasts become full while waiting for the alcohol to clear, you can hand express or pump, discarding the milk that you express
• Alternatives
  • If you’re concerned about consuming alcohol while breastfeeding you might prefer to stick to non-alcoholic drinks instead.
• If you are sober enough to drive you should be sober enough to breastfeed.

How can I have a drink and still breastfeed?

If you have 1 or 2 standard drinks a day, then time the drinks to have the least effect on your baby.

• Breastfeed your baby before you drink. You can then enjoy a drink knowing you’ll be unlikely to need to feed again within the next couple of hours.
• Eat before and while drinking.
• One way to reduce the amount of alcohol you drink is to alternate alcoholic with non-alcoholic drinks.

What if I’m planning a bigger night out than usual or had more to drink than I had planned?

• Breastmilk with a small amount of alcohol is still better for your baby than artificial baby milk.
• Express some milk ahead of your night out. The baby can have this milk if you miss a feed while drinking, or while you are waiting for the amount of alcohol in your milk to drop.
• If you know that sometimes you drink more than you plan to, you can express and freeze some milk just in case.
• If you miss a feed while you are drinking alcohol, and your breasts are feeling uncomfortable, express some milk and throw it away. This will help with your comfort and will maintain your milk supply.
• You may find that your milk flow is not as strong as usual while there’s still alcohol in your blood. Your milk flow will come back to normal again once your body has cleared the alcohol.
• Your baby may not sleep as well as usual. He might fall asleep quicker, but wake up sooner, instead of having a deep sleep lasting for a longer time.
• Arrange for someone who isn’t affected by alcohol to look after your baby.
• Don’t sleep with your baby if you (or anyone else in the bed) are affected by alcohol.

How long does alcohol stay in breastmilk?

As a general rule, it takes 2 hours for an average woman to get rid of the alcohol from 1 standard alcoholic drink and therefore 4 hours for 2 drinks, 6 hours for 3 drinks and so on. The time is taken from the start of drinking.

The following table gives more accurate times for mothers, depending on their weight. To use this table follow these steps:

1. Find the body weight closest to your current body weight down the left hand column.
2. Decide how many drinks you might have or have had from the top row.
3. Read along the row where your weight appears and then down the column that equals the number of drinks.

Table 1. Approximate time taken for alcohol to be cleared from breast milk (hours:mins)

Footnote: Time is taken from the start of drinking. It is assumed that alcohol is cleared at a constant rate of 15 mg/dL and the height of the women is 162.5 centimeters.

Example 1: For a 59 kg woman who has had 3 standard drinks, one after the other, it would take 5 hours and 33 minutes from when she started drinking for there to be no alcohol in her breastmilk. For a 70 kg woman drinking the same amount, it would take 5 hours 5 minutes.

Example 2: For an 84 kg woman drinking 2 standard drinks starting at 8:00 pm, there would be a zero level of alcohol in her breastmilk 3 hours and 4 minutes later (ie at 11:04 pm).

[Source ²⁾ ]

What if I often have 3 or more drinks a day?

Drinking 3 or more drinks a day can be harmful to your health and that of your baby. Be aware that:

• You may not be able to take care of your baby properly if you are affected by alcohol.
• Your baby may be slower to reach developmental milestones.
• Alcohol may decrease the flow of your milk and thus reduce your supply.

What is breast engorgement

Breast engorgement is when your breasts become swollen and get too full of milk. Breast engorgement is a painful condition affecting large numbers of women in the early postpartum period. Your breasts may feel hard, tight and painful. It is normal for your breasts to become larger, heavier, and a little tender when they begin making milk. Sometimes, this fullness may turn into breast engorgement, when your breasts feel very hard and painful. Breast engorgement is the result of the milk building up. Breast engorgement usually happens during the third to fifth day after giving birth. But it can happen at any time, especially if you have an oversupply of milk or are not feeding your baby or expressing your milk often. Breast engorgement can happen in the early days when you and your baby are still getting used to breastfeeding. It can take a few days for your milk supply to match your baby’s needs. Breast engorgement can also happen when your baby is older and not feeding so frequently, perhaps when they start having solid foods.

Surgical enlargement of breasts (augmentation mammoplasty) may also predispose to breast engorgement ¹⁾. Breast engorgement should be differentiated from normal breast fullness, often called physiological breast engorgement ²⁾, occurring between day two to three postpartum, in which secretory activation of the breast is triggered by the delivery of the placenta (progesterone withdrawal) and subsequent rise in prolactin levels ³⁾. Increased milk production and interstitial tissue edema ensue resulting in visibly larger, warmer and slightly uncomfortable breasts. In women with normal breast fullness, milk flow from the breast is not hindered and with frequent, efficient breastfeeding, discomfort resolves within a few days.

Breast engorgement, on the other hand, is a distressing and debilitating condition affecting between 15% and 50% of women ⁴⁾. Breast engorgement may lead to premature weaning, cracked nipples, mastitis and breast abscess.

Breast engorgement can also cause:

• Breast swelling
• Breast tenderness
• Warmth
• Redness
• Throbbing
• Flattening of the nipple
• Low-grade fever

Breast engorgement can lead to plugged ducts or a breast infection, so it is important to try to prevent it before this happens.

When breast engorgement was described as part of an inflammatory process (any mixture of redness, pain, fever, breast tension and resistance in breast tissue), 75% of women in a Swedish study experienced symptoms within eight weeks postpartum ⁵⁾. Some level of breast tenderness during the first five days after birth was experienced by 72% of women in a study by Hill and Humenick ⁶⁾. Breast engorgement symptoms occur most commonly between the second and fifth days postpartum ⁷⁾, peaking at day five ⁸⁾, but may occur as late as day 14 ⁹⁾ and are usually diffuse, bilateral and may be associated with a low‐grade fever. Complications are common and include sore/damaged nipples, mastitis, abscess formation, decreased milk supply ¹⁰⁾, premature introduction of breast milk substitutes, and premature cessation of breastfeeding ¹¹⁾. Difficulty in feeding the baby occurs in up to 82% of mothers with breast engorgement ¹²⁾.

If your baby isn’t well attached to the breast it may be hard for them to take your milk when your breast is engorged. The nipple can become a little over-stretched and flattened, and possibly painful.

Breast engorgement can still happen once you have learnt the skill of positioning and attachment, usually when your baby hasn’t fed for a while.

Your baby usually knows when they need a feed, for how long and from which breast. Early signs (cues) that your baby is ready to feed can include:

• moving their eyes rapidly
• putting their fingers into their mouth
• rooting (turning to one side with their mouth open as if seeking the breast)
• becoming restless

Crying is the very last sign that your baby needs feeding. Feeding them before they cry often leads to a much calmer feed. Keeping your baby close so you can watch and learn their early feeding cues will help.

Most of the time the discomfort goes away once you start breastfeeding regularly. Here are some ways to help with breast engorgement:

• Try not to miss or go a long time between feedings. Don’t skip night feedings.
• Express a small amount of milk with a breast pump or by hand before breastfeeding.
• Take a warm shower or put warm towels on your breasts. If your engorgement is really painful, put cold packs on your breasts.
• Tell your provider if your breasts stay swollen.
• Ask your midwife, doctor or a breastfeeding specialist for help immediately to help your baby drain your breasts more effectively.

Milk ejection reflex

Each time you express milk or sit down to breastfeed your baby, you may notice a sensation in your breasts called the ‘milk ejection’ reflex. In the early days, this takes a few minutes to appear, but later on it will occur within a few seconds. Milk ejection feels different to different women. You may have tingling or prickling in your breasts and nipples, or a feeling as if the milk is rushing in to fill them. Some mothers describe a slight pain and some mums have no sensations at all, but notice that milk starts to drip from both breasts.

Figure 1. Normal breast (female)

What to do when you have oversupply of breast milk?

An overfull breast can make breastfeeding stressful and uncomfortable for you and your baby.

What you can do:

• Breastfeed on one side for each feeding. Continue to offer that same breast for at least two hours until the next full feeding, gradually increasing the length of time per feeding.
• If the other breast feels unbearably full before you are ready to breastfeed on it, hand express for a few moments to relieve some of the pressure. You can also use a cold compress or washcloth to reduce discomfort and swelling.
• Feed your baby before he or she becomes overly hungry to prevent aggressive sucking.
• Burp your baby often if he or she is gassy so there is more room in baby’s tummy for milk.

How can I prevent engorgement?

• Feed your baby often from birth.
• Don’t limit baby’s time at the breast.
• Wake your baby for a feed if your breasts become full and uncomfortable (especially at night time).
• Ensure your baby is positioned and attached correctly, to maximize the amount of milk she is getting.

How to breastfeed

Breastfeeding positioning and attachment

If breastfeeding feels a bit awkward at first, don’t worry. Breastfeeding is a skill that you and your baby learn together, and it can take time to get used to.

There are lots of different positions you can use to breastfeed. You just need to check the following points:

• Are you comfortable? It’s worth getting comfortable before a feed. Use pillows or cushions if necessary. Your shoulders and arms should be relaxed.
• Are your baby’s head and body in a straight line? (It’s hard for your baby to swallow if their head and neck are twisted.)
• Are you holding your baby close to you, facing your breast? Supporting their neck, shoulders and back should allow them to tilt their head back and swallow easily.
• Always bring your baby to the breast rather than leaning forward to ‘post’ your breast into your baby’s mouth, as this can lead to poor attachment.
• Your baby needs to get a big mouthful of breast. Placing your baby with their nose level with your nipple will encourage them to open their mouth wide and attach to the breast well.
• Avoid holding the back of your baby’s head, so that they can tip their head back. This way your nipple goes past the hard roof of their mouth and ends up at the back of their mouth against the soft palate.

Breastfeeding positions

Some moms find that the following positions are helpful ways to get comfortable and support their babies while breastfeeding. You can also use pillows under your arms, elbows, neck, or back to give you added comfort and support. Keep trying different positions until you are comfortable. What works for one feeding may not work for the next feeding.

Clutch or “football” hold: useful if you had a C-section, or if you have large breasts, flat or inverted nipples, or a strong let-down reflex. This hold is also helpful for babies who like to be in a more upright position when they feed. Hold your baby at your side with the baby lying on his or her back and with his or her head at the level of your nipple. Support your baby’s head by placing the palm of your hand at the base of his or her head.

Cross-cradle or transitional hold: useful for premature babies or babies with a weak suck because this hold gives extra head support and may help the baby stay latched. Hold your baby along the area opposite from the breast you are using. Support your baby’s head at the base of his or her neck with the palm of your hand.

Cradle hold: an easy, common hold that is comfortable for most mothers and babies. Hold your baby with his or her head on your forearm and his or her body facing yours.

Laid-back hold (straddle hold): a more relaxed, baby-led approach. Lie back on a pillow. Lay your baby against your body with your baby’s head just above and between your breasts. Gravity and an instinct to nurse will guide your baby to your breast. As your baby searches for your breast, support your baby’s head and shoulders but don’t force the latch.

Side-lying position: useful if you had a C-section, but also allows you to rest while the baby breastfeeds. Lie on your side with your baby facing you. Pull your baby close so your baby faces your body.

How to breastfeed twins, triplets or more

How to latch your baby on to your breast

1. Hold your baby close to you with their nose level with the nipple.
2. Wait until your baby opens their mouth really wide with their tongue down. You can encourage them to do this by gently stroking their top lip.
3. Bring your baby on to your breast.
4. Your baby will tilt their head back and come to your breast chin first. Remember to support your baby’s neck but not hold the back of their head. They should then be able to take a large mouthful of breast. Your nipple should go towards the roof of their mouth.

Getting a good latch

Getting your baby to “latch on” properly can take some practice. You can try different breastfeeding holds to help your baby get a good latch.

The steps below can help your newborn latch on to the breast to start sucking when he or she is ready. Letting your baby begin the process of searching for the breast may take some of the pressure off you and keeps the baby calm and relaxed. This approach to learning to breastfeeding is a more relaxed, baby-led latch. Sometimes called biological nurturing, laid-back breastfeeding, or baby-led breastfeeding, this style of breastfeeding allows your baby to lead and follow his or her instincts to suck.

Keep in mind that there is no one way to start breastfeeding. As long as the baby is latched on well, how you get there is up to you.

• Create a calm environment first. Recline on pillows or other comfortable area. Be in a place where you can be relaxed and calm.
• Hold your baby skin-to-skin. Hold your baby, wearing only a diaper, against your bare chest. Hold the baby upright between your breasts and just enjoy your baby for a while with no thoughts of breastfeeding yet.
• Let your baby lead. If your baby is not hungry, she will stay curled up against your chest. If your baby is hungry, she will bob her head against you, try to make eye contact, and squirm around. Learn how to read your baby’s hunger signs.
• Support your baby, but don’t force the latch. Support her head and shoulders as she searches for your breast. Avoid the temptation to help her latch on.
• Allow your breast to hang naturally. When your baby’s chin hits your breast, the firm pressure makes her open her mouth wide and reach up and over the nipple. As she presses her chin into the breast and opens her mouth, she should get a deep latch. Keep in mind that your baby can breathe at the breast. The nostrils flare to allow air in.

If you have tried the “baby-led” approach and your baby is still having problems latching on, try these tips:

• Tickle the baby’s lips with your nipple to encourage him or her to open wide.
• Pull your baby close so that the baby’s chin and lower jaw moves in to your breast.
• Watch the baby’s lower lip and aim it as far from the base of the nipple as possible so that the baby takes a large mouthful of breast.

Step by Step Guide in Getting your baby into position

Breastfeeding – Step 1. Hold your baby’s whole body close with their nose level with your nipple.

Breastfeeding – Step 2. Let your baby’s head tip back a little so that their top lip can brush against your nipple. This should help your baby to make a wide open mouth.

Breastfeeding – Step 3. When your baby’s mouth opens wide, their chin should be able to touch your breast first, with their head tipped back so that their tongue can reach as much breast as possible.

Breastfeeding – Step 4. With your baby’s chin firmly touching your breast and their nose clear, their mouth should be wide open. You should see much more of the darker nipple skin above your baby’s top lip than below their bottom lip. Your baby’s cheeks will look full and rounded as they feed.

What are signs of a good latch?

Signs your baby is well attached to your breast

• The latch feels comfortable to you and does not hurt or pinch.
• Your baby’s chest rests against your body. Your baby does not have to turn his or her head while drinking.
• Your baby has a wide mouth and a large mouthful of breast.
• The baby’s tongue is cupped under the breast, so you might not see the baby’s tongue.
• You hear or see your baby swallow. Some babies swallow so quietly that a pause in their breathing may be the only sign of swallowing.
• You see the baby’s ears “wiggle” slightly.
• Your baby’s lips turn outward like fish lips, not inward. You may not even be able to see the baby’s bottom lip.
• Your baby’s chin is touching your breast, their lower lip is rolled down (you can’t always see this) and their nose isn’t squashed against your breast.
• You don’t feel any pain in your breasts or nipples when your baby is feeding, although the first few sucks may feel strong.
• You can see more of the dark skin around your nipple (areola) above your baby’s top lip than below their bottom lip, depending on the size of your areola and the size of your baby’s mouth.

What are some common breastfeeding latch problems?

Below are some common latch problems and how to deal with them.

• You’re in pain. Many moms say their breasts feel tender when they first start breastfeeding. A mother and her baby need time to find comfortable breastfeeding positions and a good latch. If breastfeeding hurts, your baby may be sucking on only the nipple, and not also on the areola (the darker skin around the nipple). Gently break your baby’s suction to your breast by placing a clean finger in the corner of your baby’s mouth. Then try again to get your baby to latch on. To find out if your baby is sucking only on your nipple, check what your nipple looks like when it comes out of your baby’s mouth. Your nipple should not look flat or compressed. It should look round and long or the same shape as it was before the feeding.
• You or your baby feels frustrated. Take a short break and hold your baby in an upright position. Try holding your baby between your breasts with your skin touching his or her skin (called skin-to-skin). Talk or sing to your baby, or give your baby one of your fingers to suck on for comfort. Try to breastfeed again in a little while.
• Your baby has a weak suck or makes tiny sucking movements. Your baby may not have a deep enough latch to suck the milk from your breast. Gently break your baby’s suction to your breast by placing a clean finger in the corner of your baby’s mouth. Then try to get your baby to latch on again. Talk with a lactation consultant or pediatrician if you are not sure if your baby is getting enough milk. But don’t worry. A weak suck is rarely caused by a health problem.
• Your baby may be tongue-tied. Babies with a tight or short lingual frenulum (the piece of tissue attaching the tongue to the floor of the mouth) are described as “tongue-tied.” The medical term is ankyloglossia. These babies often find it hard to nurse. They may be unable to extend their tongue past their lower gum line or properly cup the breast during a feed. This can cause slow weight gain in the baby and nipple pain in the mother. If you think your baby may be tongue-tied, talk to your doctor.

How to tell if your baby is getting enough milk

• Your baby will appear content and satisfied after most feeds.
• They should be healthy and gaining weight (although it’s normal for babies to lose a little weight in the first days after birth). Talk to your midwife or health visitor if you are concerned your baby is not gaining weight and is unsettled during or after breast feeds.
• After the first few days, your baby should have at least six wet nappies a day.
• After the first few days, they should also pass at least two soft yellow poos (stools) every day.

How often you should feed your baby

How often babies feed varies. As a very rough guide, your baby should feed at least eight times or more every 24 hours during the first few weeks.

It’s fine to feed your baby whenever they are hungry, when your breasts feel full or if you just want to have a cuddle.

It’s not possible to overfeed a breastfed baby.

When your baby is hungry they may:

• get restless
• suck their fist or fingers
• make murmuring sounds
• turn their head and open their mouth (rooting)

It’s best to try and feed your baby during these early feeding cues as a crying baby is difficult to feed.

How to tell if your baby is getting enough milk

When you first start breastfeeding, you may be concerned your baby is not getting enough milk. You can’t always tell how much a breastfed baby is drinking.

It’s very rare that women don’t make enough breast milk for their babies, but it may take a little while before you feel confident your baby is getting what they need.

Your baby will generally let you know, but wet and dirty nappies are a good indication, as well as hearing your baby swallow.

If you need some reassurance your baby is getting enough milk, it’s a good idea to get a midwife, health visitor or breastfeeding specialist to watch your baby feed.

Try to carry on breastfeeding if you can. Introducing bottles of formula milk can fill up your baby’s stomach so they no longer want to breastfeed as frequently. This then reduces the stimulation for you to make more milk.

Signs your baby is getting enough milk

• Your baby starts feeds with a few rapid sucks followed by long, rhythmic sucks and swallows with occasional pauses.
• You can hear and see your baby swallowing.
• Your baby’s cheeks stay rounded, not hollow, during sucking.
• They seem calm and relaxed during feeds.
• Your baby comes off the breast on their own at the end of feeds.
• Their mouth looks moist after feeds.
• Your baby appears content and satisfied after most feeds.
• Your breasts feel softer after feeds.
• Your nipple looks more or less the same after feeds – not flattened, pinched or white.
• You may feel sleepy and relaxed after feeds.

Other signs your baby is feeding well

• Your baby gains weight steadily after the first two weeks – it’s normal for babies to lose some of their birth weight in the first two weeks.
• They appear healthy and alert when they’re awake.
• From the fourth day, they should do at least two soft, yellow poos (stools) every day for the first few weeks.
• From day five onwards, wet nappies should start to become more frequent, with at least six heavy, wet nappies every 24 hours. In the first 48 hours, your baby is likely to have only two or three wet nappies.

It can be hard to tell if disposable nappies are wet. To get an idea, take a nappy and add two to four tablespoons of water. This will give you an idea of what to look and feel for.

Things that can affect your milk supply

• Poor attachment and positioning.
• Not feeding your baby often enough.
• Drinking alcohol and smoking while breastfeeding – these can both interfere with your milk production.
• Previous breast surgery, particularly if your nipples have been moved.
• Having to spend time away from your baby after the birth – for example, because they were premature: Frequent gentle hand expression will help.
• Illness in you or your baby.
• Giving your baby bottles of formula or a dummy before breastfeeding is well established.
• Using nipple shields – although this may be the only way to feed your baby with damaged nipples and is preferable to stopping feeding.
• Some medications, including dopamine, ergotamine and pyridoxine.
• Anxiety, stress or depression.
• Your baby having a tongue tie that restricts the movement of their tongue.

With skilled help, lots of these problems can be sorted out. If you have concerns about how much milk your baby is getting, it’s important to ask for help early. Speak to your midwife, health visitor or a breastfeeding specialist. They can also tell you where you can get further support.

Breast engorgement symptoms

Breast engorgement is the overfilling of breasts with milk leading to swollen, hard and painful breasts. Many women experience this during the first few days after giving birth, although it can occur later. A little breast fullness during the first few days after birth is normal, but excessive breast engorgement, which can occur from missed feedings or a change in how often your baby nurses, can be quite painful. Breast engorgement is more common when the timing of breastfeeding is restricted or the baby has difficulty sucking or the mother is separated from her newborn. This leads to the breasts not being emptied properly. Breast engorgement may make it difficult for women to breastfeed. It may lead to complications such as inflammation of the breast, infection and sore/cracked nipples.

Breast engorgement treatment

To ease the discomfort of breast engorgement, apart from your baby feeding, you could try expressing a little breast milk by hand.

You don’t need to strip the breast of as much milk as you can. This will only lead you to produce more. But taking a little off can relieve the pressure.

Ask your midwife, doctor or breastfeeding specialist to show you how.

Lastly, as strange as it might sound, one treatment for engorgement that many breastfeeding women have found effective involves cabbage. Clean, refrigerated cabbage leaves can be either torn into smaller pieces or left whole and applied directly to the breast. Whole leaves will conform to the shape of the breast if the large central stem portion is removed first. Held in place by the bra, the cabbage is left against the breast as desired or until it becomes warm and wilts. The wilted leaves can be replaced by fresh, cool ones. Either green or red cabbage can be used, but red cabbage is more likely to stain a bra or clothing. Many mothers experience an improvement in the pain and swelling of engorgement within hours after using the cabbage. There is limited clinical research on the use of cabbage for engorgement, and the exact way in which cabbage decreases breast swelling is unknown, but the treatment appears to be harmless. For engorgement, cabbage should be used only until the swelling and pain begin to subside. Continued use may decrease the milk supply too much. Some mothers regularly apply cabbage to hasten the resolution of swelling or discomfort that occurs with weaning, especially when weaning occurs over a relatively brief time.

How can I relieve engorgement?

• Take your bra off completely before beginning to breastfeed.
• Gentle breast massage or use of warmth for up to a few minutes before feeds may help trigger your let-down reflex.
• If your baby has trouble attaching to your breast, use ‘reverse pressure softening’ (see below) to soften the breast tissue under your areola or express some milk (by hand or with a pump).
• Feed your baby frequently.
• Massage the breast gently while you are feeding.
• If necessary, express for comfort after feeds.
• Use cold packs or chilled, washed, cabbage leaves after a feed to reduce inflammation.
• Ask your doctor about taking anti-inflammatory medication or pain relief if needed.

Reverse pressure softening: The aim is to push fluid in the tissue under the nipple and areola further back into the breast, to relieve the pressure. To do this, apply pressure with two or three fingers of each hand placed flat at the sides of and close to your nipple, and hold for 1–3 minutes. Or use all fingertips of one hand around the nipple and push in, holding for 1–3 minutes, until the tissue softens.

For severe engorgement

A small percentage of mothers experience severe engorgement around the time their ‘milk comes in’. In these situations, it is important to ensure that the baby is attaching well and feeding effectively, and that the length and frequency of feeds are being determined by the baby’s needs. In addition, mothers who experience severe engorgement often find it helpful to use a breast pump to completely express out the milk from their breasts.

Engorgement in the armpit

A small percentage of mothers have extra breast tissue in the axilla (armpit). This extra breast tissue is called accessory (or supernumerary) breast tissue and is not connected to the main ductal network of the breast. Accessory breast tissue is different to the breast tissue that normally extends into the armpit called the Tail of Spence. The Tail of Spence or accessory breast tissue can become engorged just like any other breast tissue can. Management for engorgement, regardless of what breast tissue it occurs in, is the same.

Expressing and storing breast milk

Expressing breast milk means squeezing milk out of your breast so you can store it and feed it to your baby later.

Some mothers find it very easy to express milk and they produce more milk than the baby requires; others need more time and may produce just enough to feed their babies. Don’t think that you are a failure if you are finding it very time-consuming to express. It does not mean that you will find breastfeeding equally difficult. After all, nature has equipped babies with a very efficient system of getting milk from the breast.

You might want to express your breast milk if:

• you have to be away from your baby, for example, because your baby is in special care or because you’re going back to work
• your breasts feel uncomfortably full (breast engorgement)
• your baby isn’t able to suck well but you still want to give them breast milk
• your partner is going to help with feeding your baby
• you want to boost your milk supply

How do I express breast milk?

You can express milk by hand or with a breast pump. How often you express your milk, and how much you express, will depend on why you are doing it.

Sometimes it takes a little while for your milk to start flowing. Try to choose a time when you feel relaxed. Having your baby (or a photo of them) nearby may help your milk to flow.

You may find it easier to express in the morning, when your breasts can sometimes feel fuller.

Expressing milk if your baby is premature

It’s recommended you express eight to 10 times a day to begin with, including at least once at night, to keep your milk supply up. In the early days, it’s often easier to express your milk by hand. Your midwife or a breastfeeding supporter can show you how.

You’ll probably only express a few drops to begin with but, if you hand express often, this will increase.

In the early days you can collect your breast milk in a small, sterile cup and store it in a syringe. Every drop is beneficial for your baby.

Once you are producing more milk, you could try using a breast pump. If your baby is in a neonatal unit, the hospital will usually be able to lend you an electric breast pump for expressing your milk. If they can’t lend you one, you can hire one.

Expressing breast milk by hand

Some women find it easier to express milk by hand than to use a pump, especially in the first few days or weeks. It also means you won’t have to buy or borrow a pump, or rely on an electricity supply.

Hand expressing allows you to encourage milk to flow from a particular part of the breast. This may be useful, for example, if one of the milk ducts in your breast becomes blocked.

Hold a sterilized feeding bottle or container below your breast to catch the milk as it flows.

These tips may help:

• Before you start, wash your hands thoroughly with soap and warm water.
• Some mothers find gently massaging their breasts before expressing helps their milk to let down.
• Cup your breast with one hand then, with your other hand, form a “C” shape with your forefinger and thumb.
• Squeeze gently, keeping your finger and thumb near the darker area around your nipple (areola) but not on it (don’t squeeze the nipple itself as you could make it sore). This shouldn’t hurt.
• Release the pressure, then repeat, building up a rhythm. Try not to slide your fingers over the skin.
• Drops should start to appear, and then your milk usually starts to flow.
• If no drops appear, try moving your finger and thumb slightly, but still avoid the darker area.
• When the flow slows down, move your fingers round to a different section of your breast, and repeat.
• When the flow from one breast has slowed, swap to the other breast. Keep changing breasts until your milk drips very slowly or stops altogether.

Expressing milk with a breast pump

There are two different types of breast pump: manual (hand-operated) and electric.

Different pumps suit different women, so ask for advice or see if you can try one before you buy.

Manual pumps are cheaper but may not be as quick as an electric one.

You may be able to hire an electric pump. Your midwife, health visitor or a local breastfeeding supporter can give you details of pump hire services near you.

The suction strength can be altered on some electric pumps. Build up slowly. Setting the strength to high straightaway may be painful or damage your nipple.

You may also be able to get different funnel sizes to fit your nipples. The pump should never cause bruising or catch your nipple as it is sucked into the funnel.

Always make sure that the pump and container are clean and sterilized before you use them.

Sterilizing baby bottles and baby feeding equipment

It’s important to sterilize all your baby’s feeding equipment, including bottles and teats, until they are at least 12 months old.

This will protect your baby against infections, in particular diarrhea and vomiting.

Before sterilizing, you need to:

• Clean bottles, teats and other feeding equipment in hot, soapy water as soon as possible after feeds.
• Use a clean bottle brush to clean bottles (only use this brush for cleaning bottles), and a small teat brush to clean the inside of teats. You can also turn teats inside out and wash in hot soapy water. Don’t be tempted to use salt to clean teats, this can be dangerous for your baby.
• You can put your baby’s feeding equipment in the dishwasher to clean it if you prefer. (Putting feeding equipment through the dishwasher cleans it but doesn’t sterilize it.) Make sure bottles, lids and teats are facing downwards. You may prefer to wash teats separately by hand to make sure they are completely clean.
• Rinse all your equipment in clean, cold running water before sterilizing.

The advice above applies to all your baby’s feeding equipment, and whether you are using expressed breast milk or formula milk.

How to sterilize baby feeding equipment

There are several ways you can sterilize your baby’s feeding equipment. These include:

• cold water sterilizing solution
• steam sterilizing
• boiling

Cold water sterilizing solution

• Follow the manufacturer’s instructions.
• Leave feeding equipment in the sterilizing solution for at least 30 minutes.
• Change the sterilizing solution every 24 hours.
• Make sure there are no air bubbles trapped in the bottles or teats when putting them in the sterilizing solution.
• Your sterilizer should have a floating cover or a plunger to keep all the equipment under the solution.

Steam sterilizing (electric sterilizer or microwave)

• It’s important to follow the manufacturer’s instructions, as there are several different types of sterilizers.
• Make sure the openings of the bottles and teats are facing downwards in the sterilizer.
• Manufacturers will give guidelines on how long you can leave equipment in the sterilizer before it needs to be sterilized again.

Sterilizing by boiling

• Make sure that whatever you want to sterilize in this way is safe to boil.
• Boil the feeding equipment in a large pan of water for at least 10 minutes, making sure it all stays under the surface.
• Set a timer so you don’t forget to turn the heat off.
• Remember that teats tend to get damaged faster with this method. Regularly check that teats and bottles are not torn, cracked or damaged.

After you’ve finished sterilizing

• It’s best to leave bottles and teats in the sterilizer or pan until you need them.
• If you do take them out, put the teats and lids on the bottles straightaway.
• Wash and dry your hands before handling sterilized equipment. Better still, use some sterile tongs.
• Assemble the bottles on a clean, disinfected surface or the upturned lid of the sterilizer.

Storing breast milk

You can store breast milk in a sterilised container or in special breast milk storage bags:

• in the fridge for up to five days at 39.2 °F (4 °C) or lower (you can buy cheap fridge thermometers online)
• for two weeks in the ice compartment of a fridge
• for up to six months in a freezer

Breast milk that’s been cooled in the fridge can be carried in a cool bag with ice packs for up to 24 hours.

Storing breast milk in small quantities will help to avoid waste. If you’re freezing it, make sure you label and date it first.

Defrosting frozen breast milk

Breast milk that’s been frozen is still good for your baby and is better than formula milk. It’s best to defrost frozen milk slowly in the fridge before giving it to your baby. If you need to use it straightaway you can defrost it by putting it in a jug of warm water or holding it under running warm water. Once it’s defrosted, use it straightaway. Don’t re-freeze milk that has been defrosted.

Warming breast milk

You can feed expressed milk straight from the fridge if your baby is happy to drink it cold. Or you can warm the milk to body temperature by putting the bottle in a jug of warm water or holding it under running warm water.

Once your baby has drunk from a bottle of breast milk it should be used within the hour and anything left over thrown away.

Don’t use a microwave to heat up or defrost breast milk. This can cause hot spots, which can burn your baby’s mouth.

Breast milk if your baby is in hospital

If you’re expressing breast milk because your baby is premature or sick, ask the hospital staff caring for your baby for advice on how to store it.

Babies don’t normally learn to coordinate the sucking, swallowing and breathing needed for feeding until about 34 to 36 weeks of pregnancy.

If your baby is born before this time, they may need to have your breast milk via a feeding tube to begin with. This goes through their nose or mouth into their stomach. The staff in the neonatal unit can show you how to feed your baby this way.

Breast milk fortifiers, which contain a mixture of minerals, vitamins and protein, may be added to your breast milk.

Babies who are very premature or sick may need to be fed via an intravenous (IV) line to begin with. A fluid containing nutrients is fed straight into your baby’s vein.

Heterotaxy syndrome

Heterotaxy also called heterotaxy syndrome, is a rare condition characterized by internal organs that are not abnormally arranged in the chest and abdomen. The term “heterotaxy” is from the Greek words “heteros,” meaning “other than,” and “taxis,” meaning “arrangement” ¹⁾. Organs are expected to be in a particular orientation inside of the body, known as “situs solitus”. Heterotaxy occurs when the organs are not in this typical orientation, but are instead in different positions in the body. Individuals with heterotaxy syndrome have complex birth defects affecting the heart, lungs, liver, spleen, intestines, and other organs. This most commonly causes complications with the heart, lungs, liver, spleen, and intestines. Specific symptoms include not getting enough oxygen throughout the body, breathing difficulties, increased risk for infection, and problems digesting food.

In the normal body, most of the organs in the chest and abdomen have a particular location on the right or left side. For example, the heart, spleen, and pancreas are on the left side of the body, and most of the liver is on the right. This normal arrangement of the organs is known as situs solitus. Rarely, the orientation of the internal organs is completely flipped from right to left, a situation known as “situs inversus”. This mirror-image orientation usually does not cause any health problems, unless it occurs as part of a syndrome affecting other parts of the body. Heterotaxy syndrome is an arrangement of internal organs somewhere between situs solitus and situs inversus; this condition is also known as “situs ambiguus.” Unlike situs inversus, the abnormal arrangement of organs in heterotaxy syndrome often causes serious health problems.

Heterotaxy syndrome can alter the structure of the heart, including the attachment of the large blood vessels that carry blood to and from the rest of the body. It can also affect the structure of the lungs, such as the number of lobes in each lung and the length of the tubes (called bronchi) that lead from the windpipe to the lungs. In the abdomen, the condition can cause a person to have no spleen (asplenia) or multiple small, poorly functioning spleens (polysplenia). The liver may lie across the middle of the body instead of being in its normal position to the right of the stomach. Some affected individuals also have intestinal malrotation, which is an abnormal twisting of the intestines that occurs in the early stages of development before birth.

Depending on the organs involved, signs and symptoms of heterotaxy syndrome can include a bluish appearance of the skin or lips (cyanosis, which is due to a shortage of oxygen), breathing difficulties, an increased risk of infections, and problems with digesting food. The most serious complications are generally caused by critical congenital heart disease, a group of complex heart defects that are present from birth. Biliary atresia, a problem with the bile ducts in the liver, can also cause severe health problems in infancy.

The severity of heterotaxy syndrome varies depending on the specific abnormalities involved. Some affected individuals have only mild health problems related to the condition. At the other end of the spectrum, heterotaxy syndrome can be life-threatening in infancy or childhood, even with treatment.

Heterotaxy may be caused by genetic changes (mutations), exposures to toxins while a woman is pregnant causing the baby to have heterotaxy, or the condition may occur sporadically. The prevalence of heterotaxy syndrome is estimated to be 1 in 10,000 people worldwide with a male to female ratio of 2:1 ²⁾. However, researchers suspect that the condition is underdiagnosed, and so it may actually be more common than this. Heterotaxy syndrome accounts for approximately 3 percent of all congenital heart defects. For reasons that are unknown, the condition appears to be more common in populations in Asia than in North America and Europe. Recent studies report that in the United States, the condition occurs more frequently in children born to black or Hispanic mothers than in children born to white mothers.

Heterotaxy is typically diagnosed through imaging of the internal organs through a CT scan or an MRI. More specific imaging of the heart such as an echocardiogram or an electrocardiogram may also be used to diagnose the condition ³⁾. If heterotaxy is suspected, further tests may be completed to check for the functioning of the internal organs. For example, blood tests may be done to make sure the spleen is working properly, and an endoscopy may be recommended to determine if the intestines are malrotated. Renal ultrasounds may also determine if the kidneys are in the correct location ⁴⁾.

Treatment for heterotaxy depends on the specific symptoms of each person including the severity of the heart defects and other organ abnormalities, but typically includes heart surgery and monitoring by a team of specialists ⁵⁾. Most patients with left atrial isomerism will require surgical procedures or catheterization to repair holes in the heart or other problems. Some patients will require implantable pacemakers or defibrillators to control abnormal heart rhythm. In rare cases, patients with left atrial isomerism won’t require any treatment, though they will need to visit a pediatric cardiologist regularly for checkups.

Nearly all patients with right atrial isomerism, and some patients with left atrial isomerism, will require a series of major heart surgeries. Surgeons will reconfigure the heart and circulatory system so that the heart functions with one ventricle (pumping chamber), instead of two. This is called Fontan circulation and requires three open heart surgeries, called staged reconstruction. The procedures include the Norwood procedure, hemi-Fontan or Glenn operation, and the Fontan procedure.

All children with heterotaxy syndrome will require lifelong care by a cardiologist. In many cases, children with this condition will have many needs and will require care from different specialist doctors for many years.

Heterotaxy syndrome types

There are different forms of heterotaxy syndrome. All usually involve heart defects of varying types and severity. In addition, organs such as the stomach, intestines, liver and lungs may be in abnormal places in the chest and abdomen.

• Right atrial isomerism: Children with this condition have multiple heart defects. They may have septal defects (holes between the tissue dividing the two sides of the heart) and problems with heart valves, particularly the pulmonary valve. They may also have abnormalities of the blood returning from the lungs to the heart (anomalous pulmonary venous connection). The spleen may be absent (asplenia), and the liver and other organs may be on the wrong side of the body.
• Left atrial isomerism: Children with this condition may have septal defects (holes between the tissue dividing the two sides of the heart) as well as problems with heart valves and the heart’s electrical system. Some children with this problem have complete heart block, which is when the upper-chamber electrical system does not communicate with the lower-chamber electrical system. Most children require pacemakers for this problem. The spleen may be absent, or there may be several small spleens (polysplenia), instead of one spleen.
• The intestines may have malrotation, which is when the loops of bowel are lined up incorrectly. With this problem the bowel can twist on itself (volvulus). Many children with malrotation need abdominal surgery to correct it.
• Some children with heterotaxy syndrome can have a very serious condition of the liver called biliary atresia. This also may require surgical intervention.
• There may also be irregularities with the skeleton, central nervous system and urinary tract.
• In some cases of heterotaxy syndrome, the spleen may not work correctly or may be missing entirely. This can cause many problems, because the spleen helps the body fight infections. When the spleen is missing or doesn’t work correctly, patients have a more difficult time recovering from surgeries or infections (patients with heterotaxy may require multiple surgeries). In some cases, there may be a functioning spleen, but it may be divided into several smaller spleens (polysplenia).
• Sometimes children with heterotaxy syndrome have dextrocardia syndrome. This means the heart is in the right chest instead of the left chest.

Heterotaxy syndrome causes

Heterotaxy syndrome can be caused by mutations in many different genes. The proteins produced from most of these genes play roles in determining which structures should be on the right side of the body and which should be on the left, a process known as establishing left-right asymmetry. This process occurs during the earliest stages of embryonic development. Dozens of genes are probably involved in establishing left-right asymmetry; mutations in at least 20 of these genes have been identified in people with heterotaxy syndrome.

In some cases, heterotaxy syndrome is caused by mutations in genes whose involvement in determining left-right asymmetry is unknown. Rarely, chromosomal changes such as insertions, deletions, duplications, and other rearrangements of genetic material have been associated with this condition.

Heterotaxy syndrome can occur by itself, or it can be a feature of other genetic syndromes that have additional signs and symptoms. For example, at least 12 percent of people with a condition called primary ciliary dyskinesia have heterotaxy syndrome. In addition to abnormally positioned internal organs, primary ciliary dyskinesia is characterized by chronic respiratory tract infections and an inability to have children (infertility). The signs and symptoms of this condition are caused by abnormal cilia, which are microscopic, finger-like projections that stick out from the surface of cells. It appears that cilia play a critical role in establishing left-right asymmetry before birth.

Studies suggest that certain factors affecting a woman during pregnancy may also contribute to the risk of heterotaxy syndrome in her child. These include diabetes mellitus; smoking; and exposure to hair dyes, cocaine, and certain laboratory chemicals.

Some people with heterotaxy syndrome have no identified gene mutations or other risk factors. In these cases, the cause of the condition is unknown.

Heterotaxy inheritance pattern

Most often, heterotaxy syndrome is sporadic, meaning that only one person in a family is affected. However, about 10 percent of people with heterotaxy syndrome have a close relative (such as a parent or sibling) who has a congenital heart defect without other apparent features of heterotaxy syndrome. Isolated congenital heart defects and heterotaxy syndrome may represent a range of signs and symptoms that can result from a particular genetic mutation; this situation is known as variable expressivity. It is also possible that different genetic and environmental factors combine to produce isolated congenital heart defects in some family members and heterotaxy syndrome in others.

When heterotaxy syndrome runs in families, it can have an autosomal dominant, autosomal recessive, or X-linked pattern of inheritance, depending on which gene is involved. Autosomal dominant inheritance means that one copy of the altered gene in each cell is sufficient to cause the disorder. Autosomal recessive inheritance means that both copies of the gene in each cell have mutations. The parents of an individual with an autosomal recessive condition each carry one copy of the mutated gene, but they typically do not show signs and symptoms of the condition. In X-linked inheritance, the mutated gene that causes the disorder is located on the X chromosome, one of the two sex chromosomes in each cell.

When heterotaxy syndrome occurs as a feature of primary ciliary dyskinesia, it has an autosomal recessive pattern of inheritance.

People with specific questions about genetic risks or genetic testing for themselves or family members should speak with a genetics professional.

Resources for locating a genetics professional in your community are available online:

• The National Society of Genetic Counselors (https://www.findageneticcounselor.com/) offers a searchable directory of genetic counselors in the United States and Canada. You can search by location, name, area of practice/specialization, and/or ZIP Code.
• The American Board of Genetic Counseling (https://www.abgc.net/about-genetic-counseling/find-a-certified-counselor/) provides a searchable directory of certified genetic counselors worldwide. You can search by practice area, name, organization, or location.
• The Canadian Association of Genetic Counselors (https://www.cagc-accg.ca/index.php?page=225) has a searchable directory of genetic counselors in Canada. You can search by name, distance from an address, province, or services.
• The American College of Medical Genetics and Genomics (http://www.acmg.net/ACMG/Genetic_Services_Directory_Search.aspx) has a searchable database of medical genetics clinic services in the United States.

Heterotaxy syndrome signs and symptoms

Heterotaxy is characterized by having internal organs that are not arranged as would be expected in the chest and abdomen. This can cause organs such as the heart, lungs, liver, intestines, and spleen to not work correctly. Symptoms of heterotaxy syndrome vary widely and depend on the organs affected. Symptoms of these organs working incorrectly may include breathing difficulties, having a bluish color to the skin (cyanosis), and problems digesting food. For some people with heterotaxy, the only sign may be a heart defect ⁶⁾. Others may have twisting of the intestines (malrotation). People with heterotaxy may have a missing spleen (asplenia) or they may have a spleen that is divided into many smaller parts (polysplenia). If the function of the spleen is affected, this can cause a reduced ability to fight infections ⁷⁾.

The heart is almost always involved in cases of heterotaxy syndrome. What type of defects are found depends on a number of things, including the type of heterotaxy syndrome (eg bilateral right sidedness or left-sidedness). Listed below are the most common heart anomalies associated with heterotaxy:

• Dextrocardia (the heart is located in the right side of the chest instead of the left)
• Single atrium (single top chamber of the heart)
• Single ventricle (single bottom chamber of the heart)
• Transposition of the great arteries (the aorta and the pulmonary artery have switched positions)
• Total or partial anomalous pulmonary venous return (the pulmonary veins enter into the heart in the incorrect location)
• Atrioventricular canal defect (large hole in the center of the heart with a single common valve)
• Coarctation of the aorta (narrowing of the aorta)
• Pulmonary valve atresia (absence of the pulmonary valve)
• Pulmonary stenosis (narrowing of the pulmonary valve)
• Double outlet right ventricle (where both main arteries of heart arise from the right ventricle)
• Complete atrioventricular block (no electrical signal from the top chambers of the heart reaches the bottom chambers of the heart resulting in a slow heart rate)
• Multiple sinus nodes or absent sinus node (the sinus node is the impulse-generating tissue of the heart)

In nearly all cases of right atrial isomerism and some cases of left atrial isomerism, symptoms will appear at birth or a few days after because the heart defects are severe. In these cases, symptoms include:

• Blue or purple tint to lips, skin and nails (cyanosis)
• Difficulty breathing
• Difficulty feeding
• Lethargy: baby is abnormally sleepy or unresponsive

Sometimes patients with left atrial isomerism don’t have any symptoms and the condition isn’t diagnosed until the child is older or an adult.

Most people with heterotaxy are first found to have the condition shortly after birth when they have symptoms related to a heart defect. However, other individuals are not diagnosed until later in childhood or adulthood due to problems with the intestines or liver that may cause abdominal pain or vomiting ⁸⁾. Other adults with heterotaxy are diagnosed because they were receiving imaging for other medical problems. In this case, a diagnosis of heterotaxy is an incidental finding ⁹⁾.

Heterotaxy syndrome diagnosis

In many cases, heterotaxy syndrome is diagnosed before birth. After the child is born, diagnosis of heterotaxy syndrome may require some or all of these tests:

• Electrocardiogram (EKG or ECG): a record of the electrical activity of the heart
• Echocardiogram (also called “echo” or ultrasound): sound waves create an image of the heart
• Chest x-ray
• Cardiac MRI: a three-dimensional image shows the heart’s abnormalities

Sometimes, cardiac catheterization will be required. In cardiac catheterization, a thin tube is inserted into the heart through a vein and/or artery in either the leg or through the umbilicus (“belly button”).

Other diagnostic tests on other areas of the body will also be required, including renal ultrasound and abdominal ultrasound.

Heterotaxy syndrome treatment

The treatment for heterotaxy depends on the specific organs that are affected in each individual. In infants diagnosed with heterotaxy syndrome, heart surgery may be necessary to correct any heart defects. For some individuals, this may require multiple procedures to correct the defect. One common procedure is known as a Fontan procedure, which creates a single ventricle of the heart that is responsible for pumping blood both throughout the body and to the lungs. Other surgical procedures such as the Ladd procedure may be necessary to correct an intestinal malrotation ¹⁰⁾.

Other treatment options include inserting a pacemaker to control the rhythm of the heart. Some individuals may require medications to lower blood pressure to reduce stress on the heart. Vaccinations or antibiotics that are taken even when there isn’t an infection (prophylactic antibiotics) may be recommended to make up for a spleen that isn’t functioning properly. In some cases, a heart transplant may be necessary when individuals who had surgical corrections as infants get older. A multidisciplinary team of doctors may be recommended to follow a person who is diagnosed with heterotaxy ¹¹⁾.

Heterotaxy syndrome prognosis

The long-term outlook for people affected by heterotaxy depends on the specific organs that are affected in each individual. When children are diagnosed with heterotaxy soon after birth, it is typically because there are heart defects that require immediate surgery. Although the Fontan procedure may allow affected children to survive infancy, people who have had the procedure typically require a heart transplant later in life ¹²⁾. If people with heterotaxy pass away, it is typically due to heart defects or complications from the Fontan procedure ¹³⁾. In a retrospective, single-center study (1997-2014) of 35 children with heterotaxy syndrome, the reported survival was 83% over a median follow-up of 65 months ¹⁴⁾. Of the 12 patients with poor outcomes (34.3%), 6 died, 1 underwent cardiac transplantation, and 5 had a New York Heart Association heart failure classification above 3.

There is limited data available about the long-term outlook for adults who are diagnosed with heterotaxy. Because most people who are diagnosed in adulthood have less severe symptoms, they may have a better prognosis than children who are diagnosed before birth or during infancy ¹⁵⁾.

Heart murmur in kids

Heart murmurs are very common in babies and young children. In the vast majority of heart murmur cases, the heart is working normally and there isn’t anything to worry about. In fact many young children have heart murmurs and neither they nor their parents will ever know anything about it as many murmurs are innocent murmurs. A heart murmur is an extra or unusual sound made by the heart as the blood flows through any of the heart’s chambers or valves. It is usually the sound of the blood negotiating its way around the tight bends inside a young child’s heart and resembles a “whooshing” or “swishing” noise. It makes a sound like water rushing through a pipe. Blood has to negotiate two tight bends as it flows through the heart. The flow of blood traveling through the heart and blood vessels in this way can also make a noise, and this is known as an ‘innocent’ murmur. Innocent murmurs can sometimes come and go, becoming noisier if the heart is beating fast – after exercise or with a fever – and quieter as a child sleeps.

Heart murmur is an extra sound that is heard in addition to the normal heart sounds which are heard when the doctor listens to the heart with a stethoscope.

Types of heart murmurs include:

• Systolic murmur. A heart murmur that occurs when the heart contracts.
• Diastolic murmur. A heart murmur that occurs when the heart relaxes.
• Continuous murmur. A heart murmur that occurs throughout. the heartbeat.

Occasionally though, a heart murmur can be linked to a problem with the way that blood flows through the heart or a structural problem with the heart. Even if an underlying problem is the reason for a baby’s heart murmur, there is treatment available. A heart murmur very rarely proves fatal.

Heart murmurs in children key points

• Heart murmurs are extra or unusual sounds made by turbulent blood flowing through the heart.
• Many heart murmurs are harmless (innocent).
• Some heart murmurs are caused by congenital heart defects or other conditions. These are called pathologic.
• If the healthcare provider hears a heart murmur when listening to your child’s chest with a stethoscope, he or she may refer you a pediatric cardiologist for more tests.

Does having a heart murmur mean that my baby/child has a heart problem?

About one out of 100 babies is born with a structural heart problem also known as congenital heart defect, so most heart murmurs are not caused by heart problems. The most common types of heart murmur are called functional or innocent murmurs. This means the heart murmur is produced by a normal, healthy heart. These types of murmur can come and go throughout childhood. They usually go away on their own as the child gets older and don’t pose any health threat.

How do I know whether a heart murmur is a sign of a heart problem?

Your baby’s doctor or pediatric cardiologist will ask you questions about whether your baby is feeding well or whether she/he gets tired while feeding. They will also examine your baby carefully and listen to your baby’s heart using a stethoscope. Following the examinations if your baby’s doctor or pediatric cardiologist thinks there may be a problem with your baby’s heart they will arrange for your baby to have an echocardiogram (ultrasound scan of the heart). This takes a special moving image of the heart’s chambers and the flow of the blood; records the size and shape of the heart’s chambers, valves, and vessels; and shows the direction of the blood flow within the heart to help determine how efficiently the heart is pumping.

What are possible complications of heart murmurs in a child?

A heart murmur has no complications. But your child may have complications related to the condition causing the heart murmur. A child with a congenital heart defect may have poor growth and development, heart failure, or other serious problems.

Heart murmur in babies causes

Young children have small, slim chests so their hearts are nearer to a stethoscope than those of teenagers and adults, and their heart rate is faster. It is common for newborn babies to have heart murmurs in the first few days of life. When babies are in the womb they get oxygen from the placenta (afterbirth). After they are born they start to breathe and get oxygen from their lungs. Two of these connections which were in use when baby was in the womb should start to close immediately after the birth. It may however take a few days to a few weeks for this to complete. Sometimes
the murmur which can be heard is blood passing through these “old” connections.

Another type of murmur can sometimes be heard as blood passes through the blood vessels to the lung. These blood vessels can be narrow in newborn babies. As the baby grows, the heart rate slows, the heart grows and lies deeper within the body and the blood vessels also grow. The normal bends within the heart become less tight and an innocent murmur therefore disappears.

These heart murmurs are called innocent murmurs. In most cases, an innocent murmur disappears as a child gets older and the bends within the heart become less tight.

In rarer cases, a heart murmur can be a sign of a problem within the heart, a heart murmur can come from abnormal blood flow within the heart and blood vessels. This might be related to either a narrow or leaking valves in the heart, a narrow blood vessel or a hole in the wall between the two chambers of the heart or between the two main arteries of the heart. These heart murmurs may be called pathologic murmur.

Other causes of heart murmurs include:

• Infection
• Fever
• Low red blood cell count (anemia)
• Overactive thyroid gland (hyperthyroidism)

Heart murmur in babies symptoms

Children with innocent heart murmurs have no outward signs or symptoms. Its presence is usually only detected during a routine doctor’s examination.

A child with a pathologic heart murmur may have one or more of the following symptoms:

• Poor feeding, eating, or weight gain
• Shortness of breath or breathing fast
• Sweating
• Chest pain
• Dizziness or fainting (syncope)
• Bluish skin, especially of the lips and fingertips
• Cough
• Swelling (edema) of the lower legs, ankles, feet, belly (abdomen), liver, or neck veins

The symptoms of heart murmur can be like other health conditions. Have your child see his or her healthcare provider for a diagnosis.

Heart murmurs are graded on a scale of 1 to 6, based on how loud they are. One means a very faint murmur. Six means a murmur that’s very loud.

Heart murmur in babies diagnosis

Your child’s healthcare provider will ask about your child’s symptoms and health history. He or she will do a physical exam on your child. During an exam, your child’s doctor will listen to your child’s heart with a stethoscope. In this way, the doctor will be able to detect the presence of a heart murmur. If your child’s doctor hears an abnormal sound, he or she may refer you to a pediatric cardiologist. This is a doctor with special training to treat children with heart problems. Following the examinations if pediatric cardiologist thinks there may be a problem with your baby’s heart they will arrange for your baby to have these tests:

• Chest X-ray. An X-ray creates images of the heart and lungs.
• Electrocardiogram (ECG). This test that measures the electrical activity of the heart.
• Echocardiography (echocardiogram). An exam that uses sound waves (ultrasound) to look at the structure and function of the heart. This is the most important test to find heart murmurs.

Heart murmur in babies treatment

Some heart murmurs are clearly ‘innocent’ heart murmurs in children with strong, healthy hearts when heard through a stethoscope. If the heart murmur is innocent, no follow-up or treatment is needed.

If the quality of the heart murmur suggests that it might be due to some sort of structural abnormality, the cause of the murmur needs to be established. Even then, most heart murmurs are not signs of a serious heart problem in children with no other symptoms.

A child might be referred to a heart specialist (pediatric cardiologist) for a thorough examination and possibly further investigations. For instance an echocardiogram (an ultrasound scan of the heart) might be recommended.

This scan is designed to show the structure, function and blood flow of the heart, and will aim to rule out any underlying problem.

Treatment will depend on your child’s symptoms, age, and general health. It will also depend on how severe the underlying condition is.

If the murmur is from a congenital heart defect, treatment may include medicine, procedures, or surgery. If the murmur is from another condition, the heart murmur will usually lessen or go away once the condition is treated.