BREASTFEEDING KNOW HOW

• How breast milk is made
• Tips for making it work
• Breast compression
• Getting enough milk

How Breast Milk is Made

Anatomy of the Breast

Knowing how the breast is made and how it works to produce milk can help you understand the breastfeeding process. The breast actually begins developing in the first few weeks of gestation, before birth. But the mammary gland, the gland that produces milk, does not become fully functional until lactation begins. When a woman's breasts become swollen during pregnancy, this is a sign that the mammary gland is getting ready to work. The breast itself is a gland that is composed of several parts, including glandular tissue, connective tissue, blood, lymph, nerves, and fatty tissue. Fatty tissue is what mostly affects the size of a woman's breast. Breast size does not have an effect on the amount of milk or the quality of milk a woman produces.

Milk is secreted from the alveoli cells. When the alveoli cells are stimulated by a hormone, they contract and push the milk into the ductules and down into larger milk ducts underneath the nipple and areola. When the baby's gums press on the areola and nipple, milk is squeezed into the baby's mouth. The nipple tissue protrudes and becomes firmer with stimulation, which makes it more flexible and easier for the baby to grasp in the mouth. In the diagram, you can see that each mammary gland forms a lobe in the breast. Each lobe consists of a single branch of alveoli and milk ducts that narrow into an opening in the nipple. Each breast has about seven to ten lobes.

The Role of Hormones

Hormones play a key role in breastfeeding. The increase of estrogen during pregnancy stimulates the ductules to grow. After delivery, estrogen levels drop and remain low in the first several months of breastfeeding. The increase of progesterone during pregnancy also causes the alveoli and lobes to grow. Prolactin, also called the "mothering hormone," is another hormone that is increased during pregnancy and adds to the growth of breast tissue. Prolactin levels also rise during feedings as the nipple is stimulated. As prolactin is released from the brain into the mother's bloodstream during breastfeeding, alveolar cells respond by making milk. Oxytocin is the other hormone that plays a vital role because it is necessary for the let-down, or milk-ejection reflex to occur. It stimulates the alveoli cells to contract so the milk can be pushed down into the ducts. Oxytocin also contracts the muscle of the uterus during and after birth, which helps the uterus to get back to its original size and lessens any bleeding a woman may have after giving birth. The release of both prolactin and oxytocin may be responsible in part for a mother's intense feeling of needing to be with her baby.

Tips for Making It Work

Breastfeeding can be a wonderful experience for you and your baby. It's important not to get frustrated if you are having problems. What works for one mother and baby may not work for another, so just focus on finding a comfortable routine and positions for you and your baby. Here are some tips for making it work:

1. Get an early start. You should start nursing as early as you can after delivery (within an hour or two if it is possible), when your baby is awake and the sucking instinct is strong. At first your breasts contain a kind of milk called colostrum, which is thick and usually yellow or golden in color. Colostrum is gentle to your baby's stomach and helps protect your baby from disease. Your milk supply will increase and the color will change to a bluish-white color during the next few days after your baby's birth.
   
   Click here to find out what will happen with your milk and your baby in the next few weeks.
   
   
   • How to bring baby to breast
   • Correct Latch
   • Breastfeeding Holds
     
     
2. Nurse on demand. Newborns need to nurse often. Breastfeed at least every 2 hours and when they show signs of hunger, such as being more alert or active, mouthing (putting hands or fists to mouth and making sucking motion with mouth), or rooting (turning head in search of nipple). Crying is a late sign of hunger. Most newborn babies want to breastfeed about 8 to 12 times in 24 hours.
3. Feed your baby only breast milk. Nursing babies don't need water, sugar water or formula. Breastfeed exclusively for about the first six months. Giving other liquids reduces the baby's intake of vitamins from breast milk.
4. Delay artificial nipples (bottle nipples and pacifiers). A newborn needs time to learn how to breastfeed. It is best to wait until the newborn develops a good sucking pattern before giving her or him a pacifier. Artificial nipples require a different sucking action than real ones. Sucking at a bottle can also confuse some babies when they are first learning how to breastfeed. If, after birth, your baby needs to be taken away from you for a length of time and has to be given formula, ask the nurse to use a syringe or cup when feeding him/her to avoid nipple confusion.
5. Breastfeed your sick baby during and after illness. Oftentimes sick babies will refuse to eat but will continue to breastfeed. Breast milk will give your baby needed nutrients and prevent dehydration.
6. Air dry your nipples. Right after birth, you can air-dry your nipples after each nursing to keep them from cracking. Cracking can lead to infection. If your nipples do crack, coat them with breast milk or a natural moisturizer, such as lanolin, to help them heal. It isn't necessary to use soap on your nipples, and it may remove helpful natural oils that are secreted by the montgomery glands, which are in the areola. Soap can cause drying and cracking and make the nipple more prone to soreness.
7. Watch for infection. Signs of breast infection include fever, irritation, and painful lumps and redness in the breast. You need to see a doctor right away if you have any of these symptoms. Click here for more information.
8. Promptly treat engorgement. It is normal for your breasts to become larger, heavier, and a little tender when they begin making greater quantities of milk on the 2nd to 6th day after birth. This normal breast fullness may turn into engorgement. When this happens, you should feed the baby often. Your body will, over time, adjust and produce only the amount of milk your baby needs. To relieve engorgement, you can put warm, wet washcloths on your breasts and take warm baths before breastfeeding. If the engorgement is severe, placing ice packs on the breasts between nursings may help. Talk with a lactation consultant if you have problems with breast engorgement. Click here for more information.
9. Eat right and get enough rest. You may be thirstier and have a bigger appetite while you are breastfeeding. Drink enough non-caffeinated beverages to keep from being thirsty. Making milk will use about 500 extra calories a day. Women often try to improve their diets while they are pregnant. Continuing with an improved diet after your baby is born will help you stay healthy. But, even if you don't always eat well, the quality of your milk won't change much. Your body adjusts to make sure your baby's milk supply is protected. Get as much rest as you can. This will help prevent breast infections, which are worsened by fatigue.
   
   If you are on a strict vegetarian diet, you may need to increase your vitamin B12 intake and should talk with your health care provider. Infants breastfed by women on this type of diet can show signs of not getting enough vitamin B12.

Breast Compression

Breast compression is a technique made popular by pediatrician and breastfeeding expert Dr. Jack Newman and helps a baby get more milk at each feeding. Once your baby is latched-on well, breast compression will keep him or her feeding actively for a longer time and to “finish” the first breast offered. This is especially helpful for babies who tend to fall asleep at the breast in the middle of a feeding. Despite what many mothers in the hospital are told, this technique does not raise your risk of getting plugged ducts.

When the baby is drinking milk, you do not need to use any breast compression, but once the baby is no longer drinking and is just nibbling, you can start the technique. See the diagrams below. Click on the "Next" button for a demonstration.

Once your baby has finished the first breast and still wants more milk, you can offer the other breast. Signs that your baby has finished with the first breast are falling asleep at the breast and doing no more opening wide, pausing, then sucking. If the compression does not work at first, it does not mean that you have to switch breasts right away. If your baby comes off the breast by him or herself, you might want to try offering the first breast again to see if he or she will drink more. If not, or if your baby is getting fussy or sleepy because the milk flow is slow, you can change your baby over to the other breast. You can experiment with this technique and do a variation of it that works best for you.

Getting Enough Milk

Most new mothers are concerned about their babies getting enough milk. In the first few days, when you're in the hospital your baby should stay with you in your room if there are no complications with the delivery or with your baby's health. The baby will be sleepy. Don't expect the baby to wake you up when he or she is hungry. You will have to wake the baby every one to two hours to feed him or her. At first you will be feeding your baby colostrum, your first milk that is precious thick yellowish milk. Even though it looks like only a small amount, this is the only food your baby needs. In the beginning, you can expect your baby to lose some weight. This is very normal and is not from breastfeeding. As long as the baby doesn't lose more than 7 to 10% of his or her birth weight during the first three to five days, he or she is getting enough to eat.

You can tell your baby is getting enough milk by keeping track of the number of wet and dirty diapers. In the first few days, when your milk is low in volume and high in nutrients, your baby will have only 1 or 2 wet diapers a day. After your milk supply has increased, your baby should have 5 to 6 wet diapers and 3 to 4 dirty diapers every day. Consult your pediatrician if you are concerned about your baby's weight gain. You should visit your pediatrician between three to five days after your baby's birth and then again at two weeks of age.

This chart shows the minimum number of diapers for most babies.
It is fine if your baby has more.

After you and your baby go home from the hospital, your baby still needs to eat about every one to two hours and should need several diaper changes. You still may need to wake your baby to feed him or her because babies are usually sleepy for the first month. In the early weeks after birth, you should wake your baby to feed if four hours have passed since the beginning of the feeding. If you are having a hard time waking your baby, you can try undressing or wiping his or her face with a cool washcloth. If your baby falls asleep while breastfeeding, you can try breast compression. As your milk comes in after the baby is born, there will be more and more diaper changes. The baby's stools will become runny, yellowish, and may have little white bumpy "seeds."

Overall, you can feel confident that your baby is getting enough to eat because your breasts will regulate the amount of milk your baby needs. If your baby needs to eat more or more often, your breasts will increase the amount of milk they produce. To keep up your milk supply when you give bottles of expressed breast milk for feedings, pump your milk when your baby gets a bottle of breast milk.

Other signs that your baby is getting enough milk are:

• Steady weight gain, after the first week of age. From birth to three months, typical weight gain is four to eight ounces per week.
  
• Pale yellow urine, not deep yellow or orange.
  
• Sleeping well, yet baby is alert and looks healthy when awake.

Remember that the more often and effectively a baby nurses, the more milk there will be. Breasts produce and supply milk directly in response to the baby's need or demand.

Problems

If you are still having problems breastfeeding after following these tips, it is important to talk with your doctor, nurse or a breastfeeding support person such as a peer counselor or lactation consultant. Click here for more information on Coping with Breastfeeding Challenges or Where to Go for Help.

Current as of August 2005

The following publications and organizations provide more information on breastfeeding know how:

Publications

1.   Breast Milk - This publication contains information on breast milk. It explains why it is better than cow's milk for infants, how breast milk is produced, how to establish, maintain or increase your milk supply, and how to store breast milk.

   http://www.nlm.nih.gov/medlineplus/ency/article/002451.htm

2. Breastfeeding 101 (Copyright © ACNM) - This publication outlines the basic steps moms need to take when preparing to breastfeed, as well as issues they may face regarding siblings of the new baby and how to develop family support.

   http://www.mymidwife.org/breastfeeding.cfm

3. Breast Feeding: Hints to Help You Get Off to a Good Start (Copyright © AAFP) - This fact sheet offers helpful hints on successful breastfeeding including the benefits, how to hold your baby, the let-down reflex, preventing and healing sore nipples, signs that your baby is getting enough milk, what to avoid eating and where to get more information on breastfeeding.

   http://familydoctor.org/online/famdocen/home/women/pregnancy/birth/019.html

4. Breastfeeding the High-Risk Newborn (Copyright © UUHSC) - This on-line resource offers information on the benefits of breastfeeding high risk newborns including how to overcome difficulties in breastfeeding, how to express breast milk, and how to maintain milk production.

   http://www.uuhsc.utah.edu/healthinfo/pediatric/Hrnewborn/bresthub.htm

5. Breastfeeding Tips (Copyright © NMC, INC.) - This on-line resource gives breastfeeding tips on establishing a good milk supply, positioning, engorgement, sore nipples, and signs that breastfeeding is going well.

   http://www.nursingmothers.org/tips.htm

6. Breastfeeding vs. Formula Feeding (Copyright © Kids Health) - This publication contains information on the benefits of breastfeeding, the pros and cons of bottle-feeding, instructions on how to breastfeed or bottle-feed your baby, as well as answers to common breastfeeding questions.

   http://www.kidshealth.org/parent/food/infants/breast_bottle_feeding.html

7. Breastfeeding Your Baby (Copyright © ACOG) - This on-line resource about breastfeeding contains information on the benefits, facts, getting started, how to breastfeed, diet, sex and birth control, work, and breast health. It also includes a glossary of terms.

   http://www.acog.org/publications/patient_education/bp029.cfm

8. Effective Sucking (Copyright © UUHSC) - This on-line fact sheet has information pertaining to breastfeeding and effective sucking. It explains what a mother should listen for during feeding and how long the newborn should nurse before self-detachment.

   http://www.uuhsc.utah.edu/healthinfo/adult/Pregnant/bfsuckng.htm

9. FAQ on Breastfeeding Twins (Copyright © LLLI) - This publication provides information on breastfeeding twins. It includes positioning techniques, feeding plans, and ways to care for oneself.

   http://www.llli.org/FAQ/twins.html

10. Got Mom... (Copyright © ACNM) - GotMom.org was created by the American College of Nurse-Midwives to provide breastfeeding information and resources for mothers and families. It contains information on why breast milk is best, dispels common misunderstandings about breastfeeding, and it provides a list of resources that can help women and families with breastfeeding.

    http://www.gotmom.org/

11. High Risk Newborn: Moving Toward Breastfeeding (Copyright © UUHSC) - This breastfeeding guide contains information on special breastfeeding concerns for mothers of a high-risk newborn. It includes signs that a baby is getting ready for breastfeeding, stages in breastfeeding progression, helpful hints for beginning to breastfeed, hints for breastfeeding at home, and relaxation techniques for the mother.

    http://www.uuhsc.utah.edu/healthinfo/pediatric/Hrnewborn/mtbf.htm

12. How Can I Increase My Milk Supply? (Copyright © La Leche League International) - This publication explains how to know if you're not producing enough breast milk for your baby and gives tips on increasing your milk supply.

    http://www.lalecheleague.org/FAQ/increase.html

13. How Can I Tell if My Baby is Getting Enough Milk? (Copyright © La Leche League International) - This publication explains how to look for signs that your baby is getting enough breast milk. It also provides additional resources on milk supply and breastfeeding for more information.

    http://www.lalecheleague.org/FAQ/enough.html

14. How Do I Wean My Baby? (Copyright © LLLI) - This publication explains why it is important to wean your baby slowly off of the breast. It also gives tips for when and how to reduce feedings to make the weaning process easier.

    http://www.lalecheleague.org/FAQ/weanhowto.html

15. How Often Should I Nurse My Baby? (Copyright © LLLI) - This publication gives guidelines for how often babies should breastfeed. It also explains why a baby may feed frequently or infrequently and what behaviors are considered normal during the period of breastfeeding.

    http://www.lalecheleague.org/FAQ/frequency.html

16. Increasing Breastfeeding Success: Why it Matters and What the Research Shows (Copyright © Breastfeeding Coalition of Washington) - This publication is a set of ten lactation presentations designed to educate physicians and their staff in the in-patient or out-patient setting.

    http://www.breastfeedingwa.org/node/116

17. Ineffective Latch-On or Sucking (Copyright © UUHSC) - This on-line fact sheet offers information on ineffective latch-on and sucking during breastfeeding. It also offers information on what one can do to help with the breastfeeding process and other ways to help the baby with ineffective sucking.

    http://www.uuhsc.utah.edu/healthinfo/adult/Pregnant/diffltch.htm

18. Preparing My Breasts to Breastfeed (Copyright © LLLI) - This publication contains information on what you need to do to prepare to breastfeed and possible challenges that you might face while breastfeeding.

    http://www.llli.org/FAQ/breastprep.html

19. Weaning Your Child (Copyright © The Nemours Foundation) - This publication discusses when to wean and also gives tips on how to start weaning to make the transition easier.

    http://www.kidshealth.org/parent/pregnancy_newborn/feeding/weaning.html

Organizations

1.   Maternal and Child Health Bureau, HRSA, HHS
2.   National Center for Education in Maternal and Child Health, MCHB, HRSA, HHS
3.   Womenshealth.gov, OWH, HHS
4. American Academy of Family Physicians
5. American Academy of Pediatrics
6. American College of Nurse-Midwives
7. International Lactation Consultant Association (ILCA)
8. La Leche League International
9. National Healthy Mothers, Healthy Babies Coalition
10. Wellstart International
11. World Alliance For Breastfeeding Action

= Indicates Federal Resources