What should I know about giving my breastfed baby a pacifier?

By Kelly Bonyata, BS, IBCLC

• When can I begin using a pacifier?
• What should I consider before using a pacifier?
• When to avoid the pacifier
• Can pacifiers help prevent SIDS?
• In conclusion...
• Links.......
• More information
• Nipple Confusion
• Some Journal Articles on Pacifier Use and Breastfeeding
• Some Journal Articles on Pacifier Use in General

When can I begin using a pacifier?

It is recommended that pacifiers and other types of artificial nipples be avoided for at least the first 3-4 weeks. I'd personally suggest that most breastfed babies - if they get a pacifier at all - would be better off without a pacifier until mom's milk supply is well established (6-8 weeks, usually) and the 6 week growth spurt is over. That way you've established a good milk supply and don't lose any much-needed breast stimulation to a pacifier.

What should I consider before using a pacifier?

After the early weeks, pacifier use is less likely to cause problems as long as you are aware of the following:

• Never substitute a pacifier for a feeding at the breast or try to hold the baby off longer between feedings with one. (See Should baby be on a schedule?)
• There are studies that indicate that babies who take a pacifier tend to wean earlier than those who do not. This is most likely because as a baby gets older - once he's established on solid food - it is often his desire to suck that ensures he continues to seek out the breast often. Babies who use pacifiers are getting that need to suck met with something other than the breast, and therefore may decide to give up breastfeeding sooner than if they did not take a pacifier.
• Some babies who take pacifiers are more prone to oral yeast (thrush) which can be transferred to mom's nipples.
• A number of studies have shown a link between pacifier use and an increased incidence of ear infections.
• Pacifiers can result in choking or strangulation if the pacifier breaks or if it is tied around the neck (which it never should be). Follow all safety guidelines and keep an eye out for the many pacifier safety recalls. Also, keep in mind that latex allergy is becoming an increasing problem - consider using a silicone pacifier rather than latex.
• Prolonged pacifier use can result in teeth misalignment, and can also occasionally lead to shaping of the soft palate or speech problems.
• Giving baby a pacifier will increase mom's chances of ovulating and getting pregnant. Exclusive breastfeeding, depending upon your breastfeeding frequency and other factors, is a method of birth control that can be more than 98% effective during the first 6 months and 94% effective during the second six months. Ensuring that all of baby's sucking needs are met at the breast increases the effectiveness of this method of contraception.

When to avoid the pacifier

If you observe any of the following problems, it would be a good idea to discontinue pacifier use, at least until the problem is resolved:

• Pacifier use reduces your baby's frequency or duration of feeds (newborns should be nursing at least 8 to 12 times a day).
• Baby is having difficulties nursing well (this may be due to nipple confusion).
• Baby is having problems with weight gain (in which case baby needs to nurse as often as possible).
• Mom is having problems with sore nipples (baby may be causing this due to nipple confusion)
• Mom is having milk supply problems (in which case she needs to put baby to breast, not pacifier, at every opportunity in order to increase milk supply).
• Mom and/or baby have thrush, particularly if it's hard to get rid of or repeated.
• Baby is having repeated ear infections (an increased incidence of ear infections has been linked to pacifier use).
  

Can pacifiers help prevent SIDS?

Have you heard in the news that pacifier use might help to prevent SIDS? Here's what the American Academy of Pediatrics says about this in their March 2000 Policy Statement Changing Concepts of Sudden Infant Death Syndrome: Implications for Infant Sleeping Environment and Sleep Position:

Four recent studies have reported a substantially lower SIDS incidence among infants who used pacifiers than among infants who do not. Although this association has been strong and consistent, it does not prove that pacifier use prevents SIDS. Mechanisms by which pacifiers might protect against SIDS have been proposed, such as stinting of the upper airway, but data are lacking to demonstrate that any of them are relevant to SIDS. Conversely, other studies have demonstrated that pacifier use can be linked to a shortened duration of breastfeeding, increased susceptibility to otitis media, and increased dental malocclusion. The Task Force believes that additional outcome studies are required before a specific recommendation about pacifiers can be made.

In conclusion...

As long as you keep the above in mind and only use a pacifier sparingly, it is up to you whether and when you wish to comfort baby yourself or with a pacifier. However, keep in mind that there is no scientific evidence that suggests that babies have a need to suck independant of the need for food. When a baby is indicating a sucking need, it's generally best that baby be encouraged to nurse, especially if there is a weight gain concern. The breast was the first pacifier and in most cases remains the best.

Increasing Low Milk Supply

By Kelly Bonyata, BS, IBCLC

• Is your milk supply really low?
• Who to contact if you suspect low milk supply
• Potential causes of low milk supply
• Increasing your milk supply
• Additional information

Is your milk supply really low?

First of all, is your milk supply really low? Often, mothers think that their milk supply is low when it really isn't. If your baby is gaining weight well on breastmilk alone, then you do not have a problem with milk supply.

It's important to note that the feel of the breast, the behavior of your baby, the frequency of nursing, the sensation of let-down, or the amount you pump are not valid ways to determine if you have enough milk for your baby.

What if you're not quite sure about baby's current weight gain (perhaps baby hasn't had a weight check lately)? If baby is having an adequate number of wet and dirty diapers then the following things do NOT mean that you have a low milk supply:

• Your baby nurses frequently. Breastmilk is digested quickly (usually in 1.5-2 hours), so breastfed babies need to eat more often than formula-fed babies. Many babies have a strong need to suck. Also, babies often need continuous contact with mom in order to feel secure. All these things are normal, and you cannot spoil your baby by meeting these needs.
• Your baby suddenly increases the frequency and/or length of nursings. This is often a growth spurt. The baby nurses more (this usually lasts a few days to a week), which increases your milk supply. Don't offer baby supplements when this happens: supplementing will inform your body that the baby doesn't need the extra milk, and your supply will drop.
• Your baby nurses more often and is fussy in the evening.
• Your baby doesn't nurse as long as she did previously. As babies get older and better at nursing, they become more efficient at extracting milk.
• Your baby is fussy. Many babies have a fussy time of day - often in the evening. Some babies are fussy much of the time. This can have many reasons, and sometimes the fussiness goes away before you find the reason.
• Your baby guzzles down a bottle of formula or expressed milk after nursing. Many babies will willingly take a bottle even after they have a full feeding at the breast. Read more here from board-certified lactation consultant Kathy Kuhn about why baby may do this and how this can affect milk supply. Of course, if you regularly supplement baby after nursing, your milk supply will drop (see below).
• Your breasts don't leak milk, or only leak a little, or stop leaking. Leaking has nothing to do with your milk supply. It often stops after your milk supply has adjusted to your baby's needs.
• Your breasts suddenly seem softer. Again, this normally happens after your milk supply has adjusted to your baby's needs.
• You never feel a let-down sensation, or it doesn't seem as strong as before. Some women never feel a let-down. This has nothing to do with milk supply.
• You get very little or no milk when you pump. The amount of milk that you can pump is not an accurate measure of your milk supply. A baby with a healthy suck milks your breast much more efficiently than any pump. Also, pumping is an acquired skill (different than nursing), and can be very dependent on the type of pump. Some women who have abundant milk supplies are unable to get any milk when they pump. In addition, it is very common and normal for pumping output to decrease over time.

See also Is my baby getting enough milk?

Who to contact if you suspect low milk supply

If you're concerned about your milk supply, it will be very helpful to get in touch with a La Leche League Leader or a board certified lactation consultant. If your baby is not gaining weight or is losing weight, you need to keep in close contact with her doctor, since it's possible that a medical condition can cause this. Supplementing may be medically necessary for babies who are losing weight until your milk supply increases. If supplementing is medically necessary, the best thing to supplement your baby with is your own pumped milk.

Potential causes of low milk supply

These things can cause or contribute to a low milk supply:

• Supplementing. Nursing is a supply & demand process. Milk is produced as your baby nurses, and the amount that she nurses lets your body know how much milk is required. Every bottle (of formula, juice or water) that your baby gets means that your body gets the signal to produce that much less milk.
• Nipple confusion. A bottle requires a different type of sucking than nursing, and it is easier for your baby to extract milk from a bottle. As a result, giving a bottle can either cause your baby to have problems sucking properly at the breast, or can result in baby preferring the constant faster flow of the bottle.
• Pacifiers. Pacifiers can cause nipple confusion. They can also significantly reduce the amount of time your baby spends at the breast, which may cause your milk supply to drop.
• Nipple shields can lead to nipple confusion. They can also reduce the stimulation to your nipple or interfere with milk transfer, which can interfere with the supply-demand cycle.
• Scheduled feedings interfere with the supply & demand cycle of milk production and can lead to a reduced supply, sometimes several months later rather than immediately. Nurse your baby whenever she is hungry.
• Sleepy baby. For the first few weeks, some babies are very sleepy and only demand to nurse infrequently and for short periods. Until baby wakes up and begins to demand regular nursing, nurse baby at least every two hours during the day and at least every 4 hours at night to establish your milk supply.
• Cutting short the length of nursings. Stopping a feeding before your baby ends the feeding herself can interfere with the supply-demand cycle. Also, your milk increases in fat content later into a feeding, which helps baby gain weight and last longer between feedings.
• Offering only one breast per feeding. This is fine if your milk supply is well-established and your baby is gaining weight well. If you're trying to increase your milk supply, let baby finish the first side, then offer the second side.
• Health or anatomical problems with baby can prevent baby from removing milk adequately from the breast, thus decreasing milk supply.

See Reasons for Low Milk Supply and Hidden Hindrances to a Healthy Milk Supply from more information on things that can decrease milk supply.

Increasing your milk supply

Milk production is a demand & supply process. If you need to increase milk supply, it's important to understand how milk is made - understanding this will help you to do the right things to increase production.

To speed milk production and increase overall milk supply, the key is to remove more milk from the breast and to do this frequently, so that less milk accumulates in the breast between feedings.

OK, now on to things that can help increase your milk supply:

• Make sure that baby is nursing efficiently. This is the "remove more milk" part of increasing milk production. If milk is not effectively removed from the breast, then mom's milk supply decreases. If positioning and latch are "off" then baby is probably not transferring milk efficiently. A sleepy baby, use of nipple shields or various health or anatomical problems in baby can also interfere with baby's ability to transfer milk. For a baby who is not nursing efficiently, trying to adequately empty milk from the breast is like trying to empty a swimming pool through a drinking straw - it can take forever. Inefficient milk transfer can lead to baby not getting enough milk or needing to nurse almost constantly to get enough milk. If baby is not transferring milk well, then it is important for mom to express milk after and/or between nursings to maintain milk supply while the breastfeeding problems are being addressed.
• Nurse frequently, and for as long as your baby is actively nursing. Remember - you want to remove more milk from the breasts and do this frequently. If baby is having weight gain problems, aim to nurse at least every 1.5-2 hours during the day and at least every 3 hours at night.
• Take a nursing vacation. Take baby to bed with you for 2-3 days, and do nothing but nurse (frequently!) and rest (well, you can eat too!).
• Offer both sides at each feeding. Let baby finish the first side, then offer the second side.
• Switch nurse. Switch sides 3 or more times during each feeding, every time that baby falls asleep, switches to "comfort" sucking, or loses interest. Use each side at least twice per feeding. Use breast compression to keep baby feeding longer. For good instructions on how to do this, see Dr. Jack Newman's Protocol to increase intake of breastmilk by the baby. This can be particularly helpful for sleepy or distractible babies.
• Avoid pacifiers and bottles. All of baby's sucking needs should be met at the breast (see above). If a temporary supplement is medically required, it can be given with a nursing supplementer or by spoon, cup or dropper (see Alternative Feeding Methods).
• Give baby only breastmilk. Avoid all solids, water, and formula if baby is younger than six months, and consider decreasing solids if baby is older. If you are using more than a few ounces of formula per day, wean from the supplements gradually to "challenge" your breasts to produce more milk.
• Take care of mom. Rest. Sleep when baby sleeps. Relax. Drink liquids to thirst (don't force liquids - drinking extra water does not increase supply), and eat a reasonably well-balanced diet.
• Consider pumping. Adding pumping sessions after or between nursing sessions can be very helpful - pumping is very important when baby is not nursing efficiently or frequently enough, and can speed things up in all situations. Your aim in pumping is to remove more milk from the breasts and/or to increase frequency of breast emptying. When pumping to increase milk supply, to ensure that the pump removes an optimum amount of milk from the breast, keep pumping for 2-5 minutes after the last drops of milk. However, adding even a short pumping session (increasing frequency but perhaps not removing milk thoroughly) is helpful.
• Consider a galactagogue. A substance (herb, prescription medication, etc.) that increases milk supply is called a galactagogue. See What is a galactagogue? Do I need one? for more information.

Herbs to avoid while Breastfeeding

By Kelly Bonyata, IBCLC

• Herbs that may decrease milk supply
• Herbs that may be harmful to mom and/or baby
• Additional Information

Herbs that may decrease milk supply

Using large amounts of the following herbs and other natural remedies should be avoided while nursing because they have been known to decrease milk supply. The amounts of these herbs normally used in cooking are unlikely to be of concern; it's mainly the larger amounts that might be used therapeutically that could pose a problem. However, some moms have noticed a decrease in supply after eating things like dressing with lots of sage, sage tea (often recommended when moms are weaning), lots of strong peppermint candies or menthol cough drops, or other foods/teas with large amounts of the particular herb. These herbs are sometimes used by nursing mothers to treat oversupply, or when weaning.

Black Walnut Chickweed Herb Robert (Geranium robertianum) Lemon Balm Oregano Parsley (Petroselinum crispum) Peppermint (Mentha piperita)/Menthol

Periwinkle Herb (Vinca minor) Sage (Salvia officinalis) Sorrel (Rumex acetosa) Spearmint Thyme Yarrow

Herbs that may be harmful to mom and/or baby

Other herbs should be avoided while nursing due to their potential for harming mom and/or baby. Check the index of herbs for more specific information. Here are a few herbs that are generally considered to be contraindicated for nursing mothers. This is by no means a complete list.

Bladderwrack Buckthorn Chaparral Coltsfoot (Farfarae folium) Dong Quai (Angelica Root) Elecampane Ephedra / Ephedra sinica / Ma Huang Ginseng (Panax ginseng)

Indian Snakeroot Kava-kava (piper methysticum) Petasites root Phen-fen, herbal Rhubarb Star anise Tiratricol (TRIAC) Uva Ursi Wormwood

Additional Information

Hidden Hindrances to a Healthy Milk Supply by Becky Flora, IBCLC

Too much milk: Sage and other Herbs (this website)

Birth control pills are also well known for decreasing milk supply, particularly the ones that contain estrogen.

Sudafed (a decongestant) can also decrease milk supply, particularly with regular use.

Individual herb listings (this website)

Disclaimer: Most herbal treatments have not been thoroughly researched, particularly in regard to lactation. Herbs are drugs, and some caution is necessary. I am presenting this data as is, without any warranty of any kind, express or implied, and am not liable for its accuracy nor for any loss or damage caused by a user's reliance on this information.

Is Baby Getting Enough Milk?

By Kelly Bonyata, BS, IBCLC

IS BABY GETTING ENOUGH? -- QUICK REFERENCE CARD

~~~ BIRTH to 6 WEEKS ~~~

WEIGHT GAIN: If baby is gaining well on mom’s milk alone, then baby is getting enough. A 5-7% weight loss during the first 3-4 days after birth is normal. Baby should regain birth weight by 2 weeks. Once mom’s milk comes in, average weight gain is 6 oz/week. If these goals are not met, call your lactation consultant. More on weight gain.

WET DIAPERS: 5 - 6+ sopping wet diapers per day (after 1st week). Expect one wet diaper on day one, increasing to 5-6 by one week. To feel what a sufficiently wet diaper is like, pour 3 tablespoons (45 mL) of water into a clean diaper (if baby wets more often, then the amount of urine per diaper may be less). Urine should be pale and mild smelling.

DIRTY DIAPERS: 3 – 4+ dirty diapers per day (after day 4). Stools should be yellow (no meconium) by day 5 and the size of a US quarter (2.5 cm) or larger. The normal stool of a breastfed baby is usually yellow and is loose (soft to watery, may be seedy or curdy). More on infant stooling.

OTHER POSITIVE SIGNS: After a feeding, mom’s breast feels softer and baby seems reasonably content. Baby is alert, active and meeting developmental milestones.

My breasts feel empty! Has my milk supply decreased?

By Kelly Bonyata, BS, IBCLC

It is normal for a mother's breasts to begin to feel less full, soft, even empty, after the first 6-12 weeks.

Many mothers have concerns about milk supply after the early weeks because they notice a drop in pumped amounts or they notice that their breasts feel "soft" or "empty". It is normal for your breasts to feel mostly soft after the first weeks, although if there has been a long stretch without nursing or pumping they might feel a little full and heavy.

The feeling of fullness (sometimes even engorgement) that nursing mothers notice during the early weeks of breastfeeding is really not the norm at all, but means that mom's breasts haven't yet adjusted to the amount of milk that baby needs. At some point, typically around 6-12 weeks (if a mom has oversupply it may take longer), your milk supply will begin to regulate and your breasts will begin to feel less full, soft, or even empty. You may stop leaking, you may stop feeling let-down (or feel it less), and if you pump you may notice that you're not getting as much milk. This doesn't mean that milk supply has dropped, but that your body has figured out how much milk is being removed from the breast and is no longer making too much. This change may come about gradually or seem rather sudden. Many people are not aware that these breast changes are normal because so many mothers stop breastfeeding early on and never see this change (or mistakenly interpret this change as a sign that milk supply has dried up and wean because of this change).

Why the change? Although milk synthesis has already switched over to autocrine control (driven by breast emptying) after mom's milk comes in, the extra hormonal influence of the early weeks and months frequently causes moms to have more milk than their baby needs. Early postpartum hormonal levels tend to "turn up the volume" on milk synthesis so that extra milk can be produced if it is needed (most moms can produce enough milk for twins or even triplets). Over the first few months, this high baseline prolactin level that is the norm in the early weeks gradually decreases to the lower baseline that is the norm for later lactation. After this point it may be easier for mom's body to adjust milk production down to baby's needs.

I'm confused about foremilk and hindmilk - how does this work?

By Kelly Bonyata, BS, IBCLC

Foremilk is the milk (typically lower in fat) available at the beginning of a feeding; hindmilk is milk at the end of a feeding, which has a higher fat content than the foremilk at that feeding. There is no sharp distinction between foremilk and hindmilk – the change is very gradual. Research from Peter Hartmann's group tells us that fat content of the milk is primarily determined by the emptiness of the breast -- the less milk in the breast, the higher the fat content.

A woman's breast really only makes one type of milk, the higher-fat milk that we typically think of as hindmilk. As milk is produced in the breast, the fat globules in the milk tend to stick to each other and to the walls of the alveoli (where the milk is made). Between feedings, milk collects in mom's breasts and gradually moves out toward the nipple, leaving more and more of the fat "stuck" further back in the milk ducts. The more time between feedings, the lower the fat content of the foremilk available to baby at the beginning of the feeding.

Once the let-down (or Milk Ejection Reflex/MER) is triggered (by baby's nursing, pumping, etc.), the milk is squeezed down the ducts until it becomes accessible to the baby. Milk production is not faster during letdown - the flow is simply faster. There are several let-downs per feed, although most mothers only sense the first one.

As the breast starts to empty, the fat globules begin to dislodge and move down the ducts (let-down facilitates this process). So the further into the feed, the higher the fat content of the milk, as more and more fat globules are forced out. The end result is that the milk gradually increases in fat as the feeding progresses.

Your breasts don't "flip a switch" at some arbitrary point and start producing hindmilk instead of foremilk. Instead, think of the beginning of a nursing session as being like turning on a hot water faucet.

The first water you get out of the tap isn't usually hot, but cold. As the water runs, it gradually gets warmer and warmer and warmer. This is what happens with the fat content in mom's milk - moms's milk gradually increases in fat content until the end of the feeding.

Since fat content is is directly related to the degree of emptiness of the breast, it is possible, depending upon nursing pattern, for fat content to be higher at the beginning of a particular feeding than it is at the end of some other feeding.

Now think about the hot water faucet again. If there is a long period of time before the faucet is used again, then you go through the "cold to hot" process once more, but if you turn the water on fairly soon after it was used then the water is either pretty warm or still hot, depending upon how long it's been since the faucet was last on.

This is how it works with mother's milk too - the longer the time between feedings, the lower the fat content at the beginning of the next feeding. If feedings are closer together, you're starting off with a higher fat content.

As a particular feeding progresses, fat content increases, milk volume and flow decrease, and milk synthesis speeds up. Because every baby varies in the amount of time it takes him to receive his fill of the higher-fat milk at the end of the feeding, it is important not to switch breasts while baby is actively nursing.

How does Milk Production Work?

By Kelly Bonyata, BS, IBCLC

To understand how to effectively increase (or decrease) milk supply, we need to look at how milk production works...

For the most part, milk production is a "use it or lose it" process. The more often and effectively your baby nurses, the more milk you will make.

• In the Beginning
• Established Lactation
• What does current research tell us about milk production?
• Feedback Inhibitor of Lactation
• Prolactin receptors
• What drives milk synthesis?
• Storage capacity
• What does the research tell us about increasing milk supply?
• Additional information

In the Beginning...

Endocrine (Hormonal) Control of Milk Synthesis -- Lactogenesis I & II

Milk production doesn’t start out as a supply and demand process. During pregnancy and the first few days postpartum, milk supply is hormonally driven – this is called the endocrine control system. Essentially, as long as the proper hormones are in place, mom will start making colostrum about halfway through pregnancy (Lactogenesis I) and her milk will increase in volume (Lactogenesis II) around 30-40 hours after birth.

During the latter part of pregnancy, the breasts are making colostrum, but high levels of progesterone inhibit milk secretion and keep the volume “turned down”. At birth, the delivery of the placenta results in a sudden drop in progesterone/estrogen/HPL levels. This abrupt withdrawal of progesterone in the presence of high prolactin levels cues Lactogenesis II (copious milk production). Other hormones (insulin, thyroxine, cortisol) are also involved, but their roles are not yet well understood. Although biochemical markers indicate that Lactogenesis II commences approximately 30-40 hours after birth, mothers do not typically begin feeling increased breast fullness (the sensation of milk "coming in") until 50-73 hours (2-3 days) after birth.

These first two stages of lactation are hormonally driven – they occur whether or not a mother is breastfeeding her baby.

Established Lactation...

Autocrine (Local) Control of Milk Synthesis -- Lactogenesis III

After Lactogenesis II, there is a switch to the autocrine (or local) control system. This maintenance stage of milk production is also called Lactogenesis III. In the maintenance stage, milk synthesis is controlled at the breast -- milk removal is the primary control mechanism for supply. Milk removal is driven by baby’s appetite. Although hormonal problems can still interfere with milk supply, hormonal levels play a much lesser role in established lactation. Under normal circumstances, the breasts will continue to make milk indefinitely as long as milk removal continues.

By understanding how local/autocrine control of milk synthesis works, we can gain an understanding of how to effectively increase (or decrease) milk supply.

What does current research tell us about milk production?

Current research suggests that there are two factors that control milk synthesis:

Milk contains a small whey protein called Feedback Inhibitor of Lactation (FIL) – the role of FIL appears to be to slow milk synthesis when the breast is full. Thus milk production slows when milk accumulates in the breast (and more FIL is present), and speeds up when the breast is emptier (and less FIL is present).

The hormone prolactin must be present for milk synthesis to occur. On the walls of the lactocytes (milk-producing cells of the alveoli) are prolactin receptor sites that allow the prolactin in the blood stream to move into the lactocytes and stimulate the synthesis of breastmilk components. When the alveolus is full of milk, the walls expand/stretch and alter the shape of prolactin receptors so that prolactin cannot enter via those receptor sites – thus rate of milk synthesis decreases. As milk empties from the alveolus, increasing numbers of prolactin receptors return to their normal shape and allow prolactin to pass through - thus rate of milk synthesis increases. The prolactin receptor theory suggests that frequent milk removal in the early weeks will increase the number of receptor sites. More receptor sites means that more prolactin can pass into the lactocytes and thus milk production capability would be increased.

Both of the above factors support research findings that tell us:

FULL Breast = SLOWER Milk Production

EMPTY Breast = FASTER Milk Production

Research indicates that fat content of the milk is also determined by how empty the breast is (emptier breast = higher fat milk), rather than by the time of day or stage of the feed.

How does milk supply vary throughout the day?

Earlier researchers observed that milk volume is typically greater in the morning hours (a good time to pump if you need to store milk), and falls gradually as the day progresses. Fat content tends to increase as the day progresses (Hurgoiu V, 1985). These observations are consistent with current research if we assume the researchers were observing babies with a fairly typical nursing pattern, where baby has a longer sleep period at night and gradually decreases the amount of time between nursing as the day progresses.

Storage capacity: Another factor that affects milk production and breastfeeding management is mom’s milk storage capacity. Storage capacity is the amount of milk that the breast can store between feedings. This can vary widely from mom to mom and also between breasts for the same mom. Storage capacity is not determined by breast size, although breast size can certainly limit the amount of milk that can be stored. Moms with large or small storage capacities can produce plenty of milk for baby. A mother with a larger milk storage capacity may be able to go longer between feedings without impacting milk supply and baby's growth. A mother with a smaller storage capacity, however, will need to nurse baby more often to satisfy baby’s appetite and maintain milk supply since her breasts will become full (slowing production) more quickly.

Think of storage capacity as a cup - you can easily drink a large amount of water throughout the day using any size of cup - small, medium or large - but if you use a smaller cup it will be refilled more often.

What does the research tell us about increasing milk supply?

Milk is being produced at all times, with speed of production depending upon how empty the breast is. Milk collects in mom's breasts between feedings, so the amount of milk stored in the breast between feedings is greater when more time has passed since the last feed. The more milk in the breast, the slower the speed of milk production.

To speed milk synthesis and increase daily milk production, the key is to remove more milk from the breast and to do this quickly and frequently, so that less milk accumulates in the breast between feedings:

EMPTY Breast = FASTER Milk Production

In practice, this means that a mother who wishes to increase milk supply should aim to keep the breasts as empty as possible throughout the day.

To accomplish this goal and increase milk production:

1. Empty the breasts more frequently (by nursing more often and/or adding pumping sessions between nursing sessions)
2. Empty the breasts as thoroughly as possible at each nursing/pumping session.

To better empty the breasts:

• Make sure baby is nursing efficiently.
• Use breast massage and compression.
• Offer both sides at each nursing; wait until baby is finished with the first side before offering the second. Switch nursing may be helpful if baby is not draining the breast well.
• Pump after nursing if baby does not adequately soften both breasts. If baby empties the breasts well, then pumping is more useful if done between nursing sessions (in light of our goal to keep the breasts as empty as possible).
  

Are you having problems with oversupply?

Mothers who are working to remedy oversupply usually need to decrease supply without decreasing overall nursing frequency or weaning baby. One way to accomplish this is by "block nursing" - mom nurses baby as frequently as usual but restricts baby to one breast for a set period of time (often 3-4 hours but sometimes longer) before switching sides. In this way, more milk accumulates in the breast before mom switches sides (thus slowing milk production) but baby's nursing frequency is not limited.

Average Weight Gain for Breastfed Babies

• Average weight gain
• Average length & head circumference gain
• A few things to keep in mind when evaluating weight gain
• Additional information and references

Baby's Age	Average Weight Gain 1	Average Weight Gain 2,3
0-4 months	5.5 - 8.5 ounces per week	5 - 7 ounces per week †
4-6 months	3.25 - 4.5 ounces per week	4 - 5 ounces per week
6-12 months	1.75 - 2.75 ounces per week ‡	2 - 4 ounces per week
[click here to see tables in Metric Units] † It is acceptable for some babies to gain 4-5 ounces per week. ‡ The average breastfed baby doubles birth weight by 3-4 months. By one year, the typical breastfed baby will weigh about 2 1/2 - 3 times birth weight. 1 Sources: World Health Organization Child Growth Standards, 2006. Available at: http://www.who.int/childgrowth/en/. To figure average weight gain, we used the weight-per-age percentile charts for birth - 5 years. The range is a combination of boys and girls 5% to 95%, rounded to the nearest quarter-ounce. Click here for more details on calculations [PDF file]. Riordan J. Breastfeeding and Human Lactation, 3rd ed. Boston: Jones and Bartlett, 2005, p. 103, 512-513. Mohrbacher N and Stock J. The Breastfeeding Answer Book, Third Revised ed. Schaumburg, Illinois: La Leche League International, 2003, p. 148-149.

Baby's Age	Avg. Length Increase	Avg. Head Circumference Increase
0-6 months	1 inch per month	1/2 inch per month
6-12 months †	1/2 inch per month	1/4 inch per month
[click here to see tables in Metric Units] † By one year, the typical breastfed baby will increase birth length by 50% and head circumference by 33%. Source: Mohrbacher N and Stock J. The Breastfeeding Answer Book, Third Revised ed. Schaumburg, Illinois: La Leche League International, 2003, p. 148-149.

See also the Infant growth calculators and breastfed baby growth charts @

A few things to keep in mind when evaluating weight gain

A 5-7% weight loss during the first 3-4 days after birth is normal. A 10% weight loss is sometimes considered normal, but this amount of weight loss is a sign that the breastfeeding needs to be evaluated. It's a good idea to have a routine weight check at 5 days (baby should be gaining rather than losing weight by day 5), so that any developing problems can be caught and remedied early.

Baby should regain birth weight by 10 days to 2 weeks. If your baby lost a good bit of weight in the early days, or if your baby is sick or premature, it may take longer to regain birth weight. If baby does not regain birth weight by two weeks, this is a sign that the breastfeeding needs to be evaluated.

Always figure weight gain from the lowest point rather than from baby's birth weight.

Baby needs to be weighed on the same scale with the same amount of clothing (preferably naked) each time to get an accurate picture of weight gain. Different scales can give very different readings (I've personally seen a difference of a pound in two different scales); clothing or diapers can vary in weight and throw the numbers off. The scale should be zeroed before weighing, and baby should be centered on the scale tray. It's never a bad idea to do a second measurement (it should be close to the first) and then use an average of the two measurements. If your baby is very active or distressed, don't expect to get an accurate measurement. Babies grow in spurts rather than at a steady rate - to keep from needless worrying, it's generally best to weigh baby no more often than once a week.

Frequent Nursing

By Kelly Bonyata, BS, IBCLC

• Tips for coping with frequent nursing
• Fine-tune breastfeeding
• Adjust your expectations
• Set priorities
• Be prepared
• Maximize sleep
• Do you feel trapped at home?
• Additional Resources

Both of my children seemed to spend the first 6 weeks or so in a constant growth spurt. If your child is doing the same, then hang in there... things almost always start to calm down somewhere between 6 and 8 weeks. With my second I figured that the early weeks would be easier since we already had one child, but I quickly found out that this just isn't the case. We were still adjusting to a change in family size (and the older child is having to adjust too - not just two adults), and our new baby was having to adjust to life outside of mom. After years of talking to mothers with new babies, I've discovered that the first 6-8 weeks with a new baby tends to be a combination of magic, exhaustion, and stress for any family - no matter how many children you have.

Tips for coping with frequent nursing

First of all, do know that frequent nursing is normal and expected in the early months - most newborns need to nurse at least 8 - 12 times per day. Frequent nursing is also needed -- to avoid/reduce engorgement in the early days, to nourish and grow a baby who has a stomach the size of his fist but who needs to double his weight within 5-6 months, to establish a good milk supply for mom, and to help a baby who has been cradled close and warm inside mom for 9 months adjust to life in the outside world. Frequent nursing may sometimes be a warning sign of inefficient milk transfer or low milk supply, but if baby has good diaper output, is gaining well and is generally happy and healthy, then the frequent nursing is unlikely to be a sign of a problem.

Remember that nursing is not just about food - it's also warmth, closeness, reassurance, comfort, healing, love... Nursing has been shown to reduce stress and pain in baby, too. If you're feeling that baby shouldn't be hungry again so soon - remember that it's sometimes Mom that baby needs just as much as the milk.

Fine-tune breastfeeding

If baby seems to be nursing all the time, you first want to make sure that breastfeeding is working well. Problems with latching can result in frequent nursing if baby is not transferring milk efficiently. If baby's latch is shallow, it can be like when you're drinking from a straw and pinch the straw mostly shut - baby is still getting milk but it takes a loooong time at the breast to get enough. Often, even minor changes in latch can help a lot. Here's more on latching. If you feel that breastfeeding is not working as well as it should, do your best to get some local help - evaluating and fixing latch problems over the phone or online is difficult. Using breast massage and breast compression can also be helpful at times for babies who are frequent nursers.

Adjust your expectations

In the early weeks of breastfeeding, it really helped me to plan my day with the expectation that I would be nursing most of the time. Once I considered frequent nursing to be the norm rather than a problem, it made my life much easier.

Many books, magazine articles, friends and other products of our modern culture suggest to us that we will be able to go on with "life as usual" after baby is born - that we can and should "train" baby to conform to an adult routine. But our lives do change greatly with the birth of a new baby, and urging baby to conform to our pre-baby routines can come at great cost to both baby and parents. Routinely delaying nursing when baby cues a need to eat can harm milk supply, affect baby's weight gain, and is very stressful to both mom and baby. It is developmentally appropriate for young babies to nurse frequently. By letting baby stretch out nursing frequency on his own (and it will happen with time) - you are preserving your nursing relationship and meeting baby's physical and emotional needs.

The first 6-8 weeks are a time when you are building your milk supply and you and baby are getting used to each other and learning about nursing. After the first 6-12 weeks, most babies are much more settled and move toward a more predictable routine. Nursing sessions do not take as much time, either, as baby becomes more efficient at nursing. Nursing will not always take this much time - soon nursing will be much quicker and easier, and you will have gotten past "boot camp" to the easy phase of nursing.

Set priorities

Will the dishes be unhappy and depressed if you neglect them for a few months? You're growing and building a relationship with your children - the dishes and housework can wait when your child needs time and attention.

Make a list of the things you'd like to get done each week, and prioritize them. For the things that absolutely need to get done, see if you can find shortcuts and/or someone else who can do the job. In the early weeks, if a friend or family member asks if they can help, take them up on it - see if someone can put a load of clothes on, or wash the dishes, or vacuum the floor while you nurse baby. Some families decide that it's worth the money to get a cleaning service to come in every couple of weeks to do the heavy cleaning. Can an older neighborhood child or a friend come over to entertain your older children while you nap with baby? Can Dad make sandwiches or cut up vegetables/fruit so you have food easily available when baby is nursing often? Be creative, and don't be afraid to let the smaller things slide. You'll have plenty of time for them later - the "in arms" phase of baby's life is so short, even though it might feel like forever when you're in the middle of it.

Be prepared

Put together a collection of items that you might need while you're nursing. If you usually nurse in one particular place, you might set up a nursing area there, or if you move around you can keep your collection in a basket or other container with a handle. Some things you might want:

• a few diapers & wipes
• extra cloth diapers or burp rags
• water bottle
• snacks
• books
• any remote controls you might want to use
• cordless phone (or make sure your answering machine is turned on)

Do you have a sling? Are you comfortable with using it and nursing baby in it? A sling will give you an extra hand (sometimes two) and allow you to keep nursing or holding baby while walking around doing other things.

Maximize sleep

Nap when baby naps. You've probably heard it a million times, but we say it because it helps! When baby goes to sleep, don't jump up to do housework - lie down and rest and try to go to sleep. If you can't sleep, then read a book, listen to music, watch a movie... but don't run around the house. If you get some sleep now, you'll have more energy to do what you need to do later.

Consider sleeping with or nearby baby so you can get more sleep. Co-sleeping (for naps, and/or during the night) is a lifesaver for many nursing moms. The closer you are to your baby, the less your sleep will be interrupted for night waking. Here are some tips on side lying nursing, and information on safely sleeping with your baby. Getting more rest can make life with baby much easier.

Do you feel trapped at home?

Many new moms feel like they're trapped at home with a frequently nursing baby, but most young babies are incredibly easy to take out and about. It can really help to get out occasionally. Here are some tips for going out:

• Get a sling. Other baby carriers can be nice, too, but with a sling (and a little practice) you can nurse your baby while you walk around the park or the mall.
• Put baby in a sling or other baby carrier or a stroller, and go for a walk.
• Go to a movie. Most young babies simply sleep and nurse through movies. And if you're nervous about nursing in public, a dark movie theater can be a good place to start. Go here for commentary and tips on nursing in public.
• If you want to go out by yourself for a bit, you don't have to leave a bottle. If your baby normally goes an hour or two between nursing sessions, then nurse baby right before you leave and plan to be back before the next nursing session. If you have a cell phone, take it with you so Dad or another caregiver can call you if the going gets rough. Even if you can only expect 20-30 minutes between nursings, go for a walk by yourself while someone watches baby. Every little bit helps, when you're feeling "touched out.".

Nursing your newborn — what to expect in the early weeks

The First Week

How often should baby be nursing?

Frequent nursing encourages good milk supply and reduces engorgement. Aim for nursing at least 10 - 12 times per day (24 hours). You CAN'T nurse too often--you CAN nurse too little.

Nurse at the first signs of hunger (stirring, rooting, hands in mouth)--don't wait until baby is crying. Allow baby unlimited time at the breast when sucking actively, then offer the second breast. Some newborns are excessively sleepy at first--wake baby to nurse if 2 hours (during the day) or 4 hours (at night) have passed without nursing.

Is baby getting enough milk?

Weight gain: Normal newborns may lose up to 7% of birth weight in the first few days. After mom's milk comes in, the average breastfed baby gains 6 oz/week (170 g/week). Take baby for a weight check at the end of the first week or beginning of the second week. Consult with baby's doctor and your lactation consultant if baby is not gaining as expected.

Dirty diapers: In the early days, baby typically has one dirty diaper for each day of life (1 on day one, 2 on day two...). After day 4, stools should be yellow and baby should have at least 3-4 stools daily that are the size of a US quarter (2.5 cm) or larger. Some babies stool every time they nurse, or even more often--this is normal, too. The normal stool of a breastfed baby is loose (soft to runny) and may be seedy or curdy.

Wet diapers: In the early days, baby typically has one wet diaper for each day of life (1 on day one, 2 on day two...). Once mom's milk comes in, expect 5-6+ wet diapers every 24 hours. To feel what a sufficiently wet diaper is like, pour 3 tablespoons (45 mL) of water into a clean diaper. A piece of tissue in a disposable diaper will help you determine if the diaper is wet.

Breast changes

Your milk should start to "come in" (increase in quantity and change from colostrum to mature milk) between days 2 and 5. To minimize engorgement: nurse often, don’t skip feedings (even at night), ensure good latch/positioning, and let baby finish the first breast before offering the other side. To decrease discomfort from engorgement, use cold and/or cabbage leaf compresses between feedings. If baby is having trouble latching due to engorgement, use reverse pressure softening or express milk until the nipple is soft, then try latching again.

Call your doctor, midwife and/or lactation consultant if: Baby is having no wet or dirty diapers Baby has dark colored urine after day 3 (should be pale yellow to clear) Baby has dark colored stools after day 4 (should be mustard yellow, with no meconium) Baby has fewer wet/soiled diapers or nurses less frequently than the goals listed here Mom has symptoms of mastitis (sore breast with fever, chills, flu-like aching)

Weeks two through six

How often should baby be nursing?

Frequent nursing in the early weeks is important for establishing a good milk supply. Most newborns need to nurse 8 - 12+ times per day (24 hours). You CAN'T nurse too often—you CAN nurse too little.

Nurse at the first signs of hunger (stirring, rooting, hands in mouth)—don't wait until baby is crying. Allow baby unlimited time at the breast when sucking actively, then offer the second breast. Some newborns are excessively sleepy—wake baby to nurse if 2 hours (during the day) or 4 hours (at night) have passed without nursing. Once baby has established a good weight gain pattern, you can stop waking baby and nurse on baby's cues alone.

The following things are normal:

• Frequent and/or long feedings.
• Varying nursing pattern from day to day.
• Cluster nursing (very frequent to constant nursing) for several hours—usually evenings—each day. This may coincide with the normal "fussy time" that most babies have in the early months.
• Growth spurts, where baby nurses more often than usual for several days and may act very fussy. Common growth spurt times in the early weeks are the first few days at home, 7 - 10 days, 2 - 3 weeks and 4 - 6 weeks.

Is baby getting enough milk?

Weight gain: The average breastfed newborn gains 6 ounces/week (170 grams/week). Consult with baby's doctor and your lactation consultant if baby is not gaining as expected.

Dirty diapers: Expect 3-4+ stools daily that are the size of a US quarter (2.5 cm) or larger. Some babies stool every time they nurse, or even more often--this is normal, too. The normal stool of a breastfed baby is yellow and loose (soft to runny) and may be seedy or curdy. After 4 - 6 weeks, some babies stool less frequently, with stools as infrequent as one every 7-10 days. As long as baby is gaining well, this is normal.

Wet diapers: Expect 5-6+ wet diapers every 24 hours. To feel what a sufficiently wet diaper is like, pour 3 tablespoons (45 mL) of water into a clean diaper. A piece of tissue in a disposable diaper will help you determine if the diaper is wet. After 6 weeks, wet diapers may drop to 4-5/day but amount of urine will increase to 4-6+ tablespoons (60-90+ mL) as baby's bladder capacity grows.

Milk supply?

Some moms worry about milk supply. As long as baby is gaining well on mom's milk alone, then milk supply is good. Between weight checks, a sufficient number of wet and dirty diapers will indicate that baby is getting enough milk.