How to Get Your Milk Supply Off to a Good Start
Lisa Marasco, IBCLC
Santa Maria CA USA
Diana West, IBCLC
Long Valley NJ USA
From: NEW BEGINNINGS, Vol. 22 No. 4, July-August 2005, pp. 142-147
Ideally, breastfeeding should begin as soon after birth as the baby is ready to nurse. A full-term healthy newborn's instinct to breastfeed peaks about 20 to 30 minutes after birth if he is not drowsy from drugs or anesthesia given to his mother during labor and delivery. In the first hour, babies are in a quiet, alert state, and have an innate ability to latch on and suckle effectively. Research has shown that when most newborn infants are placed immediately on the abdomen of their mothers, they will find her breast and initiate suckling in less than 50 minutes. Separating the infant from his mother during this crucial time misses this first window of opportunity. The baby may then become drowsy and lose his natural urge to find the nipple, which may result in more difficulty in the initiation of breastfeeding (Righard and Alade 1990; Widstrom et al. 1990; Wang and Wu 1994). Therefore, ensuring that the baby has every opportunity to suckle in the first hour after birth will be one of the most important things that you can do to make sure your baby will have as much milk as possible.
Even when nursing immediately after birth is possible for the mother, some babies do not seem to be able to latch on to the breast well following the delivery. This can be the result of epidural or other anesthesia given to the mother during labor. Certain types of anesthesia have been shown to diminish the infant's spontaneous breast-seeking and breastfeeding behaviors, as well as increasing body temperature and crying (Ransjo-Arvidson et al. 2001).
It is important to understand that not being able to nurse the baby right after birth certainly does not doom you to trouble. If the baby has difficulty sucking or latching on when he finally does get to breastfeeding, seek help from a lactation specialist sooner rather than later. In addition, it will be beneficial to breastfeed frequently in the early days to establish as many prolactin receptors as possible. (See box on page 144.)
If breastfeeding in the early hours after birth is not possible, the next best alternative is to hand-express or use an automatic-cycling electric pump for 10 to 20 minutes every two to three hours until the baby begins nursing. This will help to maximize prolactin receptors and minimize the impact of delayed nursing. If you are giving birth in a hospital or birthing center, an effective breast pump should be readily available, although you may need to specifically request one. A nurse, a lactation consultant, or a midwife should be able to show you how to operate it.
An environment that is pleasant, tranquil, and comforting is the best setting for meeting and bonding with your new baby. Although it may be difficult to create such a place in a hospital, feeling supported, encouraged, and peaceful enables mothers to manage any milk supply challenges they may face more calmly.
Breastfeeding after Cesarean Birth
Mothers who have cesarean births (c-sections) may find that nursing immediately after the baby is born is not possible. If the mother is given general anesthesia, she will not be alert enough to handle her baby in the first hour after birth. Even if the mother receives an epidural so that she is awake, abdominal suturing occupies a major portion of that first-hour window of time, and this may make breastfeeding during that time impractical. In addition, the infant may be sleepy and unreceptive to nursing if the mother received pain medications during labor before the surgery. Some studies also suggest that emergency cesarean births can result in delayed milk production (Dewey et al. 2003; Grajeda and Perez-Escamilla 2002; Rowe-Murray Fisher 2002; Hartmann 1987). However, frequent nursing as soon as it is possible after a cesarean birth will help minimize these obstacles if they do exist. It is also reassuring to know that many mothers who have had cesarean births have gone on to have plentiful milk supplies.
The Tremendous Value of Colostrum
It can be helpful for mothers to understand and appreciate the incredible value of colostrum, the translucent, yellow "pre-milk" that you will produce in the first few days. Colostrum, and the mature milk that follows, nourish and protect the baby much as the placenta did during pregnancy. Colostrum is low in fat and carbohydrates and high in protein, which is precisely the nutrient balance that the baby requires in the first days. Colostrum is easy to digest and contains living cells that serve to protect the newborn against bacteria, viruses, and allergens. Colostrum actually coats the intestinal lining and prevents the absorption of substances that trigger allergies. The immune factors IgG and IgA are more concentrated in colostrum than in mature milk. These factors also serve to stimulate and enhance the baby's own immune system, and research suggests the benefits may last his entire life. Furthermore, colostrum acts as an effective laxative, flushing meconium from the intestines, taking bilirubin, the substance that causes jaundice, along with it. And colostrum does not suddenly disappear when the mature milk comes in; rather, the transition to mature milk takes place over the first two weeks. That is why any milk you express during this time will usually appear more golden in color than milk expressed later on.
Some mothers do not see or are unable to express colostrum prior to the baby's birth. Mothers who still do not see any colostrum when the baby nurses and cannot manually express any in the first few postpartum days may worry that this means that they are unable to produce milk. In fact, not seeing colostrum when the baby nurses does not mean that it is not there. Colostrum is produced in very small quantities (an average total of 7.4 teaspoons (36.23 ml) per day, approximately 1.4 to 2.8 teaspoons (6.86 to 13.72 ml) per feeding) and is immediately swallowed by the baby (Hartmann 1987; Hartmann and Prosser 1984; Houston et al. 1983). While often golden in color, it can also be somewhat clear and can look like saliva, so that it may not be easy to identify. Expressing colostrum or milk can be difficult because the breast tissue may be swollen in the first few days postpartum. Expression is also a skill that takes some practice.
Colostrum is so valuable that even the tiniest bit that you are able to give to your baby will be a priceless gift to him. It truly will be worth any effort you can make to give your baby colostrum.
Many hospitals offer the option of having the baby stay with his mother in her room. This is often called rooming-in. Although central nurseries that kept babies in a separate location were common in hospitals a generation ago, research has shown that there is no medical reason for healthy mothers and babies to be separated, even temporarily (Yamauchi and Yamanouchi 1990; Buranasin 1991; Oslislo and Kaminski 2000). In fact, skin-to-skin contact actually helps to stimulate prolactin, your milk-making hormone (Hurst 1997). As recommended in the 2005 policy issued by the American Academy of Pediatrics (AAP), being together is good for both of you and will allow you to begin nursing on demand as soon as possible, which is most beneficial to your milk supply.
Feed the Baby Frequently
As you know, you will need to nurse your baby as often as he is interested in feeding. At the very least, this should be every two to three hours during the day and every four to five hours at night for a total of eight to 12 feedings every 24 hours. Calculate the time between feedings from the beginning of one feeding to the beginning of the next. Most feedings usually last 20 to 40 minutes, but do not watch the clock during the feeding. When your baby is a newborn, especially during the first week, nursing sessions can sometimes seem to last so long that you barely have any time to get anything done before the next session begins. Before the mature milk comes in, some babies will nurse quite voraciously because they are hungry.
This does seem to hasten the milk coming in. Frequent feedings are normal and they are essential for stimulating the maximum number of prolactin receptors to ensure production of the greatest milk supply possible. The first month is a learning time for your new baby. During this month, he will perfect his nursing skills so that near the end of it, he will need less time to consume the same amount of milk. Keeping him near you at all times will help you to be aware of his early hunger cues (rooting, fussing, etc.) so that you can feed him without allowing him to work up into a hungry, stressful cry. Minimizing your baby's crying in this way will also be less stressful on you and the other members of your household.
Even though it can seem like it at first, you will not always spend all of your time nursing. Remember that you are recovering from giving birth at this point and you need to rest. Breastfeeding is nature's way of ensuring that you do so. The time between feedings will eventually stretch out and feedings will become more manageable. Your baby will establish more of a feeding pattern, which will make life more predictable. The patterns that he establishes, however, will be his patterns and will be appropriate to his unique emotional and physiological needs. And these patterns will change as he grows and matures.
Surround Yourself with Supportive People
This is a very sensitive time in your life. You are physically and emotionally vulnerable. The last thing you need as you begin breastfeeding is to be near anyone who undermines your efforts by expressing doubts or criticism. Breastfeeding may be the biological norm, but in our society there are still people who are not comfortable being around a breastfeeding mother and baby, and these people may be even more likely to be critical if there are any questions about your milk supply. This lack of ease with breastfeeding stems from a lack of understanding and sometimes a mistaken view of the breast as sexual. You deserve to have only positive support and encouragement now. You do not need any negativity that would undermine your confidence.
It can be difficult to distance yourself from unsupportive people during this otherwise exciting postpartum time, but remember that you have the right to structure your environment so that it is most conducive to successful breastfeeding, which is essential to the well-being of your baby. Ultimately, the needs of your baby are far more important than the opinions of others. If you have difficulty fending off critical people, ask your partner or another support person to "run interference" for you.
You may be thinking to yourself, "But what if it's my mother or my mother-in-law? How do I deal with her?" Many new grandmothers may not have had successful breastfeeding experiences themselves. Some are sad for what they missed and will do anything to help their daughters and daughters-in-law succeed where they did not. Other grandmothers may be defensive about their need or choice to use formula and may view your strong commitment to breastfeeding as a criticism of their own parenting. Do you know about your mother and mother-in-law's birth and breastfeeding experiences? Ask them about their experiences and listen to their stories. Chances are that they did not have the information, support, or technical resources that you do, not to mention societal support for breastfeeding. It helps to express compassion for the struggles they faced, and to reassure them that you know they were the best parents they knew how to be. Showing empathy and acceptance of their experiences and choices may help them be more constructive in their support of you.
During the first weeks of breastfeeding, nurturing your child, breastfeeding, and caring for yourself will be your most important responsibilities. Other obligations do not matter nearly as much. If you have older children, you will certainly need to focus on them, too, but your new baby's needs and your own needs are paramount right now. Your partner or another caregiver can help you tend to your older children's basic needs during this time.
Although it is natural for your friends and family to want to visit to see the new baby and congratulate you, entertaining them can be a drain on you, and you may not feel free to nurse your baby with visitors present. Try to gently and politely discourage as many visits as possible, but for those who insist on dropping by, the best way to limit their visits is to stay in your nightgown and robe, sending a clear signal that you are convalescing and need your rest. You may want to go even one step further and receive your visitors in bed. This will usually guarantee brief visits.
Stay in Bed
For mothers who desire to do so, staying in bed for the first few days is actually one of the best things you can do to get breastfeeding off to a good start. You can bring books and magazines or even a television set into your room, have drinks and snacks near the bed, and get up only to go to the bathroom and bathe. Spending concentrated time snuggling and nursing your baby whenever he wants will ensure the greatest possible milk supply. Tell everyone it is "doctor's orders" if you feel you need justification; many doctors instruct their postpartum patients to do just this, because even though you may feel happy and exhilarated, your body has just been through a great deal of physical exertion and it needs time to recuperate. If you do not take the time to rest and recuperate now, the next few months will be much harder for you, which could impact your milk supply.
Meals and Housework
Among the obligations that you should not feel responsibility for are meals and housework. When your friends and family ask what they can do for you, request that they bring in dinner or lunch. Even if two friends bring a meal the same day, graciously accept both and freeze one. People like to feel helpful and a meal is much more valuable to a newly expanded family than another baby outfit.
Housework, especially if you have been gone a few days, can seem very compelling and yet daunting. This is not the time to resume your household chores, no matter how much they need doing or how many visitors you're likely to have. Having a tidy and clean house simply doesn't matter a fraction as much as your critical need for rest. Resist the temptation to do the housework yourself because it's easier than telling someone else how to do it. The truth is that explaining where the dishes go requires far less of your limited energy than unloading the dishwasher yourself. Remind yourself over and over again that for right now housework is not your responsibility. If it is not done, it does not reflect poorly on you at all. Only the most insensitive, unrealistic person could possibly think less of a new mother because she has a less-than-perfect house. One breastfeeding mother hit the nail on the head when she said:
Easier said than done, butrelax, ignore the house, and just nurse! Take it easy and just nurse! Forget about obligations and just nurse!
I can say this because I didn't do it and I really regret it. You have the perfect excuse to take it easy and focus just on your new little bundle and everybody understands. It makes a tremendous difference in your long-term nursing. I really wish I would have listened to this advice.
It all boils down to this: Don't expend one ounce of unnecessary energy; save all of it for nursing your baby.
Postpartum Doula Care
Many new mothers are blessed with having a partner or family member who is wonderfully supportive and quite capable of performing all of the household tasks. Even so, there is more to do than take care of the household now. You are caring for your baby, but you need special nurturing care yourself. You may also be feeling a great deal of anxiety. Having a professional postpartum doula, a woman who cares for a new mother by helping around the home and giving support and encouragement, can make all the difference. Doulas mother the mother. Some doulas help during the actual birth, but most will also help at home during the postpartum time. A doula can do household chores, help with older children, or simply focus on nurturing you. It almost does not matter what she actually does; the presence of a mature, reassuring, and non-judgmental woman will build your confidence while you focus on bonding with your new baby.
When hiring a doula, do ask about her infant care philosophies. Does she believe in demand (cue) feeding or does she favor putting babies on a schedule? Does she believe in keeping you and baby together, or does she view her responsibility as taking care of baby for you? Is she knowledgeable in breastfeeding issues? Does she refer mothers to a lactation specialist when necessary? Knowing her philosophy in advance ensures smoother sailing at home. And if any questions arise, do not hesitate to contact a breastfeeding specialist for more helpor just another viewpoint if breastfeeding is not going as well as should.
Eating, Drinking, and Sleeping Well
To have enough energy for nursing and baby care, you need nutritious meals, sufficient fluids, and a lot of sleep. Never skip a meal. In fact, try to have several nutritious snacks throughout the day in addition to regular meals. In general, the quantity and quality of your diet is more important for you than it is for your milk supply. Your body will make good milk for your baby even if your diet is less than ideal. Eating foods that you enjoy and that are good for you will nourish both your body and your soul.
Drinking properly is every bit as important as eating properly. It is important to stay hydrated by drinking to thirst. Do not, however, drink large amounts of fluids with the idea that this will increase your milk supply. It does not work that way and ingesting too much liquid can actually reduce your supply.
Water is the best fluid, although non-caffeinated teas are a good choice for their soothing properties. Fruit and citrus juice are also beneficial, and can be nutritious as well. But you need to read the labels to be sure the fruit juice you are drinking does not contain added sugarempty unnecessary calories. Some mothers have found that drinking excessive amounts of citrus juice can cause fussiness in their babies.
It is not necessary to drink cow's milk. Some babies are sensitive to the proteins in cow's milk that may be present in their mother's milk and it is not at all essential for adults to drink milk. Mothers have sometimes been told that they must drink milk to make milk. This is not true; milk is made from the nutrients we take in from many sources, not from drinking the milk of another species. Adult cows certainly do not drink milk and are able to lactate quite sufficiently.
Next to food and water, sleep is your most critical necessity. You need as much of it as you can get. Take at least one nap a daypreferably when the baby does. The baby will be awake during portions of what would otherwise be your normal sleeping time, so you will need to make up for this lost sleep. The best way to do this is to sleep when the baby does. When the baby falls asleep for a nap during the day, it may be tempting to use that time to catch up on thank-you notes, birth announcements, housework, and phone calls. But this is precious time that can be much better spent resting. It may be hard to simply drop off to sleepyou may be on edge wondering if the baby will suddenly wake up again. But it is important to learn not to worry about that and fall asleep as quickly as possible. If the baby wakes, you will, too, and you can try to nap again later. But if baby sleeps for a long time, you will get some valuable rest.
The Low Milk Supply Balancing Act
Working to increase your milk supply while you take care of your baby and your family, not to mention yourself, can be a balancing act. The needs of your baby, your family, and yourself must be carefully juggled many times a day. Sometimes it is easy to put yourself last in this difficult equation. Try to keep in mind, though, that it is only when you are at your best that you can give your best to your family. Pushing too hard will only exhaust you. It is important to find a reasonable balance in your plan and be kind to yourself through this process. Remember to take time to fall more deeply in love with your baby, who is only little for such a short time.
American Academy of Pediatrics. Policy statement: Breastfeeding and the use of human milk. Pediatrics 2005; 115(2):496-506.
Buranasin, B. The effects of rooming-in on the success of breastfeeding and the decline in abandonment of children. Asia Pac J Public Health 1991; 5(3):217-20.
Dewey, K., Nommsen-Rivers, L., Heinig, M., Cohen, R. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics 2003; 112(3 Pt 1):607-19.
Grajeda, R. and Perez-Escamilla, R. Stress during labor and delivery is associated with delayed onset of lactation among urban Guatemalan women. J Nutr 2002; 132(10):3055-60.
Hartmann, P. Lactation and reproduction in Western Australian women. J Reprod Med 1987; 32:543-47.
Hartmann, P. and Prosser, C. Physiological basis of longitudinal changes in human milk yield and composition. Fed Proc 1984; 43:2448-53.
Houston, M., Howie, P., McNeilly, A. Factors affecting the duration of breast feeding: 1. Measurement of breast milk intake in the first week of life. Early Hum Dev 1983; 8:249-54.
Hurst, N., Valentine, C., Renfro, L. et al. Skin-to-skin holding in the neonatal intensive care unit influences maternal milk volume. J Perinatol 1997; 17(3):213-17.
Oslislo, A. and Kaminski, K. Rooming-in: a new standard in obstetrics and neonatology. Ginekol Pol Apr 2000; 71(4):202-7.
Ransjo-Arvidson, A., Matthiesen, A., Lilja, G. et al. Maternal analgesia during labor disturbs newborn behavior: effects on breastfeeding, temperature, and crying. Birth 2001; 28(1):5-12.
Righard, L. and Alade, M. Effect of delivery room routines on success of first breast-feed. Lancet 1990; 336:1105-07.
Rowe-Murray, H. and Fisher, J. Baby friendly hospital practices: cesarean section is a persistent barrier to early initiation of breastfeeding. Birth 2002 Jun; 29(2):124-31.
Wang, Y. and Wu, S. Effect of early suckling and emptying the breasts after nursing on exclusive breastfeeding. Zhonghua Fu Chan Ke Za Zhi 1994; 29(8):465-7, 509-10.
Widstrom, A., Wahlberg, V., Matthiesen, A. Short-term effects of early suckling and touch of the nipple on maternal behavior. Early Hum Dev 1990; 21:153-63.
Yamauchi Y. and Yamanouchi, I. The relationship between rooming-in/not rooming-in and breast-feeding variables. Acta Paediatr Scand 1990; 79:1017-22.