Feeding your baby is a time for providing nutrition. It is also a time when babies socialize. During this time you can strengthen the bond between you and your baby. Parents often have questions about their baby’s feeding needs. This section provides up-to-date information on feeding choices and methods.

The Kintzinger Women’s Health Center was made possible by a gift from John and Jewel Kintzinger.

Breastfeeding Your Baby
Breastfeeding is the natural way a mother feeds her baby and it is a special gift only you can give your baby. The milk from mom’s breasts is specially designed for baby. Breast milk is sweet tasting and contains many special nutrients that will benefit the baby for a lifetime.

As you begin to breastfeed your baby you may discover that it does not go as easily as you had hoped. Your success in breastfeeding depends greatly on your desire to nurse and the encouragement you will receive from those around you. It is normal to feel awkward when learning a new skill. Your baby may also be sleepy. Give yourself and your baby time to practice. It may take a few days or even weeks for breastfeeding to begin to feel natural.

In addition to reading this booklet, we encourage you to ask questions. While you’re at GRMC, be sure to take advantage of our library of breastfeeding videos. If you have questions after you get home you may call the Kintzinger Women’s Health Center at any time at 641-236-2324 to ask for assistance.

Breastfeeding Advantages
The choice to breastfeed benefits you, your baby, and the community.

Advantages to the breastfed baby:

• Provides the most complete nutrition possible for the baby
• Easier to digest
• Contains three million germ-killing cells per teaspoon
• Special closeness with feedings promotes bonding
• Increases the level of intelligence, as it fosters the development of both the brain and nervous system
• Promotes stronger facial muscles, jaw structure, teeth development, and results in fewer cavities
  
• Enhances speech development
• Enhances visual development
• Decreases baby’s risk of ear infection and respiratory illness
• Provides protection against many diseases
• Reduces the risk of childhood cancers
• Reduces the risk of juvenile diabetes mellitus
• Results in fewer allergies (wheezing, vomiting, stomach/bowel disturbances)
• Prevents the body from overproducing cholesterol
• Reduces the risk of SIDS (Sudden Infant Death Syndrome)

Advantages to the breastfeeding mother:

• Convenient—“Ready to feed”
• Cost efficient (formula can cost more than $100 per month)
• Promotes bonding between mother and baby
• Helps mother return to a pre-pregnancy figure more quickly
• Reduces the risk of breast, uterine, and ovarian cancer, osteoporosis, and anemia

Advantages to the community:

• Parents miss less work when children are healthier
• Healthier children result in lowered healthcare costs
• Money saved can be applied to other family needs
• Mothers and babies are healthier throughout their lifetimes
• Decreases pollution

The Basics
Nurse your baby as soon as possible after delivery. Mothers who breastfeed within an hour after birth and feed their babies frequently on demand have their milk come in sooner and engorgement is less of a problem. Your baby may nurse eight to 12 times in 24 hours. Newborns have frequent arousals (states of alertness) in their sleep. Mothers need to be aware of these early “states of arousal” and attempt to nurse their baby at this time. A baby’s signs of arousal are stretching, opening their eyes and mouth, licking, and hand to mouth activity.

If your baby is sleepy and not arousing within three hours of the previous feeding, wake the baby for a feeding. Plan to nurse your baby at least once or twice during the night for the first few weeks.

As baby starts nursing, the beginning milk is called foremilk (similar to skim milk). As baby continues to nurse, hindmilk (similar to whole milk) is released throughout the remainder of the feeding. This hindmilk is higher in fat, promotes weight gain and stooling, and is more satisfying to your baby.

Offer both breasts at each feeding. The length of time spent at breast varies from baby to baby. Some babies wish to nurse 10 minutes a side, others up to 15 to 20 minutes per side. This extra time is comforting to your baby and satisfies the need to suck. It also stimulates your breasts to produce more milk. Fifty percent of your milk is made as your baby breastfeeds and the rest is made between feedings.

Colostrum
In the early days your breast milk is a golden yellow liquid called colostrum. Colostrum contains protein, minerals, and disease-preventing properties that are extremely beneficial to your baby. It protects baby from infections; decreases the chance of developing allergies; and acts as a natural laxative, helping baby to have stools. Gradually your colostrum will change to mature milk. Once established it can vary in color and consistency.

Let Down Reflex
When your baby nurses at your breast, two hormones are released into your bloodstream. The hormone prolactin tells your breast to make milk. The hormone oxytocin tells your breast to push milk down to your nipple. This process is called “let down.” Some early signs of let down include feeling your uterus tighten as you nurse or hearing your baby swallow.

Feelings of let down vary from woman to woman. Other signs of let down may include tingling, tightness or fullness in your breasts, dripping or spraying of milk from your breasts, or flushing of your face. Mothers may not feel these signs of let down during the early days of nursing, or it may take as long as three or more minutes.

It is important that let down occurs with every breastfeeding for your baby to obtain a full feeding. Some women may not be aware when let down has occurred. Emotions can exert a powerful influence on your body’s let down of milk. Fear, pain, fatigue, anxiety, stress, or embarrassment may prevent it from occurring.

If let down does not occur try these suggestions:

• Nurse in a quiet comfortable place.
• Relax. Do the relaxation breathing you were taught in childbirth class.
• Massage your breasts before you nurse.
• Try nipple stimulation before nursing by rolling your nipples gently between your fingers.
• Listen to soft relaxing music.
• Drink something while you nurse.
• Eat a high protein finger food while nursing.
• Get extra rest. Rest whenever baby does.

Stop or restrict smoking as it inhibits let down. If you continue to smoke, do so only after nursing. Levels of nicotine and combustible by-products are highest the first hour after smoking a cigarette.

Getting Started
As you take your baby in your arms to nurse, support your breast in your hand like a “C” or “U” shape. This hand support will lessen the weight of the breast on your baby’s chin/cheek during nursing. Maintain this hold throughout the nursing. Hold and support your baby with the “head control” positions taught to you by your nurse. Gently tickle your baby’s lower lip with your nipple and wait for a wide-open mouth. With your nipple pointing slightly upward toward the roof of baby’s mouth, lay your nipple and as much of the lower areola as possible on baby’s lower lip. Gently, but quickly bring baby onto our breast.

Your baby should grasp as much of the nipple and areola as possible (generally about one inch). You should feel several strong tugs in the first few seconds after the nipple/areola is placed in baby’s mouth. Keep your baby close so that the tip of baby’s nose and cheeks touch your breast while nursing.

Breast Structure

Breast Massage
Breast massage prior to nursing, hand expression, or pumping increases the amount of milk a mother releases from the breast. Breast massage also helps mom relax, resulting in a more spontaneous milk release and a higher fat content in mother’s milk. It is very helpful with nursing and early pumpings. Use breast massage at other times as you need it.
Methods are as follows:

Fingertip Massage: With two fingers, press lightly into your breast. Start from the back of the breast and massage in small circles all around the breast. Gradually massage closer to the areola. Massage the whole breast. Gently stroke the breast area from the top of the breast to the nipple. Continue the stroking motion to help you relax, which in turn will stimulate the milk ejection reflex. You can alternate this method with the parallel hand position.

Parallel Hand Position: Place one hand above and one hand below your breast. With the upper hand, gently stroke in a circular motion toward the nipple, support-stroke in a circular motion toward the nipple, supporting the breast with the lower hand. Repeat this using the upper hand for support as the lower hand strokes the lower portion of the breast. Alternate to the sides of your breast and repeat until you’ve covered all parts of the breast. Continue massaging until let down occurs.

Avoid These Motions:

• Do not squeeze the breast, as this can cause bruising.
• Avoid pulling the nipple, which may result in tissue damage.
• Sliding hands over the breast may cause painful skin burns.

Manual Expression of Breast Milk
Position the thumb (above the nipple) and the first two fingers (below the nipple) about 1” to 1 1/2” from the nipple. Use this measurement as a guide, since breasts and areola vary in size from one woman to another. Be sure the hand forms the letter “C” and the finger pads are at 6 and 12 o’clock in line with the nipple. Note: the fingers are positioned so that the milk reservoirs lie beneath them.

• Avoid cupping the breasts.
• Avoid spreading the fingers apart.
• Push back toward the chest wall.
• For large breasts, first lift and then push back, toward the chest wall.
• Roll thumb and fingers forward at the same time. This rolling motion compresses and empties milk ducts without injuring breast tissue. Note the position of thumb and fingernails during the finish roll as shown.
• Repeat rhythmically to completely drain ducts. Position, push in, and roll out. Position, push in, and roll out.
• Rotate the thumb and fingers around the areola to milk other milk ducts, using both hands on each breast. Doing some breast massage is helpful when manually expressing your breast milk.

Breastfeeding Positions
There are a number of breastfeeding positions you can try:

• Modified cradle (cross cradle): Opposite arm is used for supporting baby, chest-to-chest with baby’s head supported by mother’s hand. Support your breast with a U shape hold.
• Football: Baby’s head is supported by mother’s hand. Baby is tucked under the upper arm, along your side. Baby’s bottom rests along mom’s side or hip supported by your forearm. Place a pillow under your elbow and forearm for additional support in holding. Support your breast with either a U shape or C shape hold.
• Cradle: Chest-to-chest, back supported by forearm while hand cups buttock. Support your breast with a C shape hold.
• Side-lying: Mother and baby lying down on their sides, facing each other chest-to-chest. Place a rolled blanket behind baby for support.

Removing Baby from Your Breast
To remove baby from your breast, gently insert your finger into the corner of baby’s mouth, between baby’s gums. Do this to prevent injury to your breast. (The nail on the finger used should be trimmed to avoid injury to the newborn when releasing from mother’s nipple.)

Burping
Attempt to burp your baby after each breast. Your baby may not burp because very little air is swallowed while nursing. If your baby begins gulping loudly, you may need to burp more often.

Care for Your Breasts
Breast care should be done daily by gently rinsing the breasts and nipples with plain water and a clean washcloth. After nursing, massage a small amount of your milk on your nipple, and air dry your nipples before closing your bra flaps.

With each nursing or pumping do a touch assessment of all areas of your breasts. This is done to see if any lumps (plugged milk ducts) are present. If you feel lumps, you will need to massage these areas before and during nursing or pumping. This will help to soften these areas and help baby get more of your milk.

Flat or Inverted Nipples
Women with any breast shape and nipple size can nurse. Women with flat or inverted nipples can learn techniques to draw nipples “out.” Severely inverted nipples may take a number of weeks to respond to the following recommendations:

• Gently roll your nipple between your forefinger and thumb before you nurse.
• Try wearing breast shells between feedings. Do not wear them at night as they may move and cause discomfort and pressure to the breast.
• Use a hand or electric pump for a few minutes before you nurse. This helps to draw your nipple out and makes it easier for your baby to grasp.
• The natural fold or dimple seen on an inverted nipple may remain moist, causing skin irritation. The use of breast shells may be helpful to promote drying before your nipple relaxes to its natural inverted state.

Choosing a Bra
When choosing a nursing bra, it is recommended that you have two cotton support bras with a comfortable cup size. A “rule of thumb” for buying bras is as follows:

If you gained less then 30 pounds during pregnancy, you will need a bra one cup size larger than before you were pregnant. If you gained more than 30 pounds, you may need one bra size larger as well as one cup size larger. Look for a bra with cotton cups, non-elastic straps and no underwires.

Many women are more comfortable wearing their bras to bed for additional support and to hold the nursing pads in place the first few weeks after birth.

Leaking
Leaking most commonly occurs while the baby is nursing at the opposite breast. Most women leak more during the first few weeks while the milk supply is adjusting. Leaking can be reduced by complete and frequent emptying of the breasts. When you leak:

• Wear breast pads and change them frequently. Avoid plastic lined pads. Presently Johnson & Johnson and Evenflo brands are the recommended paper disposable pads. Cloth pads of 100 percent cotton are also available.
• Briefly apply pressure to your nipples with your forearm to control the initial surge of milk.
• Leaking also commonly occurs with sexual intercourse. Keep your sense of humor about the new dimension added to your love life! You may want to nurse prior to making love or have a towel handy. Wear a bra if you and your partner are agreeable to this.

Common Early Concerns

Is baby getting enough?
It’s common for a breastfeeding mother to be concerned about whether her baby is getting “enough” nourishment. Most women make enough milk for their babies.

To assure an adequate milk supply, do not forget your own needs.

Be sure to allow adequate time for your own rest. Nap when your baby does and accept help whenever it’s offered. Fatigue not only decreases your milk supply but also diminishes your ability to deal with stress.

Drink enough fluids to satisfy your increased thirst.

Eat a balanced nutritious diet to satisfy your hunger. The food you eat provides the calories needed to make enough milk for your baby.

Assure frequent vigorous nursing sessions. We recommend eight to 12 feedings or pumpings every 24 hours.

It is reassuring to observe:

• Two to five wet diapers for the first few days, then six to eight wet diapers daily.
• One bowel movement every feeding or a large, loose movement every day.
• Swallowing and gulping during nursing.
• Contentedness after nursing.
• Breasts feel full before nursing and soften after nursing.

Your baby will be weighed at each well-baby check-up. If you have concerns, please call the Kintzinger Women’s Health Center at 641-236-2324 or your healthcare provider.

Other factors that may result in a decreased milk supply are:

• Smoking
• Birth control pills
• Lifestyle changes or increased stress levels
• Recent illnesses
• Delayed emptying of breasts
• Antihistamine use
• Low thyroid level

Normal Newborn Jaundice
This is common in newborns in the first weeks of life. You may notice your baby’s skin and eyes appear yellowish and your baby may be sleepy with feedings. Current research has shown that frequent nursing aids in reducing jaundice by coating the stomach and intestine with milk and stimulating frequent stools. Awaken your baby to nurse at least every two to three hours. If baby refuses to nurse for a complete feeding, you should pump after the nursing attempt and feed baby this pumped breast milk.

Sleepy Babies
Babies are often sleepy the first days after birth. Baby needs to be fed every two to three hours in the day and every three to four hours at night.

Sleepy babies will also need to be stimulated throughout the feeding to keep them nursing vigorously. Here are some suggestions:

• Watch baby closely for arousal signs: licking, opening mouth (rooting), opening eyes, stretching, bringing hands to mouth. Nurse baby as soon as you see these cues.
• Nurse baby at least every two to three hours during the day and every three to four hours at night. If baby does not arouse on his or her own for a feeding, you must wake the baby.
• Keep a feeding diary of baby’s feeding times, stoolings, and wetting.

To wake the baby, try the following:

• Undress the baby
• Change the diaper
• Talk to baby
• Use a stimulating massage on baby from head to toe
• Sit baby on your lap and rub their back

As baby begins to awaken:

• Express a few drops of breast milk onto your nipple for baby to smell and taste as you touch baby’s lower lip with your nipple.
• Stroke baby’s lower lip gently with your nipple to begin the rooting reflex.
• Once baby has a good latch on your breast, occasionally use stroking on baby’s head, under the chin, behind the ear, or on the hands and feet to keep baby nursing vigorously.
• If baby’s sucking slows and baby does not respond to your attempts to keep baby nursing vigorously, remove baby from your breast, wake baby again, and relatch for more vigorous nursing.

If your baby has not had a full vigorous feeding you will need to pump or hand-express to maintain your milk supply.

Sore Nipples
Sore nipples occur for a variety of reasons:

• Inadequate support of the breast while nursing.
• Poor positioning of baby at mother’s breast.
• Improper grasp of mother’s nipple by baby. Your nipple should not appear creased after nursing.
• Improper release of baby from mother’s nipple.
• Baby sucking at an overfull breast.
• Baby using the breast as a pacifier.
• Use of over-the-counter nipple creams.
• Use of plastic-lined nursing pads or bras of fabric other then cotton.
• Improper use of a breast pump. Always start with minimum suction. Be sure to align your nipple properly with the breast pump cup.
• Presence of a yeast infection (thrush) in baby’s mouth.

Recommendations:

• Nurse the least sore side first.
• Alternate nursing positions (cradle, cross cradle, football, or side-lying).
• Watch baby closely for signs of arousal and nurse baby as soon as you see these (opening mouth, licking, opening eyes, stretching, hands to mouth.)
• Empty breasts every two to three hours by nursing or use of a breast pump or hand-expression.
• If baby is not vigorously nursing throughout most of the feeding, pump or hand-express to empty your breasts after each nursing attempt.
• Massage your breasts.
• You may wish to pump before “latch on” to start the milk flow and soften the breasts if overfull.
• Calm baby before latch is attempted.
• Tickle the baby’s lower lip with your nipple for a wide-open mouth to achieve a complete grasp of your nipple and areola by baby. Be sure the lower lip is flanged out.
• Occasional stroking of baby’s head, under baby’s chin, or behind baby’s ear will help to keep baby actively sucking for a vigorous nursing session. (Too much stimulation distracts baby.)
• If sleepy, frequent prompt “relatches” are recommended to ensure proper areola grasp during the nursing session
• Correctly release your nipple when removing your baby from the breast after nursing.

To speed healing:

Hand-express some of your breast milk onto your nipples after nursing. Air dry before bra flaps are closed.

• Avoid soaps and ointments on nipples.
• Limit use of nursing pads. Do not use plastic lined pads.
• You may take a mild pain relieving medication for discomfort, i.e., Tylenol or Ibuprofen as your doctor prescribed in the hospital.
• Pumping may help to allow the nipple time to heal. If you are unable to feed your baby at your breast due to nipple pain, you must pump or hand-express to maintain your supply. Feed this pumped milk to baby.

Caution: If you are unable to feed your baby at your breast, or blisters, cracking, bleeding, or pain continues during and between feedings, this is not normal. Contact the Kintzinger Women’s Health Center at 641-236-2324 or your physician for further guidance.

Breast Congestion/Engorgement
As your milk supply increases your breasts may become overfull (congested). This occurs around three to five days after your baby is born. This is normal. During this time your breasts will feel heavy, firm, and warm. You may run a low temperature. Congestion lasts 24 to 72 hours. Gradually, your milk supply will adjust to meet your baby’s needs.

The following recommendations will help minimize or resolve congestion or engorgement:

1. Breastfeed your baby at least every two to three hours, both day and night while your breasts are full.
2. Encourage vigorous nursing sessions, with frequent “relatch” if necessary to keep baby awake and to ensure a full areola grasp.
3. Apply warm, moist cloths to your breasts for 10 minutes before nursing or take a warm shower to help with relaxation before nursing/pumping.
4. Use gentle breast massage before and during feeding or with pumping.
5. It may be helpful to hand-express or pump to soften the areola before “latch” is attempted.
6. Use different nursing positions. Point baby’s nose toward the firm, congested area, this will help with emptying.
7. Nurse the first breast until soft. This may be 15-20 minutes. Offer the second breast.
8. If baby refuses to nurse one or both breasts (or has nursed lazily) pump to remove the milk and help to soften your breasts. Ten to 15 minutes of pumping per breast may be needed. (Baby contact and massaging your breasts before and during pumping is helpful for a better let down.)
9. Offer your breast to baby after you have pumped (your areolar and nipples will be softer). If baby again refuses to nurse at your breast, feed baby your pumped milk.
10. Apply cold compresses to your breast for 15 minutes after each nursing/pumping. This will relieve discomfort and swelling. (Cold compresses can be made by freezing clean, wet disposable diapers.)
11. For engorgement, cool, crisp cabbage leaves applied to the breasts for 15-20 minutes after each nursing will help to relieve the discomfort and swelling of your breasts. (Wash the outer leaves from a head of green cabbage and cool in the refrigerator or freezer.) Discontinue use of cold compresses or cabbage leaves when the swelling has decreased and your breasts are more comfortable (usually one to two days).
12. Avoid supplements of water or formula unless medically indicated by your doctor.
13. Deep breathing, soft music, something warm or cool to drink, will help you relax before and during nursing.
14. You may take a mild pain relieving medication for discomfort, i.e. Tylenol or Ibuprofen.
15. Wear a good support bra with a comfortable cup.
16. Soft 100 percent cotton nursing pads are recommended to absorb excessive breast milk discharge.

Caution: If your baby refuses to nurse, if your breasts become painful and red, or you experience an elevated temperature with “flu-like” symptoms, promptly call your physician. These symptoms can be the beginning of mastitis, an infection in your breasts.

Pumping
The care coordinator will assist you in selecting and fitting a pump that best suits your individual needs. Before expressing your milk, wash your hands in hot, soapy water. Be sure your breast pump collection container and the container in which you will store your milk are clean. Thorough cleaning is important, since residual milk can allow growth of bacteria.

Wash the containers either in the dishwasher or wash in very hot, soapy water, rinse in hot water and air dry upside down in a clean rack. It is very important that the containers are dry before they are used because bacteria will grow on wet surfaces.

Practice with the breast pump before you need to use it. Usual times to pump are during congestion, engorgement, before or after a first morning feeding, or when you are away from baby. You may want to try thinking about your baby, looking at a picture of your baby, or playing a lullaby or homemade cassette of baby’s coos or cries to help you relax. Having something cool or warm to drink or massaging your breasts gently may help you let down (release milk) more spontaneously.

Pump each breast about 10 minutes or until the spray of milk diminishes. Repeat the massaging and pumping of each breast until your breasts are as soft as when your baby has emptied them with nursing. Your first attempts to pump are for practice only. Don’t be discouraged if only a small amount of milk is obtained. The pumping is generally less than what your baby actually gets with nursing. The pump doesn’t empty your breasts as well as your baby does.

Storing Pumped Breast Milk

Storage Containers:
Store expressed mild in clean plastic baby bottles or disposable bottle liners (ex. Playtex Nursery bags which you can close with a twist-tie or rubber band.)

Milk can be contaminated by the breaking down of certain chemicals in other types of plastic bags or containers. Breast milk should not be refrigerated or frozen in glass containers because an important part of the protein in milk will adhere to the glass.

Storing Milk:
Breast milk should always be kept in the refrigerator or freezer. Expressed milk can be refrigerated for 48 hours. It can also be frozen in single feeding amounts. (Two-to four-ounce portions are easiest to handle.) You may wish to place bags in a cup until frozen and then place inside a larger zippered plastic bag, or storage container to protect it from other foods or breakage. Place the container of breast milk in the coldest part of the freezer or refrigerator. Never store milk in the freezer door.

If you want to add more milk to the same container, refrigerate your milk for about an hour each time you express it, then add it to the frozen milk that is already in the freezer. Do not add warm breast milk directly to frozen milk because the milk on top will thaw. It can be stored three to four months in a refrigerator-freezer that keeps ice cream semi-soft or four to five months in a refrigerator-freezer that keeps ice cream hard. Expressed breast milk can be stored for up to one year in a freezer where the temperature is below 0 degrees. Breast milk should never be re-frozen once it has thawed because this increases the chance for bacterial growth. Use your breast milk within 24 hours of thawing.

Milk expands as it freezes, so leave at least an inch of space at the top of the container to allow for this expansion. Be sure to label each container with the date and time(s) the milk was expressed.

To Thaw and Warm Milk
Thaw or warm breast milk in the refrigerator or by rolling the container under cool, then gradually warmer, running water, until the milk has liquefied. Breast milk should not be thawed by being set out at room temperature. Be sure to check the temperature on the top of your hand before offering it to baby.

A microwave or stove should not be used to thaw or heat breast milk. A microwave may destroy the immune properties in the milk, which are so important to the baby during the first few months. It can also heat bottles unevenly, which may cause burns in the baby’s mouth. Breast milk may separate when it is thawed. If this happens, stir or swirl milk gently as it warms, but do not shake.

Breast milk may vary in color or appearance each time it is pumped or hand-expressed. This is normal.

Milk that has been thawed and has not come in contact with baby’s mouth can be kept in the refrigerator for 24 hours, but it cannot be re-frozen. If the milk has come into contact with baby’s mouth, discard all unused portions within 60 minutes. Milk that has collected in plastic breast cups should be discarded.

Plugged Ducts
This may happen when your breasts are not completely emptied on a regular basis or from a bra that is too tight. It may occur when you return to work, when your baby starts sleeping through the night or when your baby begins solid foods. When a milk duct is plugged you may feel a tender area or painful lump. The skin over the area may be reddened. Usually plugged milk ducts do not require antibiotic treatment, but must be taken care of promptly.

Recommended measures are:

• Apply warm, moist cloths to the tender area 10 to 20 minutes before emptying your breasts by nursing or pumping.
• Gently massage the area before, during, and after nursing.
• It may be helpful to hand-express or pump to soften the areola before “latch” is attempted.
• Nurse or pump more frequently. Begin nursing on the sore breast first and completely empty the breast.
• Reposition the baby so the baby’s nose or chin points toward the plugged area. This will provide the best suction to help loosen the plug. Your baby may be reluctant to nurse from the affected side due to a flavor change in your milk. If this is the case, pump that side to assist you in keeping the breast empty.
• Cold compresses to your breast for 15 to 20 minutes after nursing/pumping will relieve discomfort and swelling.
• Rest as much as possible. Increase your fluids and protein foods. Taking a mild pain medication may help relieve some discomfort.
• After the plug has loosened and cleared, frequent nursing sessions and position changes will help prevent reoccurrence.
• If a plugged duct is not taken care of properly, an infection can develop affecting the entire breast. This is called mastitis.

Mastitis
Mastitis is a breast infection involving one or both breasts. The breast may become swollen, painful, and reddened. If not treated you will experience flu-like symptoms including fever, chills, body aches, headache, and sometimes nausea and vomiting. Women with abundant milk supplies are more prone to developing mastitis. If mastitis occurs:

• Your baby can still continue to nurse with mastitis.
• The bacteria causing the infection are not harmful to your baby. The immunities in your milk will protect your baby from the infection.
• Continue to nurse frequently.
• An empty breast heals faster than a full breast.
• Follow the suggestions listed earlier for plugged ducts.
• Call your physician. Antibiotics may be prescribed. Remind the doctor you are nursing.
  If the above suggestions do not help, please call the Kintzinger Women’s Health Center at 641-236-2324.

Thrush and Yeast Infections
Thrush is a common yeast infection that can affect both mom and baby when you are breastfeeding. A diet high in sugar and yeast-containing foods (bread products) can lead to yeast infection in the mother. It can occur when the mother or baby have been treated with antibiotics or can be picked up by baby at the time of birth if the mother has a vaginal yeast infection.

When a breastfeeding mother has a sudden onset of sore nipples after a time of comfortable nursing, thrush may be the cause.

The baby may have a diaper rash or white patches on the inside of the mouth, gums, and tongue. If these symptoms occur, call your physician and obtain medication for both mother and baby. You can continue to breastfeed.

You must also take precautions with other things that have been in baby’s mouth, such as pacifiers, bottle nipples, or teething toys. These should be boiled for 15 minutes or put through the dishwasher once or twice a day (wash and dry cycle). If this is not possible, the items should be discarded halfway through the thrush treatment, since they can harbor the yeast fungus and re-infect baby.

When Baby Refuses to Nurse
There may be times when your baby refuses to nurse for a few feedings or even a day or two. This can be very upsetting, but generally is only a temporary problem. Some common causes include thrush, breast congestion, teething, illness (earaches, head colds) or distraction (in older infants). The return of menstruation and impending mastitis or plugged ducts can also bring about refusal to nurse.

If your baby refuses to nurse:

• Provide lots of skin contact; hold, love, and cuddle your baby.
• Offer your breasts at more frequent intervals.
• Offer the breast in a quiet, darkened room, when baby is drowsy or just awakening.
• Try nursing in different positions (football or sitting up higher that usual).
• Express or pump your milk when your baby skips a nursing time or has not emptied your breasts completely.

Contact your health professional or Kintzinger Women’s Health Center at 641-236-2324 if baby continues to refuse to nurse.

Fussy Baby
All babies are fussy and uncomfortable at one time or another. Frequent periods of fussing can be very trying to new parents. A baby’s greatest comfort is to be held and nursed. Here are a few tips to use when breastfeeding a fussy baby:

• Wrap baby snugly in a warm blanket.
• Use gentle rocking or swaying with the baby.
• Before nursing apply warm compresses to your breast for 10 minutes or take a warm, relaxing shower.
• Nurse in a darkened, calm, quiet environment.
• Mother should have something near to sip on.
• Gently massage your breasts while nursing to release more fat into the milk.
• Offer a second round at the breast, making sure baby has a good latch.
• Burp baby in the over-the-shoulder or sitting position. If you were unable to get a burp, lay baby down and try later.
• Use a burp cloth with the scent of breast milk to lay baby on.
• Provide additional sucking after breastfeeding to calm baby.
• Encourage a family member or friend to assist in calming baby.

Growth and Appetite Spurts
Once in awhile, you may notice your baby wants to nurse more frequently. The baby who has been peacefully nursing every two to three hours may suddenly want to increase the number of times a day he is fed. In fact, he may seem to nurse almost constantly for a day or two. Your first reaction may be to worry that your milk supply is low and that your baby is hungry and unsatisfied. Actually, your baby will probably be experiencing a spurt in his growth and his frequent nursing will be a healthy response to his increased appetite and need for more milk.

The increase in nipple stimulation caused by these additional feedings will signal your body to produce more milk. After a day or two of frequent nursing, you will be making the additional milk to satisfy his increased appetite and your baby will probably return to his former nursing patterns.

At times, your baby may nurse more frequently in response to illness, over-stimulation, emotional distress, or physical discomfort.

Dietary Needs with Breastfeeding
It is important that you eat a well-balanced diet while nursing. You should eat sensibly and to satisfy your appetite. You need only add 500 additional calories to your pre-pregnant diet to provide energy for milk production. No foods need to be eliminated from your diet unless they seem to bother the baby.

You may notice that you are thirstier when nursing, so drink to satisfy your thirst. Drink at least eight to 10 glasses of fluid daily. Limit fluids containing caffeine to one to two cups per day. Caffeine is transferred to the baby unchanged. It stays in the baby’s body for long periods of time and can cause irritability or sleep disruption. So have your caffeinated fluids earlier in the day.

With a well-balanced diet while nursing, you can expect to lose one to two pounds per week. Weight reduction diets are not recommended while nursing as this may decrease your volume of milk. Many women will have a tendency to maintain five to 10 pounds above their ideal weight.

Additional vitamins can be taken while you are nursing. You should take the daily iron supplement recommended by your physician for two to three months to rebuild your iron stores lost during pregnancy and childbirth.

Getting enough protein every day is very important for nursing mothers. Otherwise protein is taken from mother’s own muscle tissue and can take away her strength and energy.

Examples of quick protein snacks include:

• Milk
• Cottage cheese
• Eggs
• Pudding

If you do not like milk, you must meet your calcium needs using other foods or a calcium supplement. Four doses of 300 mg each to equal 1200 mg a day are recommended. Foods high in calcium include:

• Cheese
• Ice Cream
• Cottage cheese
• Dried beans
• Custard
• Canned tuna
• Pudding
• Salmon or shrimp
• Yogurt

Other ways to increase your calcium intake include:

• Using powdered milk in casseroles or meatloaf(2 TBS. powder per cup of casserole)
  
• Using powdered milk in cookies, cakes, or pancakes.(2 TBS. powder per cup of flour)
• Eat foods using milk or cheese (custards, puddings, ice cream, cheesecake, scrambled eggs, macaroni and cheese, French toast, cheese or cream sauces, mashed potatoes, tacos, pizza, cheeseburgers, lasagna, grilled cheese sandwich)

Contact the Grinnell Regional Medical Center dietitian at 641-236-2324 for more information.

Medication Use
All medications pass through your milk to your baby. Most over-the-counter medications taken infrequently or for a short period of time are usually safe. Some birth control pills decrease your milk supply. Check with your healthcare provider regarding the best choice for you.

Contact your healthcare provider regarding other medications.

Alcohol Consumption
It is recommended that you pump your breasts and discard the breast milk after alcohol consumption. Alcohol passes into the breast milk within 30 to 60 minutes after drinking. Alcohol changes the odor of breast milk and reduces the infant’s total milk consumption.

It is generally recommended that you pump and dump one feeding for each drink you have, for example: one drink, pump and dump the next feeding; two drinks, pump and dump the next two feedings, etc.

Siblings
It is not unusual for siblings to show signs of jealousy and regression. Try to focus on the special role of the older brother or sister. Some mothers read to siblings while nursing. Others have a collection of toys for their children to play with only while mother is nursing. You might want to encourage your children to use the bathroom and offer liquids and food before you nurse to eliminate interruptions.

Your older children may naturally be curious about breastfeeding. They may want to touch your breast or taste the milk. This curiosity will pass. If you feel comfortable, let them satisfy their curiosity. This, too, is a time for patience and a sense of humor.

Returning to Work or School
Today many women are successfully nursing when they return to work or school. You will be successful with some planning and patience. You will have many options to consider and plans to make.

Preparing for Your Return
You will benefit from supportive home and work environments. Discuss your feelings about nursing with your support person and childcare provider. Their help will increase your success. Let your partner know how much you will benefit from his emotional support and help with household chores.

Reassure your employer that breast-feeding will not affect your job performance. In fact, parents of breastfed babies may miss fewer days, since breastfed babies are ill 60 percent less than formula fed babies. Discuss with your employer any special needs you may have such as a clean, private place for expressing, an area for milk storage, and flexibility in scheduled breaks.

Timing Your Return
Delaying your return to work (at least six to eight weeks) until your milk supply is well established will be helpful to both you and your infant. If you can wait to return to work until four to six months, the transition will be even easier and better for baby. Consider working part-time (two to three days a week or half-days) the first week or two back, rather than five full days. This will help with success in the early days of breastfeeding and working.

Evaluate Possible Work Arrangements
Check with your employer to find out what options are available. Can you work flextime, part time, work at home, or take your baby to work?

Explore Available Types of Childcare
Choose one that is compatible with your breastfeeding and parenting goals. Finding good childcare may take time and effort. Select a person who will comply with your wishes and is supportive of your decision to breastfeed. Is it possible to coordinate schedules so that you or your support person can be home with the baby? Is there a daycare located close to work? Can you go to baby or have baby brought to you for feedings?

How will baby be fed while you are away? Bottle? A bottle should be introduced to your baby at about three to four weeks of age. By that time your milk supply is well established. A bottle only needs to be offered one to two times a week to keep baby “in practice.” Your baby will prefer warmed milk and it may be helpful if someone other than mom offers these feedings. If baby refuses bottle, try again at another time. You should express your milk when baby is given a bottle.

Practice Trial Runs
Start by leaving for short periods, and then gradually increase the time away from baby. This allows baby and caretaker time to adjust more easily. Familiarize your child’s caretaker with special aspects of breast-feeding.

One of the next times you are away from home, check out the room at work where you’ll be expressing your breast milk. Note the refrigeration available. Practice expressing, saving, and transporting your milk.

Managing Your Return
Plan to nurse right before you leave for work and as soon as you return home. It is best if you express your milk at work close to baby’s usual feeding times, at least every three to four hours while away from your baby. Avoid pumping in restrooms due to unsanitary conditions. Be sure your breast pump and collection bottles are properly cleaned. Wash your hands before beginning to express milk.

Wear clothing that will allow easy access to your breasts. Plan a quiet activity at work just prior to pumping. Refrigerate the expressed milk and take it home for use the next day. Keep breast milk chilled when transporting it by packing ice around the milk containers. Remember to put the milk in the refrigerator or freezer as soon as you reach your destination.

If you cannot pump at work, wean down from the feedings you’ll miss when at work. Do this before you return to work. Plan at least one to two weeks to accomplish this.

It is not unusual for your milk supply to lessen upon returning to work due to the new schedule, stress, or fatigue. Some women have difficulty expressing enough milk to fulfill their baby’s complete needs during their absence. When this occurs, make up the difference with formula. Formula and beast milk can be mixed in the same bottle as long as your baby does not have milk allergies. Consult your healthcare provider regarding which formula to use.

Measures you can take to help you maintain an adequate supply of breast milk:

• Continue to nurse exclusively and frequently when you are with your baby—at night, days off, before, and after work.
• Assure a good fluid intake (eight to 10 glasses daily).
• Eat a well-balanced diet with healthy snacks while at work.
• Go to bed earlier than your usual bedtime.
• Encourage your support person to help with household tasks.
• Decrease extra activities the first few weeks you return to work.

Managing Your Daily Routine
You may need to try a variety of routines before you find one that works best for you. You might also find that your routine may work for a while, but must change as your baby grows and develops.

Your extra efforts to continue nursing are well worth it. Nursing saves time and energy that is especially important if you are combining the responsibilities of employment and family. Many mothers who work outside the home or attend school feel breastfeeding offers emotional compensation for the hours they must spend apart from their baby. The security of your breast comforts your baby and helps make the time you spend together special and rewarding for both of you. Perhaps, most importantly, nursing helps you maintain the close, loving relationship you have with your baby.

As you continue to feed and parent your baby, you will soon realize the unique relationship that has developed between the two of you. Relax and enjoy your baby, and have confidence in yourself and your wonderful ability to provide nourishment, security, and love to your baby.

Weaning
The decision to breastfeed is a personal one and the length of the breastfeeding experience is unique to each family. Weaning should be a process of substitution. You replace one source of fluid or nutrition with another.

Weaning should be performed gradually to allow the milk supply to decrease slowly and ease the separation. You may also wean some feedings and continue to nurse at other feedings. Remember the feedings you continue to nurse must be consistent from day to day. Examples are women who wean while at work and nurse when they are at home with baby, or women who wean all but morning and night feedings.

It is normal to experience some emotional changes at this time. Not all weanings are gradual, of course. If abrupt weaning is necessary, it can be managed successfully with patience and support. Leakage may occur for some time after you have weaned your baby.

Gradual weaning tips:

• Eliminate one regular breastfeeding time (the one your baby seems least interested in, usually a mid-day feeding) and substitute a bottle, cup or solids, depending on the age of your baby. After three to five days eliminate another breast-feeding time.
• Continue eliminating one breastfeeding at a time every three to five days until you’ve reached the desired frequency. Babies may nurse part time as long as the nursing times are consistent each day.
• You may apply cold compresses or cabbage leaves for 15 to 20 minutes to relieve engorgement when you stop a feeding. You may also pump briefly (for relief only) to help with engorgement until the next feeding.
• Increase the time spent hugging and cuddling your baby. This gives the security and reassurance to your baby during this time of change.

Abrupt weaning:

• Gradual weaning is best for mother and baby.
• Apply cold compresses or cabbage leaves to your breasts for 15-20 minute periods frequently throughout the day.
• Use mild pain relievers.
• Wear a comfortable supportive bra. Be sure it is not so tight that is uncomfortable.
• Express a small amount of milk as needed. This helps relieve the pressure and prevents congestion of milk that may lead to mastitis (breast infection). Call your doctor if you suspect you have mastitis.
• If you wean before your baby is one year old, give your baby formula instead of cow’s milk. If your baby is one year or older, use whole cow’s milk until the second year of age.

Bottle Feeding Your Baby
You should continue to feed your baby the type of formula he or she has been on in the hospital and do so for the first year of life. Do not use cow’s milk before 12 months of age because babies cannot digest it as well. Cow’s milk is also a poor source of iron, which can lead to iron deficiency anemia in your baby.

Formula comes in three different types: powdered, liquid, and ready to use. You may use whatever is most convenient for your lifestyle.

Powdered is the least expensive. It should be stored in a cool, dry place and mixed with warm water carefully following instructions. Never make your baby’s formula more or less concentrated than the directions instruct. Open cans can be stored for one month.

Liquid concentrate is also mixed with water carefully following instructions. Once the original metal can (concentrated or ready to feed) has been opened, place your prepared formula in a clean container (plastic or glass). Do not keep it in the original metal can. It can be stored for 48 hours in the refrigerator then must be discarded.

“Ready to serve” is the most expensive. It can simply be poured into the bottles. It can also be stored in the refrigerator for 48 hours before being discarded. All types of formula may be at room temperatures up to two hours, but then they must be discarded.

Bottles and Nipples
There are two types of feeding systems: reusable bottles and disposable bottles. Reusable bottles can be made of plastic or glass. Disposable nursers use plastic liners that are thrown away after each feeding. Nipples vary in shapes, sizes, and materials

Try different nipples to see which works best for your baby. Bottle nipples drip at different rates. A nipple should drip about one drop per second when the bottle is tipped. Wash all bottles, nipples, and equipment in hot soapy water and rinse well. It is not necessary to sterilize items except before the first use. Eight sets of bottles and nipples should be a good supply.

Well Water Testing and Bottled Water
City water supplies are tested for safety, but if you have well water we suggest testing for nitrates, bacteria, and other chemicals. You can call your county health department or the Iowa State Department of Public Health at 1-800-972-2026.

According to the Iowa State Extension Office, bottled water and tested tap water are safe for mixing with formula. Most bottled waters are treated by some filtration system and/or treatment that removes unwanted minerals and particles. As far as we know, these systems are safe, if regularly maintained. However, since there are no broad standards for bottled water, you need to read the label to be sure it is safe for drinking. Pay close attention to bottled water that says “natural.” This usually means that the water has not gone through a filtration system or has not been treated.

If you decide to use bottled water and use a reusable container, it’s very important that you clean your container as follows:

Use 1/2 tsp. bleach per gallon of regular water. Swish around and let stand three minutes. Pour out and rinse well. Air dry then seal.

Feeding Baby
Newborns can cry for many reasons. They may be cold, wet, or lonely. They may need to be loved, burped, or fed. Your baby learns trust in the first few months. You’ll soon learn what your baby needs. Some babies like to be made comfortable before a feeding. Others get angry when they are put “on hold.” Look for cues from your baby. Most newborns eat every two to four hours, about six to eight formula feedings per day.

Make sure you and your baby are both comfortable for each feeding. Always hold your baby when feeding a bottle! Hold baby’s head slightly higher than the body and turn baby so you can look into each other’s eyes and talk to one another. Show baby your love and help baby feel secure. Tilt the bottle so the baby gets only formula and not air into the stomach. For most babies, burping twice per feeding is all that’s necessary. Most feedings take about 20 minutes.

The number of ounces most babies take per feeding is figured by dividing the baby’s weight in half. (For example, an eight-pound baby may take four ounces at a feeding.) Between birth to four months of age, the total ounces taken per day will be between 21 to 29. From four to six months this will range from 29 to 32 ounces. Overfeeding during your baby’s first year of life is not healthy. Stop the feeding when your baby shows they have had enough (sucking slows, they look around more).

Better Burps
Your baby will burp better if held with some pressure on the tummy. Try seating your baby in your lap and leaning against your hand or draped over your shoulder or lying across your knees. Then gently rub or pat your baby’s back.

On the second or third day, as babies begin to take in more breast milk or formula, they may experience gas pains as a result of the beginning digestive process. Gas is a normal byproduct of digestion, but can often be quite uncomfortable for babies. Walking or rocking while holding them upright helps them to get rid of the gas.

Spitting Up
Most babies spit up occasionally if they have eaten too much too quickly or have swallowed too much air while eating. If you hold or sit your baby upright after eating, spitting up may be lessened. You can also slow down the feeding by burping more often. Although spitting up is messy and seems to concern parents, babies are rarely bothered by it.

Hiccupping
New babies often hiccup during or after eating. Their digestive system may be immature, or it may be from over stimulation resulting from eating. There is no cause for concern, and hiccups will soon stop on their own.

Drinking From a Cup
Introduce your baby to a cup at about five to six months of age. Try formula, water, or apple juice. Most children’s interest in bottle-feeding decreases between nine and 12 months of age, so this is a great age to begin weaning. Signs you may see are: the child throwing bottles, nipple chewing, or refusing to drink from the bottle.

After one year of age, you may use whole milk from a cup. Skim milk or two percent milk is not recommended from one to two years because the fat content is not enough for the rapid brain growth your baby will be experiencing.

Important Bottle Feeding Tips
It is not necessary to warm your baby’s bottle, but if you do, we recommend you avoid microwaves due to hot spots this can create. Always test the temperature on the backside of your hand before feeding milk to your baby.

• Freezing infant formula is not recommended by the manufacturers as this may cause it to separate.
• Babies do not need extra water unless the weather is exceptionally hot or the child is ill.
• Do not prop bottles or allow your baby to lie flat while bottle-feeding. Always hold your baby while feeding a bottle. Hold the baby so the head is slightly higher than the body.
• Never put your baby to bed with a bottle even when your baby is old enough to hold it. Babies put to bed with a bottle are more prone to ear infections, dental cavities, and bedtime habits that are hard to break.
• To reduce nighttime feedings, begin waking your baby in the daytime if baby has slept more than three hours. If your baby is eating well, don’t awaken at night unless directed by the hospital or your physician. If baby wakes up, feed quietly and return to bed. A feeding should take about 20 minutes.
• Do not feed juices or sweetened drinks from a bottle as this may lead to tooth decay. Give juice from a cup starting around six months of age. Limit the amount of juice to no more then four ounces a day through the toddler years. Juice is limited in nutritional value, high in calories, and can reduce a child’s appetite.
• Do not feed your baby honey or Karo syrup the first year of life due to the possibility of food poisoning.
• Do not overfeed your baby. A fat baby is not a healthy baby.

Introducing Solids
Your doctor will usually advise you to start feeding solids at four to six months. Feeding solids earlier than this will not help your baby to sleep through the night and can cause problems in certain babies.

At four to six months of age, babies are able to move food fed by a spoon from the front of the tongue to the back of the mouth and swallow. Before this age, the tongue pushes solid foods back out.

At four to six months, many babies can sit without support in a high chair and indicate their desire for food by opening their mouths, reaching for food, turning their heads away, or closing their mouths.

Rice cereal is usually the first food. Prepare baby cereal by mixing it with formula or breast milk to form a runny consistency. First feedings may consist of no more than a teaspoon or two while your baby learns to use the tongue with solid foods. Soon your baby will be taking feedings of at least two tablespoons.

Single-ingredient fruits or vegetables such as plain squash, carrots, peas, applesauce, or bananas can be started in the next one or two months.

Do not give combinations foods such as vegetable/meat combinations, dinners, or desserts. These foods have extra fillers and sweets in them that babies don’t need. Instead mix a plain vegetable with plain meat to make your own “dinner.”

You can make your own baby food by blending cooked fresh or frozen vegetables and fruits with a small amount of water or formula. This blended food can by used immediately or poured into ice cube trays and frozen. Later you may thaw a cube or two at a time for baby’s feeding. Make sure all supplies you use to make your baby’s food are clean and the food is fresh and washed.

It is best to give one new food for about three days before beginning another new food. This will give you a chance to see if a certain food does not agree with your baby.

Here are some other tips for feeding your baby:

• Feed babies at their own pace. Don’t try to go faster or slower.
• Give your baby a variety of foods, even ones you personally don’t like.
• Never feed solid foods from a bottle. Do not use an infant feeder. Spoon feeding helps your baby to develop chewing and swallowing skills.
• Do not add salt or sugar to baby food. Too much of either of these ingredients can be harmful to babies’ health. Do not add sugar, honey, or corn syrup to infant foods. Babies do not need to have their food sweetened. Honey and liquid corn syrup may cause serious food poisoning in babies younger than one year.
• Put as much food as you think your baby will eat in a small dish. Do not feed your baby directly from a baby food jar. Bacteria from the baby’s mouth on the spoon will begin to break down the food and causes it to separate and appear watery. Don’t save partially eaten foods.
• Opened jars of baby food can be stored in the refrigerator for 48 hours. Food you make can be stored in the freezer for six months.
• Good dental care begins at birth. Begin wiping the gums and teeth after each feeding with a clean wet washcloth. You don’t need toothpaste.
• Introduce your baby to a cup when you give solid foods. Offer water, formula, or apple juice for babies less than six months. After nine months you may also offer citrus juices such as orange juice. Do not give more than four ounces of juice per day.
• At eight to 10 months babies learn more chewing skills and you can begin mashed table foods and soft finger foods.
• At 10 to 12 months babies begin to self-feed with their fingers. They can eat at the table with the family, but be sure baby’s food is unseasoned and mashed, or soft and cut into small pieces.
• You can give your 12-month-old a spoon to experiment with, but most babies will be 18-months-old before they can use it well.