Breast, formula, or both!

Establishing breastmilk production

The bottom line: The first hours and days are key! To help your body learn to make the right amount of breastmilk for your baby going forward (and especially if you also give formula!) your breasts need very frequent stimulation in the first hours and days. Breastfeed at least 8-12 times a day (your baby may ask to breastfeed even more often). Or, if your baby has trouble latching, pump or hand express milk 8-10 times a day (learn about hand expression Prep your body for breastfeeding | Hey Mama (bmc.org)

Pro tip: Holding your baby skin to skin for at least an hour after delivery and frequently in the days after delivery stimulates the hormones that make milk. That closeness is key! Your baby staying in your room, even at night, also helps establish breastfeeding, that’s why babies “room in” at BMC and only leave mom’s bedside when medically necessary.

Holding your baby skin to skin helps milk come in

All babies who are stable are put skin to skin with mom for the first hour (baby's bare chest and cheek against your bare chest). The first hour of life is very important for establishing breastfeeding as it stimulates the hormones of milk production. Even if your baby doesn’t fully breastfeed that hour, just trying helps. Try to keep your baby on your chest for at least the full 60 minutes after birth, unless your provider says it’s medically necessary to remove your baby. If you aren’t sure, ask your doctor or nurse if it’s necessary to remove baby from your chest. It is best to wait to let babies look for the breast on their own in the first hour – ask your nurse not to intervene in the process. Skin to skin stabilizes your baby's temperature, heart rate, blood sugar and respiratory rate. Learn about the stages and benefits of this "Sacred hour" here: https://www.chihealth.com/en/services/maternity/labor-and-delivery/sacred-hour.html
If for some reason your baby can't be with you for that first hour, then you, your partner or nurse can perform hand expression or colostrum (first milk) to take advantage of this important hour when your hormones are acting to start milk production. And don't worry, doing skin to skin anytime in the first days and weeks is beneficial for both of you, and increases prolactin (the hormone that stimulates milk production). Hold baby skin to skin for naps to increase milk production!

Breastfeed and hand express milk frequently and on demand in the first couple days

The day your baby is born and the couple days after until your milk comes in it is normal to only have drops of colostrum, which are slowly increasing. Babies are designed to only consume colostrum for the first couple days – it is a thick and concentrated substance chock full of exactly the nutrients and living cells and enzymes that newborns need in the first couple days. At birth their stomachs are only big enough to consume drops each time they eat (newborn stomachs are the size of a grape).
Continue to perform hand expression frequently on the first day and as long as your milk hasn't yet come in. You can express after your baby has breastfed. If you collect colostrum with hand expression, you can feed it to your baby by a spoon or syringe after they breastfeed as a little dessert. Doing this frequently helps increase your milk production, helps your milk come in faster and is healthy for your baby.
If you still need to express milk after you milk comes in (turns white and larger amount) you may want to switch to the electric pump.

When will my milk come in?

“Milk coming in” is when it turns from small amounts of yellow colostrum to larger amounts of white milk. This usually happens around 2-4 days after your baby is born. When your milk comes in, you may feel your breasts get very full, bigger and even painful and hard. This is called “engorgement.”
Breastfeeding your baby frequently and hand expressing drops of colostrum after every time your baby breastfeeds helps milk come in faster. Even if you don’t see drops, the stimulation helps milk come in. Doing this is especially important if you had a cesarean delivery, or a condition like gestational diabetes, pre-eclampsia or hemorrhage that can slow down milk coming in.
If you feel “engorged” with hard, painful breasts when your milk comes in it can be hard for your baby to latch. To help soften the breasts and stop any pain, try the following:
- Very lightly stroke or massage your breasts from the nipple up toward the armpit and chest plate. This helps remove the swelling just under the skin. This is also called “lymphatic drainage.”
- Put cold packs or ice on your breasts for a few minutes
- Hand express a small amount of milk to soften the area around your nipple so your baby can more easily latch

Working on latch

Remember with latching to follow “tummy to mummy, nose to nipple, bring baby to you”
Baby should be close enough to breast that tip of nose is near the nipple and the chin is touching the breast below the nipple
Baby's head should be aligned with their body, not turned over their shoulder
Check for a too narrow latch (narrow lips) and push down on baby’s chin to widen the latch
Hold baby in a position where both of you are comfortable. Making small adjustments until you are comfy can make a big difference
Try nursing in a laid back or lounge position, with baby lying on you. This often helps baby have more control and a more comfortable latch.
If latch hurts for more than a 5-10 seconds, try again. Break baby's suction by sticking your finger inside of their mouth, then try to latch again.

What if I think my baby isn’t getting enough?

Baby’s stomachs are the size of a grape at birth, and they are designed to eat very small amounts in the first days. Your medical team will be watching your baby’s weight and will examine your baby every day. If they think your baby needs to supplement additional milk, they will make a plan with you to give your expressed breastmilk, donor milk, the colostrum you expressed prenatally, or formula. Part of that plan will be helping you to pump or hand express so your body will start to make more milk.
Being hungry in the first days is what drives babies to want to feed frequently. That frequent feeding and stimulation of the breasts is what gives your body the message to make more milk.

What is donor milk?

Donor milk is breastmilk that others have donated to milk banks. Milk banks ensure that the donors are healthy by testing them and giving them guidelines about how to keep the milk safe. The milk is pasteurized, similar to the cow’s milk we buy at the store. At BMC, you will have access to donor milk for free while you are in the hospital, if needed. Donor milk can be a good bridge if your milk is taking longer than normal to come in.
By giving donor milk instead of formula, your baby’s gastrointestinal tract will develop as healthy as possible. Donor milk is also given to preterm babies, who have much lower risk of severe infections when they receive human milk instead of formula.

What if I need more help?

In the hospital your nurse is highly trained to help establish breastfeeding
If your baby is born with certain conditions, or if you are struggling to breastfeed after your baby is 24 hours old, a lactation consultant may visit you. Lactation consultants at BMC are highly skilled and are International Board-Certified Lactation Consultants (IBCLC).
BMC has a breastfeeding medicine clinic where your provider or lactation consultant may refer you for a visit.
Go to this link for more resources around Boston, including support groups, telephone support and lactation consultants.
After you are home, check out this page Feeding babies as they grow and return to work | Hey Mama (bmc.org) for more information about feeding as your baby grows and returning to work.

What about my diet?

Drink plenty of water and eat a healthy diet. When lactating you need about 500 calories more than when you are not lactating.
Many people wonder if eating certain foods or taking supplements or teas will increase their milk production. While there are some cases where this can help, the effect is small and only helps when it is done along with frequent breast stimulation/milk expression every 2-3 hours.
People often worry that foods they eat affect their baby. In the vast majority of cases this is not true. Your body makes breastmilk by filtering from your blood specific protein, fat, and carbohydrate molecules, as well as enzymes, antibodies, and immune cells to put into breastmilk, and keeping out anything that is not needed. The food you eat has little impact on the molecules that go into the milk. Eat a healthy diet with plenty of vegetables and healthy grains and proteins. There are no specific foods to avoid.

Pumping and expressing milk

Many people don’t need to pump until their babies are older when returning to work or starting to leave the baby with other caretakers. However, sometimes the medical team may recommend that you pump if you baby is not latching well or to stimulate your body to make more milk in cases of low breastmilk production. You may need to pump/hand express for a short time if you have a lot of nipple pain and need to allow your nipples to heal. During this time you can request that any supplement or expressed breastmilk be given to your baby with a syringe or small cup so as not to interrupt the process of learning to latch to the breast. If using a bottle, use the “paced” bottle feeding method to help avoid overfeeding (see below for details).

Pumping/expressing milk works best when you are comfortable and not feeling stressed. Look at a picture of your baby. Find a way to fit pumping into your routine. There is not set amount of time to pump – a good time to stop is when you see the flow slow down and only drops or slow drip coming out. A typical time is about 15-25 minutes.

Do not try to have a freezer full of milk (not everything you see on social media is really good!) Making a lot more milk than your baby drinks is a medical condition called “hyperlactation” that is associated with breast pain and infections, and difficulty latching. If you have more than about 5oz of extra milk each day, talk to your provider about how to address this and avoid complications.

Using your hands can make pumping more effective

In addition to learning about your pump, learn how to hand express breastmilk and see how this might work for you, or help. Watch this video where Dr. Jane Morton teaches how to hand express (skip to minute 10:45 for hand expression).

1) Before pumping, briefly move your breasts around in a circle and lightly massage for a few seconds. If you are pumping a lot, feel for any tender lumps that could be “plugged” milk ducts.

2) During pumping, use your hands to compress the breasts and note if you see the milk flowing faster with certain positions of your hands.

3) After pumping, you may find that you can get a little more milk out by hand expressing for a minute or two afterward.

If you have pain while pumping

Try decreasing the suction setting of the pump. Look up your pump online and make sure you know how it works.
Check that your flange size is correct. The nipple should go into the narrow part, the areola should stay in the wide part.
Put a little coconut or olive oil on the flange so that your skin does not chafe against it.
If you have a tender “plugged duct” – these are common especially if pumping. Put ice/cold compresses on it and keep breastfeeding or pumping to remove milk.
Contact your provider if you still are having pain.

How to choose and get a pump

All health insurances cover electric breast pumps. You can ask your doctor or midwife to help you fill out a form before your baby is born indicating the type you want. If you haven’t received a pump through your insurance before baby is born, someone in the hospital can help you order a pump to be delivered directly to your room. You still have options over which pump you would like to choose, but the pumps most commonly delivered to you in the hospital are the Medela and Spectra pumps.
There are many types of pumps – electric, manual, hands free, wireless. Some people even remove milk only with their hands and get as much as with a pump. Every lactating person finds the way that works best for their body and life. If there is a reason you are only pumping (not direct breastfeeding) it is especially important to have a pump that works well for you. If you have pain or find that you are not getting very much milk out, speak with your provider or lactation consultant to see if there is a problem with your pump.

Storing and using expressed breastmilk

Breastmilk can be stored at room temperature for 4 hours. If you know your baby will eat it at the next feeding, no need to refrigerate.
Breastmilk can be stored in the refrigerator up to 6 days.
Breastmilk can be stored in the freezer up to 6 months.
If your baby does not finish a bottle of breastmilk you can put it in the fridge an use it for another feeding. Breastmilk has lots of antibodies and immune cells that help it state safe for much longer than formula.
Don’t mix breastmilk and formula, because if your baby doesn’t finish the bottle you have to throw it away.

Formula feeding - alone or mixed breastmilk and formula feeding

Baby’s stomachs are very small at birth (the size of a grape) so whether they get formula or breastmilk they only need a small amount in the first days. Talk with your nurse or baby’s provider to make sure you do not overfeed formula or breast milk if you give a bottle. As your baby gets older they will take more – watch their feeding cues to know when they are still hungry and need more.

Formula has all the macronutrients (fats, sugars and proteins) that a baby needs to grow and develop. If your baby has specific health needs, your provider may recommend a specific type of formula, but most babies can take any standard type. Formula companies spend a lot of money to sell their products and make more money, however, there is no particular benefit of one formula over another for most healthy babies, and no formula is healthier than breastmilk, even “plant-based” (a new term for soy formula).

Formula helps most babies grow very healthy. However, we also know that compared to breastfed babies, formula-fed babies are more likely to have common health problems and have a higher risk of becoming overweight and having diabetes when they are older children and adults. To help make sure your baby drinks the right amount of formula and isn’t at risk of being overweight, “paced bottle feeding” can help.

How to feed your baby: bottles, paced feeding and other options

We recommend bottle feeding using the “paced” method which helps avoid overfeeding too much formula or expressed milk, and helps babies who are also breastfeeding transition between bottle and breast more easily.

Paced bottle feeding

Touch the side of your baby’s lips/cheek with the nipple to see if they are ready to eat. If they are, they will turn their mouth towards the nipple.
For first few seconds, angle the bottle down so no milk is in the nipple. Just like at the breast, no milk comes out for the first couple sucks. Then, lift the bottle until it is parallel with the floor.
Throughout the feeding, hold bottle horizontal/parallel to floor so gravity does not make milk spill into baby's mouth. Baby has to actively work to get it out just like at breast. At the end you will have to tip it more to get the last milk out.
If your baby rests or stops sucking, tilt the bottle down so the baby can really take a break and doesn’t have milk still flowing in. Tilt it up again when they start sucking again.
Paced bottle feeding also helps avoid preference for the bottle if you are also breastfeeding.
Watch this video to learn more and see a demonstration

Bottles are not the only option for feeding your baby formula or expressed milk

Options include feeding with a syringe or finger (especially when small amounts in the first days after birth), with a cup, or with a supplemental system giving milk through a tube attached to the breast during breastfeeding.
Avoiding bottle nipples can help establish breastfeeding latch.
See more information here

Go to this link Formula & Bottle Feeding Basics | Hey Mama (bmc.org) for more information about formula-feeding.

If you are giving both formula and breastmilk:

In the first days and weeks focus on breastfeeding and establishing your breastmilk production (read this for strategies [link “Getting off to the right start”). By protecting milk production in the first weeks you ensure your body will make enough to keep giving breastmilk as long as you want.
If you are giving both and trying to increase your milk production: Try breastfeeding first and then giving formula after. If your baby is too fussy at the breast, give formula first and offer the breast when they are calmer. Anytime your baby only gets formula/bottle, pump or hand express milk so your body gets a message that milk is needed.
Unless medically recommended for our baby, wait as long as possible before starting to give formula. This will help ensure you make enough milk to breastfeed as long as your plan to.