The U.S. Department of Health and Human Services Office on Women’s Health (OWH) is raising awareness of the importance of breastfeeding to help mothers give their babies the best start possible in life. In addition to this guide, OWH offers online content at www.womenshealth.gov/breastfeeding and www.womenshealth.gov/itsonlynatural.

Through its Supporting Nursing Moms at Work site, OWH helps businesses support nursing mothers with cost-effective tips and time and space solutions, listed by industry. Learn more at https://www.womenshealth.gov/supporting-nursing-momswork. OWH also partners with the Health Resources and Services Administration’s Maternal and Child Health Bureau to educate employers about the needs of breastfeeding mothers via The Business Case for Breastfeeding.

There are so many reasons to breastfeed

- The joyful closeness and bonding with your baby

- Your breastmilk can help your baby as their immune system develops

- The cost savings

- Health benefits for mother and baby

KEEP IN MIND THAT FEEDING YOUR BABY IS A LEARNED SKILL.
It takes patience and practice. For some women, learning to breastfeed can be frustrating and uncomfortable. It may also seem more difficult, especially if your baby was born early or you have certain health problems. The good news is that it can get easier, and support for breastfeeding mothers is available.

CONTENTS

WHY BREASTFEEDING IS IMPORTANT
Healthy babies and mothers

FINDING SUPPORT AND INFORMATION
Health professionals who can help with breastfeeding, and how to find support by phone

BREASTFEEDING MYTHS
Myths about breastfeeding are common. Get the facts.

HOW YOUR MILK IS MADE
Describes how your body works

LEARNING TO BREASTFEED
Follow your baby’s lead from the first minute of life for breastfeeding success

COMMON CHALLENGES
Tips for troubleshooting common problems

COMMON QUESTIONS
Find out whether your baby needs cereal, if you can take medicine while breastfeeding, and more

BREASTFEEDING A BABY WITH A HEALTH PROBLEM
What to know if your baby has jaundice, reflux, or colic

BREASTFEEDING AND SPECIAL SITUATIONS
Having twins or more? Information for moms of multiples, mothers who are adopting, and more

BREASTFEEDING IN PUBLIC
Ways to feel comfortable feeding your baby while out and about

PUMPING AND STORING YOUR MILK
Learn about the different types of breast pumps and how to get them, plus tips on how to store your milk

GOING BACK TO WORK
Your rights and how to talk to your employer about your breastfeeding needs

NUTRITION AND FITNESS
How to take care of yourself while breastfeeding

HANDLING STRESS
Coping tips to help keep stress at bay

WEANING YOUR BABY
Get tips for when and how to wean your baby

WHY BREASTFEEDING IS IMPORTANT

BREASTFEEDING PROTECTS BABIES

YOUR FIRST MILK IS LIQUID GOLD.

Called liquid gold for its deep yellow color, colostrum is the thick first milk that you make during pregnancy and just after birth. This milk is very rich in nutrients and includes antibodies to protect your baby from infections. Colostrum also helps your newborn infant’s digestive system to grow and function. Your baby gets only a small amount of colostrum at each feeding because the stomach of a newborn infant is tiny and can hold only a small amount.

YOUR MILK CHANGES AS YOUR BABY GROWS.

Colostrum changes into mature milk by the third to fifth day after birth. This mature milk has just the right amount of fat, sugar, water, and protein to help your baby continue to grow. It looks thinner than colostrum, but it has nutrients and antibodies your baby needs for healthy growth.

FORMULA IS HARDER TO DIGEST.

Breastmilk substitutes like formula may be harder to digest than breastmilk.

Talk to your baby’s doctor if you are afraid the baby is not getting enough milk, or to see if there is a medical need to supplement with formula.

BREASTMILK FIGHTS DISEASE.

The cells, hormones, and antibodies in breastmilk help protect babies from illness. This protection is unique and changes to meet your baby’s needs. Research suggests that breastfed babies have lower risks of:

- Asthma

- Obesity

- Type 1 diabetes

- Ear and respiratory infections

- Sudden infant death syndrome (SIDS)

- Gastrointestinal infections (diarrhea/vomiting)

- Necrotizing enterocolitis (NEC), a disease that affects the gastrointestinal tract in preterm infants

CAN BREASTFEEDING HELP ME LOSE WEIGHT?

Besides giving your baby nourishment and helping to keep your baby from becoming sick, breastfeeding may help you lose weight. Many women who breastfed their babies said it helped them get back to their pre-pregnancy weight more quickly, but experts are still looking at the effects of breastfeeding on weight loss.

BREASTFEEDING BENEFITS MOMS

Did you know that your baby can smell you and knows the unique scent of your breastmilk? This is why your baby will turn his or her head to you when hungry. Your baby is born with an instinct to suckle at your breasts.

LIFE CAN BE EASIER WHEN YOU BREASTFEED.

Breastfeeding may seem like it takes a little more effort than formula feeding at first. But breastfeeding can make your life easier once you and your baby settle into a good routine. You do not have to buy, measure, and mix formula. You won’t need to warm bottles in the middle of the night! When you breastfeed, you can satisfy your baby’s hunger right away.

NOT BREASTFEEDING COSTS MONEY.

Formula and feeding supplies can cost more than $1,500 each year. Breastfed babies may also be sick less often, which can help keep your baby’s health care costs lower.

BREASTFEEDING KEEPS MOTHER AND BABY CLOSE.

Physical contact is important to newborns. It helps them feel more secure, warm, and comforted. Breastfeeding mothers also benefit from this closeness. The skin-to-skin contact boosts your oxytocin levels. Oxytocin is a hormone that helps breastmilk flow and can calm the breastfeeding mother.

BREASTFEEDING IS GOOD FOR THE MOTHER’S HEALTH, TOO.

Breastfeeding is linked to a lower risk of Type 2 diabetes, high blood pressure, certain types of breast cancer, and ovarian cancer in mothers.[1]

BREASTFEEDING GLOSSARY

Nutrients are any food substance (carbohydrates or sugar, fat, protein, vitamins and minerals) that provides energy or helps build tissue.

Antibodies are blood proteins made in response to germs or other foreign substances that enter the body. Antibodies help the body fight illness and disease by attaching to germs and marking them for destruction.

The gastrointestinal system is made up of the stomach and the small and large intestines. It breaks down and absorbs food.

The respiratory system includes the nose, throat, voice box, windpipe, and lungs. Air is breathed in, delivering oxygen. Waste gas is removed from the lungs when you breathe out.

DURING AN EMERGENCY, SUCH AS A NATURAL DISASTER, BREASTFEEDING CAN SAVE YOUR BABY’S LIFE:

Breastfeeding protects your baby from the risks of an unsafe water supply.

Breastfeeding can help protect your baby against respiratory illnesses and diarrhea.

Even if you aren’t able to eat regular meals, your baby will still be able to feed.

Your milk is always at the right temperature for your baby. The skin-to-skin contact of breastfeeding can help keep your baby’s body temperature from dropping too low.[2]

BREASTFEEDING IS GOOD FOR SOCIETY

Society benefits overall when mothers breastfeed.

BREASTFEEDING SAVES LIVES.

Recent research shows that if 90 percent of families breastfed exclusively for 6 months, more than 700 deaths among infants could be prevented.[3]

BREASTFEEDING SAVES MONEY.

Our health system would also save $3 billion per year.[3] This is because medical care costs are lower for mothers who exclusively breastfed than for those who never breastfed. Medical costs are also lower for fully breastfed infants than for never-breastfed infants.

BREASTFEEDING IS BETTER FOR THE ENVIRONMENT.

Formula cans and bottle supplies create more trash and plastic waste. Your milk is a renewable resource that comes packaged and warmed.

FINDING SUPPORT AND INFORMATION

Although breastfeeding is a natural process, many moms need help. Breastfeeding moms can seek help from different types of breastfeeding professionals, organizations, and members of their own families. Also, breastfeeding support and supplies may be covered by insurance.

Don’t forget, friends who have successfully breastfed are great sources of information and encouragement!

PROFESSIONALS WHO HELP WITH BREASTFEEDING

INTERNATIONAL BOARD CERTIFIED LACTATION CONSULTANT (IBCLC).

IBCLCs are certified breastfeeding professionals with the highest level of knowledge and skill in breastfeeding support. IBCLCs help with a wide range of breastfeeding concerns. To earn the IBCLC certification, candidates must have a medical or health-related educational background, have breastfeeding-specific education and clinical experience, and pass a rigorous exam. Ask your obstetrician, pediatrician, or midwife for the name of a lactation consultant who can help you. You also can go to www.uslca.org to find an IBCLC in your area.

CERTIFIED LACTATION COUNSELOR OR CERTIFIED BREASTFEEDING EDUCATOR.

A breastfeeding counselor or educator teaches about breastfeeding and helps women with basic breastfeeding challenges and questions. These counselors and educators have special breastfeeding training, usually limited to a week-long course.

DOULA.

A doula is professionally trained to give birthing families social support during pregnancy, labor, and birth, as well as at home during the first few days or weeks after the baby is born. Doulas that are trained in breastfeeding can help you learn to breastfeed.

BABY-FRIENDLY® HOSPITAL INITIATIVE

Look for a hospital that is designated Baby-Friendly®. Baby-Friendly® Hospitals provide support for breastfeeding mothers, including keeping mom and baby together throughout the hospital stay, teaching feeding cues and breastfeeding techniques, and providing or linking to support after leaving the hospital. For more information about Baby-Friendly® hospitals, visit www.babyfriendlyusa.org.

If you don’t have a Baby-Friendly® Hospital near you, you can still look for a hospital with policies that support breastfeeding. Ask if your hospital encourages skin-to-skin contact right after birth and rooming in with baby. You can also ask if they have breastfeeding support professionals on staff and whether they limit the use of formula, unless medically necessary.

MOTHER-TO-MOTHER SUPPORT

Other breastfeeding mothers can be a great source of support. Mothers can share tips and offer encouragement. You can connect with other breastfeeding mothers in many ways:

- Ask your doctor, nurse, midwife, or other breastfeeding expert to suggest a support group. Some pediatric practices also have an IBCLC on staff who leads regular support group meetings.

- Ask your doctor, nurse, midwife, or other breastfeeding expert for help finding a breastfeeding peer counselor. “Peer” means that the counselor has breastfed her own baby and can help other mothers breastfeed. Many state Women, Infants, and Children (WIC) programs offer peer counselors.

- Search the Internet for a breastfeeding center near you. These centers may offer support groups. Some resources include:

– Nursing Mothers Advisory Council

– Nursing Mothers, Inc.

– BreastfeedingUSA.org

- Find a local La Leche League support group by visiting the organization’s website at www.llli.org.

- Social media sites and message boards can help you connect with other moms. Don’t rely solely on these resources for medical advice or clinical breastfeeding support for challenges such as sore nipples or milk supply concerns. Talk with your doctor, nurse, midwife, or other breastfeeding expert instead.

WIC PROGRAM

The U.S. Department of Agriculture (USDA) Special Supplemental Nutrition Program for Women, Infants, and Children (commonly called WIC) offers food, nutrition counseling, and access to health services for low-income women, infants, and children.
WIC has breastfeeding staff, including peer counselors and designated breastfeeding experts, who can assist moms with normal breastfeeding and challenges. Breastfeeding mothers supported by WIC may also receive an enhanced food package, breast pumps, and other supplies. Breastfeeding mothers can participate in WIC longer than non-breastfeeding mothers. WIC has a website dedicated to supporting breastfeeding moms: www.wicbreastfeeding.fns.usda.gov.

To find contact information for your local WIC program, visit https://www.fns.usda.gov/wic/wic-contacts.

Learn more about breastfeeding basics and find other online resources at www.womenshealth.gov/breastfeeding and www.womenshealth.gov/itsonlynatural.

BUILDING A SUPPORT NETWORK

Talk to fathers, partners, and other family members about how they can help.

Breastfeeding is more than a way to feed a baby — it becomes a way of life. Fathers, partners, and other support persons can be involved in the breastfeeding experience, too. Partners and family members can:

- Support your breastfeeding by being kind and encouraging

- Help the breastfeeding mother during the night by getting the baby changed and ready to be fed

- Show their love and appreciation for all of the work that goes into breastfeeding

- Be good listeners if you need to talk about any breastfeeding concerns you might have

- Help make sure you have enough to drink and get enough rest

- Help around the house

- Take care of any other children who are at home

- Give the baby love through playing and cuddling

Fathers, partners, and other people in the breastfeeding mother’s support system can benefit from breastfeeding, too. Not only are there no bottles to prepare, but many people feel warmth, love, and relaxation just from sitting next to a mother and baby during breastfeeding.

WHAT YOUR PARTNER CAN DO

Your partner and family play a key role in supporting breastfeeding, right from the start. You and your baby have many needs. There are many things your partner can do to support you, your new baby, and the breastfeeding experience.

While you breastfeed, your partner can provide encouragement, comfort, and support by helping you relax and positioning your baby at your breast. Your partner can bring you water or snacks, take over household chores, and make sure you rest as much as possible. Spending time with your baby is essential to building a bond; your partner can cuddle, read to, burp, bathe, or just hold your baby skin-to-skin. (see page 12 for more information about skin-to-skin contact)

BREASTFEEDING MYTHS

Moms-to-be and new moms get a lot of baby advice. Although people usually mean well, not all of it is based on fact. Myths about breastfeeding are common. The fact is that breastfeeding is a healthy way to feed your baby. The decision to breastfeed is a personal one, and it should also be an informed one.

MYTH: EVERYONE USES FORMULA.

More women breastfeed than you think. According to the Centers for Disease Control and Prevention, more than 83 percent of women in the United States start out breastfeeding.[4] Research over the past 40 years has proven that mother’s milk is an inexpensive and healthy choice for babies.

MYTH: BREASTFEEDING MAKES YOUR BREASTS SAG.

Actually, it’s pregnancy that stretches the ligaments of your breast tissue, whether you breastfeed or not. Age, genetics, and the number of pregnancies you’ve had also play a role.

MYTH: IF YOUR BREASTS ARE SMALL, TUBULAR SHAPED, WIDELY SPACED, OR DIFFERENT SIZES, YOU CAN’T BREASTFEED.

For most women, the size and shape of their breasts does not affect their milk supply or the ability to breastfeed. This includes women with large areolas (the area around the nipple), flat nipples, and even women who’ve had breast surgery. (Note: If you’ve had extensive breast surgery, you may be able to partially or exclusively breastfeed. You should work with a breastfeeding professional before and after your baby’s birth.) Tubular shaped, widely spaced, or different size breasts do not always affect milk supply and are best evaluated in a clinical setting and should not be self-diagnosed. If you are having breastfeeding challenges, you can get help from a doctor, nurse, IBCLC, or midwife.

MYTH: YOU WON’T BE ABLE TO MAKE ENOUGH MILK.

Moms almost always make enough milk to feed their babies (see page 20 to know if your baby is getting enough milk). The key to making plenty of milk is to nurse your baby often during the first 14 days (8–12 times or more every 24 hours). It’s also important to make sure your baby is latched correctly and swallowing (for signs of swallowing, see page 15).

MYTH: BREASTFEEDING SPOILS A CHILD.

After spending nine months growing inside you, it’s completely natural for a baby to be attached to his or her birth mother and vice versa. Despite what you’ve heard, newborns don’t need to learn to fend for themselves at such a young age. In reality, breastfeeding provides a unique bond with your child that can last a lifetime. Research shows that breastfed children grow up to be confident and self-sufficient when parents meet their needs.

MYTH: BREASTFEEDING HURTS.

Breastfeeding is not supposed to be a painful experience. As with any new skill, there is an adjustment period, so you may have some discomfort in the beginning. But if you experience pain, it is usually a red flag that something is wrong. See pages 16 and 22 to learn more and find out when to seek help.

Learn more about the benefits of breastfeeding for both mom and baby on page 4.

HOW YOUR MILK IS MADE

Your breasts make milk in response to your baby’s suckling. The more your baby nurses, the more milk your breasts will make. Knowing how your breast makes milk can help you understand the breastfeeding process. The breast is an organ that is made up of several parts:

ALVEOLI CELLS: grape-like clusters of tissue that make the milk

AREOLA: the dark area around the nipple

LOBES: the parts of the breast that make milk; each lobe contains alveoli cells and milk ducts

MILK DUCTS: tubes that carry milk through the breast to the nipple/areola area

NIPPLE: the protruding point of the breast

The breasts often become fuller and tender during pregnancy. This is a sign that the alveoli are getting ready to work. Some women do not feel these changes in their breasts. Other women may sense these changes after their baby is born. The alveoli make milk in response to the hormone prolactin. Prolactin rises when the baby suckles. Another hormone, oxytocin, also rises when the baby suckles. This causes small muscles in the breast to contract and move the milk through the milk ducts. This moving of the milk is called the “let-down reflex.”

The release of prolactin and oxytocin may make a breastfeeding mother feel a strong sense of needing to be with her baby.

WHAT IS THE LET-DOWN REFLEX?

The let-down reflex (also called just “let-down” or the milk ejection reflex) happens when your baby begins to nurse. The nerves in your breast send signals that release the milk into your milk ducts. This reflex makes it easier for you to breastfeed your baby. Let-down happens a few seconds to several minutes after you start breastfeeding your baby. It also can happen a few times during a feeding. You may feel a tingle in your breast, or you may feel a little uncomfortable. You also may not feel anything.

Let-down can happen at other times, too, such as when you hear your baby cry or when you’re just thinking about your baby. If your milk lets down as more of a gush and it bothers your baby, try expressing some milk by hand before you start breastfeeding.

Many factors affect let-down, including anxiety, pain, embarrassment, stress, cold, excessive caffeine use, smoking, alcohol, and some medicines. Breastfeeding mothers who have had breast surgery may have nerve damage that interferes with let-down.

LEARNING TO BREASTFEED

Breastfeeding is a process that takes time and practice. When your baby drinks milk from your breasts, it is a signal to your body to produce more milk for the next feeding. All that time spent breastfeeding in your baby’s first few days prepares your body to make lots of milk, whether you go on to breastfeed for three weeks or three years.

The following steps can help you get off to a great start breastfeeding:

- Cuddle with your baby skin-to-skin right away after giving birth.

- Breastfeed as soon as possible after giving birth.

- Ask for an IBCLC to help you.

- Ask the hospital staff not to give your baby pacifiers, sugar water, or formula, unless it is medically necessary.

- Let your baby stay in your hospital room all day and night so that you can breastfeed often.

- Try to avoid giving your baby any pacifiers or artificial nipples until he or she is skilled at latching onto your breast (usually around 3 to 4 weeks old).

PREPARE FOR BREASTFEEDING BEFORE YOU GIVE BIRTH

To prepare for breastfeeding, the most important thing expectant moms can do is to have confidence in themselves. Committing to breastfeeding starts with the belief that you can do it!

Other steps you can take to prepare for breastfeeding are:

GET GOOD PRENATAL CARE, which can help you avoid early delivery. Babies born too early have more problems with breastfeeding.

TELL YOUR DOCTOR ABOUT YOUR PLANS TO BREASTFEED, and ask whether the place where you plan to deliver your baby has the staff and setup to support successful breastfeeding. Some hospitals and birth centers have taken special steps to create the best possible environment for successful breastfeeding. These places are called Baby-Friendly® Hospitals and Birth Centers.

TAKE A BREASTFEEDING CLASS. Pregnant women who learn how to breastfeed are more likely to be successful at breastfeeding than those who do not. Breastfeeding classes offer pregnant women and their partners the chance to prepare and ask questions before the baby’s arrival.

ASK YOUR DOCTOR TO RECOMMEND A LACTATION CONSULTANT. You can establish a relationship with a lactation consultant before the baby comes so that you will have support ready after the baby is born.

TALK TO YOUR DOCTOR ABOUT YOUR HEALTH. Discuss any breast surgery or injury you may have had. If you have depression or are taking supplements or medicines, talk with your doctor about treatments that can work with breastfeeding.

TELL YOUR DOCTOR THAT YOU WOULD LIKE TO BREASTFEED AS SOON AS POSSIBLE AFTER DELIVERY. The sucking instinct is very strong within the baby’s first hour of life.

TALK TO FRIENDS WHO HAVE BREASTFED, or consider joining a breastfeeding support group.

YOU DON’T NEED MANY SUPPLIES TO BREASTFEED, but there are some, including nursing bras and nursing pads, that can make it easier and more comfortable for you. You may want to pack these supplies in your bag so you have them at the hospital when you deliver your baby.

FOLLOW YOUR BABY’S LEAD

Getting your baby to “latch” on properly takes some practice and can be a source of frustration for you and your baby. One approach to learning to breastfeed is a more relaxed, baby-led latch. This laid-back, more natural breastfeeding style allows your baby to lead and follow his or her instincts to suck.

The following steps can help your newborn latch onto the breast to start sucking when he or she is ready. Letting your baby begin the process of searching for the breast may take some of the pressure off of you and keeps the baby calm and relaxed.

Keep in mind that there is no one way to start breastfeeding. As long as the baby is latched on well, how you get there is up to you.

CREATE A CALM ENVIRONMENT FIRST. Lie back on pillows or another comfortable area. Make sure you are relaxed and calm.

HOLD YOUR BABY SKIN-TO-SKIN. Hold your baby, wearing only a diaper, against your bare chest. Hold the baby upright between your breasts and just enjoy your baby for a while with no thoughts of breastfeeding.

LET YOUR BABY LEAD. If your baby is not hungry, he or she will stay curled up against your chest. If your baby is hungry, the baby will bob his or her head against you, try to make eye contact, and squirm around.

SUPPORT YOUR BABY. HELP, BUT DON’T FORCE, THE LATCH. Support your baby’s head and shoulders as the baby searches for your breast. Your baby may need help latching in the beginning. To help your baby latch, you can support your breast by using a C hold or U hold. When your baby’s chin hits your breast, the firm pressure makes him or her open his mouth wide and reach up and over the nipple. As he or she presses his chin into the breast and opens his mouth, he should get a deep latch. Your baby can breathe at your breast when positioned correctly. The nostrils will flare to allow air in. Check to make sure the nostrils are not blocked by your breast.

HOW OFTEN SHOULD I BREASTFEED?

Early and often! Newborns usually need to nurse at least eight to 12 times every 24 hours. This also helps make sure you will make plenty of milk.

Healthy babies develop their own feeding patterns. Follow your baby’s cues for when he or she is ready to eat.

HOW LONG SHOULD FEEDINGS BE?

There is no set time for feedings. They may be 15 to 20 minutes per breast. They may be shorter or longer. Your baby will let you know when he or she is finished feeding. If you are worried your baby is not getting enough milk, talk with your doctor, nurse, IBCLC, or midwife.

GETTING YOUR BABY TO LATCH

If your baby is still having problems latching on, try these tips:

Tickle the baby’s lips to encourage him or her to open wide.

Pull your baby close so that the chin and lower jaw moves into your breast first.

Watch the lower lip and aim it as far from base of nipple as possible, so the baby takes a large mouthful of breast.

SOME BABIES LATCH ON RIGHT AWAY, AND FOR SOME IT TAKES MORE TIME.

“When my son was born four years ago, we had a very difficult time breastfeeding because he wasn’t latching correctly. He seemed almost lazy and disinterested in eating. In the first two weeks, he lost quite a bit of weight and appeared gaunt and fussy. Naturally, I was nearly frantic with worry. Luckily, I connected with an amazing lactation consultant. She put me on a rigorous, week-long regimen, which consisted of nursing, then bottle feeding breastmilk, then pumping every three hours. I was completely dedicated to the regimen, and when I met with her a week later, she was stunned by the results. My son had gained an entire pound, and she said he had developed a perfect latch. She called us the miracle mom and miracle baby! I was so proud of us. My determination paid off, and I enjoyed breastfeeding for seven months. — Jill, Bridgewater, Massachusetts

SIGNS OF A GOOD LATCH

- The latch feels comfortable to you and does not hurt or pinch. How it feels is more important than how it looks.

- Your baby’s chest rests against your body. The baby does not have to turn his or her head while nursing.

- You see little or no areola, depending on the size of your areola and the size of your baby’s mouth. If areola is showing, you will see more above your baby’s lip and less below.

- When your baby is positioned well, his or her mouth will be filled with breast.

- Your baby’s tongue is cupped under the breast, although you might not see it.

- You hear or see your baby swallow. Some babies swallow so quietly that a pause in their breathing may be the only sign of swallowing.

- You see your baby’s ears “wiggle” slightly.

- Your baby’s lips turn outward like fish lips, not inward.

- Your baby’s chin touches your breast.

HELP WITH LATCH PROBLEMS

ARE YOU IN PAIN?

Many moms say their breasts feel tender when they first start breastfeeding. A breastfeeding mother and her baby need time to find comfortable breastfeeding positions and a good latch. If breastfeeding hurts, your baby may be sucking on only the nipple. Gently break your baby’s suction to your breast by placing a clean finger in the corner of your baby’s mouth. Then try again to get your baby to latch on. To find out whether your baby is sucking only on your nipple, check what your nipple looks like when it comes out of your baby’s mouth. Your nipple should not look flat or compressed. It should look round and long or the same shape it was before the feeding.

ARE YOU OR YOUR BABY FRUSTRATED?

Take a short break and hold your baby in an upright position. Try holding your baby between your breasts with your skin touching his or her skin (called skin-to-skin). Talk or sing to your baby, or give your baby one of your fingers to suck on for comfort. Try to breastfeed again in a little while.

DOES YOUR BABY HAVE A WEAK SUCK OR MAKE ONLY TINY SUCKLING MOVEMENTS?

Your baby may not have a deep enough latch to suck the milk from your breast. Gently break your baby’s suction and try again. Talk with a lactation consultant or pediatrician if you are not sure whether your baby is getting enough milk. See page 15 for signs of swallowing.

COULD YOUR BABY BE TONGUE-TIED?

Babies with a tight or short lingual frenulum (the piece of tissue attaching the tongue to the floor of the mouth) are described as “tongue-tied.” The medical term is ankyloglossia. Babies who are tongue-tied often find it hard to nurse. They may be unable to extend their tongue past their lower gum line or properly cup the breast during a feed. This can cause slow weight gain in the baby and nipple pain in the mother. If you think your baby may be tongue-tied, talk to your doctor.

A GOOD LATCH

A good latch is important for your baby to breastfeed effectively and for your comfort. During the early days of breastfeeding, it can take time and patience for your baby to latch on well.

BREASTFEEDING HOLDS

Some moms find that the following positions are helpful ways to get comfortable and support their babies while breastfeeding. You also can use pillows under your arms, elbows, neck, or back to give you added comfort and support. Keep trying different positions until you are comfortable. What works for one feeding may not work for the next feeding.

LAID-BACK HOLD (STRADDLE HOLD): a more relaxed, baby-led approach. Lie back on a pillow. Lay your baby against your body with your baby’s head just above and between your breasts. Gravity and an instinct to nurse will guide your baby to your breast. As your baby searches for your breast, support your baby’s head and shoulders but don’t force the latch.

CROSS-CRADLE OR TRANSITIONAL HOLD: useful for premature babies or babies with a weak suck because this hold gives extra head support and may help the baby stay latched. Hold your baby along the area opposite from the breast you are using. Support your baby’s head at the base of his or her neck with the palm of your hand.

CRADLE HOLD: an easy, common hold that is comfortable for most mothers and babies. Hold your baby with his or her head on your forearm and his or her body facing yours.

CLUTCH OR “FOOTBALL” HOLD: useful if you have had a C-section, or if you have large breasts, flat or inverted nipples, or a strong let-down reflex. This hold is also helpful for babies who like to be in a more upright position when they feed. Hold your baby at your side with the baby lying on his or her back and with his or her head at the level of your nipple. Support your baby’s head by placing the palm of your hand at the base of his or her head.

SIDE-LYING POSITION: useful if you have had a C-section, but also allows you to rest while the baby breastfeeds. Lie on your side with your baby facing you. Pull your baby close so your baby faces your body.

HOW LONG SHOULD I BREASTFEED?

Many leading health organizations recommend that most infants breastfeed for at least 12 months, with exclusive breastfeeding for about the first six months.

These recommendations are supported by organizations including the American Academy of Pediatrics, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American College of Nurse-Midwives, Academy of Nutrition and Dietetics, and American Public Health Association.

TIPS FOR MAKING IT WORK

LEARN YOUR BABY’S HUNGER SIGNS.

When babies are hungry, they are more alert and active. They may put their hands or fists to their mouths, make sucking motions with their mouth, or turn their heads looking for the breast. If anything touches their cheek, such as a hand, they may turn toward the hand, ready to eat. This sign of hunger is called rooting. Offer your breast when your baby shows rooting signs. Crying can be a late sign of hunger. It may be harder for the baby to latch if he or she is upset. Over time, you will be able to learn your baby’s cues for when to start feeding.

FOLLOW YOUR BABY’S LEAD.

Make sure you and your baby are comfortable and follow your baby’s lead after he or she is latched on well to your breast. Some babies will feed from (or “take”) both breasts, one after the other, at each feeding. Other babies take only one breast at each feeding. Help your baby finish the first breast as long as he or she is still sucking and swallowing. Your baby will let go of your breast when he or she is finished. Offer your baby the other breast if he or she seems to want more.

KEEP YOUR BABY CLOSE TO YOU.

Remember that your baby is not used to this new world and needs to be held close and comforted. Skin-to-skin contact between you and baby will sooth crying and help keep your baby’s heart rate and breathing rates stable. A soft carrier, such as a wrap, can help you “wear” your baby.

AVOID NIPPLE CONFUSION.

Avoid using pacifiers and bottles for the first few weeks after birth unless your doctor has told you to use them because of a medical reason. If you need to use supplements, work with a doctor, nurse, IBCLC, or midwife. They can show you ways that are supportive of breastfeeding. These include feeding your baby with a syringe, a small, flexible cup, or a tiny tube taped beside your nipple. Try to give your baby expressed milk first. Unless your baby is unable to feed well, it’s best to feed at the breast.

MAKE SURE YOUR BABY SLEEPS SAFELY AND CLOSE BY.

Have your baby sleep in a crib or bassinet in your bedroom so that you can breastfeed more easily at night. Research has found that when a baby shares a bedroom with his parents, the baby has a lower risk of SIDS. SIDS can also be prevented by placing your baby on his back when he sleeps.

MAKING PLENTY OF MILK

The more often your baby breastfeeds, the more milk your breasts will make. Babies’ tummies are small, so it doesn’t take much to fill your baby up. That means you’ll need to feed your newborn a lot: 8-12 times in a 24-hour period. Feeding your baby that often helps them grow. It also tells your body to keep making milk.

Most breastfeeding mothers can make plenty of milk for their baby. If you think you have a low milk supply, talk to a lactation consultant. See page 7 for other types of health professionals who can help you.

VITAMIN D

Babies need 400 International Units (IU) or 10 micrograms (mcg) of vitamin D each day. The American Academy of Pediatrics recommends vitamin D supplementation for babies who do not get enough. Ask your baby’s doctor about supplements in drop form. Learn more about vitamin D and your baby’s needs on page 30.

WHAT WILL HAPPEN WITH YOUR MILK, YOUR BABY, AND YOU IN THE FIRST FEW WEEKS

TIME

MILK

BABY

YOU (MOM)

BIRTH

Your body makes colostrum (a rich, thick, yellowish milk) in small amounts. It gives your baby early protection against diseases.

Your baby will probably be awake in the first hour after birth. This is a good time to breastfeed your baby.

You will be tired and excited. Be sure to rest when possible.

FIRST 12–24 HOURS

Your baby will drink about 1 to 2 teaspoons of colostrum at each feeding. You may not see the colostrum, but it has what your baby needs and in the right amount.

It is normal for your baby to sleep heavily. Labor and delivery are hard work! Some babies may be too sleepy to latch at first. Within the first 24 hours after birth, babies should eat eight or more times. Some babies may need to be woken up to ensure they eat enough. When your baby wakes up, look for signs that your baby is hungry (see page 18). Feedings may be short and all over the place — that’s OK!

You will be tired, too. Be sure to rest when possible.

NEXT 3–5 DAYS

Your mature (white) milk takes the place of colostrum. It is normal for mature milk to have a yellow or golden tint at first.

Your baby will feed a lot, most likely 8 to 12 times or more in 24 hours. Very young breastfed babies do not eat on a schedule. It is okay if your baby eats every 2 to 3 hours for several hours, then sleeps for 3 to 4 hours. Feedings may take about 15 to 20 minutes on each breast. The baby’s sucking rhythm will be slow and long. The baby might make gulping sounds.

Your breasts may feel full and leak. (You can use disposable or cloth pads in your bra to help with leaking.) Be sure to rest when possible. If you are not noticing these changes in your breasts, contact a doctor, nurse, IBCLC, or midwife for support.

FIRST 4–6 WEEKS

White breastmilk continues.

Your baby will now likely be better at breastfeeding and have a larger stomach to hold more milk. Feedings may take less time and may be further apart.

Your body gets used to breastfeeding. Your breasts may become softer and the leaking may slow down. Be sure to rest when possible.

HOW TO KNOW YOUR BABY IS GETTING ENOUGH MILK

Many babies, but not all, lose a small amount of weight in the first days after birth. Your baby’s doctor will check your baby’s weight at your first doctor visit. Make sure to visit your baby’s doctor for a checkup within 3 to 5 days after birth and/or 2 to 3 days after discharge, and then again by one month of age.

You can tell whether your baby is getting plenty of milk. He will be mostly content and will gain weight steadily after the first week of age. For the first 4 to 6 months, typical weight gain is two-thirds to 1 ounce each day.

Other signs that your baby is getting plenty of milk:

- Your baby passes enough clear or pale yellow urine. The urine is not deep yellow or orange.

- Your baby has enough bowel movements (see the chart on the next page).

- Your baby switches between short sleeping periods and wakeful, alert periods.

- Your baby is satisfied and content after feedings.

- Your breasts may feel softer after you feed your baby.

- After your mature milk comes in, you will hear or see your baby swallow.

Talk to your baby’s doctor if you are worried that he or she is not getting enough milk.

THE NEWBORN TUMMY

A newborn’s tummy is very small, especially in the early days. In the first days and weeks, your baby can only digest a small amount of milk.

HOW MUCH DO BABIES TYPICALLY EAT?

Once breastfeeding is established, exclusively breastfed babies who are 1 to 6 months old take in between 19 and 30 ounces of breastmilk each day. Every baby is different. Typically, if you breastfeed your baby eight times a day, your baby will get around 3 ounces per feeding.

TYPICAL NUMBER OF WET DIAPERS AND BOWEL MOVEMENTS IN A BABY’S FIRST WEEK
(IT IS FINE IF YOUR BABY HAS MORE)
1 DAY = 24 HOURS

BABY’S AGE

NUMBER OF WET DIAPERS

NUMBER OF BOWEL MOVEMENTS

COLOR AND TEXTURE OF BOWEL MOVEMENTS

DAY 1
(first 24 hours after birth)

1

The first one usually occurs within 24 hours after birth.

Thick, tarry, and black

DAY 2

2

3

Thick, tarry, and black

DAY 3

6

3

Looser greenish to yellow (color may vary)

DAY 4

6

3

Yellow, soft, and watery

DAY 5

6

3

Loose and seedy, yellow color

DAY 6

6

3

Loose and seedy, yellow color

DAY 7

6

3

Loose and seedy, yellow color

COMMON CHALLENGES

Breastfeeding can be challenging at times, especially in the early days. But remember that you are not alone. Lactation consultants can help you find ways to make breastfeeding work for you and your baby. And while many women are faced with one or more of the challenges listed here, a lot of moms do not struggle at all! Also, some women may have certain problems with one baby that they don’t have with their other babies. Read on for ways to troubleshoot problems.

Ask a lactation consultant for help to improve your baby’s latch. Talk to your doctor if your pain does not go away or if you suddenly get sore nipples after several weeks of pain-free breastfeeding. Sore nipples may lead to a breast infection, which needs to be treated by a doctor.

CHALLENGE: SORE NIPPLES

Many moms say that their nipples feel tender when they first start breastfeeding. Breastfeeding should be comfortable once you and your baby have found a good latch and some positions that work.

WHAT YOU CAN DO

- A good latch is key, so see page 14 for detailed instructions. If your baby sucks only on the nipple, gently break your baby’s suction to your breast by placing a clean finger in the corner of your baby’s mouth and try again. (Your nipple should not look flat or compressed when it comes out of your baby’s mouth. It should look round and long, or the same shape as it was before the feeding.)

- If you find yourself wanting to delay feedings because of pain, get help from a lactation consultant. An IBCLC can watch you breastfeed to find out why you are in pain and suggest ways to help. Delaying feedings can cause more pain and harm your milk supply.

- Try changing positions each time you breastfeed.

- After breastfeeding, express a few drops of milk and gently rub it on your nipples with clean hands. Human milk has natural healing properties and oils that soothe. Also, try letting your nipples air-dry after feeding or wear a soft cotton shirt.

- Get help from your doctor, nurse, midwife, or other breastfeeding expert before using creams, hydrogel pads (a moist covering for the nipple to help ease soreness), or a nipple shield (a plastic device that covers the nipple while breastfeeding). Some women should not use these products. Your doctor will help you make the choice that is best for you and your baby.

- Don’t wear bras or clothes that are too tight and put pressure on your nipples.

- Change nursing pads (washable or disposable pads you can place in your bra to absorb leaks) often to avoid trapping in moisture.

- Avoid harsh soaps or ointments that contain astringents (like a toner) on your nipples.

- If your nipples are cracked, use soap and water to clean them.

- If the steps above don’t help, check with your doctor to make sure there aren’t any medical issues that could be causing sore nipples.

CHALLENGE: LOW MILK SUPPLY

Most breastfeeding mothers can make plenty of milk for their babies. But many mothers worry about having enough milk. Let your doctor, nurse, IBCLC, or midwife know if you are concerned.

HOW TO TELL IF YOU ARE MAKING ENOUGH MILK

- Checking your baby’s weight and growth is the best way to make sure he is getting enough milk.

- Keep track of your baby’s wet and dirty diapers.

- Babies may want to nurse more often and longer during growth spurts (see page 29). This is common and does not mean you are not making enough milk.

- Your breasts no longer feeling full and baby only nursing for a few minutes at a time are NOT signs of low milk supply.

- Review page 20 for more ways to tell if your baby is getting enough milk.

WHAT YOU CAN DO

- Make sure your baby is latched on and positioned well.

- Gently massage or compress your breasts while your baby is latched to help release more milk.

- Breastfeed often and let your baby decide when to end the feeding. If your baby does not empty the breast, try pumping afterward. The more often you empty your breasts, the more milk your breasts will make.

- Offer both breasts at each feeding. Have your baby stay at the first breast as long as he or she is still sucking and swallowing. Offer the second breast when the baby slows down or stops.

- Use breast compressions or massage your breasts while your baby is latched to help release more milk.

- Try to avoid giving your baby formula or cereal in addition to your breastmilk. Otherwise, your baby may lose interest in your breastmilk, and as a result, your milk supply could decrease.

- Limit or stop your baby’s use of a pacifier while trying the above tips.

- If the steps above don’t help, check with your healthcare provider to make sure there aren’t any medical issues that could be decreasing your milk supply.

Talk to your baby’s doctor if you think your baby is not getting enough milk.

CHALLENGE: OVERSUPPLY OF MILK

Some breastfeeding mothers worry about an oversupply of milk. An over-full breast can make breastfeeding stressful and uncomfortable for you and your baby.

WHAT YOU CAN DO

- Breastfeed on one side for each feeding. Continue to offer that same breast for at least two hours until the next full feeding, gradually increasing the length of time per feeding.

- If the other breast feels too full before you are ready to breastfeed on it, hand express for a few moments to relieve some of the pressure (avoid pumping or hand expressing too much because it can lead to further oversupply).

- You also can use a cold compress or washcloth to reduce discomfort and swelling.

- Feed your baby before he or she becomes overly hungry to prevent aggressive sucking. (Learn more about hunger signs on page 18.)

- Burp your baby often if he or she is gassy.

Ask a lactation consultant for help if you are unable to manage an oversupply of milk on your own.

CHALLENGE: STRONG LET-DOWN REFLEX

Some women have a strong milk ejection reflex or let-down, which can cause a rush of milk. This can happen along with an oversupply of milk.

WHAT YOU CAN DO

- Hold your nipple between your first and middle fingers or with the side of your hand. Lightly compress your milk ducts to reduce the force of the milk ejection.

- If your baby chokes or sputters when breastfeeding, gently break the latch and let the excess milk spray into a towel or cloth.

- Allow your baby to come on and off the breast at will.

- Hold your baby in the laid-back position during feedings. This allows your baby to nurse against gravity and better manage the flow of milk.

FIVE ENGORGEMENT HOLDS*

1. One-handed “flower hold.” Works best if your fingernails are short. Curve your fingertips in toward your body and place them where baby’s tongue will go.

2. Two-handed, one-step method. Works best if your fingernails are short. Curve your fingertips in toward your body and place them on each side of the nipple.

CHALLENGE: ENGORGEMENT

Women can experience engorgement at any time during breastfeeding. It usually happens during the third to fifth day after giving birth. Your breasts might become large, heavy, and a little tender. This is normal and should go away as you continue to breastfeed and your supply adjusts to your baby’s needs. However, engorgement can become problematic. If your breasts remain full after your milk comes in and you are experiencing pain, swelling, tenderness, warmth, redness, throbbing, hardness, or flattening of the nipple, talk to your doctor, nurse, IBCLC, or midwife.

Engorgement sometimes also causes a low-grade fever and can be confused with a breast infection. Engorgement is the result of the milk building up. This may be more likely if you are not feeding your baby or expressing your milk often.

Engorgement can lead to plugged ducts or a breast infection (see page 26), so it is important to try to prevent it before this happens.

WHAT YOU CAN DO

- Breastfeed often after giving birth. As long as your baby is latched on and sucking well, allow your baby to nurse for as long as he or she likes.

- Work with a lactation consultant to improve your baby’s latch.

- Breastfeed often on the affected side to remove the milk, keep the milk moving freely, and prevent your breast from becoming overly full.

- Avoid using pacifiers or bottles to supplement feedings.

- Hand express or pump a little milk to first soften the breast, areola, and nipple before breastfeeding.

- Gently massage the breast.

- Use cold compresses on your breast in between feedings to help ease the pain.

- If you are away from your baby (e.g., work, school, travel), try to pump your milk as often as your baby normally breastfeeds when the baby is with you.

- Get enough rest, proper nutrition, and fluids.

- Wear a well-fitting, supportive bra that is not too tight.

- Try reverse pressure softening to make the areola soft around the base of the nipple and help your baby latch. Try one of the holds in the illustrations on the left and below. Press inward toward the chest wall and count slowly to 50. Use steady and firm pressure, but gentle enough to avoid pain. You may need to repeat each time you breastfeed for a few days.

3. Use the two-handed, one-step method. You may ask someone to help press by placing fingers or thumbs on top of yours.

4. Two-handed, two-step method. Using two or three fingers on each side, place your first knuckles on either side of the nipple and move them 1/4 turn. Repeat above and below the nipple.

5. Two-handed, two-step method. Using straight thumbs, place your thumbnails evenly on either side of the nipple.
Move 1/4 turn and repeat above and below the nipple.

CHALLENGE: PLUGGED DUCT

Plugged ducts are common in breastfeeding mothers. A plugged milk duct feels like a tender and sore lump in the breast. You should not have a fever or other symptoms.

A plugged duct happens when a milk duct does not drain properly. Pressure then builds up behind the plug, and surrounding tissue gets inflamed. A plugged duct usually happens in one breast at a time.

WHAT YOU CAN DO

- Breastfeed on the affected side as often as every two hours. This will help loosen the plug and keep your milk moving freely.

- Aim your baby’s chin at the plug. This will focus the baby’s suck on the duct that is affected.

- Gently massage the area, starting behind the sore spot. Move your fingers in a circular motion and massage toward the nipple.

- Use a warm compress on the sore area.

- Get extra sleep, or relax with your feet up to help speed healing.

- Wear a well-fitting supportive bra that is not too tight, since this can constrict milk ducts. Consider trying a bra without underwire.

- If you have plugged ducts that keep coming back, seek help from an IBCLC.

If your plugged duct doesn’t loosen up, ask for help from a lactation consultant. Plugged ducts can lead to a breast infection.

CHALLENGE: BREAST INFECTION (MASTITIS)

Mastitis is painful inflammation or an infection of the breast. Your breast may feel tender or sore, or you may feel a hardened lump. It is not always easy to tell the difference between mastitis and a plugged duct because they have similar symptoms. However, with mastitis, you will feel very ill and can have the following symptoms:

- Fever or flu-like symptoms, such as feeling run down or very achy

- Nausea

- Vomiting

- Yellowish discharge from the nipple that looks like colostrum

- Breasts that feel warm or hot to the touch

- Skin on the breasts that appears red and streaky

If you are not feeling better 12–24 hours after symptoms start, contact your doctor. You may need to be treated with medicine. (Learn more about medicines and breastfeeding on page 31.)

WHAT YOU CAN DO

- Breastfeed on the affected side every two hours or more often. This will keep the milk moving freely and your breast from becoming overly full.

- Gently massage the area, starting behind the sore spot. Move your fingers in a circular motion and massage toward the nipple.

- Apply heat to the sore area with a warm compress.

- Wear a well-fitting supportive bra that is not too tight, since this can constrict milk ducts.

Ask your doctor for help if you do not feel better within 24 hours of trying these tips, if you have a fever, or if your symptoms worsen. You might need medicine.

SEE YOUR DOCTOR RIGHT AWAY IF:

- You have a breast infection in which both breasts look affected.

- There is pus or blood in your breastmilk.

- You have red streaks near the affected area of the breast.

- Your symptoms came on severely and suddenly.

Also, talk with your doctor about any medicines you take or plan to take.

CHALLENGE: FUNGAL INFECTIONS

A fungal infection, also called a yeast infection or thrush, can form on your nipples or in your breast. This type of infection thrives on milk and forms from an overgrowth of the Candida organism. Candida lives in our bodies and is kept healthy by the natural bacteria in our bodies. When the natural balance of bacteria is upset, Candida can overgrow, causing an infection.

Signs of a fungal infection include:

- Nipple soreness that lasts more than a few days, even after your baby has a good latch

- Pink, flaky, shiny, itchy, or cracked nipples

- Deep pink and blistered nipples

- Achy breasts

- Shooting pains deep in the breast during or after feedings

- White patches in your baby’s mouth or a white coating on your baby’s tongue

WHAT YOU CAN DO

Fungal infections may take several weeks to clear up, so it is important to follow these tips to avoid spreading the infection:

- Change disposable nursing pads often.

- Wash any towels or clothing that come in contact with the yeast in very hot water (above 122°F).

- Wear a clean bra every day.

- Wash your hands often.

- Wash your baby’s hands often, especially if he sucks on his fingers.

- If there are safety concerns, talk to your baby’s doctor. Refer to the product guidelines and instructions on cleaning, safety and use for pacifiers, nipples, and toys that your baby puts in his or her mouth.

- Boil all breast pump parts that touch your milk every day.

- Make sure other family members are free of thrush or other fungal infections. If they have symptoms, make sure they get treated.

If you or your baby has symptoms of a fungal infection, call both your doctor and your baby’s doctor so you can be correctly diagnosed and treated at the same time. This will help prevent passing the infection to each other.

“I had a terrible time learning to nurse my son. My nipples were terribly sore, and it felt like it wasn’t getting any better. After visiting my doctor, the lactation consultant, and the pediatrician, it became clear that a horrible case of thrush had been the source of my pain. I honestly did not think I would make it, but I was too stubborn to quit, and I am grateful I stuck with it. I am proud to say that I breastfed my son until he was 16 months old! – Jessica, Edmonton, Alberta, Canada

CHALLENGE: NURSING STRIKE

A nursing “strike” is when your baby has breastfed well for months and suddenly begins to refuse the breast. A nursing strike can mean that your baby is trying to let you know that something is wrong. A nursing strike is usually temporary and typically does not mean your baby is ready to wean.

Not all babies will react the same way to the different things that can cause a nursing strike. Some babies will continue to breastfeed without a problem. Other babies may just become fussy at the breast. And other babies will refuse the breast entirely.

Some of the major causes of a nursing strike include:

- Having mouth pain from teething, a fungal infection like thrush, or a cold sore.

- Having an ear infection, which causes pain while sucking or pressure while lying on one side.

- Feeling pain from a certain breastfeeding position, perhaps from an injury on the baby’s body or from soreness from an immunization.

- Being upset about a long separation from the breastfeeding mother or a major change in routine.

- Being distracted while breastfeeding, such as becoming interested in other things going on around the baby.

- Having a cold or stuffy nose that makes breathing while breastfeeding difficult.

- Getting less milk from the breastfeeding mother after supplementing breastmilk with bottles or overuse of a pacifier.

- Responding to the mother’s strong reaction if the baby has bitten her while breastfeeding.

- Reacting to changes in soap or other cosmetics that smell unfamiliar.

- Responding to changes in the taste of milk because of an illness, medication, or diet.

If your baby is on a nursing strike, it is normal to feel frustrated and upset, especially if your baby is unhappy. Be patient with your baby and keep trying to offer your breasts.

WHAT YOU CAN DO

- Try to express your milk as often as the baby used to breastfeed to avoid engorgement and plugged ducts.

- Try another feeding method temporarily to give your baby your breastmilk, such as using a cup, dropper, or spoon.

- Keep track of your baby’s wet and dirty diapers to make sure he or she gets enough milk.

- Keep offering your breast to your baby. If your baby is frustrated, stop and try again later. You can also offer your breast when your baby is very sleepy or is sleeping.

- Try different breastfeeding positions, with your bare skin next to your baby’s bare skin.

- Focus on and comfort your baby with extra touching and cuddling.

- Breastfeed your baby in a quiet room with few distractions.

If you are worried your baby is not getting enough milk, talk to your baby’s doctor. The doctor can check your baby’s weight gain.

CHALLENGE: INVERTED, FLAT, OR VERY LARGE NIPPLES

Some women have nipples that turn inward instead of pointing outward, or that are flat and do not protrude. Nipples also can sometimes flatten for a short time because of engorgement or swelling from breastfeeding. Inverted or flat nipples can sometimes make it harder to breastfeed. But remember, for breastfeeding to work, your baby must latch on to both the nipple and the breast, so even inverted nipples can work just fine. Often, flat and inverted nipples will protrude more over time as the baby sucks more.

Very large nipples can make it hard for the baby to get enough of the areola into his or her mouth to compress the milk ducts and get enough milk.

WHAT YOU CAN DO

- Talk to your doctor, nurse, midwife, or other breastfeeding expert if you are concerned about your nipples.

- A lactation consultant can give you advice for safely and comfortably pulling your nipples out.

- The latch for babies of mothers with very large nipples will improve with time as the baby grows. It might take several weeks to get the baby to latch well. If you have a good milk supply, your baby will get enough milk even with a poor latch.

Ask for help if you have questions about your nipple shape or type, especially if your baby is having trouble latching well.

CHALLENGE: GROWTH SPURTS

Growth spurts can cause your baby to want to nurse longer and more often. These growth spurts can happen when your baby is around two to three weeks, six weeks, and three months old. Growth spurts can also happen at any time. Don’t be worried that your milk supply is too low to satisfy your baby (see page 23 for more information on low milk supply).

WHAT YOU CAN DO

Follow your baby’s lead. Nursing more often will help build up your milk supply. Once your supply increases, you will likely be back to your usual routine.

__________________

*Illustrations adapted from Reverse Pressure Softening by K. Jean Cotterman© 2008.

COMMON QUESTIONS

SHOULD I SUPPLEMENT WITH FORMULA?

Giving your baby formula may cause him or her to not want as much breastmilk. This will decrease your milk supply. Talk to your baby’s doctor if you are afraid the baby is not getting enough milk or to see if there is a medical need to supplement with formula.

DOES MY BABY NEED INFANT CEREAL OR WATER?

Giving the baby infant cereal may cause your baby to not want as much breastmilk. This will decrease your milk supply. When your baby is ready for solid foods, the food or infant cereal should be rich in iron. Talk to your baby’s doctor about when to feed your baby solid foods and which foods are best. Your baby does not need water in the first 6 months of life.

IS IT OKAY FOR MY BABY TO USE A PACIFIER?

Pacifiers can reduce the risk of SIDS, so it is ok to use one. If you want to try it, it is best to wait until your baby is comfortable breastfeeding. This allows your baby time to learn how to latch well on the breast and get enough milk.

DOES MY BABY NEED VITAMIN D?

Vitamin D is needed to build strong bones. All infants should get at least 400 IU (10 mcg) of vitamin D each day. Breastmilk alone does not provide infants with an adequate amount of vitamin D. To avoid developing a vitamin D deficiency, the American Academy of Pediatrics recommends that you give your baby a vitamin D supplement of 400 IU (10 mcg) each day. This should start in the first few days of life. Ask your baby’s doctor about supplements in drop form.

Even though sunlight on the skin enables the body to make vitamin D, exposing your baby’s skin to the sun can be harmful.

Once your baby is weaned from breastmilk, talk to your baby’s doctor about whether your baby still needs vitamin D supplements. Some children do not get enough vitamin D from the food they eat.

DOES MY BABY NEED IRON?

Babies are born with stores of iron they get from their mother during pregnancy. When babies are about 4 months old, they need an additional source of iron. If your baby was premature, they may need extra iron. Talk with your baby’s doctor about how much iron your baby needs.

IS IT SAFE TO SMOKE, DRINK, OR USE DRUGS?

If you smoke, it is best for you to quit as soon as possible. If you can’t quit, it is still better to breastfeed because it can help protect your baby from respiratory problems and SIDS. Be sure to smoke away from your baby and change your clothes to keep your baby away from the chemicals smoking leaves behind. Ask your doctor or nurse for help quitting smoking or go to https://women.smokefree.gov/.

Not drinking alcohol is the safest option for breastfeeding mothers. However, drinking up to 1 standard drink per day is not known to be harmful to your baby, especially if you wait at least 2 hours after a single drink before nursing. You can also pump milk before you drink to feed your baby later.

The CDC has more information on this website https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/vaccinations-medications-drugs/alcohol.html.

It is not safe for you to use an illicit drug. Drugs such as cocaine, marijuana, heroin, and PCP can harm your baby. Some reported side effects in babies include seizures, vomiting, poor feeding, and tremors.

Talk to your doctor about whether you can breastfeed if you are taking medication to treat an opioid use disorder.

CAN I TAKE MEDICINES IF I AM BREASTFEEDING?

You can take certain medicines while breastfeeding, but not all. Many medicines pass into breastmilk in small amounts, but most have no effect on the baby and can be used while breastfeeding. Always talk to your doctor and pharmacist about medicines you are using and ask before you start using new medicines. This includes prescription and over-the-counter drugs, vitamins, and dietary or herbal supplements. For some women with chronic health problems, stopping a medicine can be more dangerous than the effects it will have on the breastfed baby.

The National Library of Medicine offers an online tool to learn about the effects of medicines on breastfed babies. The website address is https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm, and the LactMed app is available through the Apple Store and Google Play. You can discuss the information you find on LactMed with your doctor, nurse, IBCLC, midwife, or pharmacist.

CAN I BREASTFEED IF I AM SICK?

Some women think that they should not breastfeed when they are sick. But most common illnesses, such as colds, seasonal flu, or diarrhea, can’t be passed through breastmilk. In fact, your breastmilk has antibodies in it. These antibodies will help protect your baby from getting the same sickness. (See page 5 to learn about antibodies.)

If you are sick with the flu, you can still breastfeed. It is important to take steps to keep your baby from getting sick. Wash your hands with soap and water before touching your baby or any item that your baby will touch. You should also wash your hands anytime you sneeze or cough on them. If you don’t feel well enough to breastfeed your baby, have someone who is not sick give your baby expressed breastmilk. When you express your milk, you should wash your hands and, if you’re using a pump, follow recommendations for cleaning your pump parts.

Talk with your doctor, nurse, IBCLC, or midwife about breastfeeding or feeding your baby expressed breastmilk if you:

- Have HIV or AIDS. You can also contact a human milk bank if you want to give your baby donor breastmilk (see page 39 for more information).

- Have untreated, active tuberculosis. You may be able to feed your baby expressed milk or resume breastfeeding after treatment.

- Have active herpes lesions on your breast. If you have an active lesion on your breast you should temporarily refrain from breastfeeding your infant or feeding your baby expressed breastmilk from the affected breast. You may breastfeed your infant and express milk from the unaffected breast but should ensure that the lesions on the affected breast are completely covered to avoid transmission.

- Have active varicella (chicken pox) infection that developed within 5 days before delivery or 2 days after delivery.

You should not breastfeed if you:

- Are infected with human T-cell lymphotropic virus type I or type II.

- Take prescribed cancer chemotherapy agents, such as antimetabolites.

- Are undergoing radiation therapy — but talk to your doctor, nurse, IBCLC, or midwife because some nuclear medicine therapies require only a temporary break from breastfeeding.

- Are infected with HIV

You can contact a human milk bank if you want to give your baby donor breastmilk (see page 39 for more information).

COMMON QUESTIONS

WILL MY PARTNER BE JEALOUS IF I BREASTFEED?

You can help prevent jealousy by preparing your partner before birth. Explain that you need his or her support. Discuss the important and lasting health reasons to breastfeed. Remind your partner that the baby will need to be fed somehow. Any method will take time, but once breastfeeding is going smoothly, it is convenient and comfortable. Be sure to emphasize that not breastfeeding can cost you money. Your partner can help by changing and bathing the baby, sharing household chores, and simply sitting with you and the baby to enjoy the special mood that breastfeeding creates.

DO I HAVE TO RESTRICT MY SEX LIFE WHILE BREASTFEEDING?

No, but you may need to make some adjustments to make sex more comfortable for you and your partner if you have the following:

- Vaginal dryness. Some women experience vaginal dryness right after childbirth and during breastfeeding. This is because estrogen levels are lower during these times. If you have vaginal dryness, you can try more foreplay and water-based lubricants.

- Leaking breasts. You can feed your baby or express some milk before lovemaking so your breasts will be more comfortable and less likely to leak. It is common for a woman’s breasts to leak or even spray milk during sex, especially during her orgasm. If this happens, put pressure on your nipples or have a towel handy to catch the milk.

DO I STILL NEED BIRTH CONTROL IF I AM BREASTFEEDING?

Yes. Your doctor will likely discuss birth control with you before you give birth. Breastfeeding is not a sure way to prevent pregnancy, even though exclusive breastfeeding can delay the return of normal ovulation and menstrual cycles. Some hormonal birth control may affect milk supply. Discuss with your doctor birth control choices that you can use while breastfeeding.

I HEARD THAT BREASTMILK CAN HAVE TOXINS IN IT FROM THE ENVIRONMENT. IS IT STILL SAFE FOR MY BABY?

Although certain chemicals can appear in breastmilk, breastfeeding is still the best way to feed and nurture young infants and children. The known risks of not breastfeeding far outweigh any possible risks from environmental pollutants. Remember that your baby was once inside your body and was exposed to the same things you were exposed to during pregnancy.

The concern over environmental toxins is a reason to breastfeed, not avoid it. Infant formula, the water it is mixed with, or the bottles or nipples used to give it to the baby can be contaminated with bacteria or chemicals. Good hygiene and sources of clean water are very important if formula is used.

DOES MY BREASTFED BABY NEED VACCINES? IS IT SAFE FOR ME TO GET A VACCINE WHEN I’M BREASTFEEDING?

Yes. Vaccines are very important to your baby’s health. Breastfeeding may also help your baby respond better to certain immunizations that protect your baby. Follow the schedule your baby’s doctor gives you and, if you miss any vaccines, check with the doctor about getting your baby back on track as soon as possible. Breastfeeding while the vaccine is given to your baby, or immediately afterward, can help relieve pain and soothe an upset baby.

Nursing mothers may also receive most vaccines. Breastfeeding does not affect the vaccine, and most vaccines will not harm your baby because they do not enter your breastmilk. However, vaccines for smallpox and yellow fever can be passed through breastmilk. Avoid these vaccinations if possible while breastfeeding and talk to your doctor.

WHAT SHOULD I DO IF MY BABY BITES ME?

If your baby starts to clamp down, you can put your finger in your baby’s mouth and take them off your breast with a firm “no.” Try not to yell, as it may scare the baby. If your baby continues to bite you, you can:

- Gently press your baby to your breast. This will cause your baby to open her mouth more to breathe.

- Stop the feeding right away so your baby is not tempted to get another reaction from you. Don’t laugh. This is part of your baby’s learning of limits.

- Offer a cold teething toy or frozen wet washcloth before breastfeeding so your baby’s gums are soothed already.

- Put your baby down for a moment to show that biting brings a negative consequence. You can then pick your baby up again to give comfort.

WHAT DO I DO IF MY BABY KEEPS CRYING?

If your baby does not seem comforted by breastfeeding or other soothing measures, talk to your baby’s doctor. The doctor and a lactation consultant can help you find ways to help your baby eat well.

BREASTFEEDING A BABY WITH A HEALTH PROBLEM

Some health problems in babies can make it harder for them to breastfeed. But breastmilk provides the healthy start your baby needs — even more so if your baby is premature or sick. Even if your baby cannot breastfeed directly from you, you can express or pump your milk and give it to your baby with a dropper, spoon, or cup.

Some common health problems in babies are listed below.

JAUNDICE

Jaundice is caused by an excess of bilirubin. Bilirubin is found in the blood but usually only in very small amounts. In the newborn period, bilirubin can build up faster than it can be removed from the intestinal tract. Jaundice can appear as a yellowing of the skin and eyes. It affects most newborns to some degree, appearing between the second and fifth day of life. Jaundice usually clears up by 2 weeks of age and is typically not harmful.

Some breastfed babies develop jaundice when they do not get enough breastmilk, either because of breastfeeding challenges or because the mother’s milk hasn’t come in. This type of breastfeeding jaundice usually clears up quickly with more frequent breastfeeding or feeding of expressed breastmilk or after the mother’s milk comes in.

Your baby’s doctor may monitor your baby’s bilirubin level. Some babies with jaundice may need treatment with a special light (called phototherapy). This light helps break down bilirubin into a form that can be removed from the body easily.

Keep in mind that breastfeeding is best for your baby. Even if your baby gets jaundice, this is not something that you caused. Your doctor can help you make sure that your baby eats well and that the jaundice goes away.

If your baby develops jaundice, let your baby’s doctor know. Discuss treatment options and let the doctor know that you do not want to interrupt breastfeeding if at all possible.

REFLUX DISEASE

Some babies have a condition called gastroesophageal reflux disease (GERD). GERD happens when the muscle at the opening of the stomach opens at the wrong times. This allows milk and food to come back up into the esophagus, the tube in the throat. Some symptoms of GERD include:

- Severe spitting up or spitting up after every feeding or hours after eating

- Vomiting (the milk shoots out of the mouth)

- Irritability and inconsolable crying as if in discomfort

- Arching of the back as if in severe pain

- Refusal to eat or pulling away from the breast during feeding

- Waking up often at night

- Slow weight gain

- Gagging or choking or having problems swallowing

- Respiratory/breathing problems (e.g., wheezing cough)

Many healthy babies might have some of these symptoms and not have GERD. Also, some babies with only a few of these symptoms have a severe case of GERD. Not all babies with GERD spit up or vomit. Talk to your baby’s doctor if your baby has symptoms of GERD. More severe cases of GERD may need to be treated with medicine.

See your baby’s doctor if your baby spits up after every feeding and has any of the other symptoms listed in this section. If your baby has GERD, it is important to continue breastfeeding. Breastmilk is usually easier to tolerate than formula for babies with GERD.

COLIC

Many infants are fussy in the evenings, but if the crying happens for long periods of time for no clear reason, it may be colic. Colic is when a baby cries for more than three hours a day and three times a week without a clear cause. A baby may cry inconsolably or scream, extend or pull up his or her legs, and pass gas. The baby’s stomach may be enlarged. Crying can happen anytime, although it often gets worse in the early evening.

Colic usually starts between 2 and 4 weeks from birth. It will likely improve or disappear by 3 or 4 months after birth. Doctors don’t know why some babies get colic. Some breastfed babies may be sensitive to a food their breastfeeding mother eats, such as caffeine, chocolate, dairy, or nuts. Colic could be a sign of a medical problem, such as a hernia or some type of illness.

If your infant shows signs of colic, talk to your doctor. Sometimes changing what you eat can help. Some infants seem to be soothed by being held, “worn” with a baby wrap or sling, rocked, or swaddled (wrapped snugly in a blanket). When your baby shows signs of trying to roll, swaddling should no longer be used because it is not safe.

PREMATURE OR LOW BIRTH WEIGHT

Premature birth is when a baby is born before 37 weeks. Prematurity often will mean that the baby is born at a low birth weight, defined as less than 5½ pounds. When a baby is born early or is small at birth, the mother and baby will face added challenges with breastfeeding and may need to adjust, especially if the baby has to stay in the hospital for extra care. Keep in mind that breastmilk has been shown to help premature babies grow and stay healthy.

SOME BABIES CAN BREASTFEED RIGHT AWAY.

This may be true if your baby was born at a low birth weight but after 37 weeks. These babies will need more skin-to-skin contact to help keep warm. These smaller babies may also need feedings more often, and they may get sleepier during those feedings.

EVEN IF YOUR BABY IS BORN PREMATURELY AND YOU ARE NOT ABLE TO BREASTFEED AT FIRST, YOUR BABY CAN STILL BENEFIT FROM YOUR MILK. YOU CAN:

- Use hand expression to express colostrum in the hospital as soon as you can.

- Talk to the hospital staff about renting an electric pump. Call your insurance company or local WIC office to find out whether you are eligible for a breast pump.

- Pump milk as often as you would normally breastfeed — about eight times in a 24-hour period.

- Give your baby skin-to-skin contact once your baby is ready to breastfeed directly. This can be very calming and a great start to your first feeding. Be sure to work with a lactation consultant on proper latch and positioning. It may take some time for you and your baby to get into a good routine.

If you leave the hospital before your baby, you can express milk for the hospital staff to give the baby.

There are some health conditions that don’t allow you to breastfeed your baby at all. For example, babies that have classic galactosemia, a rare genetic metabolic disorder, cannot have breastmilk and need lactose-free formula. If you or your baby have a health condition, talk with your doctor about whether you can breastfeed.

BREASTFEEDING AND SPECIAL SITUATIONS

TWINS OR MULTIPLES

The benefits of breastfeeding for mothers of multiples and their babies are the same as for all mothers and babies — possibly greater, since many multiples are born early. The idea of breastfeeding more than one baby may seem overwhelming at first! Many moms of multiples find breastfeeding easier than other feeding methods because there is nothing to prepare. Many mothers successfully breastfeed more than one baby even after going back to work.

SEEKING SUPPORT

Reach out to other moms of multiples and get help and information by:

- Finding a lactation consultant who has experience with multiples. Ask the lactation consultant where you can rent a breast pump if the babies are born early.

- Finding Internet and print resources for parents of multiples. Some good resources include:

– La Leche League Great Britain lalecheleague.org.uk/twins

– Mothering Multiples: Breastfeeding and Caring for Twins or More!

- Joining a support group for parents of multiples through your doctor, hospital, local breastfeeding center, or La Leche League International.

DID YOU KNOW?

Even if your babies need to spend time in the neonatal intensive care unit, breastfeeding is still possible with some adjustments.

MAKING ENOUGH MILK

Most breastfeeding mothers can make plenty of milk for twins. Many mothers exclusively breastfeed or express their milk for triplets or quadruplets. Keep these tips in mind:

- Breastfeeding soon and often after birth is helpful for multiples the same way it is for one baby. The more milk that is removed from your breasts, the more milk your body will make.

- If your babies are born early, using an electric double breast pump in between nursing sessions will help you make more milk.

- The doctor’s weight checks can tell you whether your babies are getting enough breastmilk. You can also track wet diaper and bowel movements to tell whether your babies are getting enough milk. For other signs that your babies are getting enough milk, see page 20.

- It helps to have each baby feed from both breasts. You can “assign” a breast to each baby for a feeding and switch at the next feeding. Or you can assign a breast to each baby for a day and switch the next day. Switching sides helps keep milk production up if one baby isn’t eating as well as the other baby. It also gives babies a different view to stimulate their eyes.

Many breastfeeding basics are the same for twins or multiples as they are for one baby. Learn more about these important topics:

- How to know your babies are getting enough milk (page 20)

- How to troubleshoot common challenges (page 22)

- Ways to keep milk supply up (page 23)

“When they were first born, it was too overwhelming for me to care for them at the same time. I fed them one at a time, which was nice, because I was able to bond with each individually. But then I realized that I was pretty much feeding one of them every one to two hours, and in order to get more sleep, I started feeding them at the same time. Once I got the hang of feeding both at once, I was able to free up so much more time! They started to get on the same eating/sleeping schedule, and while both were sleeping, I would find myself having a solid two to three hours to catch up on some sleep, relax, and clean up around the house. It was so liberating and much needed! I’m so glad I figured out something that worked for all of us.
– Jen, Charleston, South Carolina

BREASTFEEDING AFTER BREAST SURGERY

How much milk you can make depends on how your surgery was done, where your incisions are, and the reasons for your surgery. People who have had incisions in the fold under the breast are less likely to have problems making milk than people who had incisions around or across the areola, which can cut into milk ducts and nerves. People who have had breast implants usually breastfeed successfully.

If you have had surgery on your breasts for any reason, talk with a lactation consultant. If you are planning to have breast surgery, talk with your surgeon about ways he or she can preserve as much of the breast tissue and milk ducts as possible.

ADOPTION AND INDUCING LACTATION

Many mothers who adopt want to breastfeed their babies and can do it successfully with some help. In fact, many adoptive mothers can breastfeed exclusively, and those who have been pregnant in the past may have an easier time. Lactation is a hormonal response to a physical action. The stimulation of the baby nursing causes the body to see a need for and make milk. The more your baby nurses, the more milk your body will make. Some mothers won’t be able to breastfeed exclusively and may need to supplement their breastmilk with donated breastmilk from a milk bank or with infant formula.

If you plan to adopt and want to breastfeed, talk with both your doctor, nurse, midwife, or other breastfeeding expert. They can help you decide the best way to try to establish a milk supply for your new baby. You might be able to prepare by pumping every three hours around the clock for two to three weeks before your baby arrives, or you can wait until the baby arrives and start to breastfeed then. You can also try a supplemental nursing system or a lactation aid to ensure your baby gets enough nutrition and that your breasts are stimulated to make milk at the same time.

USING MILK FROM DONOR BANKS

If you can’t breastfeed and still want to give your baby human milk, you may want to consider a human milk bank. Some human milk banks can dispense donor human milk if you have a prescription from your doctor. Many steps are taken to ensure the milk is safe.

Some reasons you may want or need a human milk bank include:

- You are unable to breastfeed because:

– Your baby was born premature.

– Your baby has other health problems.

– You take certain medicines that are dangerous for babies and can be passed to your baby in your breastmilk.

– You have a specific illness (like HIV or active tuberculosis).

– You get radiation therapy, though some therapies may mean only a brief pause in breastfeeding.

- Your baby isn’t thriving on formula because of allergies or intolerance.

- You want to give your baby breastmilk, but made the choice not to breastfeed or pump.

Some breastfeeding mothers give their milk directly to parents of babies in need. This is called “casual sharing.” This milk has not been tested in a lab such as a human milk bank. The Food and Drug Administration recommends against feeding your baby breastmilk that you get directly from other women or through the Internet.

The Human Milk Bank Association of North America (https://www.hmbana.org/) follows voluntary guidelines for safety, but are not regulated by the federal government. They collect, process, and provide human milk donated by nursing mothers.

To find out if your insurance will cover the cost of the milk, call your insurance company or ask your doctor. If your insurance company does not cover the cost of the milk, talk with the milk bank about payment options.

WHEN MOM OR BABY HAVE A HEALTH CONDITION

- In some situations, alternatives to breastmilk may be necessary. You or your baby may have a health condition that impacts your ability to breastfeed. Speak with your doctor, nurse, IBCLC, or midwife before you decide to feed your baby anything besides your breastmilk. Learn more about the health conditions that could prevent you from breastfeeding your baby on page 31.

BREASTFEEDING IN PUBLIC

Some mothers feel uncomfortable breastfeeding in public. You are feeding your baby and not doing anything wrong. Even though it may seem taboo in some places, awareness of the support new breastfeeding mothers need is building.

The federal government and many states have laws that protect nursing women. These laws are based on the recognition of organizations such as the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the World Health Organization, and many others that breastfeeding is the best choice for the health of a mother and her baby. You can see the laws in your state at the National Conference of State Legislatures website at www.ncsl.org/research/health/breastfeeding-state-laws.aspx.
It is important to believe in yourself and your choice to breastfeed your baby. Remind yourself that you can succeed, and wear your confidence!

Some tips for breastfeeding in public include:

- Wear clothes that allow easy access to your breasts, such as tops that pull up from the waist or button down.

- Use a special breastfeeding blanket around your shoulders.

- Breastfeed your baby in a sling. Be aware that some slings may be risky for newborns. Slings or other soft infant carriers are especially helpful for traveling — it makes it easier to keep your baby comforted and close to you. Check with the Consumer Product Safety Commission for warnings before buying a sling.

- Breastfeed in a women’s lounge or dressing room in stores.

- Practice breastfeeding at home so that you can make sure you are revealing only as much as you feel comfortable with.

- Face the wall at a restaurant or sit in a booth.

It helps to breastfeed your baby before he or she becomes fussy so that you have time to get into a comfortable place or position to feed. (Over time, you will learn your baby’s early hunger cues.) When you get to your destination, find a place you can breastfeed where you will feel most comfortable.

If someone criticizes you for breastfeeding in public, know the laws where you are and don’t be afraid to respond. Most of all, it is important to remember that you are meeting your baby’s needs. It isn’t possible to stay home all the time, and you should (and can) feel free to feed your baby while you are out and about. You should be proud of your commitment! Plus, no bottles mean fewer supplies to pack and no worries about getting the milk to the right temperature.

PUMPING AND STORING YOUR MILK

PUMPING YOUR BREASTMILK

If you are unable to breastfeed your baby directly, it is important to remove milk during the times your baby normally would feed. This will help you to continue making milk.

Before you express breastmilk, be sure to wash your hands with soap and water. If soap and water are unavailable, use an alcohol-based hand sanitizer that contains at least 60 percent alcohol. Make sure the area where you are expressing and your pump parts and bottles are clean.

If you need help to get your milk to start flowing, you can:

- Think about your baby. Bring a photo or a blanket or item of clothing that has your baby’s scent on it.

- Apply a warm, moist compress to your breasts.

- Gently massage your breasts.

- Visualize the milk flowing down.

- Sit quietly and think of a relaxing setting.

WAYS TO EXPRESS YOUR MILK BY HAND OR PUMP

You can rent an electric pump from a lactation consultant at a local hospital or from a breastfeeding organization. This type of pump works well for creating a milk supply when a new baby can’t feed at the breast. Mothers who struggled with other expression methods may find that these pumps work well for them.

Your health insurance plan may cover the cost of a breast pump. You may be offered a rental or a new pump you can keep. Your plan may provide guidance on whether you will receive a manual or electric pump, how long the coverage of a rented pump lasts, and when they’ll provide the pump. Talk to your insurance company to learn more.

Learn more about your breastfeeding benefits at Healthcare.gov/coverage/breast-feeding-benefits/ and talk to your insurance company to learn their specific policies on breast pumps.

STORING YOUR BREASTMILK

Breastmilk can be stored in clean glass or hard BPA-free plastic bottles with tight-fitting lids. You also can use milk storage bags, which are made for freezing human milk. Never store breastmilk in disposable bottle liners or plastic bags that are not intended for storing breastmilk.

Storage bottles or bags to refrigerate or freeze your breastmilk may qualify as tax-deductible breastfeeding gear.

BEFORE EXPRESSING OR HANDLING BREASTMILK

- Wash your hands well with soap and water. If soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60 percent alcohol.

- Express breastmilk by hand or with a manual or electric pump.

- If using a pump, inspect the pump kit and tubing to make sure it is clean. Discard and replace moldy tubing immediately.

- If using a shared pump, clean pump dials, power switch, and countertop with a disinfectant wipe. Pump kits should not be shared.

AFTER EACH PUMPING

- Label the storage container with the date. If you will be delivering breastmilk to your childcare provider, label the container with your child’s name and talk with your childcare provider about other requirements they might have for labeling and storing breastmilk.

- Refrigerate or chill milk right after it is expressed. Do not store breastmilk in the door of the refrigerator.

- Freeze expressed breastmilk right away if you do not think you will use it within four days.

- Use any leftover breastmilk your baby doesn’t finish during a feeding within two hours. After two hours, leftover breastmilk should be discarded.

- Store breastmilk in an insulated cooler bag with a frozen ice pack for up to 24 hours when traveling. Use milk right away, store it in a refrigerator, or freeze it once you arrive at your destination.

TIPS FOR FREEZING MILK

- Freeze breastmilk in small amounts of 2 to 4 ounces (or the amount that will be offered at one feeding) to avoid wasting breastmilk that might not be finished. Freezing small amounts of breastmilk also allows you to thaw milk faster.

- Try to leave an inch or so between the milk and the top of the container because milk will expand when freezing.

- Store milk in the back of the freezer — not on the shelf in the freezer door.

TIPS FOR THAWING AND WARMING MILK

- Use the oldest stored milk first.

- Thaw frozen milk in the refrigerator overnight, or you can hold the frozen bag of milk under warm running water or setting it in a container of warm water. Test the temperature by dropping some on your wrist. It should be comfortably warm.

- Find the right breastmilk temperature for your baby. Breastmilk does not necessarily need to be warmed. Some moms prefer to take the chill off and serve at room temperature.

- Do not put a bottle or bag of breastmilk directly on the stove or in the microwave. Microwaving milk creates hot spots that could burn your baby and damage the milk.

- Swirl the breastmilk to mix the fat. Shaking the milk is not recommended — this can cause some of the milk’s valuable parts to break down.

- Use thawed breastmilk within 24 hours (this means from the time it is no longer frozen or completely thawed, not from the time when you took it out of the freezer). Do not refreeze thawed breastmilk.

SAFELY CLEAN PUMP EQUIPMENT

Clean, sanitize, and store your pump equipment properly. This will help protect your breastmilk from contamination.

- Take apart breast pump tubing and separate all parts that come in contact with your breast and breastmilk.

- Rinse the breast pump parts by holding them under running water to remove remaining milk. Do not place parts in sink to rinse.

- Clean pump parts in a dishwasher or by hand in a clean basin with soap and water. Do not wash the parts directly in the sink because the germs in the sink could contaminate items.

- Air dry the items on a clean dishtowel or paper towel.

- Using clean hands, store the parts in a clean, protected area.

- Discard and replace moldy tubing immediately.

- If using a shared pump, clean pump dials, power switch, and countertop with a disinfectant wipe. Pump kits should not be shared.

For extra germ removal, sanitize pump parts, wash basin, and bottle brush at least once daily after they have been cleaned. Items can be sanitized using steam, boiling water, or a dishwasher with a sanitize setting. Sanitizing is especially important if your baby is less than 3 months old, was born prematurely, or has a weakened immune system due to illness or medical treatment.

Make sure you also clean, sanitize, and store your baby’s bottles and other feeding items properly.

For more information, visit https://www.cdc.gov/healthywater/hygiene/healthychildcare/infantfeeding.html.

“I was committed to breastfeeding, but learning to nurse while learning to take care of a newborn was tough. My baby hated taking the entire nipple, and slipping off as she nursed was painful. And when it’s 3 a.m. and your baby is fussing and you are sore, those bottles are incredibly tempting.

At the same time, most of the health professionals I came in contact with — as well as many of my family members and friends — seemed to be undermining my breastfeeding relationship. My day care providers seemed afraid of my breastmilk, my workplace didn’t offer me a place to pump, and other mothers would act as though my breastfeeding was condemning their choice not to.

But I remembered that my nurse, Charlene, asked me to give it at least 8 weeks. I remembered that advice and decided to wait a little longer. I went back to Charlene for help, and she showed me how to combat my daughter’s slipping latch. She also put me in touch with a local support group and helped me find professionals who really knew how to help. They got me through the most critical period, but it was only my willingness to seek out their guidance that allowed me to keep nursing. Don’t be afraid to ask for help whenever you need it!
– Lin, Lock Haven, Pennsylvania

GUIDE TO STORING FRESH BREASTMILK FOR USE WITH HEALTHY FULL-TERM INFANTS

TYPE OF BREAST MILK

STORAGE LOCATION AND TEMPERATURES

COUNTERTOP
77°F (25°C) or colder
(room temperature)

REFRIGERATOR
40°F (4°C)

FREEZER
0°F (-18°C) or colder

FRESHLY EXPRESSED OR PUMPED

Up to 4 Hours

Up to 4 Days

Within 6 months is best
Up to 12 months is acceptable

THAWED, PREVIOUSLY FROZEN

1–2 Hours

Up to 1 Day (24 hours)

NEVER refreeze human milk after it has been thawed

LEFTOVER FROM A FEEDING (BABY DID NOT FINISH THE BOTTLE)

Use within 2 hours after the baby is finished feeding

You can keep germs from getting into the milk by washing your pumping equipment with soap and water and letting it air dry. For more information, visit: https://www.cdc.gov/healthywater/hygiene/healthychildcare/infantfeeding.html.

Source: https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm

GOING BACK TO WORK OR SCHOOL

Taking time off after you give birth can help you become more comfortable with breastfeeding and pumping and settle into a good breastfeeding routine. It also helps your body recover. Take as much time off as you can. Find more information about returning to work here https://www.fns.usda.gov/tn/breastfed-babies-welcome-here.

BEFORE YOUR BABY IS BORN

Planning ahead for your return to work or school can help ease the transition. Learn as much as you can ahead of time and talk with your employer or academic advisor about your options. This can help you continue to enjoy breastfeeding your baby long after you return from taking time off.[5]

- Discuss different types of schedules with your boss or academic advisor, such as going back part-time at first, registering for morning or evening classes, or taking split shifts.

- Find out if your company or school offers a lactation support program for employees or students.

- Talk to other women at your company or school. Ask the lactation program director, your supervisor, your academic advisor, your school health center, the wellness program director, the employee human resources office, or other coworkers or classmates if they know of other women who breastfed after returning to work or school.

DURING YOUR TIME OFF

- Take as many weeks off as you can. At least six weeks of leave can help you recover from childbirth and settle into a good breastfeeding routine. Twelve weeks is even better.

- A breast pump may be the best method for efficiently removing milk during the workday or school day.

- Help your baby adjust to taking breastmilk from a bottle (or cup, syringe, or dropper). Babies used to nursing might prefer to take milk a different way when someone else gives it.”

- If possible, wait at least a month before introducing a bottle (cup, syringe, or dropper) to your infant.

- Work with your doctor, nurse, IBCLC, or midwife to find the best way to feed your baby breastmilk when you return to work.

- Talk with your family and your child care provider about your desire to breastfeed. Let them know you will need their support.

BACK AT WORK OR SCHOOL

- Keep talking with your supervisor or academic advisor about your schedule and what is or isn’t working for you. Keep in mind that returning to work or school gradually gives you more time to adjust.

- If your child care is close by, find out whether you can visit to breastfeed over lunch.

- When you arrive to pick up your baby from child care, take time to breastfeed first. This will give you both time to reconnect before traveling home and returning to other family responsibilities.

GET A QUALITY BREAST PUMP

A good-quality electric breast pump may be your best strategy for efficiently removing milk during the workday.

Electric pumps that allow you to express milk from both breasts at the same time reduce pumping time. See page 42 for more information on types of breast pumps and how to work with your insurance company to get them.

FIND A PRIVATE PLACE TO EXPRESS MILK

Work with your supervisor or school administrator to find a private place to express your milk.

If your company does not provide a private lactation room, find another private area you can use. You may be able to use an office with a door, a conference room, or a little-used storage area.

The room should be private and secure from intruders when in use. The room should also have an electrical outlet if you are using an electric breast pump. Explain to your supervisor that it is best not to express milk in a restroom. Restrooms are unsanitary, and there are usually no electrical outlets. It can also be difficult to manage a pump in a toilet stall.

WHEN TO EXPRESS MILK

At work or school, you will need to express and store milk during the times you would normally feed your baby. (In the first few months of life, babies need to breastfeed eight to 12 times in 24 hours.) This turns out to be about two to three times during a typical eight-hour work period. As the baby gets older, the number of feeding times may go down. Expressing milk can take about 10 to 15 minutes. Sometimes it may take longer. Many women use their regular breaks and lunch break to pump.

HOW MUCH MILK SHOULD I SEND WITH MY BABY DURING THE DAY?

You may need to pump two to three times each day to make enough milk for your baby while he or she is with a caregiver. Research shows that breastfed babies between 1 and 6 months old take in an average of two to four ounces per feeding.

Some babies eat less during the day when they are away from their breastfeeding mothers and then nurse more often at night. This is called “reverse-cycling.” Babies may eat during the day and still nurse more often at night. This may be more for the closeness with you that your baby craves. If your baby reverse-cycles, you may find that you do not need to pump as much milk for your baby during the day. Track your baby’s weight and diapers to make sure your baby gets enough milk.
(See page 20 for more ways to tell whether your baby is getting enough milk.)

PUMPING TIPS

It may take time to adjust to pumping breastmilk in a work or school environment. For easier pumping, try these tips for getting your milk to let down from the milk ducts:

- Relax as much as you can.

- Gently massage your breasts.

- Visualize the milk flowing down.

- Think about your baby. Bring a photo of your baby or a blanket or item of clothing that smells like your baby.

STORING YOUR MILK

Breastmilk is food, so it is safe to keep it in any clean refrigerator used for food storage or a cooler with ice packs. Talk to your supervisor or school administrator about the best place to store your milk. If you work in a medical department, do not store milk in the same refrigerators where medical specimens are kept.

Be sure to label the milk container with your name and the date you expressed the milk.

YOUR BUSINESS CAN TAKE EASY STEPS TO SUPPORT BREASTFEEDING!

SUPPORTING NURSING MOMS AT WORK

The Office on Women’s Health has resources to help businesses support nursing mothers at work at this website https://www.womenshealth.gov/
supporting-nursing-moms-work. This site offers cost-effective tips and time and space solutions listed by industry.

THE BUSINESS CASE FOR BREASTFEEDING

The Office on Women’s Health partnered with the Health Resources and Services Administration to create a toolkit that encourages business owners to support breastfeeding. The program points out the benefits of breastfeeding to businesses and gives them easy steps to make a breastfeeding-friendly work environment. Share this site with your employer: https://www.womenshealth.gov/
breastfeeding/breastfeeding-home-work-and-public/breastfeeding-and-going-back-work/business-case.

NUTRITION AND FITNESS

HEALTHY EATING

A healthy diet is important for moms who are breastfeeding babies, but many new moms wonder whether they should be on a special diet while breastfeeding. The answer is no. In fact, you can continue to enjoy the foods that are important to your family, including the special meals you know and love.

As for how your eating habits affect your baby, there are no special foods that will help you make more milk. You may find that some foods you eat can cause stomach upset in your baby. You can try avoiding those foods to see if your baby feels better and ask your baby’s doctor for help.

Keep these important nutrition tips in mind:

- Drink plenty of fluids to stay hydrated. Drink when you are thirsty, and drink more fluids if your urine is dark yellow.

- Limit drinks with added sugars, such as sodas and fruit drinks.

- Limit the amount of caffeine you get each day. Drinking a moderate amount (one or two cups a day) of coffee or other caffeinated beverages does not cause a problem for most breastfeeding babies. Too much caffeine can cause the baby to be fussy or not sleep well.

- Talk to your doctor about taking a supplement. Vitamin and mineral supplements should not replace healthy eating, but in addition to healthy food choices, some breastfeeding women may need a multivitamin and mineral supplement.

- Talk to your doctor or nutritionist to ensure you are consuming the right amount of calories and a well-balanced, nutrient-rich diet.

- See page 30 for information on drinking alcohol and breastfeeding.

ADVICE ABOUT EATING FISH

Fish and other protein-rich foods have nutrients that can help your child’s growth and development. This chart can help you choose which fish to eat, and how often to eat them, based on their mercury levels. https://www.fda.gov/media/102331/download.

VEGAN DIETS

If you follow a diet that does not include any forms of animal protein (meat, fish, milk and milk products, and eggs), you or your baby might not get enough vitamin B-12. In a baby, B-12 deficiency can cause symptoms such as loss of appetite, slow motor development, being very tired, weak muscles, vomiting, and blood problems. You can help protect your and your baby’s health by taking vitamin B-12 supplements while breastfeeding. Talk to your doctor about your supplement needs.

CHOOSEMYPLATE FOR MOMS

GET A DAILY PLAN FOR MOMS DESIGNED JUST FOR YOU.

The USDA’s online, interactive tool can help you choose foods based on your baby’s nursing habits and your energy needs. Visit choosemyplate.gov/browse-by-audience/view-all-audiences/adults/moms-pregnancy-breastfeeding to figure out how much you need to eat, choose healthy foods, and get the vitamins and minerals you need.

CAN THE FOOD I EAT AFFECT MY BREASTMILK?

Sometimes a baby may be sensitive to something the breastfeeding mother eats such as eggs or dairy products like milk and cheese. Watch your baby for the symptoms listed below, which could indicate that your baby has an allergy or sensitivity to something you eat:

- Diarrhea, vomiting, green stools with mucus or blood

- Rash, eczema, dermatitis, hives, dry skin

- Fussiness during or after feedings

- Inconsolable crying for long periods

- Sudden waking with discomfort

- Wheezing or coughing

These signs do not mean your baby is allergic to your milk, only to something that you ate. You may need to stop eating whatever is bothering your baby or eat less of it. You may find that after a few months you can eat the food again with better results.

Talk with your baby’s doctor if you notice your baby having any of the symptoms listed above. If your baby ever has problems breathing, call 911 or go to your nearest emergency room.

FITNESS

Being active helps you stay healthy, feel better, and have more energy. It does not affect the quality or quantity of your breastmilk or your baby’s growth. It may help to wear a comfortable support bra or sports bra and pads in case you leak during physical activity. It is also important to drink plenty of fluids. Be sure to talk to your doctor about how and when to slowly begin exercising following your baby’s birth.

HANDLING STRESS

Both short- and long-term stress can affect your body. In fact, stress can make you more likely to get sick. It can also make problems you already have worse. It can play a part in a range of issues, including trouble sleeping, stomach problems, headaches, and mental health conditions.

Having a new baby and learning to breastfeed may be stressful. It is important for new mothers to take care of themselves. Try to listen to your body so that you can tell when stress is affecting your health.

Take these steps to help ease stress while breastfeeding:

RELAX.

Try and find a quiet, comfortable, relaxing place to nurse. This will help make breastfeeding more enjoyable for you and your baby. Use this time to bond with your baby, listen to soothing music, meditate, or read a book.

SLEEP.

Your stress could get worse if you don’t get enough sleep. With enough sleep, it is easier to cope with challenges and stay healthy. Try to sleep whenever possible.

SURROUND YOURSELF WITH SUPPORTIVE PEOPLE.

It really does take a village to raise a child. Let family and friends help you with housework or hold your baby while you rest or take a bath.

GET MOVING.

Physical activity improves your mood. Your body makes certain chemicals, called endorphins, before and after you exercise. These relieve stress and improve your mood. If you are a new mother, ask your doctor when it is okay to start exercising.

DON’T DEAL WITH STRESS IN UNHEALTHY WAYS.

This includes drinking too much alcohol, using drugs, or smoking, all of which can harm you and your baby. It is also unhealthy to overeat in response to stress.

GET HELP FROM A PROFESSIONAL IF YOU NEED IT.

A therapist can help you work through stress and find better ways to deal with problems. Medicines can help ease symptoms of depression and anxiety and help promote sleep. Talk to your doctor or pharmacist before taking any medicine. See page 31 for more information.

DID YOU KNOW?

Breastfeeding may help mothers relax and handle stress better. Skin-to-skin contact with your baby has a soothing effect.

WEANING YOUR BABY

Are you ready to wean? Do you think your child is ready to wean?

From the first time you feed your baby something other than your milk, the process of weaning begins. Weaning is the journey between when your child is fully breastfed (or breastmilk-fed, if you feed expressed milk) and when your child stops nursing for comfort and nutrition.

In the normal course of breastfeeding, weaning happens gradually and without any conscious effort or action. However, you may have a desire or reason to wean before your child would have naturally stopped nursing or receiving your milk.

If you need or want to actively wean before it happens on its own, it is best for you and your child to go slowly. Weaning suddenly can be physically painful for you and emotionally hard on you and your baby.

WHEN TO WEAN YOUR BABY

In cultures where there is no social pressure to wean, children usually stop breastfeeding or receiving their mother’s milk between 2½ and 7 years old.[6]

In families that let it happen on its own, weaning happens very gradually, often without any fuss, process, or effort.

The American Academy of Pediatrics recommends:

- Breastfeed exclusively (no other foods or drinks) for the first 6 months of your baby’s life.

- After 6 months of age, continue to breastfeed and begin to add solid foods (this is when weaning begins).

- After your baby’s first birthday, continue to breastfeed for as long as both you and your baby are comfortable. Some mothers and babies continue to nurse into the toddler years and beyond. Breastfeeding is good for mother and child at any age, and no evidence has been found of developmental harm from breastfeeding an older child.

You may also want to consider delaying weaning if:

- Your child is teething or sick. Your baby will need extra comfort during these times. Also, the antibodies in your breastmilk help your baby fight off illness and germs.

- Your family is going through a major change, like moving or if you recently went back to work and your baby is now in child care.

- Your baby is struggling. If your baby is resisting all your attempts to wean, it may just not be the right time. If you can, wait and try again in another month or two.

If you have been advised to stop breastfeeding because you need surgery or you take a certain medicine, be sure to get a second opinion. There are very few reasons that complete weaning is absolutely necessary. In most cases, you can still breastfeed after surgery, and many medicines are safe for both baby and the breastfeeding mother.

Talk to an IBCLC who can help you decide whether you truly need to wean or just need some help getting you and your baby through a difficult time.

Also, try not to make the decision to wean on a day when breastfeeding is difficult.

HOW TO TELL WHEN YOUR CHILD IS READY TO WEAN

Children who wean themselves rarely do so suddenly and without warning. The process is generally slow and gradual, even for babies who wean from the breast earlier than is normal due to separation from their breastfeeding mother, pacifier use, or bottle-feeding.

If your baby suddenly rejects your breast, it is more likely a nursing strike, not a readiness to wean. Read more about nursing strikes on page 28.

You can watch for these signs, but they may be so gradual you may not notice:

NURSING SESSIONS HAPPEN LESS OFTEN.

As children age, they naturally become more occupied with playing, exploring, and using their new skills like walking, talking, and eating interesting foods. Nursing sessions get further apart, even to the point of happening once a day, or, as time goes on, once every few days or a few times a month.

HE OR SHE LOSES INTEREST IN NURSING.

Young children (younger than a year) who seem to lose interest in breastfeeding may do so because they get the comfort they need from sucking on pacifiers or their thumbs. These comforting behaviors may be more familiar to them than nursing. For these babies, weaning from the breast may not be difficult, but their nutritional and emotional needs will remain.

DOES MY CHILD NEED FORMULA WHEN I WEAN?

It depends on the age of your child, and whether they are able to get enough nutrition from other foods and beverages.

IF YOUR BABY IS YOUNGER THAN 1 YEAR, it depends on how much breastmilk your baby is still getting. Talk to your baby’s doctor to determine if your baby needs formula and how much.

IF YOUR BABY IS OLDER THAN 1 YEAR, they do not need formula.

HOW TO WEAN YOUR BABY

Weaning works best when it happens slowly, in its own time. However, there are some reasons you may have to stop breastfeeding before your baby is ready and even perhaps before you planned to stop breastfeeding.

Weaning your child suddenly — going “cold turkey” — may cause your breasts to become painfully engorged.

- If your baby is still very young, you may need to express some milk from your breasts or pump a tiny amount if your breasts become uncomfortable. Do not express or pump the amount you normally would for a feeding. When you pump or nurse, your breasts make more milk in response. By removing less milk than normal, your breasts will make less milk. Contact an IBCLC if you have overly full breasts while weaning.

- You will need to substitute your milk with formula if your baby is younger than 1 year. If your baby is older than 1 year, you can stop offering the breast and drop one feeding a time, over several weeks.

- Start by taking away his or her least favorite feeding first. Nursing sessions that come before falling asleep or after waking are often the ones to go last. Wait a few days to drop another feeding.

- Avoid sitting in your special nursing chair, but do offer extra cuddles or babywearing during this transition so your child can still enjoy being close to you.

- Distract your child with an activity or outing during the times when you would normally nurse.

- If your baby likes to nurse to sleep, try a car ride or let your partner do the bedtime routine.

- Remember, even if you and your child are ready to wean, it can be hard emotionally on both of you. Give your baby lots of extra love and attention during this time.

- Talk to your child about weaning. Even young children can understand what you are saying and offer their opinions and ideas for how best to stop breastfeeding.

Even when you wean slowly and gradually, it may still be uncomfortable for you. Try these tips to ease discomfort.

- Hand-express or pump just enough milk to take the pressure off.

- Do not bind your breasts. This can cause plugged ducts or a breast infection.

- Talk to your doctor about whether a pain reliever, such as ibuprofen, might be helpful for you.

HEALTH INFORMATION FROM THE OFFICE ON WOMEN’S HEALTH

The Office on Women’s Health (OWH) offers a wide range of health information for women and girls through our website womenshealth.gov.

Follow us on Facebook (www.facebook.com/HHSOWH) or Twitter (www.twitter.com/womenshealth) to get the latest on breastfeeding and other women’s health topics.

www.womenshealth.gov
Empowering women to live healthier lives

www.womenshealth.gov/itsonlynatural
Sharing benefits of breastfeeding with African-American women

www.girlshealth.gov
Helping girls learn about health and growing up

________________

[1]https://effectivehealthcare.ahrq.gov/topics/breastfeeding/research

[2]Mori, R., Khanna, R., Pledge, D., Nakayama, T. (2010). Meta-analysis of physiological effects of skin-to-skin contact for newborns and mothers. Pediatr Int; 52(2):161-70.

[3]Bartick, M.C., Schwarz, E.B., Green, B.D., Jegier, B.J., Reinhold, A.G., Colaizy, T.T., Bogen, D.L., Schaefer, A.J., Stuebe, A.M. (2017). Suboptimal breastfeeding in the United States: Maternal and pediatric health outcomes and costs. Matern Child Nutr; 13 (1).

[4]https://www.cdc.gov/breastfeeding/data/reportcard.htm.

[5]Ogbuanu, C., Glover, S., Probst, J., Liu, J., Hussey, J. (2011). The effect of maternity leave length and time of return to work on breastfeeding. Pediatrics; 127(6):e1414-27)

[6]Dettwyler, K. A., Stuart-Macadam, P. (Eds.). (1995). Breastfeeding: Biocultural Perspectives. Piscataway, NJ: Aldine Transaction. Accessed on August 4, 2014, from Rogoff, B. (2003). The Cultural Nature of Human Development. Oxford University Press. pp. 64–65.