Should Your Child See a Doctor?

Breast-Feeding Questions

Definition

  • This guideline covers common questions asked about breastfeeding

Topics Covered  

If your infant is healthy, go directly to the number of the topic that relates to your child for specific care advice:

  1. Frequency of feedings to bring in the milk supply
  2. Length of feedings to bring in the milk supply
  3. Signs of adequate milk supply (Do I have enough milk?)
  4. How to increase milk supply
  5. Supplemental formula
  6. Extra water
  7. Severe engorgement (generalized swelling and pain) of both breasts
  8. Blocked milk ducts (1 or more tender lumps in the breast)
  9. Sore or cracked nipples
  10. Mother's medicines
  11. Mother's smoking or tobacco use
  12. Mother's diet
  13. Sick infants
  14. Sick mother (with acute illness)
  15. Normal stools during the first weeks of life
  16. Normal infrequent breastmilk stools after 1 month of age
  17. Leaking breastmilk
  18. Vitamin D and fluoride for breastfed baby
  19. Storage of pumped milk

Consultants:  

Lisbeth Gabrielski, RN and Marianne Neifert, MD, lactation specialists

When to Call Your Doctor for Breast-Feeding Questions

Call 911 Now (your child may need an ambulance) If

  • Unresponsive or difficult to awaken
     
  • Not moving or very weak
     
 

Call Your Doctor Now (night or day) If

  • Your child looks or acts very sick
     
  • Age under 1 month old and looks or acts abnormal in any way
     
  • Signs of dehydration (less than 3 wet diapers/day, pink-colored urine, sunken soft spot and very dry mouth)
     
  • Age under 1 month old and refuses to breastfeed for more than 6 hours
     
  • Refuses to drink anything for over 8 hours
     
  • Looks deep yellow or orange
     
  • Age under 12 weeks with fever above 100.4° F (38.0° C) rectally (Caution: Do NOT give your baby any fever medicine before being seen.)
     
 

Call Your Doctor Within 24 Hours (between 9 am and 4 pm) If

  • You think your child needs to be seen
     
  • Doesn't seem to be gaining weight by day 5
     
  • Less than 3 normal-sized, yellow-colored, seedy stools/day during the first 4 weeks of age
    (EXCEPTION: before 5 days of life while milk is coming in)
     
  • Day 2-4 of life and no stool in over 24 hours
     
  • Less than 6 wet diapers/day (EXCEPTION: before 5 days of life while milk is coming in)
     
  • Day 2-4 of life and no urine in over 8 hours
     
  • The mother has signs of breast infection (red, tender area on breast)
    (EXCEPTION: localized engorgement)
     
 

Call Your Doctor During Weekday Office Hours If

  • You have other questions or concerns
     
  • Seems hungry after feedings (Reason: needs a weight check)
     
  • Needs a supplement (formula or expressed breastmilk) during first month (Reason: breastfeeding not going well)
     
 

Parent Care at Home If

  • Breastfeeding question about healthy child and you don't think your child needs to be seen
     
 

Home Care Advice for Breastfeeding; Topics 1-19

  1. Frequency of Feedings to bring in the milk supply:
    • Every 1½ to 3 hours for the first month (8 to 12 times/day).
    • During the day, wake your baby up if more than 3 hours have passed since the last feeding.
    • During the night, wake your baby if more than 4 hours pass without a feeding.
    • After 1 month of age, allow your baby to sleep longer. If your baby is gaining weight well, feed on demand and do not awaken for feedings.
       
     
  2. Length of Feedings to bring in the milk supply:
    • Offer both breasts with each feeding
    • 10 min. on first breast and up to 15 min. on second breast if your baby is actively suckling
    • Alternate which breast you start on
    • Needing to stimulate your baby to take the second breast is normal
    Length of Feedings after milk supply is in: (by day 8 at the latest)
    • Allow your baby to nurse as long as she wants to on the first breast (up to 20 minutes). (Reason: to get the high-fat, calorie-rich hind milk)
    • You can tell your baby has finished the first breast when the sucking slows down and your breast becomes soft. Then offer the 2nd breast if she's interested.
    • Alternate the breast you start with at each feeding.
       
     
  3. Signs of Adequate Milk Supply: (i.e., your baby is receiving enough breast milk)
    • STOOLS: 3 or more good-sized, yellow-colored, seedy stools/day (EXCEPTION: May not be present while the milk is coming in until day 5 of life. See Care Advice #15 on Breastfed Stools for additional information). Caution: Once the milk is in, infrequent BMs are not normal until after 4 weeks of age.
    • URINE: 6 or more wet diapers/day (EXCEPTION: 3 wet diapers/day can be normal while milk is coming in until day 5 of life). Note: if uncertain about diaper being wet, place tissue in diaper.
    • Satisfied (not hungry) after feedings
    • Breasts feel full before feedings and soft after feedings
    • It is very important that your baby is latched on correctly, so she can get enough milk. Look and listen for consistent swallowing; this shows that your milk has letdown. The letdown reflex is the automatic release of breastmilk into the milk ducts just before a feeding. It develops after 2 to 3 weeks of nursing. Initially, milk letdown may require 60 to 90 seconds of sucking before it starts.
       
     
  4. How to Increase Milk Supply:
    • Adequate sleep (extra naps), reduced stress (ask for help), relaxed environment, adequate fluids (1 quart of milk and 1 quart of water per day). (Minimum: One 8 oz. glass of fluid every 4 hours while awake)
    • Increase the frequency of nursing and minimize the use of the pacifier
    • Pump the breasts for 10 minutes after each feeding for a few days (see lactation consultant). Electric breast pumps give the best results.
       
     
  5. Supplemental Formula:
    • Don't offer your baby any bottles of formula before 3 to 4 weeks old (Reason: it will interfere with establishing a good milk supply)
    • EXCEPTION: Medical indications to prevent dehydration or severe jaundice include the following: The milk is not in (day 2 - 4) AND your baby is very hungry (especially preterms), inadequate number of wet or soiled diapers or your baby is quite jaundiced. (Reason: prevent dehydration)
    • Method: give 1 oz. of expressed breastmilk or formula after every breastfeeding for 1 or 2 days. Also see your baby's doctor within 24 hours for a weight check.
       
     
  6. Extra Water:
    • Never give extra water to infants younger than 6 months because it can cause a seizure.
    • It's not needed. (Reason: breast milk contains 88% water)
    • If your baby gets adequate breastmilk, additional fluids are not necessary and may decrease your baby's interest and ability to breastfeed.
       
     
  7. Engorgement (Generalized swelling and pain of both breasts) :
    • Engorgement usually begins 2 or 3 days after delivery
    • Also can occur at anytime when breasts are not emptied regularly
    • Breastfeed your baby more frequently (avoid the use of pacifiers).
    • Hand express or briefly use a breast pump to remove a little milk before feeding your baby.
    • Compress the areola with your fingers at the start of each feeding to soften the areola and help your baby latch-on. Milk release won't occur if your baby only latches on to the nipple.
    • Pump your breasts, whenever they hurt, a feeding doesn't relieve the pain or when you must miss a feeding.
    • Use cold compresses on the breasts between feedings ( A bag of frozen peas works well).
    • Call your doctor or lactation consultant if: not improved after 24 hours of treatment.
       
     
  8. Blocked Milk Ducts (tender lump in the breast):
    • Caused by incomplete emptying of the breast
    • Treatment goal: open up the blocked milk ducts
    • Breastfeed your baby more frequently (avoid the use of pacifiers)
    • After each breastfeeding session, apply heat to the breast lump for 10 minutes (e.g., with a hot shower, hot bath or heating pad).
    • While applying heat, massage the swollen areas toward the nipple.
    • Try different breastfeeding positions which may drain the affected area (ducts) better.
    • Call Your Doctor If:
      • Lump becomes red and very painful
      • Fever over 101 F (38.3 C) occurs
      • Not improved after 24 hours of treatment
      • Your baby starts acting sick
         
       
     
  9. Sore or Cracked Nipples:
    • Usually due to friction from improper latching on or non-areolar grasp
    • Clean with warm water once daily (avoid soap which dries out the skin)
    • Then coat and lubricate nipple and areola with breast milk for sore nipples
    • For cracked nipples, apply 100% lanolin (no prescription) after feedings (Exception: mother allergic to wool)
    • Help your baby latch on to as much of the areola as possible by compressing areola. (Proper latching-on should prevent nipple injury)
    • Prevent the breast from pulling out of your baby's mouth by supporting the breast from below during feedings
    • Start feedings on the side that is least sore
    • Limit feedings to less than 10 minutes on the sore side
    • Don't pull your baby off the nipple until she has released her grip. You can break the seal by placing your finger in baby's mouth between the gums.
    • Call your doctor if: not improved after 24 hours of treatment.

     
  10. Mother's Medicines:
    • It's best to take your drug at the end of a feeding
    • Most commonly used drugs are safe: e.g., acetaminophen, ibuprofen, penicillins, erythromycin, cephalosporins, stool softeners, cough drops, nose drops, eyedrops, and skin creams.
    • Avoid decongestants (pseudoephedrine and phenylephrine) because they reduce milk production in some mothers.
    • Avoid aspirin because of a small risk for Reye's syndrome.
    • Avoid sulfa drugs (Septra and Bactrim) until baby is 4 weeks old.
    • Antihistamines for allergy symptoms are usually acceptable during breastfeeding. Non-sedating antihistamines (e.g., Loratadine) are preferred, given as needed once per day at bedtime. Avoid combination products with decongestants.
    • Birth control pills can decrease your milk volume. Make sure that your milk supply is well established (6 weeks or more) before starting. Ask your baby's doctor which birth control medication is best.
    • For all other drugs, call your doctor or consult the LactMed website.
      • LactMed is a drug/lactation website that provides information regarding the safety of medications while nursing. It's located on TOXNET , the toxicology data website of the National Library of Medicine.
         
       
     
  11. Mother's Smoking or Tobacco Use:
    • It is best to avoid tobacco; however, the benefit of giving your baby your milk generally outweighs the risks of tobacco use.
    • The nicotine and its byproducts pass into the milk and may cause restlessness, increased heart rate, and loose stools. Heavy tobacco use (over ½ pack per day) can decrease your milk supply and affect letdown.
    • When used as directed, smoking cessation aids pose no more problems for the breastfed infant than smoking.
    • If you smoke, do not smoke around your baby.
       
     
  12. Mother's Diet:
    • Foods: Eat a diet that is varied and balanced. No specific foods should be eaten or avoided. The effect on the baby of foods in the mother's diet (including chocolate) is overrated. Most foods eaten in moderation are well tolerated.
    • Caffeine: Excessive caffeine from coffee, tea or soft drinks can cause restlessness, crying or even diarrhea. Limit caffeine drinks to two 8 oz. servings/day.
    • Alcohol: It is best to avoid alcohol during breastfeeding. Excessive alcohol can cause drowsiness and affect your milk letdown. Limit to an occasional drink of beer or wine (no more than 1 per day).
       
     
  13. Sick Infants:
    • Do not discontinue breastfeeding for vomiting, spitting up, diarrhea, cough, jaundice, etc. See the appropriate guideline for that symptom.
    • Continue breastfeeding whenever possible.

     
  14. The Mother is Sick (has an acute illness):
    • Continue breastfeeding, even if you have a fever. (Reason: Breast milk carries your antibodies which can protect your baby from the full-blown infection.)
    • Try to prevent the spread of infection by good hand rinsing, especially after blowing your nose (for colds) or after stools (for diarrhea)
    • Contraindications to breastfeeding are rare: AIDS, Herpes simplex rash (fever blisters) on the nipple/areola, substance abuse and tuberculosis. Talk with your doctor.
       
     
  15. Breastfed Stools During the First Weeks of Life:
    • Meconium Stools are dark greenish-black, thick and sticky. They normally are passed during the first 2 days of life.
    • Transitional Stools (a mix of meconium and milk stools) are greenish-brown and loose. They are passed day 3 to 4 of life. While breastmilk is coming in (Days 1 to 4), babies should pass at least one stool per day. By day 5, passing black or dark green stools is abnormal and lactation needs assessment.
    • Normal Breastmilk Stools without any meconium present are seen from day 5 onward. Once breastmilk is in, breastfed babies pass from 3 stools per day to 1 after each feeding during the first month. The stools are runny, mustard-colored and can contain seedy particles. Normal size stool is usually 1/2 to 1 tablespoon (8 to 15 ml). Normal breastfed stools can even become green or have a water-ring around them during the first month. (Reason: rapid transit)
    • If breastfed babies receive any formula, their stools become darker, more frequent, more formed and odorous.
    • Breastfed stools have changed to true diarrhea if:
      • They contain blood or mucus
      • Develop a bad odor or abruptly increase in number
      • Your baby feeds poorly, acts sick, or develops a fever
       

     
  16. Normal Infrequent Breastfed Stools After 1 Month of Age:
    • Between 4 and 8 weeks of age, some breastfed babies change to normal infrequent stools.
    • They can pass 1 large soft stool every 4 to 7 days.
    • Reason: complete absorption of breastmilk.
    • The longer they go without a stool, the larger the volume that is passed.
    • There is no pain or crying with stool passage.
       
     
  17. Leaking Breastmilk:
    • Leaking milk is a common problem that nursing mothers experience during the first months. Usually, the leaking decreases as a balance is established between what the baby drinks and what the breasts make. Here's what you can do:
    • Maintain a regular nursing pattern. Try to avoid skipping or postponing feedings. (Reason: More milk leaks from over-full breast)
    • Use nursing pads (disposable or reusable) under your bra. Change pads frequently to keep your nipples dry.
    • Tops (shirts) with patterns hide milk spots better.
    • If this advice doesn't help, ask a lactation consultant for additional suggestions.
       
     
  18. Vitamin D and Fluoride for the Baby:
    • Breastmilk contains all the necessary vitamins and minerals except Vitamin D and fluoride.
    • Beginning in the first week of life, all breastfed babies need to receive 400 IU per day of Vitamin D (AAP Committee on Nutrition 2009). You can use separate Vitamin D drops. Or, you can use use Vitamin ADC drops in a dosage of 1 ml per day. No prescription needed.
    • Continue Vitamin D supplements until your child receives at least 32 oz (1000 ml) of formula or cow's milk per day.
    • Starting at 6 months of age, children who are breastfeeding and not drinking any water (with fluoride) need 0.25 mg of fluoride drops each day to prevent tooth decay. This is a prescription item that you can obtain from your child's physician.
       
     
  19. Storage of Breastmilk:
    • Freshly pumped breast milk can be stored for 5 days in a refrigerator.
    • Frozen breastmilk can be kept 3-4 months in a self-contained refrigerator unit or up to 6-12 months in a deep freezer. If your ice cream is solidly frozen, the temperature is adequate.
    • To thaw frozen milk, put the container of breast milk in the refrigerator, where it will take a few hours to thaw.
    • For quicker thawing, place it in a pan of warm water until it has warmed up to the temperature your baby prefers. Never warm it up in a microwave or boiling water; this would destroy the protective antibodies.
    • After thawing, breastmilk can be kept safely in the refrigerator for 24 hours. Do not refreeze. After feeding your baby, discard unused breastmilk in a bottle after 1 hour.
       
     
  20. Call Your Doctor If:
    • Your baby has trouble latching on with most feeds
    • Your baby is not sucking and swallowing consistently
    • Your baby acts hungry after most feeds ( e.g., crying after feeds)
    • Your baby starts acting abnormal
    • Breastfeeding is painful
    • You have other questions about breastfeeding
     

And remember, contact your doctor if your child develops any of the "When to Call Your Doctor" symptoms.

References

  1. American Academy of Pediatrics, Academy of Breastfeeding Medicine. ABM Protocols (Protocol #3): Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate. http://www.bfmed.org  
  2. American Academy of Pediatrics, Academy of Breastfeeding Medicine. ABM Protocols (Protocol #8): Human Milk Storage Information for Home Use for Healthy Full Term Infants. http://www.bfmed.org  
  3. American Academy of Pediatrics, Academy of Breastfeeding Medicine. ABM Protocols (Protocol #10): Breastfeeding the nearterm infant (35-37 weeks gestation). http://www.bfmed.org  
  4. American Academy of Pediatrics, Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics. 2001;108(3):776-788.
  5. American Academy of Pediatrics, Committee on Nutrition: Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008;122:1142-1152.
  6. American Academy of Pediatrics. AAP Policy Statement: Breastfeeding and the use of human milk. Pediatrics. 2005;115(2):496-506.
  7. Dewey KG. Maternal and fetal stress are associated with impaired lactogenesis in humans. J Nutr. 2001;131(11):3012S-3015S.
  8. Escobar GJ, Gonzales VM, Armstrong MA. Rehospitalization for neonatal dehydration. Arch Pediatr Adolesc Med. 2002;156:155-161.
  9. Freed GL and Clark SJ. Breastfeeding and maternal illness. Contemp Pediatr. 1996;13(4):49-61.
  10. Gilhooly J and Hellings P. Breast-feeding problems and telephone consultation. J Pediatr Health Care. 1992;6:343-348.
  11. Hale T. Medications and Mothers' Milk. 12th Ed. Texas: Pharmasoft Publishing; 2006.2008.
  12. Medela. Breastmilk Collection and Storage: Guidelines for Healthy Newborns. (2006).
  13. Meek JY, (Editor). New Mother's Guide to Breastfeeding. Elk Grove Village, IL: American Academy of Pediatrics;2002.
  14. Neifert M. Early assessment of the breastfeeding infant. Contemp Pediatr. 1996; 13(10):142-166.
  15. Neifert MR. Prevention of breastfeeding tragedies. Pediatr Clin North Am. 2001;48(2):1-23.
  16. Philipp BL. Every call is an opportunity: supporting breastfeeding mothers over the telephone. Pediatr Clin North Am. 2001;48:525-532.
  17. Philipp BL and Cadwell K. Fielding questions about breastfeeding. Contemp Pediatr.1999;16(4):149-164.
  18. Powers NG and Slusser W. Breastfeeding update 2: Clinical lactation management. Pediatr Rev. 1997;18:147-161.

Disclaimer

This information is not intended to be a substitute for professional medical advice. It is provided for educational purposes only. You assume full responsibility for how you choose to use this information.

Author and Senior Reviewer: Barton D. Schmitt, M.D.

Last Reviewed: 8/1/2010

Last Revised: 10/1/2010 1:03:49 PM

Copyright 1994-2011 Barton D. Schmitt, M.D.