How Does Milk Production Work in the Early Days Postpartum?

The first few days and weeks after your baby is born can be confusing. You have so much to learn and so many things to worry about. It's stressful and scary. You want to be sure you're doing the best you can for your baby, and that includes making sure he's getting enough to eat. When you're breastfeeding, it can be hard to tell how much your baby is taking in and whether it's as much as he needs or wants.

So let's talk about how milk production works in those early days, so that you can be more confident that your baby is satisfied.

You start producing the early milk, called colostrum, between 10 and 14 weeks of pregnancy. Colostrum is milk, but it's not the mature milk you'll see a few days after your baby is born. Rather, it's a highly concentrated, thick, golden liquid consisting mostly of protein, beta carotene, and antibodies. Colostrum is sometimes called "liquid gold" because it is so valuable to a newborn baby to help protect his tender new gut, support his undeveloped immune system, and prepare him for life outside the womb.

10mL (2 tsp) of colostrum pumped on my baby's second night of life.

The presence of the placenta and the progesterone it produces keeps your milk volume low, so you won't produce mature milk until after your baby is born and the placenta is expelled. Your levels of prolactin - the hormone that tells your breasts to produce milk - are very high at the birth of your baby, but it's just floating around in your blood stream with no way to send the message until you start actually nursing a baby. The action of the baby suckling at your breast (or of a breast pump or hand expression) creates "prolactin receptors," places for the prolactin to attach within the breast so that the message to produce milk can be sent. The takeaway from this is simple: The more you nurse your baby in the first 3 days of life, the better your milk supply will be even months down the line.

Now, once the baby is born and the placenta detaches, your levels of progesterone, the hormone produced by the placenta that supports the pregnancy, drop, and you've started establishing prolactin receptors. This paves the way for the prolactin to do its job, and your body will begin producing more milk - and that milk will be the mature, watery, white substance we think of when we think of "milk."

It takes about 48 to 72 hours for your milk volume to increase. In the first two to three days of your baby's life, he does not need to eat much. Remember that he was being constantly fed by the umbilical cord while inside you, and his intestines are full of meconium - a greenish-black, tarry substance that coats the intestines. There isn't room for much food until the meconium is cleared out. Colostrum, along with all of its other amazing properties, acts as a laxative to help clear out that meconium. Your baby's stomach is very tiny at first and cannot hold more than about a teaspoon (5mL) of milk anyway, so it doesn't take much for him to feel full. Remember, in the last few weeks of your pregnancy, he was packing on fat stores to help him survive these first few days of life where he suddenly isn't eating much.

Though your baby isn't super hungry at birth, he will have a high need to suck. This high need to suck serves a few purposes. First, when the baby suckles at the breast, it stimulates the release of oxytocin, which helps the mother's uterus shrink back down and slows her postpartum bleeding. Second, as mentioned before, it helps set up receptors for the milk-production hormone called prolactin. Third, the sucking stimulates the baby's intestines to start moving out the meconium to make room for the milk. Finally, newborns find sucking comforting. Babies even suck on their hands inside the womb!

Remember that breastfeeding takes practice. The best thing to do in these first few days postpartum is to bring the baby to breast absolutely as often as possible, at least 12 times in 24 hours, or as often as the baby asks. The quickest and easiest way to learn your baby's hunger signals is to start out by offering the breast every time your baby fusses. You'll begin to recognize certain movements of his head and mouth that indicate that he wants to nurse. You'll learn the different types of cries that mean he's hungry or tired or uncomfortable. By offering the breast every time your baby seems fussy, you'll give yourself and the baby every opportunity to practice nursing and to establish those prolactin receptors and build your milk supply!

By about 72 hours after the birth, you should notice that your breasts feel fuller and are now producing something that looks a great deal more like "milk" than the colostrum did. Some women find they become extremely engorged literally overnight, while others notice a more gradual increase in volume. If your milk hasn't increased in volume by about 72 hours after birth, you may need to speak with a lactation consultant and/or your baby's pediatrician about providing supplemental donor milk or formula until you have a greater volume of milk available. It is important that your baby start eating so that he can grow.

Once the milk supply does increase, you'll want to know that your baby is getting enough to eat. You can monitor how much the baby is getting by counting diapers - what goes in must come out! A 3-day-old baby should have three wet diapers and three poops per day. A 4-day-old should have 4 and 4. A 5-day-old should have 5 and 5, and after that, there should be at least 6 pees per day and anywhere from about 3 to 6 or more poops. In order to be sure that your baby is really producing at least that many wet diapers, you need to check your baby's diaper at least that many times per day. If you're not sure how to tell if the diaper is wet, or you are concerned that your baby isn't wetting as often as he should, you can place a piece of tissue in a clean diaper. When you check the diaper, if the tissue is wet, then your baby has peed.

Another way to reassure yourself that your baby is getting enough to eat is to watch his growth. Your pediatrician will want to see your baby several times in the first two months of life. Your baby should be gaining at least half an ounce a day, if not more, and should be back up to his birth weight by the time he's 10 to 14 days old. Even if you don't get to weigh your baby often, you'll notice as he starts outgrowing his clothing and diapers, becomes heavier for you to hold, and starts to fill out.

If you're concerned that he's not taking in milk, you can do what's called a "weighted feed," where you weigh the baby hungry, then feed him, then weigh him again on the same scale with the same amount of clothing. This requires a sensitive baby scale that can measure in small increments. Many baby boutiques and lactation consultants will have scales like this available to do weighted feeds and to check your baby's growth. Typically, a newborn baby will take in about 2oz. of milk in a feeding, which you can see because he'll be 2 oz. heavier after feeding!

Finally, you can tell if a baby is getting enough by making sure he's not dehydrated. His eyes and mouth should be moist, skin should be smooth and not have dry patches, and the fontanel (the soft spot on top of the head) should not be sunken. He should not be lethargic or floppy, should have periods where he's awake and alert, and should wake on his own to eat. If you see orange urine crystals in his diaper or he has fewer than six pees in 24 hours after day 5 of life, call your pediatrician immediately. Dehydration in a baby can be very serious but is also very treatable.

If you have any reason to be concerned about your baby, don't hesitate to call your pediatrician. Trust your gut. If your baby is not himself, it doesn't hurt to have him looked at. Often the nurse can listen to your concerns on the phone and help you determine if the doctor needs to see the baby.

Remember that a newborn typically eats 12 or more times in a 24-hour period, but that doesn't necessarily mean he's eating exactly every two hours. He might eat three times in three hours, then sleep for three hours, then eat twice more in the next four hours, then sleep for two hours, etc. Watch the baby, not the clock, for when you should feed him next, and follow his cues.

The best way to ensure that your milk supply is healthy and your baby is well-fed is to simply nurse, nurse, nurse. Avoid artificial nipples such as pacifiers and bottles until at least three to four weeks of age, when breastfeeding should be well established. Have your baby's latch evaluated if you have any pain while nursing. Sometimes it may look like your baby is nursing well but he's actually not transferring milk efficiently. Listen for the sounds of swallowing and for a suck-swallow-breathe pattern. If your baby is sucking but not pausing to swallow or breathe, he may not actually be getting any milk, or not enough to trigger the swallow reflex.

Check out my videos on newborn nursing to see what it looks like (and sounds like!) when a tiny baby nurses!

Let's Talk about Sleep, Baby!

If there's a topic common to all parenting blogs, websites, Facebook pages, and playgroups, it's sleep. Sleep, sleep, sleep. "Does your baby sleep well?" "When did your baby sleep through the night?" "How many times do you feed your baby at night?" "How much sleep are you getting?" "Does your baby sleep in your bed?" Sleep. Always sleep.

Sleep is a necessity, and we feel it when we don't get enough. The whole day is affected by how well we slept the night before, whether or not we have kids. But when our sleep is disrupted because of an external force - the baby - we can become resentful and frustrated, because it feels like something outside of our control. Then the discussions about "sleep training" begin. "How do I get my baby to fall asleep on his own?" "How do I get him to stop waking up at night?" "Is he really hungry at night or just eating out of habit?" "Would a pacifier help? What about a lovey?"

Here's what I know about baby sleep.

1. Sleep patterns are not linear.
We have this idea that babies start out waking every three hours to eat, then decreasing the night wakings over time until they're *poof* sleeping through the night, at which point they will continue to do so. This is really, really not the case. Many full-term, healthy, breastfed newborns will sleep fairly soundly, waking every three to four hours or so to eat, especially when they sleep in close proximity to their mothers. However, at around four months of age, there are some major developmental spurts that cause what we call a "sleep regression." Your baby who was sleeping three to four hours at a time, or even more in some cases, suddenly starts waking every hour or two to eat, fussing, crying, needing to be held or rocked. All the "tricks" you had don't work, and you're exhausted. Things slowly improve, and then, around eight or nine months, it happens again! And again at 13 months. And again at 18 months. While you probably will experience these changes in your baby's sleep habits, you should notice an overall trend, over months and years, toward more acceptable (by adult standards) sleep patterns. Some kids don't sleep through the night until after two years old. Some sleep through the night for a while and then stop. Just because your formerly excellent sleeper is now waking every hour and a half doesn't mean you're doing anything wrong. It just means your baby is growing and experiencing physical and mental growth, learning new skills, erupting teeth, and meeting milestones. And while those years sure seem long when you're in them, one day you will sleep again. I promise.

2. Babies don't need to be taught to sleep on their own.
Sleeping through the night is not a skill that needs to be taught; it's a developmental stage that will be reached when the baby is ready. You have not fallen into some great trap if you don't "teach" your baby to sleep through the night by six months, or a year, or two years. You are not doing your baby a disservice by feeding or comforting him when he wakes at night. You are not reinforcing "bad" habits by shushing, patting, rocking, nursing, feeding, offering a pacifier, or bringing him to your bed when he wakes up at night. You are not creating a future insomniac by assisting your baby in falling back to sleep. There are some methods that may help your baby sleep in longer stretches or cease to wake you up at night, and these range from slow and gradual night-weaning to "extinction" crying. Some of these methods work some of the time for some babies. You may successfully teach your baby to sleep well at night and then find, a few months on, that he starts waking again at night. You haven't done anything wrong if you do "sleep train" and it wears off, and you haven't done anything wrong if you don't "sleep train." And, just because your baby sleeps through the night doesn't mean there's anything wrong with someone else's baby who doesn't.

3. Some babies do need to eat at night, and some don't.
Many pediatricians and sleep experts, especially the "old school" ones, will tell you that a baby older than six months doesn't need to eat at night, developmentally speaking, and that if your eight-month-old baby is still waking to nurse or takes a bottle at night, it's because you're reinforcing a bad habit and not because the baby is genuinely hungry. While some babies will stop waking to eat by six months of age (my oldest stopped waking for a bottle at about 5 months), others will continue to wake up hungry throughout the night long beyond that arbitrary age. A baby needs a given number of calories in a 24-hour period, and while some will take in enough during the daylight hours to sustain them through the night, others will not. If your baby is eating enthusiastically at those 1:00 and 4:00 a.m. wake-ups, then I think it's safe to say she really is hungry at those times. If she sucks a few times and then falls asleep for three hours, she's probably doing what we call "non-nutritive sucking," meaning she's not taking in much milk but just needed a little help soothing herself back to sleep. Increasing daytime feeds (in frequency and/or quantity) may help to decrease nighttime feeds. Remember that, especially in the early weeks and months, those early morning and middle-of-the-night feeds are essential for your milk supply, as prolactin levels are much higher at night.

4. Do what works for you and your baby.
If your baby sleeps the best cuddled up with you, then let your baby sleep cuddled up with you (assuming you're in a safe cosleeping environment, of course). If your baby sleeps the best swaddled in a bassinet in another room, then put your baby to bed swaddled in a bassinet in another room. If you simply cannot function because of how often your baby wakes at night, try a method to get him to sleep in longer stretches, whether that's crying-it-out or cosleeping or something in between. If you are content with your baby's sleep patterns and you can function during the day with the amount of sleep you're getting, don't let someone else's experience make you think you're doing something wrong by leaving things as they are. If you feel there is a medical reason your baby is not sleeping, consult with a doctor. If you feel that your baby is not getting enough sleep for her, see what you can do to help her sleep better. With sleep, as with all things baby, finding what works for you is going to make your parenting journey that much smoother.
 

Breastfeeding a Newborn: How Often Does My Baby Nurse?

I have a confession to make: I have no idea how often or for how long my baby nurses.

That's right! Gasp! I don't keep track!

When someone asks me, "How often does he eat?" or "How many times do you get up at night to feed him?", I don't have an answer beyond, "I don't know. It's not bad."

Look, this is my fourth kid and my third nursling. I've never been a "charter." I've never kept very careful track of diaper changes or when feedings started and ended. But now, fourth kid, time has no meaning. Sometimes an hour between feedings can seem luxuriously long. Other times, an hour can seem like, "Hey, didn't you just eat?"

I know a given nursing session doesn't take long. For example, today, I fed him for five minutes at one point. I happen to know because I happened to have glanced at my watch when he started, so I figured, hey, let's see how long this actually lasts. It was five minutes. It seemed awfully short, so I tried to offer him more. He didn't want it. When did he next feed? I don't know. Was it long enough to get something done in between? Yes, I think so.

The thing is, I tend to be doing other things while he nurses. For example, he nursed yesterday at my oldest's dentist appointment. He nursed in the Moby wrap while I watched N get his teeth cleaned, shepherded S to the bathroom, and changed G's diaper. (Yes, I nursed and changed a diaper simultaneously...standing in the middle of a single-use public restroom in a medical building. That now qualifies as the weirdest nursing situation I've been in.) So how long did that feeding last? I have no clue. I was busy watching my oldest get his teeth cleaned, taking another one to the bathroom, and changing a diaper!

Usually, my multitasking isn't quite that exciting, though. Typically I've got my phone in one hand while I support the baby with the other, and I play Candy Crush and check Facebook 14 times while I nurse. Sometimes I read a book. A real one. Other times, I read a book on my Kindle app. Lots of times, I'm tending to one or more of my other kids while poor Y hangs on for dear life.

The great thing about breastfeeding is you don't have to meter it. You don't have to measure anything. You don't have to time it or schedule it or worry about whether he'll want just a little more. When the baby is hungry, you feed him. It's that simple. As long as baby is growing, producing plenty of wet and dirty diapers, is alert and interactive, and otherwise seems healthy, then you don't have to know exactly how long every feeding lasts and how often you're nursing. There will be times when he nurses for five minutes several times in an hour and other times where he sleeps three hours and then nurses for 20 (or more!). There's no rule for any given baby, and there's no general rule, either, except, "When the baby is hungry, you feed him." Check for active sucking and swallowing and watch him expand practically before your eyes. (If your baby has any health problems, has slow weight gain, or was premature, your doctor may ask you to track feedings and diapers to ensure that your baby is taking in enough calories. This is important in a situation like that. Also, if feedings seem to last an hour or more, your baby may have problems with his latch that makes it difficult to efficiently extract milk. In that case, it is probably a great idea to make an appointment with a lactation consultant to see if there's anything else going on.)

So how often is my six-week-old eating? I have no idea. How long does it take him to finish? No clue. Doesn't seem long, though. Is he happy? Reasonably. Is he growing? Heck, yeah (he's already in 3-month clothing and filling those out nicely)! Does he eat well? Yep!

Enjoy your baby. Don't be obsessed with the clock or the calendar. Watch your baby. Get to know him. Learn what his cries mean and figure out what he likes to do. Follow his lead. Follow his cues. Time has no meaning for him, and it shouldn't matter so much to you, either. Get a book, or your phone, or your e-reader, or the TV remote, sit back, relax, and nurse that baby!

Check out my YouTube channel for lots of breastfeeding videos!

Coming Home with Baby: What to Expect on Days Three and Four Postpartum

Assuming you had an uncomplicated, vaginal birth in a hospital, you'll be going home on day two or three postpartum. Legally, in the United States, insurance is required to pay for 48 hours postpartum in the hospital, and it's up to you, your family, your doctor, and your baby's doctor whether you want to stay for that long or if you want to go home sooner. This will depend on your health, your baby's health, and how confident you feel about taking full responsibility for your care and your baby's care weighed against how much more comfortable you'll be at home compared to the hospital environment. Many first-time parents prefer to take the full 48 hours in order to have assistance with breastfeeding, diapering, and general baby care, while more veteran parents are often in a hurry to get home to the older kid(s) and back into an already-established routine. (On the other hand, if you have several children, you may enjoy the relative quiet of your hospital room!)

Leaving the Hospital
When you're getting ready to leave the hospital, make sure you collect everything you brought. Don't forget small things like your cell phone charger, eyeglasses or contact lenses, jewelry and watch, and so forth. Go over the room a few times and collect everything that belongs to you.

Then, collect everything that the hospital gave you. Sanitary pads, ice packs, peri bottle, mesh underwear, diapers, alcohol wipes, bottles, pacifiers, thermometer, bulb syringe, breastpump parts, baby wipes, samples of baby shampoo, water bottle - anything they gave you that's consumable, they have to throw away when you leave. You're paying for it, one way or another, so you may as well take it with you. The only things they'll ask you to leave behind are typically the hospital gown, the baby shirts, and the receiving blankets (although we've ended up with more than a few hospital receiving blankets over four kids, so somehow quite a few of those have slipped through...). Often the nurses will offer to bring you more of anything you might need, such as another pack of diapers. Accept it! The less you have to worry about running out to buy the minute you get home, the better. (The only thing I'd recommend leaving behind, if offered, are formula samples if you're breastfeeding. See my "Just One Bottle" post for more on that topic. Or, take them with you but don't make them easily accessible.)

Have your partner or whoever is taking you home bring up the infant car seat (if you're using one) from the car so you can take your time buckling your baby securely. See my videos (here and here) on properly buckling your newborn in the car seat for instructions on keeping your precious new baby safe on his first car ride. (If you're starting out with a rear-facing convertible car seat, obviously you'll have to carry the baby down to the car and buckle her in there. I'm not suggesting that you wouldn't be using a car seat at all!)

Baby Blues
Whether you're still in the hospital or back home, days 3 and 4 postpartum will be very difficult. There's a major hormonal plunge at three days postpartum, which usually coincides with your milk supply increasing dramatically. Your progesterone levels, which were kept high by the placenta, finally plummet, now that the placenta has been delivered. Progesterone inhibits milk production, so when the placenta is delivered and progesterone levels fall, milk production suddenly increases. This is when you'll see the changeover from small amounts of colostrum to a much larger volume of milk.

While a welcome change as far as feeding your baby, this increase in milk production can cause new problems. Even if breastfeeding was going well up to this point, your milk volume increase may result in engorgement, making your breasts bigger, hard, and painful to the touch, which can make it difficult for your baby to latch, even if there were no problems with her latch before. The speed and force with which your milk may emerge from your breasts may confuse or upset your baby, who was used to the slower, thicker flow of colostrum. These combined issues may cause frustration for you, adding to the hormonal and emotional roller-coaster of the first week or so postpartum.

The result of this perfect storm of hormonal and physical changes is often inconsolable, irrational sobbing. Many newly postpartum women find themselves crying over nothing. I remember dissolving into tears because I couldn't figure out what to do about feeding my two older kids lunch when my third was three days old. Sometimes, your crying may be triggered by nothing at all, while other times small stressors can result in big sobs.

It's important to know to expect these "baby blues," because at least if you know it's coming, you can be prepared to ride out the crazies. Make sure your partner and other support people know about this phenomenon so that they'll know that your crying is not something they did wrong and so they can remind you that it will pass. You may feel overwhelmed, incompetent, or confused. Having someone there who can remind you that you're doing great, that this will pass, and to help you with all the little things that suddenly seem monumental will be vital. And if you do need to cry, go cry. Let it out. Crying releases toxins and is very freeing and cleansing, even if it's not much fun. Better to sob it out than try to hold it in.

Ask for Help
Ask for help. Ask for help. Ask for help. If you need assistance with breastfeeding, with housekeeping, with meals, with shopping, with simple baby care, a ride to the doctor, a cup of coffee, or someone to keep you company, ASK FOR HELP. If someone says, "What can I do?", tell them. If they offer, accept the offer. Be kind to yourself. Don't expect to be able to do everything yourself, even if you're used to being in charge and handling it all. You cannot handle everything at three days postpartum, and no one, including yourself, should expect you to. Your postpartum time is just about universally accepted as a time to rest, bond with your baby, and learn about parenthood (even if you're a parent for the second or third or fourth time!). Your body is healing, your brain is changing, and your life will never be the same. Lie down and let someone else take care of the mundane stuff.

Postpartum Depression
Baby blues should not last more than a week or two and should not be accompanied by severe anxiety, thoughts about harming yourself or your baby, hallucinations, or extreme paranoia. If you experience any of these more severe symptoms or if your "blues" last more than two weeks, contact your OB or midwife immediately. These are signs of postpartum depression, postpartum anxiety, or even postpartum psychosis, which are serious but can be treated with therapy and/or medication. Many psychotropic medications are compatible with breastfeeding and can help you feel like yourself again. Don't be afraid or ashamed to reach out for help if you suspect there's something more than hormonal changes going on.

Uterine Cramps and Bleeding
Especially if this is not your first baby, the cramping caused by your uterus shrinking back to its prepregnancy state can be fairly painful. If you were prescribed pain killers, take them! Ibuprofen (Advil/Motrin) and acetaminophen (Tylenol) are both compatible with breastfeeding, and even narcotics such as Percocet and Vicodin used sparingly are relatively safe (although narcotics may make your baby sleepy - if you don't need them, it's probably better to avoid them). If you are in pain as well as having emotional symptoms, you will find it hard to enjoy your baby and your rest. Your postpartum bleeding should have slowed but will still be relatively heavy. Don't overexert yourself. If you soak through a maxipad in less than an hour, see clots larger than the size of a golf ball, or have a fever, contact your provider, as these may be signs of postpartum hemorrhage or infection.

Vaginal Symptoms and Hemorrhoids 
If you had a vaginal delivery and tore at all or had an episiotomy, this will still be healing. Don't squat or try to lift anything heavy, as this may tear your stitches and cause additional damage. If you're still experiencing swelling or any external pain, using ice packs and witch hazel on the area may help. Also, taking a sitz bath may speed healing and relieve pain and swelling. If you were given a cooling or numbing spray or foam, use it as directed. Drink plenty of water and avoid constipating foods to keep your bowel movements soft and help your hemorrhoids heal. Hemorrhoidal creams can be soothing as well. Use your peri bottle to clean your perineum after using the bathroom so that you don't have to wipe too aggressively with toilet paper.

After a C-Section
If you had a c-section, you'll likely still be in the hospital at three days postpartum. After my c-section, on day three, I woke up in the middle of the night crying. My nurses insisted that I was in pain and brought me more pain pills, but I knew that wasn't it. It turned out it was the aforementioned baby blues, which I had no idea existed! I was resentful that the nurses also didn't seem to know what was going on and that no one had warned me to expect them. A c-section will also cause different physical issues as well. Your incision is still very new at three and four days postpartum, and laughing, sneezing, and coughing will be painful. Hold a pillow against your middle if you need to do any of these things to help support and protect your incision. Watch for signs of infection such as smelly discharge from the incision site and fever. Follow your doctor's and nurses' instructions for keeping the incision site clean and dry. Some of the treatment will depend on the type of incision and the type of sutures used. You will still experience postpartum bleeding and cramping, and if you had the c-section after pushing for any length of time, you may also experience some perineal swelling and hemorrhoids.

Breastfeeding Help
As alluded to above, day three and four may present new breastfeeding challenges, as your milk volume increases and you experience engorgement for the first time. If you are so engorged that your breasts are hard and painful, or the engorgement causes your nipples to flatten out such that your baby cannot latch, it may be helpful to express some milk prior to feeding. Use warm compresses or take a warm shower to help start the milk flowing, then use hand expression (NSFW video) or a breast pump to remove some milk. If you are in severe pain, taking pain medication can sometimes relieve some of the pain so that you can express. Pump or express just enough to soften the breast so that the baby can latch and to relieve the rock-hard feeling. Removing more milk than necessary will signal your body to produce more milk, which will perpetuate the cycle of engorgement. You want to train your body to make the amount of milk your baby needs, so feed the baby on demand and let him nurse as long as he desires, and pump only enough for comfort. (Do save whatever you pump, either for later bottle-feedings or to donate.)

If you are having any breastfeeding difficulties, contact a lactation consultant, La Leche League Leader, or an experienced breastfeeding friend for help. Many breastfeeding issues can be solved with a little intervention, but if they are not addressed, they can become big problems. Some techniques that can help in the meantime are making sure your baby is latching well, keeping baby skin-to-skin as much as possible, and trying different breastfeeding positions to see if any of them are more effective or more comfortable for you or your baby.

For a proper latch, make sure baby's lips are flared outward, that his mouth is opened very wide, that his tongue is over his lower gums, and that your nipple is far back in his mouth; some of the areola should be in his mouth as well - he should not be sucking just on the nipple.

Follow these four rules to help with positioning:
1. Tummy to tummy: Keep your baby facing you, with ear, shoulder, and hip in a straight line.
2. Nipple to nose: Align your baby's head so that your nipple points to her nose. Brush your nipple down across her lips to her chin, then drop the nipple in when she opens her mouth wide.
3. Allow the baby to tilt his head back slightly: Don't crunch your baby's chin down toward his chest, and don't put your hand on the back of his head. Instead, support his head at the base of the skull so that he can tilt his head back slightly. This will help get a deep, asymmetrical latch.
4. Bring the baby to your breast, not your breast to the baby: Don't be afraid to pull your baby in close. Support your arms and back with pillows if you need to. You don't want to be hunched over and stretching your breast toward the baby's mouth. Rather, pull the baby close to you and straighten your neck and shoulders.

See my "Breastfeeding a Newborn" (here and here) and "Breastfeeding Positions" (here) videos for more help.

If your nipples are damaged, talk to a lactation consultant about using a nipple shield to protect your nipples and help your baby latch. Also, you can use lanolin to help them heal. Hydrogel pads can assist with pain and healing as well.

What surprises did you encounter in the early days postpartum? What other tips or advice would you add?

Jaundice, Part II: What is Jaundice and How is it Treated?

This is the second in a two-part series on jaundice, a relatively common and usually mild condition that occurs in newborn babies. In Part I, I described my own experience with jaundice in my fourth baby. Here in Part II, we'll look at jaundice from a clinical perspective.

What is newborn jaundice?

Jaundice in newborns is caused by rising bilirubin levels in the blood. Bilirubin is a byproduct of the breakdown of red blood cells, which all babies have an excess of at birth. Normally, bilirubin is processed by the liver and excreted through bowel movements. While many babies will effectively and efficiently process this excess bilirubin, some babies have too much bilirubin, or their liver can't handle all of the bilirubin they're producing, which causes it to build up in the blood. When this happens, some of the bilirubin is passed to the skin, which will give the whites of the eyes and the skin a yellow-ish tint. If the bilirubin levels in the blood reach high levels, treatment may be recommended.

There are three basic types of jaundice found in newborns:

• Physiological Jaundice is the normal course of elevated bilirubin caused by the breakdown of red blood cells in the newborn baby. This type of jaundice is normal and not dangerous unless bilirubin levels reach a certain threshold. Most babies will require no special treatment.
• Breastfeeding Jaundice occurs when a breastfed baby isn't getting enough to eat in the first several days of life. Because he is not feeding well, he is not having enough bowel movements to clear out the bilirubin from his system. If bilirubin levels reach a certain threshold, various treatment scenarios may be proposed. Otherwise, assistance with improving breastfeeding is typically all that is needed.
• Breastmilk Jaundice occurs in a very small percentage of babies and is when an exclusively breastfed baby has elevated bilirubin levels but no other symptoms of jaundice and is feeding well and growing as expected. This is not a dangerous condition and will typically resolve within 6 to 10 weeks without intervention.

Notice that all three types of newborn jaundice usually resolve without treatment. Once good feeding is established and the baby's digestive system is kicked into gear, he will clear out the bilirubin on his own. 

Jaundice occurs more commonly in premature babies or babies whose liver may otherwise be compromised. It also may be caused or complicated by blood type incompatibility between the baby and the mother, birth injury, medications, or infection.

My oldest son N with jaundice. You can see how yellow his forehead looks. He was being treated in the hospital and was taken off the lights for a feeding in this picture.

When does jaundice need to be treated?

The trouble with elevated bilirubin is that it is known, at high levels, to cause a totally preventable, irreversible, severe brain damage called kernicterus. Kernicterus occurs when bilirubin literally stains the brain cells. Babies with kernicterus will suffer lifelong mental retardation, which may include both physical and cognitive delays. Kernicterus happens when the bilirubin levels in the blood are so high that bilirubin is conducted into the brain. It is not known what these levels need to be to cause kernicterus, and it is not clear if simple physiological jaundice, breastfeeding jaundice, or breastmilk jaundice alone can cause this terrible outcome or if other complications are involved. It is clear, however, that by reducing bilirubin levels before they reach a high concentration will prevent kernicterus.

To determine if your baby is at risk for needing additional treatment for jaundice, your pediatrician will order a blood test to measure your baby's bilirubin level. This will be plotted on a chart along with the baby's age (see below). There are four identified curves on this chart: Low Risk, Low Intermediate Risk, High Intermediate Risk, and High Risk. If your baby's bilirubin levels fall into the High Intermediate or High Risk zone, treatment will likely be recommended.

Find your baby's age along the bottom and plot the Serum Bilirubin level on the vertical axis 

to see which zone your baby's jaundice risk falls in.

Aside from kernicterus, jaundice may cause other difficulties in the early days of your baby's life, which may prompt your doctor to recommend treatment or management. High levels of bilirubin may cause your baby to become sleepy and uninterested in eating. This will make it more difficult for your baby to clear out bilirubin, and it will mean fewer feedings at the breast, which may cause a delay in your breastmilk increasing in volume, or it may cause a low supply due to lack of stimulation. This, in turn, will mean your baby is not getting enough to eat even when he does wake to eat, which will make him more dehydrated and lethargic, which will make him less likely to wake to feed, which will further reduce the amount of calories and fluids he takes in, which will worsen the jaundice and continue the cycle. This is a very dangerous cycle because you end up with a starving baby and a delay in milk production or a reduced supply. In this case, treating both the feeding issues and the jaundice are priorities.

Most pediatricians will recommend treating any kind of jaundice before bilirubin levels reach 20mg/dL in the blood. Most babies will not reach this critical point, but some may approach it, and it is important to know what the treatment options are so that you can make an informed decision about whether, when, and how to treat your baby for jaundice.

How do we treat jaundice?

The simplest treatment for jaundice is feeding. If your baby has not been feeding well, increasing the number and quality of feedings will help stimulate bowel movements and clear out the bilirubin. Make sure your baby is eating at least 12 times a day and that when he feeds, he is actually taking in colostrum or milk. Watch for signs of a deep suck and swallowing when your baby is feeding. Make sure he is actively sucking and swallowing for at least several minutes at a time. If he falls asleep at the breast after a very short time, try to stimulate additional sucking by massaging the breast while he is latched on. You can try to wake the baby by burping him or changing his diaper and then return him to the breast for further feeding. Also, be sure to monitor diaper output. 

If your breastmilk has not increased in volume by the end of the third day postpartum (72 hours), it is important to feed your baby from some other source, whether donor breastmilk or formula. The number one rule, here, is feed the baby. Ideally, this supplementation would occur at breast using a feeding tube or syringe so that the baby can continue to stimulate milk production while receiving the supplemental milk or formula. A three to four-day-old baby does need more than colostrum, though colostrum is enough for a baby in the first and second days of life.

If the baby is feeding well but bilirubin levels remain in the High or High Intermediate Risk zones on the above chart, phototherapy may be recommended. Phototherapy involves the use of a special blue light that shines on the baby, with a maximum amount of skin exposed to the light. The light breaks the bilirubin down into a water soluble form that the baby can excrete through his urine. This, in addition to regular bowel movements, will bring down his bilirubin levels much more quickly. Phototherapy can be done in the hospital nursery or at home using a portable phototherapy device. Your doctor will likely have a preference as to whether to keep your baby in the hospital (or readmit him) to use the hospital phototherapy bed or whether to have a home healthcare service bring you a home phototherapy machine to use. It typically takes 12 to 24 hours, or up to two days at the outside, of phototherapy to bring down bilirubin levels to an acceptable range. It is important for the baby to continue to feed regularly while under phototherapy. Continue breastfeeding about every two to three hours. Phototherapy is not invasive and not painful for the baby. The baby is kept warm and generally just sleeps while under the lights.

Baby N on home phototherapy. A pad that emits light is against his back, connected to a machine 

by the gray tube you can see emerging from his blankets.

Some pediatricians may recommend supplementing with formula for 12 to 24 hours, or even a course of "interrupted breastfeeding" for 12 to 24 hours, to clear out breastfeeding or breastmilk jaundice. This path only becomes necessary if breastfeeding is not going well and the baby is clearly in need of feeding beyond what he is getting from his mother alone. Supplementation with formula will help to treat the jaundice, as it will cause the baby to pee and poop much more than from colostrum and early milk alone. It will also help to rouse a baby who is lethargic from lack of feedings and/or high bilirubin levels and may be helpful in severe cases. However, be aware that introducing formula may have other long-term consequences to your baby and your breastfeeding relationship. It is important to weigh the risks and benefits of supplementation. If possible, discuss these risks with your pediatrician and a lactation consultant before making your final decision. If you do choose to supplement, be sure you do not reduce the amount of at-breast feeding your baby does. If you cannot be with your baby, you should pump your breasts every two to three hours, or in between feedings, to stimulate your own milk production. It may be possible to supplement your baby with your own pumped milk rather than formula, if you are able to produce for a pump.

How long does it take for jaundice to go away?

Bilirubin levels will generally peak between days four and six of your baby's life and then taper off into a normal range in about one to two weeks. Your doctor may want to monitor your baby's bilirubin levels until they begin to fall by ordering daily blood tests. Assuming your baby is otherwise healthy and feeding well, once it is clear that his bilirubin has begun to fall, no further treatment will be necessary. Typically, once bilirubin levels peak and begin to drop, they will continue this downward trend.

The exception to this is breastmilk jaundice. Babies with breastmilk jaundice may appear yellow and have elevated bilirubin for up to about 10 weeks of age. Breastmilk jaundice is not dangerous and will go away on its own. As long as the baby is otherwise healthy, alert, feeding and growing well, and meeting milestones, you can simply wait until the jaundice resolves. Some pediatricians may recommend interrupting breastfeeding (stop breastfeeding and give formula) for one to three days to clear out breastmilk jaundice. While this will effectively "treat" the jaundice, it may have a negative impact on your breastfeeding relationship as well as introducing other risks of formula feeding. Unless there is other cause for concern, this is probably not a necessary step in simple breastmilk jaundice.

In the first week of life, while bilirubin is still elevated, watch your baby for sleepiness, not waking to feed, floppiness, and dehydration (urine crystals in the diaper, dry mouth, sunken fontanel). Examine your baby in natural light to look for increased yellowing. Contact your pediatrician immediately if you have any cause for concern.

Also, be aware that jaundice tends to run in families. If you have one baby with jaundice, there is an increased chance that a future baby will have jaundice as well. Jaundice is more common in boys than girls, as well. Indeed, all four of my boys had jaundice! 

I hope this information* helps you to have an meaningful conversation with your pediatrician if your baby is diagnosed with jaundice.

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*Please note that I am not a medical professional and cannot offer medical advice. This information is provided for your education only and should not be used in place of the advice of your pediatrician during an in-person examination.

New Edition of Kindle Book is Available!

Check out the new, updated Jessica on Babies Breastfeeding FAQ, available for Kindle from Amazon.com. Makes a great new-mom gift or a quick purchase just before (or just after) you have your own baby. At $1.99, you get Jessica's basic breastfeeding advice in the palm of your hand, accessible any time and anywhere you need it.

Some sample questions and answers from the book:

What is the most important piece of advice you would give a new mother about breastfeeding?

The first thing I would say to any new mother is, “Keep nursing!” The more you nurse, the easier it gets, and the more you nurse, the more milk you make. You’ll often hear “breastfeeding is normal” or “breastfeeding is natural,” which is true, but it’s important to remember that breastfeeding is a skill that must be learned and practiced, by both mother and baby. Just like with any skill, the more you do it, the better at it you get. When my first son was born, I was so convinced that breastfeeding was natural and instinctive that I was very discouraged by how complicated it all seemed. I felt like I needed three or four hands. When my second son was born, despite all the reading I had done, it still took several weeks for me to find comfortable positions and the easiest way to get him latched on and sucking as quickly as possible. As awkward as you may feel in the first few weeks, you’ll find it getting easier by the day if you just keep at it. The third time around, I knew things would get better, but the first three days or so were very hard; he would scream every time I unlatched him from my breast. I had to keep reminding myself that the more he nursed, the better things would get. Sure enough, by the end of the third day, he became a much more content baby, and I was able to settle into a more comfortable nursing routine.

The second basic piece of advice I always offer is, “Give it six weeks.” The first few days and weeks can be challenging, and even painful, as you adjust to having a new baby and all the new demands placed on you by this change in your life. If you persevere through the first six weeks, nursing on demand, getting used to the baby’s cues and needs, it only gets easier. I’ve seen new mothers go from “Why is this so hard? I don’t want to do this anymore!” to “Oh yeah, I think I’ll nurse for at least a year,” in the space of just those few weeks. There’s something about that six-week point after which everything starts to seem easier. Also, as the baby grows, breastfeeding gets easier just because the baby’s mouth gets bigger, his neck is stronger, and he is more able to support himself. If you stick it out for those first six weeks and put in the work at the beginning, you’ll be able to continue your breastfeeding relationship for as long as you and your child desire.

I heard that giving a bottle of formula before bed, or adding rice cereal to the bottle, will help my baby sleep better and longer. Should I try this?

It is not a good idea to offer anything but breastmilk to your baby before six months of age. Remember that your milk supply is governed by the baby’s demand. If you give a bottle or other food instead of nursing the baby from the breast, you are telling your body that your baby doesn’t need milk at that time. This can cause your milk supply to drop, requiring that you continue to give your baby a bottle, which can cause your milk supply to drop further. It’s a vicious cycle that is difficult to get out of. 

There is no evidence that giving a bottle of formula at bedtime will help your baby sleep better at night. There is mounting evidence that doing so may be harmful to your milk supply as well as possibly contributing to postpartum depression or other maternal health issues. Recent studies show that mothers who breastfeed exclusively in the early months feel happier and better rested than those who attempt to supplement with formula in order to get more sleep. My sons woke frequently to nurse, and it was much easier just to pull the baby to my breast and go back to sleep than it would have been to get up and prepare a bottle for him. My husband and I were both much more sleep-deprived with our first son, who was formula-fed, than we were with our breastfed babies.

As for adding rice cereal to a bottle, or giving any other kind of solid (non-breastmilk) food to a young baby, this is highly discouraged by the American Academy of Pediatrics, the World Health Organization, and many other groups. It is recommended that you do not feed any foods or liquids except breastmilk to an infant under six months of age, unless under a doctor’s direction for a medical reason. Putting rice cereal in a bottle is also a choking risk. 

Also, giving a bottle in the early weeks of life may have a negative effect on the baby’s desire to latch properly on your breast (see “Should I give my baby a bottle?” below for more on bottles).

My nipples are bleeding. What do I do?

For short-term care, squeeze a little milk from your breast after a feeding and apply it to the bleeding nipple. Breastmilk has healing properties that will help the nipple heal faster and prevent infection. You may also purchase pure lanolin (usually found under the brand name Lansinoh) to apply to your nipples after a feeding. Lanolin is safe to leave on when your baby is ready to eat again and will soothe your nipples and help them heal. However, bleeding nipples are typically a sign of a bad latch or other feeding problem, and you shouldn't hesitate to contact a lactation consultant if the problem doesn’t resolve within a few days.