Module 3: Breast/Chest-Feeding
While breastfeeding comes naturally to some and offers many benefits (including medical and emotional from skin-to-skin), it can feel challenging or overwhelming to master at the start. In this module, we’ll review positioning, milk storage, and troubleshooting of common issues.
Note: I use the term breast/chest-feeding in this module to be inclusive of LGBTQ+ families on their parenting journey, and who may not identify with the typical gendered language of “breastfeeding.”
Benefits and Current Breastfeeding Recommendations
What Are The Benefits of Breast/Chest-Feeding?
There’s many! I usually divide it into three categories, to make it easier to think about.
Immune Protection: Mom’s antibodies get transferred through breastmilk, which gives extra protection against lower respiratory and diarrheal illnesses as well as ear infections.
Lower Risk Of Chronic Diseases: Asthma, eczema, and Type 1 diabetes are less frequent in breastfed babies (though it’s important to know that there’s other factors, like genetics, that influence these conditions as well). Obesity and Sudden Infant Death Syndrome (SIDS) are also less common.
Cost and Digestibility: While you have to consider the cost of pumping equipment (especially if hands-free, which is expensive), breast/chest-feeding costs less than formula-feeding, which helps free up money for other essentials like diapers. It’s also more digestible than formula, which tends to lead to less fussiness or stomach and intestinal issues.
What Are The Current Recommendations For Breastfeeding?
The American Academy of Pediatrics (AAP) updated their guidelines in 2022. They now recommend exclusive breast/chest-feeding for the first 6 months, after which solids are introduced. After that, breast/chest-feeding is recommended until two years (or longer).
A note on this statement. I fully encourage breast/chest-feeding and celebrate its benefits, but think it’s important to give grace for different lifestyles that make it hard to sustain it (e.g., having to return to work full-time at a demanding job), as well as struggles with latch issues, low supply, infant anatomy, or other factors that may fall outside of your control. In some parents, breast/chest-feeding can cause more emotional distress than benefit, and can contribute to feeling like they’re “failing” if it just doesn’t click. I encourage families to use resources like lactation consultants, since they’re a huge help. However, don’t feel guilty or obligated to follow this recommendation if it doesn’t work for you. Many families choose to breast/chest-feed for the first 6 months and then transition to formula (or decide not to breast/chest-feed altogether), and you’re no less of a parent if you opt for that route. You do what’s best for you!
Common Breastfeeding Positions
Breastfeeding Initiation and Troubleshooting
How Do I Optimize Breast/Chest-Feeding In The Hospital?
After delivery, the healthcare team will give your baby to you for skin-to-skin. This calms your newborn, stabilizes temperature and vital signs, and stimulates hormones that increase milk supply. Starting skin-to-skin early and feeding within the first hour increase your chances of successful feeding. In the hospital, your first attempts are in the laid-back position, which offers more comfort and takes advantage of your newborn’s instincts and reflexes. We want them to latch onto the entire areola, rather than just the nipple, so that they compress the milk ducts fully.
If they’re having trouble with a strong latch, try hand expression of colostrum (the earliest milk). Your partner can collect the hand-expressed milk via a spoon, and then feed it to your newborn afterwards so that it isn’t wasted. As milk leaves, more will come in, so this helps supply, too.
A lactation consultant should visit during the hospitalization to help with optimal positioning, teaching hand expression, and ensuring a proper latch. If there’s issues, they’ll troubleshoot and determine if it’s something that can be resolved with an easy fix, or if it’s something that’ll require a larger intervention (like a severe tongue tie that may require clipping). Sometimes, they only come once, and it can be hard to arrange outpatient follow up with them quickly in the chaos of taking care of a newborn, so don’t feel guilty asking about asking “too many” questions when they arrive - that’s what they’re there for, and they’re happy to help!
When Will My Supply Come In?
In the first 1-2 days, you’ll make colostrum, which is thick, nutrient-rich, and calorie-dense (as a result, you’ll make less of it, since a little goes a long way). Try not to worry much if there isn’t a lot, that’s normal! Around Day 3-5, mature milk supply comes in, though it may occur later if there’s other health conditions in the background. You’ll know this is happening if you feel fuller/heavier, or if there’s leakage of milk, flattening of the nipples, or swelling of the breasts/chest.
What Are The Most Common Breast/Chest-Feeding Issues?
Shallow Latch: As mentioned above, we want a deeper latch with breast/chest-feeding, where the majority of the areola is in the infant’s mouth, so that they can massage and compress the milk ducts to fully empty them and allow more supply to come in. If only the nipple goes into the mouth, you’ll notice fussiness, frequent falling off of the breast/chest, and irritation, rawness, redness, and tenderness of the nipples over time (which you can treat with Lanolin), as well as engorgement from inadequate emptying.
Tongue / Lip Ties: The little attachment of tissue that connects the tongue to the base of the mouth or the lips to the gums is called a frenulum, and in some infants, it’s very short or located in a way that restricts ability of the tongue or lips to move freely. This complicates feeding and if severe, may require an Ear, Nose, and Throat specialist to clip the tie. It’s not always required, and I usually don’t recommend it unless there’s a slow weight trend or, later in life, speech issues.
Low Supply: The golden rule of breast/chest-feeding is that emptying the breast/chest stimulates more milk to come in. If there’s poor emptying, supply will decrease. So, if you’re struggling, the first troubleshooting step is to get milk flowing! Optimize skin-to-skin, create a calming environment (e.g., relaxing music, comfortable positioning), hand express, massage your breasts/chest prior to feeds, and use a hospital-grade electric double breast/chest pump between feeds to ensure more complete emptying. It’s also important to make sure you keep up with hydration and meals for yourself, since breast/chest-feeding burns a lot of calories. If you’re still stuck, work with a lactation consultant (insurance will sometimes cover a limited number of outpatient visits). They can help figure out if the issue is due to improper latch, a medical issue, or a medication. They can also work with your PCP to recommend trialing supplements (like Fenugreek) if the above tips aren’t yielding expected results.
Engorgement: Occurs when the breasts are overly full with milk, causing swelling, tenderness, and a hard consistency. If you’re struggling to feed while engorged, try heat to get milk moving. Use warm washcloths against the breasts/chest or take a warm shower and apply gentle massage. If you’re dealing with discomfort related to engorgement after a feed, try cold to calm inflammation (cool washcloths, frozen vegetables wrapped in a towel, or refrigerated and rinsed cabbage leaves for 20 minutes, 2-3x/daily). In some situations, engorgement can lead to mastitis, which is tissue inflammation (sometimes with infection) from clogged milk ducts. There’s redness, warmth, and swelling in addition to tenderness. If you notice this, contact your doctor, since it will require antibiotics.
Storage of Breast Milk & Supplies To Consider
How Do I Store Breast Milk?
I use the Rule of 4s! At room temperature, it’s acceptable to leave it out for up to 4 hours. You can keep it in the refrigerator for 4 days, and in the freezer for 4 months (technically slightly longer, though this is a good rule of thumb). Use storage bags or containers that are BPA-free, and label them with the date of milk expressed so you don’t lose track of how long something is in the refrigerator or freezer for. If milk is going in the freezer, leave a little room at the top of the container, since it will expand slightly as it freezes.
You can thaw milk by running it under warm water, setting it in a container with warm water, or leaving it in the refrigerator overnight. Never microwave, since it can lead to uneven heating and cause burns. Once milk is fully thawed, use it within 24 hours. Never re-freeze milk that’s already been thawed. If you’ve started a feed with a pumped bottle of milk and have some left over, make sure to finish it within 2 hours and then toss any remaining milk.
What Supplies Will I Need?
In general, few. Here’s some to consider and why you’d need them.
Nursing Pads: Go over the areola and nipple to soak up any leakage and keep you dry.
Nursing Bras: Have a clip that allow a cup to be dropped for easy access during feeding.
Lanolin or Hydrogel Pads: To help with sore, inflamed, or cracked nipples.
Nipple Shields: Usually more of a temporary solution to help establish latch while working with a lactation consultant, these can be helpful for flat or inverted nipples.
Breast/Chest-Feeding Pillow / Cushion: To keep you and your newborn comfortable.
Breast Milk Storage Containers: Can be either bags or plastic containers (BPA-free).
Hydration, Snacks, Activities: Have a station near you with water, tea, and snacks so that you don’t need to get up and interrupt a latched-on newborn if you’re dehydrated or hungry. Keep items within easy reach (like a book, tablet, or cell phone for catching up with friends / listening to calming music or podcasts) in case you’re in need of a distraction.
Pump: If you’re struggling with engorgement or want to create an extra supply for your newborn (e.g., if you’ll be away from your newborn for several days or are returning to work), a pump is extremely helpful, and a session can last as little as 15 minutes.
Types of Pumps: Manual (hand-operated, like the Haakaa, which is also handy to place on the free side to collect milk during letdown), Battery-Powered (cordless and often hands-free, like the Elvie or Willow), and Electric (requires an outlet and is most effective at extracting milk, like the Spectra). Manual devices are single pumps (one side at a time), electric devices are often double pumps (both sides simultaneously, more efficient), and battery-powered can be either.
Which Pump To Choose? The pump you choose depends on lifestyle. Will you be at work and require something hands-free? Will you travel a lot and need something lightweight? Is there access to an outlet? Is there a tight budget requiring something cheaper or covered by insurance? A pump is a very individual and tailored decision, so choose what’s right for your needs.
Commonly Asked Questions
Can I Drink Coffee or Alcohol While Breast/Chest-Feeding?
Coffee is acceptable up to 300 mg of caffeine daily, which is usually up to 2-3 coffees daily.
With alcohol, it’s a little more tricky. If you’re drinking alcohol, the American Academy of Pediatrics recommends to try to limit it to one serving (12 ounces of beer, 4 ounces of wine, or 1 ounce of hard liquor) and drink in moderation. With timing, it’s recommended to consume your alcohol right after a feed and allow two hours to pass prior to your next feed. This way, there’s minimal to no transfer through the milk to your infant. If you’re going to a special event like a wedding and need a night off where you know you’ll indulge in more than one drink, you can “pump and dump” and rely on your backup supply instead.
Are There Any Medications I Can’t Take While Breast/Chest-Feeding?
In general, most medications are safe. This includes analgesics (such as Motrin / Tylenol), daily allergy medications (such as Claritin / Zyrtec), antacids (Nexium / Prilosec), and medications for gastrointestinal issues (Miralax, Dulcolax).
However, there are some medications that are best avoided if able (some seizure medications, anti-cancer drugs, and harsher topical and oral acne medications). I also recommend avoiding Aspirin for safety reasons and decongestants (e.g., Sudafed) to avoid decreasing milk supply. Make sure your prescribing doctor is aware you’re breast/chest-feeding, and talk with them about alternate options if their first choice isn’t the safest choice.
What About Vitamin D Drops?
If you are predominantly breast/chest-feeding, the AAP recommends Vitamin D supplementation 400 IU daily. The reason for this is that breastmilk is low in Vitamin D compared to the needs of your infant in this age range (formula has it added in by the manufacturer, which is why infants who are mostly formula-fed don’t need it). Vitamin D is sold as a solution given to your infant via syringe. My favorite is D Drops, since you only have to give a drop and it causes minimal fussiness. Continue this until you wean if <1 year and at 1 year if you decide to breast/chest-feed for longer.
