Breastfeeding is recommended for two or more years because of its importance to the health of the mother, the baby, and the family. Breastfeeding mothers may worry about their baby’s breastfeeding behaviours, patterns, and sounds, their baby’s milk intake, or the quality of their milk. Knowing the range of what is normal, how to support the baby at the breast, how to prevent problems, and when to seek help is critical to breastfeeding success.
Breastfeeding recommendations and importance
Organizations concerned with the health of babies and mothers such as the World Health Organization (WHO), recommend breastfeeding for two or more years because of the extensive health benefits for both. For example, mothers who breastfeed are at a lower risk of breast and ovarian cancer and their babies are less likely to develop infections and chronic illnesses. Families, societies, and the environment also benefit when children are breastfed. All organizations recommend starting solids around six months and some allow for starting as soon as four months, especially if the baby is at a high risk of certain food allergies. Many organizations recommend giving vitamin D to babies.
Healthy breasts and nipples and making milk
Most mothers’ breasts are normal with a range of sizes and shapes. Most nipples and breasts are normal and able to accommodate a breastfeeding baby. Breasts undergo large hormone-driven changes in order to make milk, a bioactive fluid. As the baby grows, milk changes slightly to accommodate the changing needs of the baby.
Pregnancy and preparing to breastfeed
Mothers-to-be can benefit from learning about normal breastfeeding, addressing specific concerns, and preventing possible problems. There are some items such as breast pads that breastfeeding mothers may find useful. Some purchases may not be necessary or their cost can be minimized.
Breastfeeding holds and positions
Breastfeeding holds are used to position a baby at the breast. The choice of holds and positions depends on various factors. Both mother and baby should be comfortable while breastfeeding, the baby’s mouth should be directly in front of the nipple, and the baby’s body should be supported.
Effective breastfeeding happens when mothers follow their baby’s hunger signs for feeds. Feeds should be of an average length and number and babies should latch and have typical sucking patterns. Babies may take one breast or two. They will change their patterns and breastfeeding behaviours as they grow. Because of its unique and dynamic nature, there is a wide range of what constitutes normal breastfeeding.
Getting enough milk and typical growth
Ensuring that the baby is taking in enough milk is very important and indeed, many mothers worry about their baby’s growth. Happily, most babies grow well and this can be monitored using the baby’s breastfeeding patterns, appearance, behaviour, and weight gain.
The quality of milk
Breastfeeding mothers often, but unnecessarily worry about the quality and colour of their colostrum and milk. As long as a mother is healthy, she will most likely make milk that can meet all of the nutritional needs of her baby. Mothers generally do not need to adjust their diet. Those with a low milk supply will have normal quality milk; there just isn’t enough of it. Significant nutritional deficiencies and having high levels of toxins in the mother’s body can affect the quality of breast milk.
Large milk supply
While most mothers have a normal milk supply, a small number of mothers can have even more milk. This can create a few problems such as frequent choking by the baby at the breast and occasional breast tenderness in the mother. These can usually be settled with minor changes and clear with time. Rarely, mothers may need to take active steps to decrease their milk supply.
Breastfeeding changes with age
Getting breastfeeding off to a good start is very important to establishing the milk supply, in ensuring that the baby takes in enough milk, and for breastfeeding success. Over time the baby’s breastfeeding patterns, behaviours, and output will change and mothers will notice less breast filling.
Breastfeeding after the first year
Extended breastfeeding (breastfeeding past one year of age) is normal, is recommended, and has benefits for mother and child. No group concerned with the health of mothers and babies has placed a limit on the duration of breastfeeding. If safe, mothers may choose to continue breastfeeding through the next pregnancy. They may tandem breastfeed an older child and a newborn baby. Mothers may encounter individuals with unsupportive attitudes, making extended breastfeeding more difficult.
Twins and multiples
Having twins is not as simple as having two babies. Twins are more likely to be born early and have associated feeding and health problems. Mothers too are more likely to have health problems and be tired from the work of caring for two sick babies. Twin families benefit from extra support. Mothers who breastfeed twins need to make sure they are taking in enough calories and nutrients.
Clamping, tugging, biting, and teeth
Babies can misbehave at the breast. They may clamp, tug, or bite and cause nipple pain and skin damage. Occasionally this can be a sign of a breastfeeding problem. Mothers should address and try to stop these behaviours.
Babies are not little adults. They have unique behaviours, appearances, and needs which sometimes cause unnecessary concern for families. Examples include spitting, choking at the breast, stooling, solid foods, and sleep patterns. One frequent cause of concern is crying, which happens when babies are bothered by hunger, pain, or not having other needs met. It is important to know the cause of the crying so it can be eliminated or minimized and thereby limit the stress on babies and their families.
Healthy babies' behaviours and appearance
Babies have unique behaviours and appearances. It is important to know which are normal and which can be a sign of a problem.
Healthy babies' crying
Crying means that the baby is very upset; there can be a number of reasons, including hunger, the evening fussies, or being put down. If the baby’s problem is fixed, the crying will stop which helps both the baby and the family. Normal babies cry for short periods. Extended crying is not normal. Caring for and nurturing the baby prevents crying and has long-term health and psychological benefits for the baby. Breastfeeding reduces stresses that cause crying and helps the mother respond to and settle the baby.
Babies make a variety of sounds. While breastfeeding, the baby’s sounds can indicate they are getting lots of milk. Rarely, the baby’s sounds can be a sign of a health problem.
Stooling and peeing
Normal pooping (stooling) and peeing can be an indicator of good health in a baby. It can change if the baby is sick or not taking in enough milk.
Sleep time changes as babies grow. Newborns tend to wake up to breastfeed every two to three hours. Most babies continue to wake up at least once during the night for the first year of life. Sleeps of more than five hours may decrease the amount of milk a baby takes in. Families should ensure that their sleep practices and the baby’s sleep location is safe.
Solids or solid foods, are foods other than milk that are given to babies. Although breast milk is the main food for breastfeeding babies for most of the first year, solid foods become an increasingly important source of nutrients. Solids are generally started around six months of age but if a baby is at a high risk of certain food allergies, they may be started between four and six months. A baby’s solid foods should be safe. There are benefits to making a baby’s foods and avoiding commercially-produced ones. Babies can be given sips of water, expressed breast milk, cow’s milk, or infant formula if their solid foods are dry.
Occasionally breastfeeding babies do not grow well. This can be due to illness in the baby or to breastfeeding problems that keep them from taking in enough milk; knowing the difference is critical for the baby’s health. There are numerous causes of infant hunger and similarly numerous tools to address and fix this. Knowing these allows mothers to identify the problem and maximize the amount of breast milk they can give their babies.
A small number of breastfeeding babies do not grow well as they are not taking in enough milk. They may have a mother with a low milk supply or may not breastfeed often or well enough. They may also grow slowly because they are sick. There are a number of possible solutions once the cause is found.
Underfed newborn babies
Newborn babies are particularly vulnerable to being underfed. The risk increases if they were born at 38 weeks or less. They may be very irritable or very sleepy. If not addressed, they can become yellow, have low sugar levels, or become dehydrated. They quickly need to take in more milk. This can be done by optimizing breastfeeding or supplementing. They should be closely monitored until they are feeding well.
A small number of babies cannot latch or stay latched onto the breast. This keeps them from getting enough milk. There are a number of tools to help them latch including using a nipple shield. Some mothers may need to express breast milk for the baby’s feeds until the latching problem can be fixed. Other babies may slowly or suddenly refuse to breastfeed on one or both breasts. There are a number of ways to help babies resume normal breastfeeding.
A nipple shield is a silicone nipple and areolar cover that can help babies latch and get more milk. While useful if used properly, they can also cause pain and prevent the baby from getting enough milk. Some mothers will use them to treat nipple pain. They come in several different styles and sizes and require cleaning after use.
Low milk supply and milk coming in late
Occasionally a mother may not make enough milk or it may come in late. There are a number of causes of each; some can be overcome but others not.
Breast surgery can affect the breast’s ability to make milk and to let it pass through the nipple and the nipple’s ability to accommodate breastfeeding. The extent of the problem depends on the type of surgery and how it was performed.
Reduced milk supply
Many mothers worry about “losing their milk” but it is not common without a cause. Examples include infrequent breastfeeding and the increasing use of infant formula and the early return of a mother’s periods (menses). It may be possible to increase the milk supply by removing the cause and using certain tools such as expressing and medication.
How to give extra milk
Giving extra milk (supplementing) is necessary if mothers cannot breastfeed exclusively. Milk supplements of an appropriate type and amount should be given right after breastfeeding. If a mother is using a tube-at-the-breast system, the supplement is given while breastfeeding. If the mother is not breastfeeding, supplements are given when the baby shows hunger signs. These are called replacement feeds. Supplements may be given for non-medical reasons or if no longer needed; these can be decreased or possibly stopped.
Bottles and other tools for giving extra milk
Some babies need to be given extra milk (supplements). A feeding tool will be needed to bring the milk to the baby. The most common feeding tool is a bottle but there are a number of others. Each will have advantages and disadvantages and their use will depend on the family's situation and choices.
Types of extra milk
The ideal milk for babies is the mother’s own breast milk. This can be obtained by breastfeeding or by expressing from the breast with a pump or by hand. When not available, alternatives include pasteurized human donor milk, the milk of a friend, or infant formula. The latter has a variety of types, brands, and forms (powdered or liquid), and is heavily promoted. Infant formula must be safely prepared and stored, and can be expensive.
Increasing milk supply
Mothers with a low milk supply may be able to increase it, reducing or eliminating the need to supplement their babies with extra milk. Optimizing breastfeeding, expressing by pumping or manual expression, medication (pills), and herbs are possible tools. Any efforts to increase milk supply should be effective and stopped when the milk supply is no longer increasing.
Breastfeeding with a low milk supply and measuring milk supply
Some mothers have a permanently low milk supply. There are many benefits for mother and baby to continuing to breastfeed while also giving extra, appropriate milk. Some mothers are interested in knowing how much milk they are making; there are a number of tools to determine this. Mothers in this situation often benefit from support from breastfeeding specialists.
Nipple pain is common in breastfeeding mothers. With proper treatment and a little time, it usually stops. Nipple pain can start right after giving birth or can develop after a pain-free period. It is important that mothers identify the cause of pain quickly and accurately in order to start appropriate treatment. Breast pain is a little less common but this too is generally fixable. Nipples and the area behind the nipple can be abnormal and cause nipple pain and latching problems.
Inverted and abnormal nipples and areolas
A small number of mothers have abnormalities in the nipple or the area behind the nipple (nipple root). Problems include inverted or abnormal nipples, and swelling of the nipple root. This can prevent the baby from latching and result in nipple pain and skin damage.
Nipple pain soon after birth
It is common for mother to have nipple pain soon after the birth of the baby. This is usually related to the mechanics of breastfeeding and how the nipple and breast cope with the baby’s latching and sucking. Most pain stops within weeks of starting to breastfeed if treated properly. Painful nipples can go on to develop more painful nipple skin damage.
Nipple skin can become damaged and painful while breastfeeding. This is most common soon after the birth of the baby but can develop after a period of pain-free breastfeeding. Damage is best healed by moist-wound healing and damage is prevented by identifying and removing the cause.
Late-onset nipple and areolar pain and skin changes
Nipple pain can develop after a period of pain-free breastfeeding. There are a number of possible causes and the cause will direct the treatment.
Nipple yeast infection and thrush
Breastfeeding mothers can have a yeast infection of their nipples and areolas. This causes a characteristic pain during and after breastfeeding on both sides and is often accompanied by a rash. Treatment includes antifungal cream or pills. Some babies may have the same yeast microbe growing in their mouth and will show signs of this on the insides of their cheeks and lips or on their tongue. This is called thrush and also needs treatment.
Nipples that turn white
Some mothers with painful or damaged nipples have nipple vasospasm, a condition in which blood vessels suddenly narrow and don’t let blood into the nipple. This causes the nipple face to turn white or rarely purple. It can be painful and last for up to one hour or more from the end of breastfeeding. This can also happen with other nipple stimuli such as feeling cold. This will clear once the underlying problem is fixed. Temporary relief is possible with massage and warmth.
Breastfeeding can result in painful breasts. They may be painful because they are working normally or because of problems such as being overfull, engorged, or plugged. Breasts can also feel painful when a mother has nipple pain.
Mastitis and abscesses
When breastfeeding, mothers can develop a breast infection (mastitis). This often needs treatment with an antibiotic. Ideally mothers continue breastfeeding as this is part of the treatment. If mastitis becomes complicated, it can liquify in the centre (abscess). The treatment for a breast abscess is to drain it, ideally with a needle. If very severe, it may have to be drained by surgery. As long as the baby is not in contact with infected tissue or pus and can latch, they should continue to breastfeed.
Breastfeeding mothers may notice one or more breast lumps. They may be related to breastfeeding and of no concern or they may be a sign of a problem. Problematic lumps can be caused by plugged ducts and abscesses, cysts, non-cancerous lumps, or cancer. Mothers should see their health-care providers if they have a lump that persists for more than one week.
Illness in a baby can result in difficulty breastfeeding, poor growth, or an unhappy baby. Sick and premature babies may require extra feeding support until they are well and their mothers may need to use various breastfeeding tools to help their babies transition to full breastfeeding. Mothers too, may be ill and require medication, surgery, or hospitalization; these need not interfere with breastfeeding.
Premature babies often have both health and breastfeeding challenges. They are frequently cared for in hospital. Mothers can help their babies by establishing and maintaining their milk supply and providing skin-to-skin care. As babies grow and develop, they are often able to progress to breastfeeding. They should be closely monitored during this time.
Abnormal crying, colic, allergies, and reflux
A small number of babies may be in pain or distress, possibly because of an allergy to cow’s milk or other items in the mother's diet or other illness. Abnormal crying is unlikely to be caused by teething, swallowing air, lactose intolerance, or colic. Recently, the large number of babies diagnosed with milk protein allergy and reflux has raised concerns among researchers and experts.
Some babies are born with a tongue-tie, a condition that restricts the movement of the tongue and may interfere with breastfeeding. These can be treated by cutting with a scissor or a laser. Tongue-tie diagnosis have recently become very popular and numerous researchers and experts have cautioned that some surgery may be unnecessary.
Most sick babies are able to continue breastfeeding. There are many benefits; breastfeeding helps fight infection, speeds healing, and can calm the baby. If babies cannot breastfeed, their mothers can express milk to give to the baby or store for later use. They can resume breastfeeding as soon as the baby is well.
Mothers' medication and illness
Mothers who are ill or hospitalized are generally encouraged to continue breastfeeding if able. Most medication is compatible with breastfeeding. Maternal smoking, substance use problems, and infection with HIV may negatively affect the baby and may require weaning. These issues should be discussed with the mother’s health-care providers.
Expressing milk from the breast is a valuable tool if the baby is unable to breastfeed effectively or to support breastfeeding for periods of mother-baby separation. Expressing can be done by hand (manual expression) or by pumping. Effective expressing needs proper techniques, and if pumping, appropriate equipment. Expressed milk must be safely stored.
Expressing: pumping and manual expression
Expression, the removal of milk from the breast, can be done with a pump or by hand. There are many reasons to express: to establish a milk supply, to provide milk for the baby, or to manage periods of mother-baby separation. Expression needs to be effective; removing the expected amounts of milk, taking the expected amount of time, and not be painful. Mothers need to decide on how to express, on the type of pump (if they are pumping), and on how often to express.
Storing and preparing breast milk
Breast milk needs to be properly stored to prevent the growth of dangerous microbes. Once left to settle in a refrigerator, the cream will rise to the top and appear as a thin white layer; this is normal. Occasionally stored milk develops an unusual odor. This can be prevented by scalding. Stored milk may be given to the mother’s baby or donated to a milk bank.
Mothers who are separated from their babies need to express their breast milk in order to avoid painful problems and a decreasing milk supply. This requires a little planning. Returning to work can create additional challenges.
Successful breastfeeding is much more likely with support from partners, family, friends, health-care providers, the workplace, and society. Breastfeeding is not always possible or desired. If weaning, mothers should ensure that it is safe for themselves and their baby.
Breastfeeding mothers benefit greatly from support. This can be material such as a cooked meal, emotional as with praise from their family, or practical advice from a health-care provider. Low community breastfeeding rates, unsupportive hospital practices, and the public shaming of breastfeeding mothers are barriers to breastfeeding success.
Emotional aspects of breastfeeding
There are many possible barriers to breastfeeding and many mothers do not meet their breastfeeding goals. Barriers may not just be physical as with pain or a low milk supply but also emotional as with depression or anxiety. The lack of support is another barrier. Mothers should consider obtaining support from family and friends as well as their health-care providers.
Weaning and medical reasons for not breastfeeding
Weaning means to stop breastfeeding and to stop expression for the baby’s milk. Weaning may be mother- or baby-led and must be done safely. Rarely, weaning must happen for medical reasons.