Chapter Three

Establishing Breastfeeding

THE ADVICE IN this chapter is designed to allow you to establish a good milk supply before moving on to my standard 7pm to 7am Sleeping Baby Routine (Chapters Four and Five), which will see you through until the weaning stage (at 4–6 months).

There is so much conflicting advice out there on breastfeeding. Firstly, when breastfeeding you should be offering your baby both breasts at each feed. This is not only to stimulate, increase and maintain your milk supply, but also to ensure that your baby is full after each feed. You should also alternate the breast you start with at each feed. This ensures that each breast is emptied at least every other feed. Your baby (or you!) may tend to favour one breast which can often produce more milk than the other or is easier to latch on to. If you always start on the favoured breast you could end up with one breast larger than the other and produce much more milk on the favoured side, so make sure you swap the starter breast at each feed.

The First 24–48 Hours: Stimulation and Establishing Lactation

Before your breasts start to produce milk, you will produce colostrum, a thick yellowish or clear sticky liquid. This is top-quality, powerful stuff – high in protein and packed full of antibodies. It also has a laxative effect to help push out your baby’s meconium stools. It is important to regularly stimulate your breasts with short, active bursts of feeding while in the first few days of producing colostrum.

In order to stimulate your milk production, offer your baby short bursts of 10–15 minutes of active feeding on each breast every 1–2 hours during the day for the first 24–48 hours. This is to give frequent active stimulation during the day which encourages lactation. After 9/10pm let your baby sleep for longer if he wants to as this will also give you the rest needed after giving birth, which is as much a benefit to your milk supply as frequent sucking. Encouraging longer gaps between feeds at night and a greater intake of milk and feeds during the day will also help your baby to quickly establish the difference between night and day. If you are uncomfortable with leaving your newborn to wake naturally for a feed, you can feed him every 4–5 hours during the night until the morning. However, it is unlikely that your baby will sleep for any length of time at night at this stage and will wake when he is hungry.

Feeding your baby every 1–2 hours during the day and 4+ hourly at night will be more stimulating for your breasts than leaving him to suck or comfort suck on an empty breast. Common advice is to let your newborn feed as long as he wants to, whenever he wants to. In my experience, the trouble with this is, if there is no milk to drink, sucking for long periods on an empty breast can make your nipples very sore and damaged by the time your milk actually does come in. This is also not ‘active stimulation’ so won’t have the same impact as active sucking frequently for shorter bursts, as my routine encourages.

It can take from 24 hours to 10 days for your milk to ‘come in’, so how long you stay on this routine will depend on when this happens. Signs that your milk has come in are:

• you become temporarily engorged
• your breasts swell and become hard
• your milk turns a milky-white colour

Once your milk has come in

When your milk has come in, extend the time on each breast to 20–30 minutes at each feed, feeding three-hourly during the day. If your baby is over 2.72kg (6lb), is feeding well during the day and is going over four hours between feeds at night, letting him naturally wake is fine as long as he is gaining weight. Leaving longer periods between feeds at night will mean that you get more rest, which is essential for recovery and producing milk. Some women start lactating within 24 hours but it can take up to 10 days for your milk to come in, especially if you’ve had a C-section.

Some babies are born sleepy and not so hungry, while others are ravenous. If the latter, giving a little formula of 30ml (1oz) maximum in the first 48 hours will not only satisfy your baby overnight but will give you much-needed sleep to recover and help encourage your milk supply. This will also save your nipples from being damaged due to lengthy sucking on empty breasts. In my experience, giving formula through a bottle will not discourage a baby from the breast if given in very small, controlled quantities, but instead will give the breasts a chance to rest and do what they need to do to start producing milk. Formula is best given in the evening so as to not interfere with your daily stimulation and to allow you both to get some sleep. Of course, if you give your baby too much formula, he will be disinterested in latching on to the breast when you want him to. Like everything, it’s all about balance.

Check your breasts for milk to gauge if you have any milk left (see box below) whenever you break to wind your baby, which should be after every 5–10 minutes of active sucking, or if your baby has fallen asleep or is comfort sucking. If your baby is sleepy and inactive during a day feed, make sure you express to keep stimulation up and encourage your milk supply (see here for more on this).

How to check your breasts for milk

Squeeze through the breast to the nipple with your forefinger and thumb. If milk is released easily your breast may not be empty and you should offer your baby five more minutes on that side, and then check again. You should spend a maximum of 30 minutes on each breast. Some mothers will always have a little milk left whenever they check as they are constantly producing, but for most this is a great way of checking if your breasts are empty. Test this method by expressing straight after feeding to see how much milk you have left. If it is less than 30ml (1oz) then your baby has drained your breast.

Active feeding

The objective is to teach your baby that your breasts are for feeding and not for comfort or for inducing sleep, which can be tricky in the first six weeks of life as your baby snuggles into your body and the soporific action of sucking alone makes it very hard for him to stay awake. I often see parents trying to wake their baby by patting, rocking or jiggling them around, which will have the opposite effect and will send a baby to sleep. Background noise, such as the radio, TV, chatting or kitchen appliances, will also lull a baby to sleep. Newborns are heat-, light- and sound-sensitive (see here).

Below are some tips on encouraging active and wakeful feeding:

• Wake your baby 10–15 minutes before each day feed and strip him down to just his vest bodysuit in order to cool his body temperature down in preparation for the feed. Tickling his hands and feet will help with waking.
• Keep your baby cool while feeding. At a room temperature of 19–20°C a vest bodysuit is all the clothing needed. A baby’s body will heat up while breastfeeding and digesting and being close to Mum. Don’t worry if your baby’s feet and hands feel or look cool, it’s the warmth of his body you need to check.
• A cool water nappy change usually helps wake a snoozy baby.
• Tickle your baby’s hands and feet, and anywhere you find sensitive, to help keep him actively feeding and to help with waking for winding.
• A newborn often won’t be able to stay sucking actively while breastfeeding for longer than 5–10 minutes at a time. Place your baby down on a muslin square or towel on the floor and he will awaken more easily as he is not having bodily contact with you. Briefly laying your baby on his back also helps bring up wind (see here).

Winding

Always ensure you wind your baby effectively as trapped air can swell up in his tummy, making him feel unnaturally full and sleepy (see here for more on this). Wind your baby every 5–10 minutes or when feeding has naturally slowed down. Always wake your baby before winding as it is virtually impossible to wind a sleeping baby. Newborns often grunt and make throaty noises which can be mistaken for burps – you should be able to hear a burp clearly when you have successfully released the trapped wind. Bear in mind that some babies will let out a single large and guttural burp, while others will release two or three smaller burps. In time you will get to know what is normal for your baby.

Keep a baby routine diary

Keeping a baby diary will help you to remember which breast you last fed on (especially when it is 3am and you can’t remember!) and will allow you to log your baby’s feeds (the start time and duration), any winding details, his daily awake time, your milk supply and the expressing time, length and quantity.

Week 1: Three-hourly Feeding

This routine is to be followed during the first week of life only, feeding three-hourly as your milk starts to come in.

Time the feeds from the start of each feed, running from 6am to 9pm, or 7am to 10pm, and then four- to five-hourly thereafter during the night. If your baby is over 2.72kg (6lb) and is gaining weight you can leave him to wake naturally. Feed your baby for 20–30 minutes on each side, which includes winding, and 15 minutes each side for night feeds. If for some reason your baby is too tired or unable to take both breasts, express the side that has not been drained so that both breasts are being stimulated and drained every three hours during the day. This will encourage a good milk supply – in the first week of lactation it is all down to stimulation and draining the milk you are producing.

Stay on this routine until you have established a milk supply, your baby is over 2.72kg (6lb) and is gaining weight. You can then follow the routines outlined in Chapter Four.

Three-hourly Feeds While Establishing Breastfeeding
6am	Start on left breast Feed for 20–30 minutes each side Total awake time (including feed): 1–1½ hours
7/7.30am	Nap
9am	Start on right breast Feed for 20–30 minutes each side Total awake time (including feed): 1–1½ hours
10/10.30am	Nap
12pm	Start on left breast Feed for 20–30 minutes each side Total awake time (including feed): 1–1½ hours
1/1.30pm	Nap
3pm	Start on right breast Feed for 20–30 minutes each side Total awake time (including feed): 1–1½ hours
4/4.30pm	Nap
6pm	Left breast only Feed for 20–30 minutes
6.30pm	Bath (34–35°C) or strip wash and change for the night
6.45pm	Right breast only Feed for 20–30 minutes
7.15pm	Nap
9/9.15pm	Start on left breast Feed for 20 minutes each side
9.40/10pm	Bedtime (swaddled)
During the night	Feed for 15 minutes each side whenever your baby wakes (night-time feeds are kept much smaller) Change your baby’s nappy before the feed

Notes on routine

• Wake your newborn 10–15 minutes before each feed to ensure he is wide awake and enthusiastic before going on to the breast. Strip off his sleepsuit/Babygro and feed in just a vest bodysuit; babies get very warm while breastfeeding.
• Alternate the breast you start on at each feed. Before changing to the second breast, check your breast for milk (see here). If you still have milk, give another five minutes on the first side before checking again. Change to the other breast when you have run out of milk on the first side or when your baby has been feeding for 30 minutes.
• Change your baby’s nappy after feeds during the day – most babies dirty their nappies while feeding. If you do change before a feed, change the nappy again after the feed to ensure the nappy lasts through to the next feed. (See here for more on nappy changing.)
• Change your baby’s nappy before feeds during the night to help avoid stimulation after the feed and aid a smooth transition back to bed.
• Swaddling for the last five minutes of a night feed will also help a smooth settling process. Get your baby’s wind up using the over-the-shoulder position (here) and then put him back to bed.
• Keep night feeds dark (barely lit) and quiet.
• Winding properly is very important, so take another look at Chapter One for help with getting this right. Make sure your baby is wide awake while winding and feeding as it’s almost impossible to wind a sleeping baby. Wind your baby every 5–10 minutes while feeding if active sucking has slowed or to help wake your baby if he falls asleep.
• In the first week of life, you are unlikely to be able to keep your baby awake long enough to have any real awake time, but if he is in fact able to do so then allow no more than 1½ hours timed from the start of the feed. Feeding every three hours means he is already having a lot of activity, being woken for feeds, and will need at least 1½–2 hours’ sleep between daytime feeds. He should, however, be able to stay awake for the one-hour feed period. Structured play/awake time will start when you move on to the more realistic 3½–4-hourly feeding routine (Chapter Four).

Gilly’s five-day consultation

Monday

Gilly is three weeks old but was born four weeks premature and weighs 2.46kg (5lb 7oz). To help Gilly gain weight, on leaving hospital Antonia (Gilly’s mum) was advised to not let Gilly go more than three hours between feeds. Gilly was therefore being fed every three hours day and night and had reached a great weight of over 3.17kg (7lb). I have cared for hundreds of premature babies and, if they are gaining weight and Mum’s milk supply is ahead of baby’s demand, there is no reason why, if the baby is over 2.72kg (6lb), they cannot be put straight on to my 7pm–7am routine.

My advice to Antonia on leaving hospital would have been to feed Gilly every three hours for a 12-hour day and then every 4–5 hours during the night, which would have given Antonia rest and encouraged Gilly to have longer stretches of sleep during the night. This would have made day feeds more effective, not to mention teaching Gilly the difference between day and night from the off. Gilly, having been woken every three hours during the day and night, was understandably exhausted, not feeding well and was falling asleep while being breastfed. As a result she was too tired to take a full feed during the day and then was not sleeping well day or night because of her low milk intake and reliance on several feeds at night to reach the milk intake needed for her age and weight.

Exhausted and distraught, Antonia contacted me. Firstly I advised her to stop waking Gilly at night and to let her wake of her own accord. Having lower milk intake at night would naturally increase her appetite, and therefore her milk intake during the day, and would also give her enough sleep to be able to focus and stay awake for day feeds as well as a little playtime. I also advised Antonia to keep feeding every three hours during the day, starting from 6am, introduce the staggered bedtime feed at 6pm, and express after the morning feeds to help increase her milk supply in preparation for moving on to the 7pm–7am routine, and to gather enough milk for the post-bath bottle.

Gilly’s new routine looked like this:

6am	Breastfeed for 45–60 minutes
7am	Express for 15–20 minutes
7.30am	Nap
9am	Breastfeed for 45–60 minutes
10am	Express for 15–20 minutes
10.30/11am	Nap
12pm	Breastfeed for 45–60 minutes
1pm	Express for 10–15 minutes
1.30/2pm	Nap
3pm	Breastfeed for 45–60 minutes No express
4.30pm	Nap
6pm	Breastfeed for 20–30 minutes
6.30pm	Bath (34–35°C)
6.45pm	Bottle-feed: 60–120ml (2–4oz) expressed breast milk
7.30/8pm	Bedtime (swaddled)
During the night	Feed for 15 minutes each side (30 minutes maximum) whenever Gilly wakes

I also advised making sure Gilly was woken 15 minutes before a feed to ensure she was wide awake and ready to actively feed, and also to keep Gilly stimulated while feeding, which in turn would result in an increase of milk intake and breast stimulation.

Tuesday

I checked in with Antonia to see how the new plan was working out. Gilly had dropped a feed in the night, feeding twice instead of the usual three times. Antonia and I decided she should stay on the three-hourly feeding for another day before moving over to the 7pm–7am routine the following day and to gradually increase the post-bath, bedtime bottle by 30ml (1oz) at a time until night feeds were phased out completely.

Wednesday

Gilly woke twice in the night for a 30-minute feed at 1am and 4.30am, but was hard to settle after this later feed. We discussed keeping Gilly swaddled for feeds if she woke after 4am and to offer a shorter feed of 10–15 minutes. Gilly was also unsettled after the 3pm feed.

We moved Gilly on to the 7pm–7am routine, lengthening the time between feeds. With fewer feeds during the day it was important that Gilly was actively feeding and draining the breasts. If Gilly still looked hungry after the afternoon feed, Antonia was to offer 30–60ml (1–2oz) from a bottle as a top-up, straight after the breastfeed. On the new routine Antonia could start to gradually increase Gilly’s awake time to up to two hours at each feed period.

Thursday

Gilly’s bedtime bottle had increased to 150ml (5oz) and she woke once at 3am on Wednesday night. Great result! My advice was to now add an express between 8pm and 9pm, which would help maintain Antonia’s milk supply and ensure she was comfortable overnight.

Friday

Gilly was well on her way to sleeping through the night and woke at 3am on Thursday night for a 20-minute feed. Increasing her awake time impacted on how much sleep she needed at night, but overall her increase of milk intake during the day was satisfying most of the milk needed in a 24-hour period. This daily volume will need to increase until she sleeps through and her growth slows down.

Although frequent feeding day and night is advised to stimulate a mother’s milk supply and to help the baby gain weight, exhaustion often counteracts that effect for both mother and baby. An exhausted mother can find it hard to supply enough milk for full feeds to sustain her baby for any length of time, and the baby therefore only gets enough milk to snack frequently. The more rested the mother, the greater the milk supply to satisfy her baby’s appetite. Now Gilly’s mother is well-rested, sleeps eight hours at night and has enough expressed milk to store in the freezer – happy days!