Getting ready for the birth of your baby is an exciting, yet busy, time. There are many things to do, such as choosing a name for your child, picking out baby supplies, and deciding how you are going to feed your baby. One thing you should consider is breastfeeding since this provides many benefits for you and your baby.

If you have never breastfed before — and even if you have — it is natural to have some questions. For instance, you may be wondering if your breasts can make enough milk to feed your baby or if you can keep nursing after you go back to work. (The answer to both questions is "Yes!") This information was developed by the American Academy of Pediatrics to help answer your questions and give you information about the following breastfeeding issues:

• why breastfeeding is so good for your baby and you.
• the first feeding.
• nursing after the first feeding.
• medications, illnesses, and other special situations.
• breastfeeding after you go back to work.
• weaning your baby from the breast.

Why is breastfeeding so good for my baby?

Human milk and infant formula are different. Not only does human milk provide all the protein, sugar, fat, and vitamins your baby needs to be healthy, but it has special benefits that formulas cannot match. It helps protect your baby against certain diseases and infections. Because of the protective substances in human milk, breastfed children are less likely to have the following:

• Ear infections (otitis media)
• Allergies
• Vomiting
• Diarrhea
• Pneumonia, wheezing, and bronchiolitis
• Meningitis

Research also suggests that breastfeeding may help to protect against Sudden Infant Death Syndrome (SIDS).

Other reasons why human milk is good for your child include the following:

• It is easier for babies to digest.
• It does not need to be prepared.
• It costs nothing to make and is always in supply.
• It is even good for the environment since there are no bottles, cans, and boxes to put in the garbage.

Breastfeeding also provides physical contact, warmth, and closeness, which help to create a special bond between a mother and her baby.

There are also many health benefits for you because breastfeeding does the following:

• Burns more calories and helps you get back to your prepregnancy weight more quickly.
• Reduces the risk of ovarian cancer and, in premenopausal women, breast cancer.
• Builds bone strength to protect against bone fractures in older age.
• Delays the return of your menstrual period, which may help extend the time between pregnancies. (Keep in mind that breastfeeding alone will not prevent pregnancy.)
• Helps the uterus return to its regular size more quickly.

The longer you breastfeed, the greater the benefits will be to your baby and you, and the longer these benefits will last. The World Health Organization (WHO) and many other experts encourage women to breastfeed for as long as possible, 1 year or even longer, because human milk provides the best nutrition and protection against infections.

Who can help me?

After deciding to breastfeed, it is helpful to have support from family and friends. Although fathers cannot experience the intimate feeling of breastfeeding, they can share many other special, personal moments with their infants. Older siblings can also help by holding the baby, changing diapers, and playing with him.

Before your baby is born, learn as much as you can about breastfeeding. Read, watch videos, and talk to other women who have breastfed. Take a breastfeeding class; many hospitals and health organizations offer them. The following are other helpful sources of information:

• Your obstetrician and pediatrician
• Prenatal instructors and lactation consultants at your local hospital
• La Leche League International, a worldwide organization dedicated to helping families learn about breastfeeding

Before your baby is born, talk to your doctor about your plans to breastfeed. It is best to start breastfeeding within the first hour after birth, if possible. Also, while you are in the hospital you and your baby should remain together as much as possible. "Rooming-in" with your baby during your hospital stay has been shown to help make breastfeeding more successful.

Talk to your obstetrician and pediatrician to make sure any medications that you are taking will not harm your baby when they pass through your milk. Most medications are not a cause for concern.

How does my body prepare for breastfeeding?

When you become pregnant, your body naturally starts to prepare for breastfeeding. During the fourth or fifth month of pregnancy your body is capable of producing milk. This first milk, called colostrum, is packed with all the nutrients that your newborn baby needs. It also contains many substances to protect new babies against infections. Colostrum is thick and yellowish or orangish in color. Your body will produce colostrum for several days after delivery until your mature milk "comes in." The milk then thins, becomes milk-like in color and begins to adjust to the baby’s needs for the rest of the time that you breastfeed. One of the special qualities of human milk is that it changes during the time you nurse your baby to match the changing needs of your growing infant.

How is human milk produced?

During pregnancy, your body increases its production of a hormone called prolactin. This hormone stimulates the cells in your breasts to make milk. The amount of prolactin also increases when you nurse your baby. The size of your breasts is not a factor in how much milk you make; your baby’s nursing controls milk production. In other words, the more you nurse, the more milk your body produces.

Oxytocin is another hormone that increases during pregnancy. This hormone causes tiny muscle cells within the breasts to contract and squeeze milk down the milk ducts toward the nipples. This process, called the let-down reflex, occurs each time you nurse your baby.

Do I have to do anything to prepare my breasts for breastfeeding?

During pregnancy, you do not have to care for your nipples or breasts in any special way. Just make sure your bras provide enough support. Since your breasts will get larger, buy nursing bras that allow room for growth. Wash your breasts with warm water only. Soaps, lotions, and alcohol are not necessary, may be irritating, and should not be used. Ask your obstetrician or family physician to examine your breasts and nipples during pregnancy.

Inverted Nipples

Although not very common, a few women have nipples that are drawn inward, or are inverted. When nipples are inverted, a baby may not be able to grasp the areola properly to get milk.

The problem of inverted nipples usually clears up on its own during pregnancy as breasts get larger. If this does not happen, inverted nipples can be treated late in pregnancy or soon after the baby is born.

The first feeding after delivery

Immediately after delivery, your baby should be placed on your chest or abdomen, skin to skin. Babies are very alert after they are born, and they are usually hungry, too! Your baby’s first feeding can take place within 30 minutes to an hour after delivery. The protection against infection that human milk provides is important immediately after birth. Your milk will also give the baby nutrients to prevent a low blood sugar level. This early taste of your milk also stimulates the baby to nurse better later.

If you had a vaginal delivery, you can nurse in bed or in a chair in the following ways:

• Lie on your side with your baby facing you.
• Hold your baby in the cradle position, with the head in the crook of your arm. Firmly support the baby’s back and buttocks. When feeding this way, make sure your baby’s entire body is facing your body, not the ceiling.

If you had a Cesarean-section delivery you can nurse your baby in the following ways:

• Sit up using one or two extra pillows to support your baby and protect your incision.
• Lie down on your side with your baby facing you.
• Use a side-sitting or "football" hold.

Always take time to make yourself comfortable. Do not be shy about asking for help during the first few feedings. Just as with learning anything new, it may take several feedings before you and your baby become a skilled nursing team.

Latching-on

Touching your breast to the center of your baby’s lips stimulates your baby to open his mouth widely. This is called the "rooting reflex". As this occurs, pull your baby straight forward onto the nipple and areola. Keep in mind that when a baby is correctly positioned, or "latched-on," your nipple and much of the areola are pulled well into the baby’s mouth. Your baby’s lips and gums should be around the areola and not on the nipple. This is why it is important for the baby’s mouth to be open wide.

You can help your baby latch-on by holding the breast with your free hand. Place your fingers under the breast and rest your thumb lightly on top (back behind the areola). Make sure your baby is properly lined up at your breast. Also be sure your fingers are well back from the areola so they do not get in the way.

When the baby first nurses there will be a tugging sensation. If the latch-on hurts, pinches, or produces pain, the latch-on may be incorrect. Break the latch-on by slipping your finger into the corner of your baby’s mouth, reposition, and try again. It can take several tries.

If your nipples are not sore, breastfeeding should not be painful. If it hurts while you breastfeed, then your baby may not be latched-on correctly and may need to be repositioned.

Correct latch-on is very important. As it:

• makes milk flow better
• prevents sore nipples
• keeps your baby satisfied
• stimulates a good milk supply
• helps to prevent overly full (engorged) breasts

If your baby is latched-on correctly but you still have pain while breastfeeding, talk with your pediatrician.

Babies use their lips, gums, and tongues to get the milk to flow from the breast. This is known as suckling. Simply sucking on the nipple will not draw milk and may hurt the nipple.

Most babies will nurse actively if they are hungry and positioned correctly. For the first few weeks after birth until breastfeeding is well-established, breastfeeding newborns should not be given any supplements (water, sugar water, formula, etc.) unless there is a medical reason for it. A baby who is breastfeeding regularly and effectively will get all of the water and nutrients she needs. Some authorities believe that introducing a bottle or using a pacifier may cause nipple confusion and interfere with the establishment of breastfeeding. Others disagree and feel that nonnutritive sucking is good and does not interfere with breastfeeding. Ask your pediatrician for more information.

What is "let-down"?

The let-down reflex occurs every time you breastfeed. The first few times you breastfeed this let-down reflex may take a few minutes. Afterward, let-down will occur much more quickly, usually within a few seconds.

The signs of let-down are different for each woman. Sometimes when your baby starts to nurse, you may feel a brief prickle, tingle, or even slight pain in your breast. Or, milk may start dripping from the breast that’s not being used. These feelings and milk flow are signs of the let-down reflex. This means your body is making it easier for your baby to nurse.

You may feel strong cramping in your uterus when your milk lets-down. The hormone oxytocin, which stimulates milk flow, also causes the muscles of the uterus to contract. Nursing helps your uterus go back to its original size. This cramping is totally normal and is actually a sign of successful nursing. The cramping should go away in a week or so.

To help the let-down process along, try these tips:

• Sit in a comfortable chair with good support for your arms and back. Many nursing mothers find that rocking chairs work well.
• Make sure your baby is in the proper position on your breast. Correct positioning is one of the most important factors in successful breastfeeding.
• Listen to soothing music and sip a nutritious drink during feedings.
• Do not smoke, drink alcohol, or use illegal drugs. These all contain substances that can interfere with let-down and affect the content of breast milk. They are not good for you and not good for your baby.
• Wear nursing bras and clothes that are easy to undo. Nursing bras have front closing flaps that come down to expose your nipple and part of your breast.
• If your household is very busy, set aside a quiet place ahead of time where you will not be disturbed during feedings.
• Sometimes just thinking about your baby helps let-down take place.

How do I take care of my breasts during breastfeeding?

By the third or fourth day of breastfeeding, your milk will change from colostrum to what looks more like skim milk. Your breasts will also go from feeling soft to firm. If your nipples leak, use a nursing pad or clean folded handkerchief squares inside your bra to catch the leaking milk. Be sure to change these often. Do not use plastic-lined pads because they will prevent air from circulating around your nipples.

Between feedings, gently pat your nipples dry. This helps prevent them from getting irritated. You may also want to apply a little expressed colostrum, human milk, or medical grade modified lanolin on your nipples to prevent dryness.

How often should I nurse?

Breastfed babies tend to feed more often than formula-fed babies, usually 8 to 12 times a day. The main reason for this is that their stomachs empty much more quickly because human milk is so easy to digest.

Initially, your newborn will probably nurse every couple of hours, regardless of whether it’s day or night. By the end of the first month, your baby may start sleeping longer at night. Let your baby feed on demand—that is, whenever he is hungry. Watch for different signals from your baby, rather than the clock to decide when to nurse. When your baby is hungry, he may do any of the following:

• nuzzle against your breast.
• show the rooting reflex.
• make sucking motions or put hand to mouth.
• cry.

It is best not to wait until your baby is overly hungry before you breastfeed.

Some newborns can be sleepy and hard to wake. Do not let your baby sleep through feedings until your milk supply has been developed, usually about 2 to 3 weeks. If your baby is not demanding to be fed, wake her if 3 to 4 hours have passed since the last feeding. If this persists, call your pediatrician.

What is engorgement?

Feeding on demand not only ensures that your baby’s hunger is satisfied, but it also helps prevent engorgement. Engorgement occurs when your breasts become too full with milk. A little engorgement is normal, but excessive engorgement can be uncomfortable or painful. If your breasts do become engorged, try the following:

• Express some milk before you breastfeed, either manually or with a breast pump. (See "How to Express Milk".)
• Soak a cloth in warm water and put it on your breasts. Or take a warm shower before feeding your baby. For severe engorgement, warmth may not help. In this case, you may want to use cold compresses as you express milk. Ice packs used between feedings can relieve your discomfort and reduce swelling.
• Feed your baby in more than one position. Try sitting up, then lying down.
• Gently massage your breasts from under the arm and down toward the nipple. This will help reduce soreness and ease milk flow.
• Do not take any medications without approval from your doctor. Acetaminophen (eg, Tylenol) may relieve pain and is safe to take occasionally during breastfeeding.

It is important to keep breastfeeding. Engorgement is a temporary condition and will be most quickly relieved by effective milk removal.

Once the engorgement passes, your breasts will become soft again. This is normal and is exactly what should happen.

How to express breast milk

You can express milk manually with your hands or with a breast pump. Breast pumps are used to ease engorged breasts or to collect milk when you are away from your baby (for example, if you are ill or at work). Pumping enables you to continue to breastfeed by keeping your milk production stimulated. If milk is not emptied from the breast regularly, it sends a message back to your body to stop making milk.

To express milk manually:

• Make sure your hands are clean. Wash them well with soap and water.
• Put a clean cup or container under your breast.
• Massage the breasts gently toward the nipples.
• Place your thumb about 1 inch back from the tip of the nipple and your first finger opposite.
• Press back toward your chest, then gently press the areola between the thumb and finger and release with a rhythmic motion until the milk flows or squirts out.
• Rotate your thumb and finger around the areola to get milk from several positions.
• Transfer the milk into clean covered containers for storage in the refrigerator or freezer for possible later feeding for your baby. Always label the container and put a date on it. (See section on milk storage.)

Some women prefer hand expression because it can be done silently and does not require special equipment. Other women may find it easier and faster to express milk with a breast pump. Pumps are manual, battery-operated, or electric. You can find manual pumps in most pharmacies and baby stores. Do not buy those that look like a bicycle horn, because they can not be cleaned properly and milk may become contaminated.

Good hand pumps have two cylinders, one inside the other, attached to a rigid funnel-like device that fits over the breast. As you slide the outer cylinder up and down, negative pressure is created over the nipple area. This causes milk to collect in the bottom of the cylinder. This collecting cylinder can be used with a special nipple to feed your baby without transferring the milk. The entire pump can be cleaned in the dishwasher or by hand with soap and hot water.

Some hand pumps have a handle to squeeze that creates a negative pressure and draws the milk into a bottle. These may have a soft, pliable flange that fits around the nipple and areola and produces a milking action while pumping.

For most women, electric pumps stimulate the breast more effectively than manual expression or hand pumps. They are used mainly to keep breastfeeding going when a mother is not able to breastfeed for several days or more. These pumps are easier and more efficient than hand pumps, but they are much more expensive. However, you may be able to save money by renting an electric pump from your hospital or a medical supply store.

When shopping for an electric pump to buy or rent, make sure that it creates a milking action and is not simply a sucking device. Pumps that express milk from both breasts at the same time increase your amount of milk and save time. No matter which type of pump you choose, make sure that all parts of it that come into contact with your skin or milk can be removed and cleaned. Otherwise, the pump will become a breeding ground for bacteria, and the milk will not be safe for your baby.

How long does breastfeeding take?

While some infants nurse for only 10 minutes on one breast, it is quite common for others to stay on one side for much longer. Some feedings may be longer than others depending on your baby’s schedule and the time of day. Some babies may be nursing even though they appear to be sleeping. If your baby has fallen asleep at your breast, or if you need to stop a feeding before your baby is finished, gently break the suction with your finger. Do this by slipping a finger into your baby’s mouth while he or she is still latched-on. Never pull the baby off the breast without releasing the suction.

When you breastfeed, alternate between which breast you offer first. (You may want to keep a safety pin or short ribbon on your bra strap to help you remember on which breast your baby last nursed.) While you should try to breastfeed evenly on both sides, your baby may prefer one side over the other and nurse much longer on that side. When this happens, the breast adapts its milk production to your baby’s feedings. Remember, your baby’s feedings control how much milk your breasts produce. It is important to let your baby nurse on both sides so that each breast gets stimulation over the course of a day.

You will soon get to know your baby’s feeding patterns. Each baby has a particular style of eating, some slower, some faster. Learning your own baby’s eating patterns makes it easier to determine when she is hungry, when she has had enough, how often she needs to eat, and how much time she needs for feedings.

Spitting up, hiccups, and other reactions

Spitting up is a common reaction that infants have during or after feeding, and some just spit up more easily than others. There is usually no need to be concerned when your baby spits up. Unlike formula fed babies, the spitting up of human milk does not smell bad and does not stain clothing or linen. If your baby does spit up, do the following:

• Try to make each feeding calm, quiet, and leisurely.
• Avoid interruptions, sudden noises, bright lights, and other distractions.
• Burp your baby at least twice during the feeding.
• Hold your baby more upright during feedings.
• Put your baby in an upright position right after a feeding.
• Do not jostle or play vigorously with your baby right after a feeding.

If the baby repeatedly vomits, especially in a forceful manner (shooting out), call your pediatrician right away.

Most babies also hiccup from time to time during feedings. If this happens, you can continue to nurse your baby, hiccups will stop on their own.

How can I tell if my baby is getting enough milk?

There are several ways you can tell whether your baby is getting enough milk. One is by the number of wet diapers he has in a day. Make sure he has at least six wet diapers per day with pale yellow urine, beginning around the third or fourth day of life. Your infant should also have several small bowel movements daily (there may be one after every feeding in the first few weeks). During the first week of life, your infant should have at least two stools per day. From about 1 to 4 weeks old these should increase to at least 5 per day. As your baby gets older, bowel movements may occur less often, and may even skip a number of days. Bowel movements of breastfed babies usually smell somewhat sweeter than the stools of formula fed babies.

Your baby’s feeding patterns are also an important sign that he is feeding enough. A newborn may nurse every 1½ to 3 hours around the clock. If your baby sleeps for stretches of longer than 4 hours in the first 2 weeks, wake him for a feeding. It is most important that your baby is latched-on properly during feedings. (See "Latching-on".) Listen for gulping sounds to know that your baby is actually swallowing the milk and not just sucking. Also look for slow, steady jaw movement.

Your baby should be steadily gaining weight after the first week of life. During the first week, some infants lose several ounces of weight, but they should be back up to their birth weight by the end of the second week. Your pediatrician’s office will weigh your baby at each visit. Keep in mind that your baby may breastfeed more often during growth spurts.

Signs that baby is getting enough milk are as follows:

• at least six wet diapers per day and two to five loose yellow stools per day, depending on baby’s age. (Your baby’s stools should be loose and have a yellowish color to them. Be sure your child’s stools are not white or clay-colored.)
• steady weight gain, after the first week of age.
• pale yellow urine, not deep yellow or orange.
• sleeping well, yet baby looks alert and healthy when awake.

Most breastfeeding babies do not need any water, vitamins, or iron in addition to breast milk for at least the first 6 months. Human milk provides all the fluids and nutrients a baby needs to be healthy. By about 6 months of age, however, you should start to introduce your infant to baby foods that contain iron. Your pediatrician may prescribe Vitamin D if there is a need for it.

The American Academy of Pediatrics and the American Academy of Pediatric Dentistry recommend that breastfed infants (as well as bottle fed infants) not receive fluoride supplements during the first 6 months of life. After 6 months of age, check with your pediatrician to see if you need to give your baby fluoride.

If your baby cannot or will not nurse, or if you are having problems with breastfeeding, it is important that you call your pediatrician as soon as possible. Refusal to breastfeed may be a sign of illness that needs prompt attention.

Do I need to be careful about medication and food?

Medication

Most medications are safe to take during breastfeeding, but there are a few that can be dangerous for the baby. To be sure, let your doctor and your baby’s pediatrician know that you are breastfeeding. Get approval for all medications, including non-prescription drugs. Also, take the medication just after you nurse rather than just before.

Some birth control pills also might affect your milk production, but effects vary from woman to woman and with the type of pill. Discuss this with your doctor.

Other substances

While you are nursing, avoid drinking alcohol because it can pass through your milk to your baby. If you choose to drink alcohol, drink it just after you nurse rather than just before.

Do not smoke while you are breastfeeding, or around children at all! Secondhand smoke is dangerous to all children, but especially to newborns. It increases the risk of SIDS.

Try to avoid caffeine or at least reduce your intake while you are breastfeeding. Caffeine tends to build up in babies’ systems because their bodies cannot get rid of it very easily. A morning cup of coffee is not likely to harm your baby, but too much caffeine can cause problems such as poor sleeping, nervousness, irritability, and poor feeding. Try using decaffeinated coffee and tea and avoid colas and other carbonated drinks that have added caffeine.

Food sensitivities

Sometimes breastfeeding babies react to certain foods that their mothers eat. You might notice that after eating spicy or "gassy" foods, your baby cries, fusses, or even nurses more often. Since babies with colic often have similar symptoms, the best way to tell the difference between a food reaction and colic is by how long symptoms last. With food reactions, symptoms are usually short-lived, lasting less than 24 hours. Symptoms caused by colic occur daily and often last for days or weeks at a time. If your baby gets symptoms every time you eat a certain type of food, stop eating that particular item.

Dairy products

In rare instances, your breastfed infant may be allergic to the cow’s milk in your diet. Symptoms can appear anywhere from a few minutes to a few hours after she breastfeeds and may include: diarrhea, rash, fussiness, and gas.

To tell whether your baby is allergic, you need to cut out all dairy products from your diet for 2 weeks. Then one by one, return each dairy product to your diet to see whether your baby has a reaction after nursing.

Special situations and breastfeeding

Maternal illness

Many parents are concerned that breastfeeding has to stop if the mother gets ill. During most illnesses, including colds, flu, bacterial infections, and even surgical conditions, breastfeeding can and should continue. Both the mother and baby benefit if it does.

If you are breastfeeding, by the time you show symptoms of an illness, your baby has already been exposed to it. The best thing to do is to keep breastfeeding. This is because you have already started to produce antibodies that through your milk protect your baby from getting infected. If you stop breastfeeding when cold or flu symptoms appear, you actually reduce your baby’s protection and increase the chance of the baby getting sick.

If you are unable to breastfeed your infant while you are ill, keep up your milk supply by expressing milk for your baby either by hand or using a pump. The milk can then be fed to the baby.

Even with more serious illnesses, such as breast abscess, gall bladder surgery, or severe infections, you usually only need to stop breastfeeding for a short period. There are a few infectious diseases that mothers have that can be transmitted through human milk to the baby, including HIV and untreated tuberculosis. Mothers in the United States with HIV are advised not to breastfeed.

Similarly, mothers with tuberculosis should not breastfeed until appropriate treatment has been started. Mothers with hepatitis B can breastfeed their infants if the infant receives the hepatitis B vaccine in the first few days after birth. There is no evidence that hepatitis C is transmitted by breastfeeding. Mothers with chronic hepatitis C are often advised that they can nurse their infants, but they should discuss this with their physician. Other types of infections need to be evaluated by the obstetrician and pediatrician, but nearly all will be found to be safe for breastfeeding.

Mastitis

Mastitis is an infection of the breast. It causes swelling, burning, redness, and pain. This usually occurs in just one breast and may also cause a nursing mother to feel feverish and ill. If you have any of these symptoms, let your doctor know at once so that you can start treatment. Lots of rest, warm compresses, antibiotics, breast support, and continued breastfeeding are all that are usually needed.

Mastitis occurs when a milk duct gets blocked and bacteria infect a portion of the breast. Rest and good nutrition will help you get back your energy. Also, frequent nursing will help drain your breasts and prevent the infection from spreading.

You should not stop breastfeeding while you have mastitis since the infection will not spread to your milk. It is important to keep the milk flowing in the infected breast. If it is too painful to have your baby nurse on the infected breast, open up both sides of your bra and let the milk flow from that breast onto a towel or absorbent cloth. This relieves the pressure as you feed the baby on the opposite side. Pumping the affected side may also be necessary.

Cracked nipples

If your baby is not positioned properly or does not latch-on well when you start breastfeeding, you might end up with cracked or sore nipples. To prevent cracked nipples, position the baby better and be sure the baby’s lips and gums are on the areola and not on the nipple. Also, try to vary your baby’s position at each feeding. Get help from your pediatrician or a lactation consultant.

The best treatments for cracked nipples are dryness, light, and warmth. Do not wear plastic breast shields or plastic-lined nursing pads that hold in moisture. Instead, gently pat your nipples dry then apply human milk or medical grade modified lanolin. Wash your breasts only with water, not soap. Many creams and lotions, which must be removed before nursing, will not help and may actually make the problem worse. If these steps do not solve the problem, consult your doctor for further advice.

Cancer

Some studies show that breastfeeding may offer some protection against breast cancer. However, if a woman already has been diagnosed with cancer and has had a malignant tumor removed, the doctor may advise against breastfeeding due to the follow-up treatment on the affected breast. If a woman has a benign (noncancerous) lump or cyst removed, it is safe to breastfeed afterward.

Plastic surgery

There is still some question as to whether it is safe to breastfeed if you have silicone breast implants, but there is no conclusive evidence that infants are harmed. The surgery for breast implants usually does not interfere with milk ducts or the nipples unless the incision was made around the edge of the areola. This surgery should not prevent successful nursing. However, plastic surgery to reduce the size of breasts may interfere with breastfeeding, especially if the nipples were transplanted. If you have had plastic surgery on your breasts, you may only find out whether or not you can successfully breastfeed by trying.

Premature babies, twins, and triplets

Many premature and seriously ill babies are able to breastfeed. If your baby is not able at first to nurse, you can collect your milk and feed your baby by tube or cup. Express your milk at the times when your baby would usually feed, so that your body becomes used to the schedule, usually about eight times per day by electric breast pump. Most hospitals have breastfeeding experts to help you get started. Once you start to breastfeed, let your baby nurse often to build up your milk supply. Human milk has been shown to be very beneficial to premature and sick newborns by helping growth and preventing many diseases.

If you have twins, it is possible to breastfeed them at the same time, having one baby at each breast. You can hold one baby at each side, called the "football hold," or you can cradle them both in front of you with their bodies crossing each other, as they would have been in utero. Alternate the breast each baby uses at each feeding or at least once a day. If this is too difficult, or if you are not producing enough milk, you may supplement feedings with formula.

With triplets it is possible to breastfeed, but most mothers supplement feedings with formula. Nurse two of the babies at a time and give formula to the third. At the next feeding, give the formula to a different baby. It is important that all three babies have a chance to breastfeed.

Can I still nurse after I return to work?

Human milk has the same important benefits for older babies as it does for infants. Just because you are returning to work does not mean you have to stop breastfeeding. You can do both! Knowing that you are providing your milk for your baby while you are away and nursing when you are home will help ease the transition back to work.

The following are different ways working women manage breastfeeding:

• Extend maternity leave so as to have more time to get breastfeeding well-established.
• Nurse your baby once or more during the work day if he is in a child care facility at your workplace or nearby.
• Work at home.
• Work part-time, feed before going to work and upon return home.
• Express milk—usually every 3 to 4 hours while you are at work for your baby to drink later from a bottle or cup.
• Breastfeed when you are with your baby. When you are away the baby receives formula or solids (if approximately 6 months of age).

Be sure to select a child care provider or center that supports breastfeeding and can safely handle the milk and feedings per your instructions. Also, engage the support of your boss, human resources staff, occupational nurse, and coworkers. Assure them that pumping milk will not interfere with your work. And since studies show that breastfed infants do not get as sick as often as formula-fed infants, you may even miss fewer days of work to care for a sick baby.

If possible, go back to work on a part-time or flexible schedule at first. This can help you and your baby adjust to the new routine. If this is not possible, go back to work midweek to make it easier for you and your baby to adjust.

At work you will need to find a quiet, private place to express milk if your company does not have a lactation room or someplace else set aside for you. An office, break room, or wherever privacy can be assured can work just fine. You will need 15 to 30 minutes each time you express milk (usually twice a day). You will need access to soap and water to wash your hands before expressing. You will also need a refrigerator or a small cooler and ice packs where you can keep milk cold until you get home.

How to store and prepare your expressed milk

Follow these safe storage and preparation tips to keep your expressed milk healthy for your baby.

• Always wash your hands before expressing or handling your milk.
• Be sure to use only clean containers to store expressed milk. Try to use screw cap bottles, hard plastic cups with tight caps or special heavy nursery bags that can be used to feed your baby. Do not use ordinary plastic storage bags or formula bottle bags for storing expressed milk.
• Use sealed and chilled milk within 24 hours if possible. Discard all milk that has been refrigerated more than 72 hours.
• Freeze milk if you will not be using it within 24 hours. Frozen milk is good for at least 1 month (3 to 6 months if kept in a 0° freezer). Store it at the back of the freezer and never in the door section. Make sure to label the milk with the date that you freeze it. Use the oldest milk first.
• Freeze 2 to 4 ounces of milk at a time, because that is the average amount of a single feeding. However, you may want some smaller amounts for some occasions.
• Do not add fresh milk to already frozen milk in a storage container.
• You may thaw milk in the refrigerator or you can thaw it more quickly by swirling it in a bowl of warm water.
• Do not use microwave ovens to heat bottles because they do not heat them evenly. Uneven heating can easily scald your baby or damage the milk. Bottles can also explode if left in the microwave too long. Excess heat can destroy important proteins and vitamins in the milk.
• Milk thawed in the refrigerator must be used within 24 hours.
• Do not re-freeze your milk.
• Do not save milk from used bottle for use at another feeding.

Weaning your baby from the breast

There is no "right" time to wean. It depends entirely on the desires and needs of you and your baby. Either one of you can begin the weaning process.

Some babies lose interest in breastfeeding between 9 and 12 months of age or after they learn to drink from a cup. If you notice this starting to happen, do not try to force your baby to keep breastfeeding. Understand that this is not a rejection of you but the first sign of your child’s growing independence.

You may feel sad, guilty, lonely, or depressed about giving up the closeness and intimacy that comes from breastfeeding. These feelings are natural. Cuddle and interact with your baby even more, and remember that weaning is a natural step in helping your child to grow up.

You can wean your child first to a bottle and then to a cup, or directly to a cup. During weaning, you can express milk with which to feed your baby from the cup or bottle, or you can use infant formula. Because formula cannot provide all the special nutrients and protective qualities that your milk can, your baby benefits the longer she drinks human milk.

If you choose to supplement breastfeeding with formula, you will still need to express milk. This keeps your milk production going and your breasts from getting engorged.

If using a bottle, introduce it gradually over several days. Use it with one feeding and work your way up to more. It helps if your baby is not extremely hungry, because then she may be more patient when trying out the bottle. It also helps if your spouse or a caregiver introduces the bottle when you are not around. Many babies will get very upset if they are given a bottle when their mother is in the house; they may even refuse the bottle because they want to breastfeed instead. Do not force your baby to take a bottle. It may take time. Excess pressure on the baby to take a bottle may cause her to refuse the bottle totally.

After bottle-feedings have started, some babies may get frustrated when they breastfeed because the milk does not flow as fast from the breast as from a bottle. The following may help.

• Try to select a bottle nipple with a slow flow.
• Pump for 1 to 2 minutes before you breastfeed.
• Massage the breast as you nurse to help the milk flow.
• Use relaxation techniques with feeding to enhance milk flow.
• Offer the breast before your baby gets very hungry so that he is not impatient.

Introducing baby to a cup

Weaning to a cup has the following advantages over a bottle:

• Eliminates the step of weaning first to a bottle and then to a cup.
• Bottle-feeding for long periods of time or while sleeping can lead to tooth decay.
• Drinking from a bottle while lying flat can lead to middle ear infections.
• Prolonged bottle-feeding can lead the bottle to become a security object, especially after a child is 1 year old.

To introduce your baby to a cup, start with a trainer cup that has two handles and a snap-on lid with a spout. Or you can use a small plastic glass. This will keep spills small as your baby tries holding the cup (and throwing it) different ways. Do not be surprised if your baby treats the cup as a plaything at first.

Offer your milk when available, starting with just one meal a day. It may be easiest to substitute a cup for breastfeeding at the midday feeding first and the nighttime feeding last. (Nighttime feedings are often a source of comfort and calming before sleep.)

Be patient and wait until your baby can get most of the liquid down his throat before you fill the cup with juice or milk. Since weaning is a process, it may take months before your baby is willing or able to take all of his liquids from a cup. Proceed gradually and let his willingness and interest guide you.

To begin weaning your baby from the breast, substitute a feeding with either a cup or bottle for a feeding in which you breastfeed. The midday feeding may be easiest to start with. Babies may be more attached to the first and last feedings of the day because they get comfort as much as nutrition from them. Once you have stopped breastfeeding entirely, your breasts will stop producing milk very quickly.

Breastfeeding: a natural gift

For some mothers and babies, breastfeeding goes smoothly from the start. For others, it takes a little time and several attempts to get the process going effectively. Like anything new, breastfeeding takes some practice. This is perfectly normal. If you need help, ask the nurses while you are still in the hospital, your child’s pediatrician, a lactation consultant, or a breastfeeding support group. Remember, the most important keys to successful breastfeeding are proper positioning and correct latch-on.

Until you and your baby develop a feeding routine, stay positive and try not to get discouraged. Remember, your milk gives your baby more than just food. It also provides important antibodies to fight off infection and has medical and psychological benefits for both of you. Breastfeeding is the most natural gift that you can give your baby.

Other AAP Related Information on Breastfeeding

AAP Breastfeeding Resources

Policy Statement: Breastfeeding and the Use of Human Milk (RE9729)