Three Basic Rules for Successful Breastfeeding
Help your breastfed baby gain weight and have satisfying feedings. Maximize your milk supply* while enjoying breastfeeding more.
*Milk production amounts vary for individual women. See Rule Two for more information
A Well-Fed Newborn Baby Is:
- Easy to wake and keep awake during feedings most of the time
- Actively sucks and swallows (you should be able to hear the swallows)
- Looks satisfied after nursing
- Is content to feed every 2–3 hours (more frequent feeding can be normal during growth spurts, and for a few hours once a day, but for newborns it may show ineffective feedings)
- Does not have concerning levels of jaundice or low blood sugar in the first days of life
- Has moist lips and obvious saliva inside of mouth
- Loses no more than 4% in the first 24 hours of life and 7% by 48 hours of life (for vaginally birthed babies); 5% and 8%, respectively, for cesarean-born babies). See the Newborn Weight Loss Tool to evaluate your baby's loss/gain; a well-fed baby is above the yellow line on the graph
- Gains about an ounce/day (after Day 4)
- Is back to birth weight by Day 10
- Has 6–8 wet diapers a day, light or pale yellow urine
- Has 3–5 dirty diapers a day (can be fewer than this depending on their age)
- Softens your breasts after feeding
Rule One: Feed the Baby
Rule One: Feed the Baby
If your goal is exclusive breastfeeding, a full milk supply will be necessary, and a well-fed baby has plenty of energy to stimulate the breasts effectively. A baby who isn’t getting enough calories will not have strength and stamina to empty your breasts well, and will often sleep more to conserve energy. Breasts need to be emptied frequently and thoroughly by an energetic baby (or pump) to make enough milk.
If your milk supply is low (which will be addressed in Rule 2: Optimizing Your Milk Supply), the most important thing to do is to make sure your baby is getting enough milk to fully meet their body's needs and gain weight appropriately. The earlier you start this process, the best chance of success* you will have
*You define “success.” There are many ways to breastfeed successfully, exclusive breastfeeding, pumping, and combination feeding with formula are all successes if the whole family is thriving.
- not gaining weight well
- usually unsatisfied after breastfeeding
- sleepy (or fussy) at the breast most of the time
- having more than twelve or fewer than eight breastfeeds a day
- having many feedings that are very long (>40 min) and frequent (<2 hourly)
there may be an issue with either your milk supply or their ability to transfer the milk that you have. (It should go without saying that neither are your fault.) Occasional cluster feeding is normal for babies who are gaining weight well, after your milk is in; however, for a newborn who is losing weight or not gaining about an ounce a day, if they are showing clear signs of ongoing hunger even after nursing for hours, they are hungry, and they—and your breastfeeding relationship—would benefit from a little extra milk.
(Note: sometimes these are signs of an underlying medical problem; always check with your pediatrician first if your baby is not feeding well.)
If your baby typically has a worried expression on their face while breastfeeding, often with a furrowed brow, this can be a sign they're not getting enough milk.
Science to the rescue!
Many people think pumping, bottles, or formula use should be a last resort; that you always need to wait until “breastfeeding is established,” a term which is somewhat vague, or until your milk supply increases enough to be sufficient. However, when it comes to a baby with clear signs of unsatisfied hunger, a little help may be needed.
Rule number one for solving the problem is to feed the baby to satisfaction at each and every feeding. There is no advantage of waiting until your baby shows late signs of low breast milk intake, such as dehydration or persistent lack of weight gain. The priorities here are: your baby’s health, maximizing your milk production, and giving them the energy they need to suck vigorously.
First, make sure you optimize the baby's latch, as they can get more milk if they are latched on deeply. Second, make sure you are doing breast compressions (see video below) to help your baby drink more milk more quickly. This will not only save you time, it will also help keep your baby awake and interested in feeding and empty your breasts more thoroughly, thereby stimulating more milk production.
Source: International Breastfeeding Centre
Here is why it’s important not to wait when it is discovered that a baby is not taking enough breast milk. First of all, there are short-term medical risks to underfeeding, such as dehydration, low blood sugar, and excessive jaundice. These conditions require immediate medical assessment. Long term, sufficient nutrition is important for optimal health.
Does this mean that breastfeeding is risky?
Every feeding method has its own set of risks and benefits, but provided that early, acute, and chronic signs of hunger are acted upon immediately by supplementation, human milk is the preferred food for most babies. What is certainly risky, however, is the misconception that maintaining exclusive breastfeeding is more important than ensuring the baby is sufficiently fed, even if some formula (also known as “science milk”) has to be used, when you had not planned or wanted to do so. Again, the fact that breastfeeding not going perfectly is not your fault!
Here are some scenarios in which supplementation is appropriate (either expressed breast milk or infant formula can be used; the important thing is to feed the baby until they are satisfied):
- You have a strong gut feeling that your baby is not getting enough milk
- Baby is difficult to wake up and keep awake for breastfeeds
- Baby has lost more than 75th%ile on the NEWT nomogram (click on first 30 days tab if your baby is >72 hours old)
- Baby is still losing weight at 96 hours of life
- Baby’s weight has not stabilized or increased by 96 hours of life
- Dehydration is suspected or confirmed (some clues are a dry, sticky mouth; urine that is dark, infrequent, and a minimal amount; or reddish-orange specks called uric acid crystals in the diaper).
- Baby has low blood sugar or high bilirubin levels
- Baby seems unsatisfied after most feedings
- Milk is not in at 72 hours postpartum
- Baby is not maintaining their growth curve
- Your pediatrician recommends it for medical reasons
- You just want to. It's your baby, you don't need a reason!
What about over-feeding?
Babies can tell when they’re full, and they will stop sucking and refuse more milk. If they accidentally ate a teaspoon more than they needed, they’ll spit it up. (If your baby spits up, it doesn’t necessarily mean they overate; most babies spit up, breastfed and bottle-fed alike, because they have immature digestive systems.)
You may have heard that it’s easy to overfeed with a bottle, but this is not true; if you are watching and respecting your baby’s fullness cues, you will see that your baby is quite capable of deciding when they’re comfortably full but not overstuffed. (More on bottle-feeding)
Waiting to fully feed the baby until there is enough breast milk risks inadequate breast stimulation, which can cause a permanent reduction in milk supply, and it is not fair to the baby, who suffers hunger and thirst. Pumping helps of course, but a mechanical breast pump is not as sweet and cuddly as your baby and adds the extra chore of washing parts.
Does this mean supplementing or pumping from Day 1? Not necessarily, because some mothers produce large volumes of colostrum, and some babies have tons of energy to gulp it down enthusiastically. It is, however, more common for colostrum production to be low, especially for first-time moms, and for newborns to be sleepy. If you see signs like the bullet points above, trust your gut and supplement appropriately.
Watching your baby’s diapers is helpful, but they are not an accurate way of measuring baby's intake until around Day 4. Prior to that, baby is mostly eliminating what was already inside them from before birth. Orange/red/brown color in urine can be a sign of dehydration.
(Note that if you see uric acid crystals in the first 24 hours along with copious clear urine, it is not necessarily dehydration. Some newborns need to flush out these crystals. Also, baby girls can have bloody vaginal discharge from maternal hormones. Save the diaper and talk to your nurse or pediatrician if you are unsure.)
Rule Two: Optimize Your Milk Supply
Rule Two: Optimize Your Milk Supply
Simply put, a full milk supply usually makes breastfeeding much easier. A full supply is defined as the amount of milk it takes for your baby to lose no more than 4–7% of their birth weight, then gain about an ounce a day from Day 4 to four months of age. This is usually accomplished by at least 25–27 oz (750–800 ml) of milk production per day by Day 14, and 30–35 oz (900–1050 ml) or more by Day 40.
With a full supply, your baby will not have to work that hard to take large gulps of milk, will stay awake without you having to constantly stimulate them, and will become satisfied after feedings and gain weight appropriately. To know if you are producing this amount, you can do one of these two things: (1) 24 hours of weighted feeds with a scale accurate to 2 g (you will probably have to rent it, as most commercial scales do not have this level of accuracy); (2) pump and bottle-feed for 24 hours with a high-quality double electric breast pump.
You may have heard that babies are more effective than pumps at emptying the breasts. For most mother-baby pairs, pumping is in fact just as effective as the baby; this scientific review of evidence on breast pumps reported that “a healthy breastfeeding infant removes approximately 80% of the total ingested human milk volume in 5 minutes, and an efficient breast pump removes 85% of the available milk in the breast in 15 minutes.” So the baby may be quicker, but the end result is about the same. (Occasionally a mother who is exclusively breastfeeding and not used to pumping will have a hard time getting milk to flow with a pump, but for the majority of mothers, pumping provides a good estimate of milk production.)
As mentioned above, when your baby is not getting enough to eat, they will not have the energy or patience to suck vigorously and calmly at the breast. They may fall asleep within a few minutes, come off and cry repeatedly, or even fight you when you put them to the breast. Your baby does not hate you or your breasts; they’re not telling you they don’t want you to breastfeed overall; your body is not broken or defective. It can just be frustrating to the baby when they’re trying hard and not getting their hunger/thirst satisfied quickly enough.
There is usually a solution to low milk production, and it is (almost) always to empty the breasts more frequently and thoroughly. (Note that the breasts are a constantly running milk factory and can never be 100% emptied.) If you would like to follow a (non-hellish) triple feeding plan for maximum stimulation, I suggest this one, as it allows you to get a 5-hour chunk of uninterrupted sleep without compromising your milk supply; in fact getting enough sleep decreases stress hormones, which directly counteract lactation hormones.
Aside from feeding the baby sufficiently, establishing your milk supply is the most time-sensitive aspect of breastfeeding success. Babies can learn to latch at a more relaxed pace, but in the first 14 days after birth, your body is actively trying to figure out how much milk to make, based on how much is taken out of the breasts and how frequently. After that, it may be more difficult (or even not possible) to develop a full milk supply. Everyone is different though; the only way to know for sure is to try.
One caveat that you should keep in mind is that, as a milk factory, many breasts are capable of producing more than one baby needs. Much more. Oversupply sounds like a good problem to have, but believe me that it is not. Along with it comes constantly leaking breasts, practically drowning your baby at feedings, frequent engorgement (which comes with increased risk of plugged ducts and mastitis), and probably a gassy, miserable baby.
Aside from feeding the baby sufficiently, establishing your milk supply is the most time-sensitive aspect of breastfeeding success. Babies can learn to latch at a more relaxed pace, but in the first 14 days after birth, your body is actively trying to figure out how much milk to make. After that, it may be more difficult (or even not possible) to develop a full milk supply. Everyone is different though; the only way to know for sure is to try.
What if Nothing Works?
- About 10–15% of women cannot produce a full supply, for biological reasons that are not their fault.
- For about 5-8% of mothers, the milk doesn’t even come in, except for maybe drops.
This is often a devastating blow to mothers who had wanted to exclusively breastfeed. It’s important to understand that it is not your fault if this happens to you, and your bond with your baby will be just as strong. Human milk has many wonderful qualities—but formula is pretty amazing too, and being improved all the time. It’s still ok to be sad and grieve your loss, and no one should minimize your feelings.)
After Rules 1 and 2 are satisfied, the third and perhaps most difficult rule needs to be addressed—fixing the breastfeeding problem.
Rule 3: Fix the Breastfeeding Problem
Rule 3: Fix the Breastfeeding Problem
Unfortunately without evaluating you and your baby directly, I can't tell you how to fix your specific problem, so you will have to follow Rule 3 by working with a lactation consultant. Make sure while you are following Rules 1 and 2, you are working on positioning and latching your baby optimally. If you have concerns about oral ties, please read this.
There are many sources from which you can find information about all manner of breastfeeding problems. The difficulty is knowing what information or expert you can trust. I recommend asking friends and family who have been successful with breastfeeding, interviewing several lactation consultants, speaking with your pediatrician, and reading evidence-based websites like the ones listed at the bottom of this page. Trust your instincts also; there will be plenty of people who say everything is fine, but if it feels like it’s not, listen to your gut and get help.
Interview several lactation consultants, and ask local mom friends for recommendations. Be wary of advice you find on the internet (says the person giving advice on the internet); run things by your pediatrician, who knows your baby and their specific health needs best.
Remember that the earlier you get help, the easier and more successful you are likely to be in solving the problem and meeting your goals. Getting Rules 1 and 2 addressed are the most time sensitive. But fixing the breastfeeding problem—especially if it is causing you physical or emotional pain—is important too, because you are important!