Cover article

FIRST OF TWO PARTS

Challenges in breastfeeding:
Maternal considerations

By John B. Cahill, MD, and Carol L. Wagner, MD

When a newborn or his mother is too ill for him to nurse, special steps are needed to ensure that baby gets the breast milk he requires. Pediatricians can do much to help mothers pump properly, maintain their milk supply, initiate breastfeeding, and more.

Human milk is the superior form of nutrition for the great majority of babies. Its diverse bioactive properties facilitate postnatal growth during critical periods of brain, immune system, and gut development, making it superior to formula.^1–4 Strategies for breastfeeding a healthy, term newborn, however, fall short with an infant who is premature or has another medical complication. A newborn who has been on a ventilator, for example, may not be able to coordinate sucking and swallowing and may have an aversion to anything being put in his mouth—even his mother's nipple.

An understanding of each infant's clinical and neurodevelopmental status is, therefore, necessary to design a breastfeeding plan that optimizes the baby's physical and central nervous system functions. If breastfeeding is to succeed, that feeding plan must be conveyed clearly to the mother and other care providers of the infant. In infants with complications, progress is often measured not in hours or days but rather in weeks or months.

We begin this in-depth look at breastfeeding challenges with an overview of maternal physiologic changes that normally accompany lactation. We then discuss ways to help the mother pump and maintain her milk supply when she or her infant is too ill to nurse and how to achieve suckling during the infant's convalescence. We also cover issues pertinent to the mother who is nursing multiple infants, planning to nurse an adopted baby, or initiating relactation. In the article that immediately follows, we address potential problems experienced by the infant during breastfeeding, the use of human milk fortifiers, and the special needs of particular groups of infants who often have feeding difficulties.

The physiology of lactation

The synthesis of human milk begins by the sixth or seventh month of pregnancy, at which time secretory activity within the mammary gland intensifies (Table 1). The increased mitotic activity that began early in gestation continues. Acini and alveoli—the basic milk- producing units of the mammary gland—become distended with colostrum, the areolae increase in diameter, and pigmentation darkens. Superficial veins become more visible on the skin surface and erectile activity of the nipple and areola increases. Even a woman who delivers an extremely premature infant has undergone these changes and is capable of producing milk.

TABLE 1
Mammary gland changes during pregnancy

Secretory activity within the mammary gland intensifies

Milk synthesis begins by the 6th or 7th month of pregnancy

Acini and alveoli become distended with colostrum

Areolae increase in diameter; pigmentation darkens; erectile activity increases

Superficial veins become more visible

Milk production is minimal until after delivery of the placenta

The volume of milk secreted by the mammary epithelial cells remains small until after the infant is born. It is delivery of the placenta that heralds an increase in milk production: Estrogen and progesterone levels fall, and the negative feedback by these hormones on pituitary-prolactin release is reversed. Prolactin levels rise, leading to increased milk synthesis.

When the neonate is placed at the breast and begins suckling, touch receptors densely located around the nipple and areola are stimulated. The tactile sensations create impulses that activate the dorsal root ganglia via the intercostal nerves.^4,5,6 These impulses ascend the spinal cord, creating an afferent neuronal pathway to the paraventricular nuclei of the hypothalamus, where a key hormone, oxytocin, is synthesized, secreted, and stored by the pituitary gland. Impulses created by the suckling cause oxytocin to be released, which in turn causes the myoepithelial cells that line the breast ducts to contract. When stimulated, these smooth, muscle-like cells expel milk from alveoli into ducts and subareolar sinuses that empty through a nipple pore—a reflex known as letdown.

If an infant is too weak to suckle effectively, sensory stimulation of the nipple and activation of the hypothalamus and pituitary are diminished. Unless a mother has a conditioned response to her infant, where just the sight or smell of her baby causes the release of oxytocin, she may have difficulties with letdown. If letdown does not occur, milk removal decreases. If milk is not expressed, the breasts may become engorged and milk production—which depends on cyclical milk removal—ultimately diminishes. The rate of milk synthesis is related to the degree of emptiness or fullness of the breast; an emptier breast makes milk faster than a fuller one.

Initiating breast pumping

Neonatal enteral nutrition is often the last topic discussed with the family of a critically ill infant, yet this aspect of care becomes increasingly important as the infant is convalescing. It is imperative to discuss the benefits of breast milk as a source of bioactive factors and essential nutrients for optimal growth and recovery. Parents who would not otherwise have considered breastfeeding are often very willing to start lactation if it will help their sick baby. Given the well-known benefits of colostrum in priming the gut and establishing the tolerance of feedings, the practitioner should encourage the mother to at least consider breastfeeding, even for a few weeks.

A mother whose infant is too ill to nurse, or a mother who herself is too sick to breastfeed—because of preeclampsia or chorioamnionitis, for instance—must express her milk by hand or by manual or electric pump. If milk is not removed, levels of prolactin and oxytocin fall and remain low, and the milk itself, with its putative feedback inhibitor of lactation (FIL), causes milk production to decrease.⁵ Pumping should be initiated as soon as possible after the baby is born, preferably within the first day. If the mother is too ill to pump in the immediate postpartum period, she should be counseled about the need to initiate pumping as soon as she feels better. Though that may not be until days or weeks after delivery, the delay is not an insurmountable obstacle—the very act of pumping will stimulate the afferent sensory input to the hypothalamus and pituitary glands, causing an increase in prolactin and leading to milk production. Health-care providers should help the mother develop a feeding plan that can evolve as her own health improves.

Most women find that their milk supply is higher if they use a double-pumping, electric breast pump because it empties both breasts more completely than manual expression.^6,7 The mother should be instructed how to use an electric pump and its manual attachment and taught clean technique. Steps that a mother should take each time she pumps are outlined in the Guide for Parents.^3,4,6–8

Instruct the mother to pump at least every three hours while awake and every four to five hours during the night, particularly if her breasts feel full. Early on, she should pump each breast for 10 to 15 minutes, at the minimum pump pressure setting if she is using an electric pump. Once lactation is established, she can decrease the frequency of pumping but should increase its duration to 15 to 20 minutes or the time necessary to completely empty the breasts. Even if her breasts are not full and her milk production is low, she should pump for at least 15 to 20 minutes to stimulate milk production.

As a rule, a mother should try to pump for at least 100 cumulative minutes per day, divided into a minimum of five times,³ to maintain adequate milk supply until the infant is able to nurse.^1,7 If her milk production falls, we recommend that she increase the frequency of her pumping. A mother who produces copious amounts of milk may think she needs to pump less often because she has "so much in reserve." But if she plans to breastfeed her infant when the baby is well enough to nurse, she should be encouraged to pump at least three or four times daily. (If the mother still has extra milk even after the infant begins nursing and his feeding requirements increase, she can donate it to a human milk bank.)

Once the mother begins pumping, the practitioner should evaluate the adequacy of her milk supply and whether she is having any difficulties. Examples of questions to ask are listed in Table 2. Question the mother during the first postpartum week and weekly thereafter until she is nursing successfully. This ongoing dialogue can uncover problems early on and facilitate resolution. For example, improper application of the pump attachment to the breast may lead to nipple trauma; instruction in proper technique and a follow-up session to ensure that the mother has no pain during pumping can prevent lactation problems. Or, if letdown does not occur—a common problem for the mother who is initiating pumping—certain strategies can be employed to facilitate letdown.

TABLE 2
Questions for a mother who is pumping

Breast milk expressed during each session should be placed in a clean or sterile, non-glass (preferably polypropylene) container approved for milk storage and then frozen at a temperature of minus 20° C or colder. The container should be labeled with the infant's name and medical record number and the date the milk was expressed. Because the volume of milk an infant requires soon after birth may be small, the mother should be encouraged to freeze in each container no more than the amount of milk the baby will consume in 24 hours—it is wiser to thaw an additional container than to have to discard precious unused milk. Care should be taken to place each mother's milk in a separate bin clearly labeled with the infant's name. Each nursery should have a policy to reduce the risk of inadvertent administration of another mother's milk to an infant.

Consider encouraging the mother to keep a daily milk diary, in which she records the date, time, and duration of pumping; the volume pumped from each breast; the pumping pressure (if she is using an electric pump); and any problems she may be having. Health-care professionals involved in the care of the mother or baby should review this diary with her, and the mother should be encouraged to let medical staff know if her milk production has diminished so the problem can be corrected promptly.

When milk supply declines

As noted, one way to try to increase milk production is to increase the frequency of pumping. Another is to use relaxation techniques. Milk letdown requires a relaxed maternal state. The mother of a sick infant—who must now pump her breasts instead of breastfeed, is concerned about her baby's survival, and may be worried about her ability to care for a sick child—may have a difficult time relaxing, and her milk production may decline as a result. Some mothers find biofeedback and visualization helpful. Table 3 lists relaxation techniques. Once relaxed, the mother should begin pumping. If she does not feel comfortable setting up the pump and its attachments the first few times, she should be encouraged to ask for assistance— all the relaxation in the world won't matter if she can't get the pump to work properly!

TABLE 3
Relaxation techniques for achieving letdown

Pumping in a quiet, nonthreatening environment

Holding the infant before the pumping session

Bringing a photo or a blanket of the infant to the pumping session

Massaging the breasts for a few minutes, circular motion from periphery inward to the nipple

Breathing slowly and deeply

Sitting with eyes closed, visualizing the infant or a relaxing place

Listening to soothing music

If, despite relaxation techniques and frequent, effective pumping, a mother has difficulty maintaining milk supply, an oral galactogogue (Table 4) is an option. A galactogogue is any substance that increases milk production, typically through stimulation of prolactin production by the anterior pituitary or prolactin receptors in the mammary gland. Common galactogogues include fenugreek (an ancient medicinal herb and an Indian spice common in curried foods), hops, alfalfa, blessed thistle, and a mother's milk tea.^9,10 While most of these herbal remedies can be safely taken as a tea or in pill form (a more concentrated and standardized preparation than tea), there are few pharmacologic studies about efficacy, mechanism of action, active metabolites, and potential side effects. Certain galactogogues, such as goat's rue or borage, should be avoided. High doses of borage have been associated with liver damage. Although goat's rue has been used for centuries as a galactogogue, its effect on the nursing infant remains unknown.

TABLE 4
Increasing milk supply: Common galactogogues

As with any medication, health risks of a galactogogue, and possible effects of the herb on any medications the patient is taking, must be carefully reviewed beforehand. Fenugreek, for example, has hypoglycemic and lipid-lowering effects and so may affect the insulin regimen of a diabetic mother. It also may act as a blood thinner and should not be used in women taking warfarin sodium (Coumadin).

If herbal therapies are ineffective, the practitioner can prescribe medical therapies, including oxytocin nasal spray to facilitate milk letdown and metoclopramide or domperidone—dopaminergic antagonists that increase prolactin and, in turn, milk production.¹¹ (Domperidone is not approved for clinical use in the US.) Such medications may be prescribed by the mother's obstetrician, the family physician, or the pediatrician in consultation with the mother's physician.

Kangaroo care

Unlike the neonatal intensive care unit of a decade ago, today's NICU tries to promote daily parental interaction with the infant, including physical contact. The concept of skin-to-skin contact, or so-called kangaroo care, has evolved over time. Much literature exists that associates kangaroo care with enhanced neonatal outcome.^1,3,4,12–18 Studies show that convalescing newborns who receive kangaroo care have enhanced thermoregulation, heart rate stability, oxygen saturation, and weight gain.¹⁹ There appear to be psychological benefits to both the parent and the infant, as well as the documented physical benefits to the infant, perhaps because of the comfort the infant receives.

This daily event increases the readiness of the mother who is pumping her breast milk in preparation for the day she will begin breastfeeding, as well as the readiness of her baby. Kangaroo care becomes the "learning forum" during which time the infant learns to lick, then suck, the mother's nipple. Last, when the mother holds her infant, they share the same skin and respiratory "environment." As a result, she will likely provide the infant with antibodies to mutual pathogens once breastfeeding begins: The mother passes immunoglobulin to her infant through her breast milk, thereby bestowing passive immunity.¹

Transitioning from sucking to suckling

When the infant exhibits spontaneous sucking and is medically stable (for example, off a ventilator and advancing on feedings), the mother should let him try to suckle at the breast, regardless of the baby's gestational age. This activity, a natural extension of kangaroo care, ideally will have been implemented soon after delivery. The initial sucking, called non-nutritive sucking, is characterized by a rapid suck that occurs when no liquid is introduced into the infant's oral cavity.^3,4,6,12 The infant who has been ill or who is premature will need to transition from non-nutritive sucking to coordinated suckling (a nutritive suck) characterized by slower sucking that occurs when liquid is introduced into the mouth.^6,12,20–22 (Common feeding problems that occur when making the transition to suckling are discussed in Part 2 of this article.)

Successful breastfeeding may take several weeks, or even months. With each session, the mother becomes more at ease handling her fragile infant and the infant, in turn, gains a sense of comfort. He starts to associate the mother's smell with her milk, and the drops that he tastes from the nipple will stimulate the gastrocolic reflex, enhancing gut peristalsis. A mother who has a strong letdown, with copious milk flowing from her nipples, may want to pump prior to these early breastfeeding sessions, to reduce the infant's risk of choking as suck-swallow coordination is developing. Some infants require a transitional feeding aid such as a finger or cup feeder or a supplemental nursing system (discussed later in this article). A mother who is not experiencing letdown may need a lactation aid to facilitate ongoing or more vigorous suckling—a supplemental nursing system, for example, or a syringe filled with her milk, used to place droplets on her nipple. Letdown typically occurs 30 to 90 seconds after continuous suckling is initiated.

Although the breastfeeding session should take place in a relaxed atmosphere, many of these infants are still attached by wires to monitors and pulse oximeters—hardly a relaxing environment. At the least, a screen should be placed around the bed space of the infant to afford a degree of privacy. It is best to begin breastfeeding when the infant is alert and not frantic to feed. The mother should be seated in a comfortable chair with the back more upright than reclined. Placing the infant on a nursing pillow that allows him to be closer to the mother at the level of her breast will facilitate nursing, particularly in the preterm or hypotonic term infant.

Proper positioning of the infant is essential for each breastfeeding session. The infant may be placed in the typical cradle rest or in the football hold (see the Guide for Parents for more details on positioning). The head and legs of a premature infant or recuperating term infant should be at the same level as the mother's breast. The mother may have to change from the C hold to the U hold if the weight of her breast on the infant's face interferes with the ability to suckle. The infant may require frequent rests, especially if he does not have a consistent breathing-sucking-swallowing pattern.

If the infant was alert at the beginning of the session but falls asleep during it, the mother can try switching to the opposite breast or using a transitional lactation aid to reduce infant fatigue. If the infant gags on milk during a session or does not initiate suckling, the mother can try repositioning him or expressing a little of her milk so that he tastes it when she places her nipple and areola into his mouth.^{3,4,6,7,12,23} If the infant nurses for less than 10 minutes a session, the mother should pump afterward to empty her breasts and maintain her milk supply.

Not without controversy, nipple shields have been used since the 1500s to facilitate latch-on. Specific indications and potential risks are listed in Table 5.⁴ Nipple shields should be prescribed with caution, and with the mother's informed consent, as a transitional device. Risks include decreased milk supply and the associated effects on the infant of low weight gain and acute dehydration. If nipple shields are prescribed, an infant's weight should be monitored closely and the mother should be informed about the shield's transitional use.^3,4

TABLE 5
Pros and cons of nipple shields

Benefits

May facilitate latch-on if:

Risks

One way of accurately assessing an infant's caloric intake during a breastfeeding session—whether or not a nipple shield is used—is to test-weigh him before and after each session using an accurate infant scale, preferably an electronic one. This allows both the practitioner and mother to confirm that the infant is receiving enough milk. Once documented weight gain has bolstered the mother's confidence in her ability to nurse, test-weighing can be discontinued.

Breastfeeding multiple infants

Nursing multiple siblings, such as twins or triplets, requires extra time, energy, and nutritional intake on the part of the mother. It is estimated that a mother who exclusively breastfeeds an infant needs 500 kcal/d more than her usual intake to meet the baby's requirements for growth. A woman who exclusively nurses two or more infants must increase her dietary intake accordingly. As when nursing just one infant, mothers of twins or triplets should begin each breastfeeding session with the infant on the breast opposite the one last suckled.

Whereas some mothers with multiple infants breastfeed exclusively, others combine breastfeeding and pumping, and still others pump exclusively, delivering milk to the infants via cup, syringe, or bottle. Those mothers who do not have enough breast milk for their infants can supplement with formula or banked breast milk, if available. Health-care providers of any infant who is one of several children being breastfed must ensure that the infant is receiving adequate nutrition for optimal growth and that the mother has a support network in place that allows her to succeed at the type of feeding she has chosen. There is no right or wrong here. Breast milk is clearly beneficial, but if the mother is so exhausted and overwhelmed by nursing multiple infants that she has little energy to interact with them outside of nursing, then exclusive breastfeeding may not be the best course. Encouraging the father or extended family to help with feedings may alleviate some of the stress, particularly if one of the infants has colic or is on a very different schedule than his siblings.

With tandem nursing—the continued breastfeeding of one child after the birth of another—the mother's body produces milk at the same rate that it is removed (as is the case with a mother who nurses twins or triplets). Mothers who nurse two or more infants therefore produce greater amounts of milk than mothers who nurse only one. This increased rate of milk synthesis and secretion places metabolic and nutritional demands on the mother who is tandem nursing, making it essential that she increase her food intake after delivery by at least 500 kcal/d.

The quality and salt content of a mother's milk changes during pregnancy, especially near the end of the second trimester. During these times, the breastfeeding infant may want to wean from the breast. Once the newborn arrives, he should be given the mother's milk first, as that milk is essential for his survival.

Nursing the adopted infant

A mother who wants to nurse her adopted infant may be able to induce milk production. In the absence of hormonal stimuli during pregnancy, the mammary gland of a nonpregnant woman must undergo changes in response to the physical stimulation of suckling or breast pumping. Milk production appears one to six weeks later, with a mean time of four weeks.^3,4 Lawrence and Lawrence advise beginning stimulation well before the arrival of the adopted baby, as the adoption process can be stressful and may interfere with milk production.³

A useful aid is the supplemental nurser, such as Supplemental Nursing System (Medela) or Lact-Aid Nursing Trainer System (Lact-Aid International). This lactation device provides milk via a tube taped to the mother's breast, the tip of which ends just in front of the nipple. A syringe or closed bag attached to the tube holds the milk. This system allows the infant to receive nutrition while suckling; at the same time the mother's breast is stimulated, activating the neuroendocrine loop that results in prolactin production and, consequently, milk production. This should work in theory, but the actual increase in prolactin is variable.

Certain drugs can augment lactation. These include conjugated estrogens, growth hormone (which shares structural similarities with prolactin), chlorpromazine, metoclopramide, and domperidone. Since a key component in successful lactation is letdown, which depends directly on adequate levels of circulating oxytocin, intranasal oxytocin may be of benefit.^3,4,6,7,23

Relactation

Mothers who have started nursing but chosen to stop, because, say, their infant was sick or they themselves were ill, may choose to relactate weeks or months later. Approximately half of these women will do so successfully. The process is similar to that which takes place when lactation is initiated in an adoptive mother. Stimulation of the nipple activates the neuroendocrine loop.

A supplemental nursing system and kangaroo care can help induce lactation. Compared with mothers who lactate for the first time, mothers who have lactated before may have the psychological advantage of knowing that they previously produced milk. For more detailed information on relactation, readers can refer to the books by Lawrence and Lawrence³ and by Riordan and Auerbach.⁴

Advocacy backed up by support

Human milk is the superior form of nutrition for most growing infants, including those with medical complications. The techniques used to breastfeed a healthy term newborn often must be modified when an infant is ill or premature or the mother herself is sick. Most mothers do not know how to pump their breasts, how to optimize milk production, and what nonmedicinal and medicinal therapies are available to increase milk production if and when it diminishes.

Encouraging pumping and breastfeeding but not having the supportive staff available to help a mother do so successfully can undermine the confidence and morale of that mother, who is particularly vulnerable after delivery of a preterm or sick child. Every hospital should have health-care providers who are readily available to the mother and knowledgeable about human lactation—the physiology, the mechanics, and ways to adapt the breastfeeding process to the recuperating infant.

REFERENCES

1. Schanler RJ, Hurst NM, Lau C: The use of human milk and breastfeeding in premature infants. Clin Perinatol 1999;26(2):379

2. Garofalo RP, Goldman AS: Expression of functional immunomodulatory and anti-inflammatory factors in human milk. Clin Perinatol 1999;26(2):361

3. Lawrence RA, Lawrence RM: Breastfeeding: A Guide for the Medical Profession, ed 5. St. Louis, Mosby, 1999

4. Riordan J, Auerbach KG (ed): Breastfeeding and Human Lactation, ed 2. Sudbury, Mass., Jones and Bartlett Publishers, 1999

5. Neville MC: Physiology of lactation. Clin Perinatol 1999;26(2):251

6. Black RF, Jarman L, Simpson JB: The Process of Breastfeeding. Lactation Specialist Self-Study Series. Sudbury, Mass., Jones and Bartlett Publishers, 1998

7. Neifert MR: Clinical aspects of lactation. Clin Perinatol 1999;26(2):281

8. Auerbach KG: Sequential and simultaneous breast pumping: A comparison. Int J Nurs Stud 1990;27:257

9. Medical Economics Research Group: PDR for Herbal Medicines, ed 2. Montvale, NJ, Medical Economics Co., 2000

10. Hoffman D: The Complete Illustrated Holistic Herbal: A Safe and Practical Guide to Making and Using Herbal Remedies. Shaftesbury, Dorset, Rockport, Mass., Element Books, 1996

11. Briggs GG, Freeman RK, Yaffe SJ: Drugs in Pregnancy and Lactation, ed 6. Philadelphia, Lippincott Williams & Williams, 2002

12. Black RF, Jarman L, Simpson JB: The Management of Breastfeeding. Lactation Specialist Self-Study Series. Sudbury, Mass., Jones and Bartlett Publishers, 1998

13. Howard CR, Howard FM, Lamphear B, et al: The effects of early pacifier use on breastfeeding duration. Pediatrics 1999;103(3):E33

14. Walker M, Driscoll JW: Breastfeeding Your Premature or Special Care Baby: A Practical Guide for Nursing the Tiny Baby. Weston, Mass., Lactation Associates Publication, 1989

15. Tornhage CJ, Stuge E, Lindberg T, et al: First week kangaroo care in sick very preterm infants. Acta Paediatrica 1999;88(12):1402

16. Moran M, Radzyminski SG, Higgins KR, et al: Maternal kangaroo (skin-to-skin) care in the NICU beginning 4 hours postbirth. MCN, Am J Mat Child Nursing 1999;24(2):74

17. Meyer K, Anderson GC: Using kangaroo care in a clinical setting with full-term infants having breastfeeding difficulties. MCN, Amer J Mat Child Nursing 1999; 24(4):190

18. Bauer K, Uhrig C, Sperling P, et al: Body temperatures and oxygen consumption during skin-to-skin (kangaroo) care in stable preterm infants weighing less than 1500 grams. J Pediatr 1997;130:240

19. Hurst NM, Valentine CJ, Renfro L, et al: Skin-to-skin holding in the neonatal intensive care influences maternal milk volume. J Perinatol 1997;17:213

20. Bu'Lock F, Woolridge MW, Baum JD: Development of coordination of sucking, swallowing and breathing: Ultrasound study of term and preterm infants. Dev Med Child Neurol 1990;32(8):669

21. Narayanan I, Mehta R, Choudhury DK, et al: Sucking on the 'emptied' breast: Non-nutritive sucking with a difference. Arch Dis Childhood 1991;66:241

22. Maher SM: An Overview of Solutions to Breastfeeding and Sucking Problems. Franklin Park, Ill., La Leche League International, 1988

23. Powers NG: Slow weight gain and low milk supply in the breastfeeding DYAD. Clin Perinat 1999;26(2): 399

DR. CAHILL is neonatal fellow and DR. WAGNER is associate professor, division of neonatology, department of pediatrics, Medical University of South Carolina, Charleston.

GUIDE FOR PARENTS

When your baby is too ill to breastfeed

Even though your baby is not well enough to nurse from your breast, he can still be fed your milk. This guide reviews how to establish your milk supply through pumping, what to do if you are not producing enough milk, and how to begin breastfeeding your baby once he is well enough to start nursing.

Pumping your milk

Begin pumping as soon as possible after your baby is born, preferably with a double-pumping electric breast pump. Pump at least every three hours while you are awake and every four to five hours during the night, especially if your breasts feel full. Pump each breast for 10 to 15 minutes each session. Once your milk supply is established (you are able to pump an ounce or more from each breast) you can pump less often but should increase the amount of time you pump each breast to 15 to 20 minutes, or the time it takes to completely empty both breasts. Even if your breasts are not full and your milk production is low, it's still a good idea to pump for at least 15 to 20 minutes because the pumping itself stimulates milk production. After pumping, your breasts should feel empty. If they do not, pump until they feel soft.

It is important to use clean technique every time you pump. Wash your hands with soap and water for at least 30 seconds before and after pumping. Clean the pump and attachments thoroughly with a dish detergent and warm water after each use. Make sure to wash off the fat that collects on the parts.

Store the milk you have pumped in a clean or sterile container specifically approved for milk storage (a polypropylene container, for example). Each container should contain only the amount of milk your baby will consume in 24 hours; this way unused milk won't have to be discarded.

In the hospital, each container should be labeled with your baby's name, medical record number, and date of birth, and with the date and time the milk was pumped. If your baby is not being fed your milk right now, the milk should be frozen at minus 20° C or colder for later use. Once your baby begins receiving your milk, you may be instructed to bring a fresh milk sample to the hospital. Keep this sample refrigerated at home and then place it in a cooler pack while transporting it to the hospital.

It may be helpful for you to keep a milk diary (see the example below). Include the date and time you pumped and for how long, how much milk you pumped from each breast, the pressure setting (if you are using an electric pump), and any difficulties you may have had. Let your health-care provider or lactation specialist know of any problems, including any discomfort or pain while pumping, skin breakdown or redness on your nipples, or redness on your breasts. They can offer ways to help. If your nipples are sore, for example, you may be advised to use a nursing bra and massage your breasts before pumping.

Also let your health-care provider know if you cannot achieve letdown—the ejection of milk from your nipple. With letdown, a tingling, burning, or prickly sensation usually occurs in the breast before you pump or when you begin to pump.

Increasing milk production

Milk production depends on milk removal; an emptier breast makes milk faster than a fuller one. If you are producing less milk than your baby requires, try pumping more frequently. Drink adequate amounts of water or other fluid, but avoid caffeinated beverages such as tea, soft drinks, or coffee. You should need to urinate as often as you pump; if you don't, you are not drinking enough fluid.

Stress can diminish milk production, so try to relax before and during pumping. Pump in a quiet, nonthreatening environment. To help you relax, bring a photo or blanket of your baby to the pumping session. Massage your breasts for a few minutes—a circular motion from the outside of your breast inward to the nipple. Practice slow, deep breathing. Sit with your eyes closed—visualize your baby or a place of relaxation. If you are able to be with your baby, hold him before starting to pump. Listen to soothing music. Once you feel relaxed, start pumping.

Throughout the ages, certain herbs—called galactogogues—have been used to increase the amount of milk a mother produces. Examples include fenugreek, alfalfa, and a mother's milk tea. These herbs are generally safe for both mother and baby if used as directed. Some of them do have side effects, however, and some can be harmful, so talk to your health-care provider before you use any. Also, your doctor may be decide to prescribe a medication, such as Reglan or oxytocin nasal spray, to help increase milk production if other methods have not worked.

Working toward successful nursing

When your baby is well enough to begin nursing, he will need time to learn how. Success is measured not in hours but in days, weeks, or, in some cases, months, so don't be discouraged. Daily skin-to-skin contact between you and your baby will help prepare him for breastfeeding. Express a few droplets of your milk onto your nipple so he will smell and taste your milk, suck the nipple and then the areola, and start to coordinate sucking and swallowing. Touch his upper lip with your nipple to try and elicit the rooting reflex—the mouth should open to take in the nipple and areola. Sucking and rooting behaviors are cues that your baby is ready to breastfeed successfully.

For the breastfeeding session itself, a relaxed atmosphere and proper positioning are key. Sit in a comfortable chair that is more upright than reclined. A breastfeeding pillow can provide leverage and give you a firmer hold of your infant. Hold your baby comfortably. Two common positions are the cradle rest and the football hold:

Cradle rest. Rest his head in your arm on the side that you will nurse from and place his stomach level with, and facing, your stomach. Swaddling him in a blanket may be comforting to him and make it easier for you to direct his body.

Football hold.Place your baby's head in your hand or on your forearm, and tuck his feet and legs behind your arm toward your back—as you would hold a football.

Hold your breast in either a "C" or "U" hold:

C hold.Place your thumb above your areola and your remaining fingers below your breast, so your fingers encircle your breast in the shape of the letter C.

U hold. Place your fingers underneath your breast, your thumb on one side and your remaining fingers on the other. Hold your breast up and away from the baby's nose but allow your nipple and areola to come in contact with his mouth. The U hold may work better than a C hold if your baby is premature or you are concerned about the weight of your breast on his face.

To begin breastfeeding, express a few milk droplets on your nipple and touch your baby's upper lip to elicit the rooting reflex and begin suckling. If you have flattened nipples that make it difficult for him to suckle, try pumping for two or three minutes before breastfeeding. This helps the nipple to become erect, making it easier for the baby to latch on to.

Monitor your baby's behavior during the breastfeeding session:

• Is he falling asleep? He may need to rest. Or, he may need to be restimulated; try switching to the other breast. A transitional lactation aid, such as a supplemental nursing system, can also help reduce fatigue.

• Is he gagging on the milk? Try pumping before the breastfeeding session to reduce his intake. Or, express a few droplets on the nipple. You can also try repositioning him.

• Is he frustrated because he is not getting milk? Try pumping for two or three minutes before breastfeeding to achieve letdown. Also, give your baby 2 to 3 mL of milk that you have pumped before the breastfeeding session to take the "edge" off of his hunger.

If your breasts do not feel empty after breastfeeding, pump them until they feel soft.

For more information

If you have any questions or concerns, contact your health-care provider or lactation specialist. For general information on pumping and breastfeeding, here are a few Web sites you may find helpful:

www.breastfeeding.org

www.breastfeeding.com

www.bflrc.com

www.lalecheleague.org

This Guide for Parents may be photocopied and distributed without permission to give to parents of your patients. Reproduction for any other purpose requires express permission of the publisher.