Patient education: Deciding to breastfeed (Beyond the Basics)

INTRODUCTION — Breast milk is the optimal source of nutrition for virtually all babies. It meets essentially all of the nutritional needs of babies born at full term (or up to one month early) for the first six months of life. Breast milk also has important health benefits for premature babies.

This topic discusses the importance of breastfeeding and how to prepare for breastfeeding. Other aspects of breastfeeding are discussed separately:

●(See "Patient education: Breastfeeding guide (Beyond the Basics)".)

●(See "Patient education: Health and nutrition during breastfeeding (Beyond the Basics)".)

●(See "Patient education: Common breastfeeding problems (Beyond the Basics)".)

●(See "Patient education: Pumping breast milk (Beyond the Basics)".)

●(See "Patient education: Weaning from breastfeeding (Beyond the Basics)".)

In this article, we use the term "breastfeeding" to refer to feeding an infant at the breast or chest. Many of the benefits of breastfeeding can also be achieved by feeding expressed (pumped) human milk by bottle.

WHY IS BREASTFEEDING IMPORTANT? — Exclusive breastfeeding (meaning giving only breast milk and no formula or other foods) is widely recommended for approximately the first six months after birth. After this, experts recommend continuing to breastfeed for at least the first year, in addition to introducing complementary solid foods. Often, people choose to breastfeed beyond the first year, and many of the benefits continue during this time.

Breastfeeding offers important benefits and protection for both you and your baby. Many families also benefit from the cost savings and convenience of breastfeeding:

Benefits for the baby — Some of the short-term benefits of breastfeeding for babies are:

●Better digestive tract (gastrointestinal) function and protection from digestive tract infections that can cause vomiting and diarrhea

●Reduced risk of respiratory infections, wheezing, ear infections, and urinary tract infections

●Reduced risk of sudden infant death syndrome (SIDS)

There is also a growing body of evidence showing multiple longer-term benefits of breastfeeding, including a reduced risk of type 1 diabetes, inflammatory bowel disease, wheezing, and certain dental problems and, possibly, a reduced risk for obesity, allergies, and certain childhood cancers. (See "Infant benefits of breastfeeding".)

Benefits for you — Compared with people who feed their babies formula, people who breastfeed experience:

●Reduced blood loss after childbirth – Breastfeeding helps the uterus to contract, which reduces uterine bleeding

●Decreased risk of breast cancer, ovarian cancer, hypertension, and type 2 diabetes

Benefits for the family — These include:

●Reduced cost for feeding the baby – In the United States, infant formula and bottle supplies typically cost approximately $1000 to $2000/year (for those not receiving public assistance via the Special Supplemental Nutrition Program for Women, Infants, and Children [WIC] program). This is two to three times the usual cost of breastfeeding supplies and nutrition for the mother. The cost savings from breastfeeding relative to family income are even higher for families living in low-income countries.

●Other savings – In addition to money saved by not buying formula, other savings come from having a healthier baby. This reduces the cost of health care as well as the amount of time parents need to take off from work to take care of a sick baby.

COMMON QUESTIONS

Is breastfeeding comfortable? — Most people can be completely comfortable while breastfeeding. If you experience any pinching, rubbing, or sensation of pain in your nipples, this usually can be fixed immediately by adjusting how the baby is attaching to the breast. Your health care provider or lactation consultant can show you how to adjust the latch by gently removing your baby's mouth from your nipple and having them latch on again, as shown in the figure (figure 1). It is important to adjust the latch until it is comfortable to avoid rubbing of the nipple (which can injure it) and to avoid compressing the nipple (which can interfere with milk flow). (See "Patient education: Breastfeeding guide (Beyond the Basics)", section on 'Helping your baby latch on'.)

Occasionally, you might feel pain in your breasts because of breast engorgement or swelling. Enlargement or swelling and tenderness of your breasts approximately two to four days after giving birth is expected and is a sign that your body is transitioning to making ounces of milk instead of drops of colostrum. Other causes of breast or nipple pain include breast infections, nipple trauma from an ineffective latch or misuse of breast pumps, and a few other conditions. Your health care provider can help determine the cause of the problem and its solution. (See "Patient education: Common breastfeeding problems (Beyond the Basics)".)

Do breastfed babies sleep well? — Healthy newborn babies wake easily and frequently to feed, regardless of whether they are breastfed or formula fed. They then sleep comfortably for a variable period of time after a feeding. Most babies feed at least 8 to 12 times in 24 hours, including several times during the night. Although this can be exhausting for you, remember that it is completely normal for a newborn to wake easily and feed frequently. Your baby will sleep for longer stretches as they get older. Some tips for dealing with exhaustion are shown in the table (table 1). Feeding your baby anything other than breast milk will not help your baby sleep more and might also lead to a decrease in your milk supply.

Will I make enough milk?

●Normal milk production – Most people can make enough milk for their baby. Your breasts will produce more milk if they are "signaled" and emptied frequently, either by having the baby feed or by pumping; in other words, the milk supply responds to the demand.

•During the first few days after birth, your breasts naturally produce colostrum, or "first milk," which is a gold or yellow liquid that is rich in nutrition and healthy antibodies that help protect your baby from infections. Although the quantity is small, colostrum is very concentrated and provides all of the nutrition the baby needs in the first few days as long as they are receiving it frequently (ie, every time they show signs of wanting to suckle).

•Several days after giving birth, your breasts transition to making larger quantities of mature milk. This is sometimes called the "milk coming in," though that is a misnomer because colostrum is also considered breast milk, just in an early and concentrated form. You will recognize this transition because your breasts feel more full and firm (engorged), and some milk might leak out. This usually happens between two and four days after the birth but is sometimes delayed for seven or more days. The frequency and effectiveness of your baby's suckling (at least 8 to 12 times in 24 hours) helps trigger this transition and increases the milk volume. If the transition is delayed (ie, more than five days after birth), consultation with a clinician skilled in breastfeeding is suggested. The clinician can advise how to trigger your breasts to make more milk and assess whether your baby is getting enough milk. (See "Patient education: Breastfeeding guide (Beyond the Basics)", section on 'Getting started with breastfeeding'.)

●How can I tell if my baby is getting enough milk? – It is normal for a baby to lose some weight during the first week after birth, then start gaining weight after that. To make sure that a baby is getting enough milk, health care providers will weigh and assess your baby for well-being and adequate milk intake at least twice during the first two weeks of life and periodically after that. When there is concern about more weight loss than usual or poor feeding, your health care provider will weigh and assess your baby more often in the first weeks of life to follow their weight closely and offer you breastfeeding support. They will also tell you how to look for signs that the baby is feeding well and is well hydrated.

If your baby is not getting enough milk, your health care provider will evaluate you and your baby and suggest solutions. They might help you adjust your baby's attachment to the breast, help boost your milk supply, or both to ensure that your baby is getting what they need. This is discussed separately. (See "Patient education: Common breastfeeding problems (Beyond the Basics)", section on 'Inadequate milk intake'.)

Can everybody breastfeed? — Most people who give birth are able to breastfeed. For parents who did not give birth, there are ways to get some of the benefits of breastfeeding for both parent and baby; these are discussed below.

●Birthparent – Certain conditions and situations may interfere with breastfeeding, most of which can be addressed by extra support from a health care provider or lactation consultant. Examples include:

•Flat or inverted nipples – Flat or inverted nipples may sometimes interfere with the initiation of breastfeeding because the baby might have a harder time latching onto the breast (figure 2). If you have flat or inverted nipples, you might need to use special techniques to help the baby latch on. This can be addressed once you start breastfeeding.

•Early or premature birth or another medical condition in the baby – In these cases, the baby may not be able to suck or swallow well until they are older or are more medically stable. In these situations, pumping and/or hand expressing your milk on a regular basis (at least 8 to 12 times in 24 hours) beginning right after birth can help achieve and maintain a full milk supply until your baby is ready to breastfeed.

•Breast reduction or other surgeries – If you had breast surgery, you will likely still be able to breastfeed; however, this may impact your milk production, particularly if you had breast reduction surgery. Breast enlargement surgery (breast implants) usually does not affect your milk supply or breastfeeding.

Close follow-up is recommended for anyone who is breastfeeding and had breast surgery until it is clear how much milk your body can produce. The amount of milk that people can produce after breast surgery varies; in some cases, you might need to supplement with donor milk or infant formula.

•Medications – Most medications are safe to take while breastfeeding, but a few are not. Check with your health care provider about any medications you take (including herbal medications or supplements) to make sure that they are safe for the baby. You can also look up your medications in the LactMed database, which is a free reference for lactation compatibility for prescription and over-the-counter drugs.

There are only a few situations in which breastfeeding is not recommended, including use of illegal drugs, or classic galactosemia (a rare genetic condition) in the baby.

•Conditions for which breastfeeding is not recommended are listed on the Centers for Disease Control and Prevention (CDC) website: www.cdc.gov/breastfeeding-special-circumstances/hcp/contraindications.

•People who are breastfeeding are advised not to use cannabis (marijuana) or cannabidiol (CBD) in any form, because the effects of the chemicals or contaminants on the baby are not known (CDC guidance is here: www.cdc.gov/breastfeeding-special-circumstances/hcp/vaccine-medication-drugs/marijuana.html).

•Parents with human immunodeficiency virus (HIV) who desire to breastfeed have the option of doing so under certain conditions, including taking prescribed antiretroviral medication consistently (for you and your baby) and having undetectable viral loads and close follow-up. If you are HIV positive and are interested in breastfeeding, consult with your medical professional before your baby is born.

●Non-birthparents – Non-birthparents have several options to give their baby the benefits of breastfeeding. Non-birthparents might include the birthparent's partner or parents whose baby was adopted or born to a gestational carrier ("surrogate"). Options include:

•Allowing the baby to "comfort" suckle at the breast or chest without feeding – This can provide comfort and bonding even if the baby is getting their nutrition from bottle feeding. (See 'How can my partner or support people be involved with feeding the baby?' below.)

•Donor milk – If neither parent can breastfeed and you prefer to give the baby human milk rather than formula, you can use donor human milk, but this can be very expensive. If you choose this option, it is important to use milk from an established human milk bank because these organizations follow safety regulations for optimal milk collection, pasteurization, storage, and shipping. Use of donor milk obtained over the internet and/or unpasteurized human milk is not recommended, because of the risk of infection. Advice about informal milk sharing is available from the Academy of Breastfeeding Medicine. Information about certified milk banks can be found online (through the Human Milk Banking Association of North America or other country-specific resources), or your health care provider can provide resources.

•Inducing lactation – If you feel strongly that you want to feed the baby directly from your breast or chest, you can ask your health care provider about the possibility of taking hormones that can help signal your body to "induce" lactation; the hormones are then stopped prior to starting milk expression. However, this technique requires prescriptions and monitoring from a health care provider with special expertise, such as a breastfeeding and lactation medicine specialist. The amount of milk that people are able to produce after induced lactation varies, and supplementation with donor milk or infant formula may be necessary.

Can my baby get all their nutrients from breast milk alone? — Breast milk supplies almost all of the nutrients that your baby needs. It is recommended that they receive some extra vitamin D to support bone health, starting shortly after birth. The amount, options, and other considerations are discussed separately. (See "Patient education: Breastfeeding guide (Beyond the Basics)", section on 'Nutritional content of breast milk'.)

How can my partner or support people be involved with feeding the baby? — If you are breastfeeding, your partner or another caregiver can still be closely involved in many other aspects of the baby's and your care. For example, they might change the baby's diaper or burp them after each feed. Once the baby is several weeks old and is breastfeeding well, you may want to start expressing (pumping) some milk from your breasts in place of a feeding once or twice/day. The expressed milk could then be fed in a bottle.

Providing some feeds by bottle can allow your partner or others to be involved with feeding and helps prepare for whenever you might need to be away from your baby (for example, return to work or school). For bottle feeding, it may be helpful to use strategies to slow the milk flow so that it is more similar to what the baby experiences while breastfeeding. This might include making sure that your baby opens their mouth wide and is actively engaged in sucking, holding the bottle more horizontal to the ground rather than at a slant so that milk flow is triggered by sucking rather than gravity, and taking frequent breaks ("paced" bottle feeding). The technique of paced bottle feeding is demonstrated in a video from the Institute for the Advancement of Breastfeeding and Lactation Education. (See "Patient education: Pumping breast milk (Beyond the Basics)".)

Is breastfeeding convenient? — Most people find that breastfeeding is very convenient (and usually more convenient than formula feeding) once they get used to it. You have a constant supply of fresh milk, and you don't need to buy, store, prepare, or warm the milk.

Many people find that, with some practice, they can easily breastfeed when they are away from home. This allows more flexibility as you don't need to think about packing formula for outings with your baby or having supplies for mixing, cleaning, and storing. If you wish, you can use a cloth or thin scarf to cover your breast while feeding in public. Or, you may choose to find a private place to breastfeed, such as your car or a quiet room. You will quickly find a way of feeding your baby that you are comfortable with. In many places all over the world, people breastfeed in public without thinking twice about it. In the United States, there are laws that protect your right to breastfeed in public.

What if I need to go back to work or school? — Most people are able to continue breastfeeding after returning to work or school or if they are away from the baby for a few days. You can pump your milk while at work, store the milk in the refrigerator or freezer, and have another caregiver feed the milk to the baby while you are away by using a bottle. You can buy or rent an efficient electric breast pump for this purpose. In the United States, most commercial health insurance plans cover the cost of renting a hospital-grade breast pump and employers are required to provide a private place at your workplace for you to pump that is not a restroom. (See "Patient education: Pumping breast milk (Beyond the Basics)".)

How does breastfeeding affect my breasts and body?

●Breast shape and fullness – Most people's breasts enlarge and may feel tender during early pregnancy as the milk producing glands mature (figure 3). After birth, the breasts start to fill with milk around two to four days after birth, whether or not you breastfeed. If you breastfeed, your breasts will continue to fill with milk and will generally look and feel more full and firm, especially before feedings, as long as you continue to breastfeed. Once you stop breastfeeding, your breasts will usually gradually return to their previous shape but may remain slightly larger than before breastfeeding. (See "Patient education: Weaning from breastfeeding (Beyond the Basics)".)

●Body weight – Bodies have a wide range of responses to pregnancy and delivery. Some people lose the weight that they gained during pregnancy easily, and others do not. You burn 300 to 500 more calories each day when you are breastfeeding, which may help you lose some of your pregnancy weight as long as you continue to eat a regular diet. When you are breastfeeding is not a time for any special diets. The best way to reach a healthy body weight after pregnancy is to eat a healthy and balanced diet and get plenty of physical activity.

●Cancer and diabetes risk – Studies show that breastfeeding reduces your long-term risk for ovarian cancer, uterine cancer, breast cancer, and type 2 diabetes, even if you had gestational diabetes. (See 'Benefits for you' above.)

PREPARING TO BREASTFEED

What supplies will I need? — It is not necessary to buy any breastfeeding supplies before birth. Many people who breastfeed will rent or purchase a breast pump at some point, but many experts suggest waiting until after the baby is born to make the decision about when and how to do this. Most people only need the pump once they return to work or have to spend time away from the baby. If a pump is needed sooner (for example, to pump milk for a premature baby), a lactation consultant or health care provider can advise you about the type of pump to get and where to purchase or rent one. (See 'Where to get more information' below and "Patient education: Pumping breast milk (Beyond the Basics)".)

Do I need to prepare my nipples or breasts? — There is no need to do anything to prepare or condition your nipples for breastfeeding. You should not try to "toughen" the skin or stretch the nipple. This will not help with breastfeeding and might even injure the nipple. The baby actually does not touch the nipple when feeding but rather compresses behind the nipple. Compressing or pinching the nipple itself interferes with milk flow. You can plan to bathe and wash your breasts with a gentle soap as you normally would with no other special care.

What to expect in the first few days — Most hospitals specifically encourage and support you to breastfeed with these steps:

●When to start breastfeeding – You should start breastfeeding within the first few hours after giving birth, whenever possible. This usually happens in the birthing room as part of "skin-to-skin contact" immediately after the baby is born (figure 4). Most babies will instinctively find the nipple and start sucking (though it can take as long as one hour, so it is important for this skin-to-skin time to be uninterrupted). This first feed helps them practice and gives them their first meal of colostrum, or concentrated breast milk that is packed with nutrition and protection for your baby.

●Rooming-in – During the first few days, the baby will breastfeed frequently throughout the day and night and will feel most comfortable and the least stressed with you and near you. It is recommended that your baby stay in the room with you ("rooming-in"). Rooming-in allows you to learn and respond to your baby's cues when they are ready to feed and allows you to comfort them with your voice, smell, and close contact.

It is normal for your breasts to produce only small amounts of colostrum during the first few days, and this is all that your baby needs. With frequent feedings and effective emptying of the breast to signal your body that the baby is here, your milk supply will increase every day as your baby's needs increase. (See 'Will I make enough milk?' above.)

●Postpartum support – The nursing and medical staff in birth hospitals should observe you feeding your baby and provide general advice about breastfeeding, including how to help the baby latch on in a comfortable and effective manner. If you need more help, you can get more detailed guidance from a lactation consultant or peer counselor. (See 'Finding a lactation consultant or other support' below.)

More details on breastfeeding techniques are provided in a separate topic review. (See "Patient education: Breastfeeding guide (Beyond the Basics)".)

FINDING A LACTATION CONSULTANT OR OTHER SUPPORT — Resources for finding a lactation consultant, peer support (online or in-person), and other types of support are listed in the table (table 2).

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Deciding to breastfeed (The Basics)
Patient education: Breastfeeding (The Basics)
Patient education: Health and nutrition during breastfeeding (The Basics)
Patient education: Medicines and breastfeeding (The Basics)
Patient education: Common breastfeeding problems (The Basics)
Patient education: Pumping and storing breast milk (The Basics)
Patient education: What to expect in the NICU (The Basics)
Patient education: When a baby is born premature (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Breastfeeding guide (Beyond the Basics)
Patient education: Common breastfeeding problems (Beyond the Basics)
Patient education: Health and nutrition during breastfeeding (Beyond the Basics)
Patient education: Pumping breast milk (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Breastfeeding: Parental education and support
Initiation of breastfeeding
Common problems of breastfeeding and weaning
Infant benefits of breastfeeding
Maternal nutrition during lactation
Contraception: Postpartum counseling and methods
The impact of breastfeeding on the development of allergic disease
Safety of infant exposure to antidepressants and benzodiazepines through breastfeeding
Prevention of HIV transmission during breastfeeding in resource-limited settings

Websites — The following organizations also provide reliable health information:

●United States National Library of Medicine

(www.medlineplus.gov/breastfeeding.html)

●Centers for Disease Control and Prevention (CDC)

(www.cdc.gov/breastfeeding/php/about/index.html)

●American Academy of Pediatrics

•Professional website (www.aap.org/en/patient-care/breastfeeding)

•Parenting website (www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/default.aspx)

●Academy of Breastfeeding Medicine

(www.bfmed.org/protocols)

●La Leche League International

(www.llli.org/resources)

●Office on Women's Health

(www.womenshealth.gov/patient-materials/health-topic/breastfeeding)

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