A Breastfeeding Guide for a Realistic World

By Kate D. Shand, PA-C, CBS (Certified Breastfeeding Specialist)

Everyone knows “Breast is Best” for your baby. Any quick Google search will show a bevy of information (some good and some bad) for new moms to read when preparing to breastfeed their child. And let’s not forget the friends and family members who will chime in with their experiences and opinions as well (again, some good and some bad). Here at Legacy Pediatrics, we have seen and heard it all from new moms with what works and what doesn’t. I’ve compiled a list of what I think is the most important “rules” (a term I use lightly) when trying to breastfeed your newborn. I’d like to think this is a less strict/realistic approach than what you will read elsewhere while taking into account everything that is going on in those stressful first few weeks home with your new baby.

1 – It’s quantity AND quality.

Quantity.   This is in regards to how many times within a 24-hour period, you are putting the baby to breast. The key rule here is 8-12 times in that 24 hour period. This means every 1-3 hours from beginning of nursing session to the beginning of the next nursing session – NOT the time in between nursing sessions. Breastfeeding is all supply and demand. Your body will not make enough milk if you aren’t properly stimulating it and removing it. The goal is to stimulate the breast and empty it so more can be made. If you are exclusively pumping, this means pumping 8-12 times within a 24-hour period.

Also, I recommend no more than 15 minutes per side when nursing. Current lactation consulting recommendations are to let the baby nurse for as long as they want until they “fall off” the breast. I think this is unreasonable. Many babies will eat, and then continue to suck on the breast to pacify themselves and to be close to mom. This sounds lovely, but can cause two problems that we commonly see in the office. The first is that we see the baby having trouble gaining weight. This happens because the baby uses all of its energy sucking at one breast for 30 minutes and then won’t take the second breast. Moms will (understandably) take the sleepiness as the baby being full after one side, but the reality is that the baby finished eating in 10 minutes and then just stayed there and pacified itself to sleep. Studies show that most babies will empty the breast pretty efficiently; within 5-10 minutes! So letting them stay on the breast for much longer is unnecessary. The second problem with letting them nurse for as long as they want is that your nipples will become very sore. Having a baby on the breast for 40+ minutes, 8-12 times a day, will mean your nipples will never get a break.

Quality. This is in regards to quality of the baby’s latch. This, by far, is the hardest part of breastfeeding. Getting that baby to properly latch will not only make sure the milk is transferred to the baby properly, but also ensure that your nipples aren’t cracked and bleeding. When babies have a shallow latch (are just nursing off the tip of the nipple), they aren’t properly draining the milk out of the breast, which can lead to low milk supply issues. A baby should have most of the areola in his mouth with the chin pushed into the breast and nose facing upwards. The chin movement against the breast will massage the breast and initiate milk let down. Also, when the baby only has the tip of the nipple in his mouth, the nipple is rubbing against the hard palate of the baby’s mouth which will cause very sore nipples. If the nipple is appropriately deeper in the mouth toward the soft palate, it will feel much better to the mother. Watch this video to see a demonstration:


2 – Pacifiers and bottles are not the devil.

This is something you can read a lot about and hear lots of opinions on. “Nipple confusion” is a term used to describe when a baby confuses a plastic nipple/pacifier with a mother’s breast and has trouble nursing because of it. This is a hot topic, most likely because there seems to be more opinion then solid science behind it. You can’t debate black and white research and there isn’t much on this. Therefore, to add to the debate, it is in my opinion that it doesn’t exist. When you have a mother who is motivated to breastfeed and is following the “quantity” and “quality” rules as mentioned above, adding a pacifier to calm the baby between breastfeeding sessions should not get in the way of successful breastfeeding. If a mother uses a pacifier IN PLACE of a breastfeeding session, then this would pose a problem. But using a pacifier appropriately, which would be to calm down a baby after eating or when trying to go to sleep, then there shouldn’t be any problems.   To have a baby choose a plastic pacifier (which gives nothing in return) instead of its mother (who provides milk, warmth, and emotional bonding), not only doesn’t make sense, but doesn’t happen.

Lots of lactation consultants will suggest certain gadgets or methods to help with supplementing in the first few weeks of life if it’s needed for your baby.   This ties into the “nipple confusion” debate. They believe that supplementing with a bottle is the least favorable option to give a baby milk so instead, they have come up with cup feeding (using a tiny shot glass and letting the baby lick the milk out of it like a cat), syringe feeding (using a small syringe with plastic curved tip to slowly inject milk or formula into the baby’s mouth), and SNS (supplemental nursing systems) which are devices where you have milk in a container that hangs around your neck and flows thru a tiny piece of tubing into the baby’s mouth or thru a nipple shield and into the baby’s mouth. In my experience, all of these methods are just barriers to getting moms to breastfeed. I see mothers after their hospital stay and when all this stuff is used, they get confused, frustrated, and feel overwhelmed that this is the way in which to successfully breastfeed. So no wonder moms often times will stop nursing if this is the manner in which they need to get breast milk to their baby. Paced bottle feeding, I believe, is a happy medium. This is a method of slowly “pacing” the feeding with a bottle so the baby doesn’t get used to a deluge of milk and then, theoretically, not take to the breast. The baby is fed upright and the parents are instructed to pick up the bottle so the baby can take a few gulps, and then tip the bottle back down (but not completely out of the mouth) to stop the flow of milk. When the baby starts sucking again, the bottle can be tipped up and a few more gulps allowed. Here is a link that shows how to do paced bottle feeding:

3 – Formula is not poison

Supplementing is ok! A lot of mothers have an idea of breastfeeding as needing to be all or nothing. “Exclusively breastfeeding” has turned into a goal for some woman that sometimes is unattainable. I think there is a key role for supplementing in the first few weeks. In fact, I feel that sometimes supplementing with formula can actually make breastfeeding more successful. This can happen in the case of a mother whose milk is slow to come in, or in a baby who is losing too much weight (most pediatricians will allow for a 10-11% weight loss before suggesting supplementation). In those moms who don’t have a lot of milk yet, we tend to see what I like to call the “hangry” baby. Hungry + Angry = Hangry baby. This is a baby past the first 24-48 hours of sleepy newborn time, who wakes up and is very very hungry and goes to the breast and doesn’t get much. This is a baby who will scream and scream at the breast and won’t latch. Now historically, we were told if needing to supplement, mothers should supplement after a nursing session in order to appropriately stimulate the breast and encourage milk coming in. But if you have a screaming baby at the breast, what can you do? This is where what I call the “formula appetizer” comes in. A mother can give her baby a tiny amount of formula (or pumped breast milk if she has it) to basically take the “edge” off. The baby calms down enough to latch and finish his session at the breast. Without that little supplement to calm him down, we will end up with a very frustrated mother who, after enough episodes of a screaming baby at the breast, will get exasperated enough where she will stop wanting to breastfeed. Most babies will eventually learn to latch without the “appetizer” when mom’s milk comes in.

4 – Pump it up

Putting the baby to breast is key, but in the case of a sleepy/lazy baby, sometimes you will need to pump. When a baby isn’t properly draining the breast (latch issues, sleepy baby), the pump is your friend. I usually will suggest that moms try to pump after an attempted nursing session. This ensures proper draining of the breast and an empty breast will then tell the body to make more milk. Even with a baby who is doing everything right and nursing great, it is good to pump every so often to get a back up supply in the case that mom wants/needs to get away for a period of time so the caregiver can have milk to give the baby while mom is gone. Also, many moms will start building up their pumped milk supply for when they go back to work. And remember, thanks to the Healthcare Affordability Act, most insurances will pay for a large amount of a personal use breast pump with a prescription from a provider.

5 – Pay attention

In the first few weeks of life, you will need to watch your baby nurse. Have the lactation consultant in the hospital or the provider at your pediatrician’s office watch you nurse and teach you what to look for so you know the baby is sucking and swallowing. This includes jaw movement and listening for that suck/swallow sound. Some babies get very sleepy at the breast and will need some reminders to stay awake and do their job. Babies who fall asleep at the breast may look like they are nursing, but what they are really doing is what we call “non-nutritive sucking” which is basically using mom’s nipple as a pacifier. This will just make mom’s nipples very sore and will not efficiently take milk out of the breast. When you see this, take the baby off, or try to wake them up and get them to eat. Your nipples will thank you.

6 – Getting enough?

This is by far, the number one concern of new parents. If only breasts had a gage on them! This fear of the baby not getting enough, is the reason why a lot of new moms will turn to pumping and bottle feeding so they know exactly what their baby is getting. But, knowing what to look for when breastfeeding (see rule #5), and frequent weight checks at your pediatricians office, will do just the same. Trust me, we will not let your baby starve!

7 – Sore nipples

The bottom line is that this sucks, and is unfortunately a part of breastfeeding in the beginning. But, there is help! There are creams, nipple shells, positioning tricks, and help with baby’s latch, just to name a few. So make sure you ASK someone to help you if this is an issue. And remember, it WILL get better!

8 – Goals

Be realistic with yourself and whoever is helping you with your goals. Do you want to breastfeed until you go back to work? Do you want to do it for 6 months, 9months, or 12 months?   Whatever your goal is … be flexible with yourself. Things might change and that all too familiar “mother’s guilt” needs not to rear its ugly head. We all want to do what’s best for our children, but sometimes what is best for our children can make us crazy. If you walk into this breastfeeding world with the goal of doing as much as you can for as long as you can and leave it at that, then you won’t be disappointed.

9 – It will get better!

Nursing is hard. And as much as it is “natural,” it isn’t easy for the vast majority of moms and babies that I see in the office. I tell moms if you can get thru the first 2-4 weeks of breastfeeding, it will get much easier. The baby will be bigger and more mature which means they will be more efficient at latching and eating in a timely fashion, and you won’t have to watch them like a hawk while nursing once they get the hang of it. And all the tricks and pumping and extra stuff you sometimes have to do in the beginning usually will not be necessary once the two of you figure it out. Then it’s smooth sailing!

10 – Support for Mom

You will need lots of support in those first few weeks home with your baby. Your hormones will be on a roller-coaster, your body will feel like it just went thru a war, and your mind will be racing with a gazillion questions. I cannot say this enough: Use the support system around you. That includes the people at the hospital, your friends and family members, and your significant other. If you have help around the house, my advice is to concentrate on eating, drinking water, sleeping, and nursing. That is your job. Notice how I didn’t say change diapers, clean the house, change the baby’s clothes, etc. Your job is to take care of yourself so you can heal and be the amazing milk making machine that you were meant to be!

Kate D. Shand, PA-C is also our lactation specialist at Legacy Pediatrics. Please contact her at the office with any questions about breastfeeding or to make an appointment to see her with your baby.