A Lactation Consultant Answers Your Burning Questions About Breastfeeding

Welcome to Ask the Expert, a series in which real medical experts answer questions from real Babylist parents. For the first installment, Julie Cunningham, a Registered Dietician and International Board Certified Lactation Consultant (IBCLC) is taking your questions about breastfeeding, which can be one of the biggest challenges for parents of a new baby. Which means you probably have questions! In fact, Babylist parents submitted tons of great queries about latching, supply, schedules, returning to work and if the thing that your baby is doing is normal (short answer: it probably is, and if it’s not there’s help available).

Read on for answers to your questions about nursing your baby, from the early stages of newborn feeding all the way to weaning.

1. How do I know when my breastfed newborn is full? I’d feel so much better if I could actually see how much my baby is eating.

This is a common concern among new parents, and an even more common concern among grandmothers who bottle-fed their babies and may not feel completely comfortable trusting a newborn to regulate their appetite.

A newborn’s stomach is extremely small—about the size of a cherry or a large marble at birth, so your newborn can only take in a teaspoon or two of colostrum or breast milk at a time.

What goes in must come out, so counting wet and poopy diapers is the best way to know whether your newborn is getting enough to eat. A newborn baby should have at least one wet diaper per day of life until day six (one on day one, two on day two, etc). From day six forward, they should have at least six wet diapers every day.

Your baby will pass dark, tarry meconium for the first few days of life, and then around day four, their stools should transition to a seedy, yellow mustard-like consistency.

If your newborn baby is making plenty of wet and dirty diapers but you feel like they want to nurse around the clock, this is normal. They’ve spent nine months inside your body. You’re their safe space, and they feel most comfortable when they’re connected to mom.

2. If my baby is feeding every hour throughout the day, does that mean they are not getting enough milk from my breasts?

For newborns, see the first question. For infants two months and older:

• Does your baby sleep longer stretches at night?
• Do they produce at least six wet diapers and one poopy diaper a day?
• Are they growing and gaining weight well?

If so, it may just mean that your baby likes to be near you and enjoys snacking throughout the day, or they may be experiencing a growth spurt and temporarily need more calories. If your baby is not meeting these criteria, talk with your pediatrician and a lactation consultant.

3. Do I have to feed on both sides every time? My baby had a hard time as a newborn getting back on once he came off so he has done full feeds on one side each time for seven months now. My baby exclusively breastfeeds and I’ve never had a supply issue. My breasts have completely adapted to just doing one side per feeding, so I’m not sure if I’m missing something?

Most babies need to feed on both sides to get full, and that’s why we recommend that you offer both breasts at each feeding. As long as your baby is growing well, it sounds like the two of you are doing just fine, and there’s no need to fix something that’s not broken. You’re doing great!

4. How do I know if I have a forceful letdown? Will it subside over time?

If you have a forceful letdown (also called an overactive milk ejection reflex), your baby will typically start nursing and then pull off the breast while choking and sputtering just a few minutes after nursing starts. Using a breast pump or hand expression for a few minutes prior to putting your baby to the breast may help. This will allow the most forceful letdown to occur before you nurse your baby. (The goal is not to empty the breast, just to express until your milk lets down.)

5. How do I know if I have a foremilk/hindmilk imbalance and should I be concerned?

Foremilk is the thirst-quenching milk at the beginning of a feeding; hindmilk is the rich, fatty milk at the end of a feeding. If your baby has a lot of abdominal pain, gas, and green, foamy stools, they may be getting too much foremilk and not enough hindmilk.

It’s impossible to know how much hindmilk your baby gets based on the amount of time they spend at the breast, but if this sounds like your baby, offer more frequent breastfeeds to try to increase the amount of hindmilk they receive.

6. What does a proper latch feel like? Why do so many moms have a hard time figuring it out?

Unlike other countries, many people in the US have never seen someone breastfeed before they try to nurse their own babies. We don’t have a model of what breastfeeding looks like, so we do the best we can once we give birth. Likewise, babies are born with an instinct to suck, but latching on is a skill they have to learn. So, parents and babies have to figure out latching together.

A good latch draws in more of the nipple than you might imagine. The infant’s top and bottom lips should be flanged out like a fish. You should feel a tugging sensation, but not pain. If you feel pain, immediately insert your finger into your infant’s mouth and break the suction; then start again. When you’re a sleep deprived new parent, it’s tempting to allow your baby to nurse with a poor latch. But don’t do it—this teaches your baby a habit you’ll have to break.

(During the first one to two weeks of nursing, many moms have sore/sensitive nipples, but nipple pain that lasts beyond the two-week mark is not normal and needs to be evaluated by a lactation consultant.)

7. My baby never latched and I am still exclusively pumping. Every time I try to latch my baby on, he just starts crying and gets frustrated. He also pulls away from my nipple, which is painful. The pediatrician said there is no tongue tie. I worked with a lactation consultant from the hospital but it didn’t go well and I’m hesitant to see someone else. Should I give it another try? Why does he hate the breast?

By the time a baby is two to three months old, their sucking and swallowing patterns are pretty well established. It would likely take a great deal of effort and one-on-one work with a qualified lactation consultant to get your baby to accept the breast. Your baby doesn’t hate you or your breast, he knows sucking from a bottle is easier for him, and like most people, he wants to do what feels easiest.

Some people are extremely disappointed when breastfeeding doesn’t go as planned, and that’s completely understandable; there’s a lot of pressure to get it “right.” I’m a dietitian and a lactation consultant, and I still think breastfeeding is one of the hardest things I’ve ever done.

As a parent, you have to decide whether you really want to get professional help in hopes of getting the baby back to the breast (which may or may not happen) or whether you are able to make peace with the fact that your baby is well-fed and growing on a combination of your pumped milk and formula. You are already doing a great job as a parent no matter how your baby is fed.

8. Is there any risk to using a nipple shield long term if that is the only way my baby will latch?

Try to take a deep breath. No harm will come from long-term use of the nipple shield. They can be a pain to keep up with and keep clean, but there’s no medical or nutritional risk here.

9. How do you distinguish normal versus abnormal nipple and breast pain, especially in the early postpartum period when you are establishing breastfeeding?

Nipple soreness is not unusual in the first two weeks postpartum. Nipple cracks, bleeding nipples, toe-curling nipple pain, red streaks in the breast, fever, and/or deep pain in the breast are not normal and need to be evaluated. Trust your gut. If you feel like something is amiss, reach out for professional help.

10. I’m over a month postpartum and my nipples/breasts are still always in pain from breastfeeding and pumping. I’ve tried topical antibiotics, nipple shields, and heat compress after feeding, but nothing seems to help. It makes wearing even loose-fitting bras really uncomfortable. Is this abnormal and how long can it last?

Nipple soreness beyond two weeks postpartum is not typical, and it definitely needs to be evaluated. There are a wide variety of things that could be causing your pain, from a yeast infection to a poorly fitting breast pump flange. I’d encourage you to see an IBCLC in your local area as soon as possible.

11. How do I change my one-month-old baby’s habit of snacking and cluster feeding? Takes hours to feed and loves being on the boob all the time. I don’t have time to eat or shower!

I know this feels exhausting, but snacking and cluster feeding are completely normal for a one month old, and so is hanging out on the boob all the time. Intentionally hand your baby to your partner or another caregiver and take the time to eat, shower, or go outside and take a break without guilt. In another month, you should have a bit more room to breathe.

12. I’ve been breastfeeding my 10-week-old exclusively, now I am trying to switch to bottles as I head back to work next month. He has refused the bottle from me every attempt. Any advice?

Chances are he’s going to refuse bottles from you, at least at first. He knows you have the real thing! Try having your partner, friend or family member offer the bottle when you know your baby is hungry, and when you are not in the house. Babies are smart, and they can sense your presence.

I’m not sure if you’re offering bottles of pumped breast milk or formula, but he will likely more readily take breast milk from a bottle since that’s what he’s used to. Ask the baby’s caregiver to drip some breast milk onto his lips before trying to put the bottle nipple into his mouth, so he can taste it and understand what’s coming his way. And lastly, you may have to experiment with a few different nipples until you find one he’ll accept.

13. What are the chances of a mom with low milk supply at four weeks postpartum actually building her supply if it hasn’t already built up?

For the first few weeks, milk supply is mostly hormonally driven. After that, milk supply is more related to demand (the more nursing/pumping you do, the more milk is produced.)

To maximize your milk supply, breastfeed at least eight times every 24 hours (12 times is preferred), and be sure not to go more than four hours in between feedings, even at night.

Dehydration is sure to lead to a low milk supply, so drink at least two liters of water per day, and also eat plenty of calories (2200 is a minimum for a nursing person).

You may find recommendations for several different herbal supplements to enhance milk supply, but there is little clinical evidence that any of these supplements work. The prescription medication Reglan can increase milk supply, but may have the side effect of depression. There is another medication called Domperidone used to enhance milk supply in other countries, but it is not approved for use in the US as a milk supply enhancer.

14. I’ve just returned to work, and I can’t always pump at the time I’d prefer due to meetings. I’d like to pump every two to three hours, but sometimes in reality I pump every four hours at work. Am I hurting my milk supply? Is it okay to use formula during the week but not on the weekends?

In order to maintain your milk supply, you need to feed your baby or pump at least eight times in 24 hours, and preferably, you need to pump at work every time your baby feeds when you’re away from them.

Some people have an easier time maintaining their milk supply than others, and the reality is that your body may not respond to a pump the same way it responds to your baby.

The main goal is to have a well-fed baby, not to create impossible demands on yourself. It’s very difficult to work full time and pump enough to maintain a full milk supply. Some people can do this, but many cannot. If you can’t, be gentle with yourself. If you need to use formula during the week (or on the weekend) you’re doing the best you can and remember that you’re providing for your baby financially as well as nutritionally.

15. How do I wean my baby?

Babies need breast milk or formula until at least their first birthday. The World Health Organization (WHO) recommends breastfeeding for two years and beyond. Some babies will naturally wean themselves by nursing less and less frequently; other nursing parents are ready to wean before their babies decide to let go of the breast.

When you decide to wean, gradually eliminate one breastfeeding at a time to minimize your risk of mastitis (breast infection) and to ease your baby’s transition.

If you co-sleep with your infant, it may help to wear a lounging bra to bed so that your older baby can’t easily access your breasts while you sleep. During the day, be ready to use books, games, music, etc. to distract the toddler who wants to nurse.

16. My baby is 11 months old and has started to bite. Is it time to wean?

Only you can decide if you’re ready to wean, but being bitten is no fun. If you want to continue to nurse, teach your baby not to bite. When they bite, immediately take them off the breast and sternly say, “No!” Don’t allow them to nurse again for a couple of hours. They will likely be startled and upset; that’s OK. They’re coming to the age where they can understand that you have feelings too.

17. I want to start trying for baby number two. My 15-month-old is still happily nursing twice daily with no indication of wanting to stop (and I love nursing her, as well). Is it safe to continue nursing while pregnant?

For most women, nursing while pregnant is safe. (If you have a history of preterm labor, you should stop nursing before becoming pregnant again.) Once you become pregnant, the taste of your breast milk will become more salty, and you may find that your daughter naturally weans herself. Then again, she may not be bothered by that at all.

18. I felt like I really figured out nursing for the first six months, then I introduced solids and now I feel like I’m adding all these calories that aren’t a complete meal like milk is, and I don’t know how to wean milk appropriately! How do I know how much my baby should eat?

Around age six months, your baby is really just learning how to move food with his tongue and experimenting with flavors and textures. Solid foods don’t contribute a lot of calories to his diet at this point, so he should still be nursing almost as much as he did before you introduced food, even if you’re offering small amounts of pureed foods two to three times per day.

At nine months and older, babies begin to take in a larger amount of pureed and semi-solid food and will gradually decrease the amount of nursing at the breast.

By the age of one year, most babies will be taking in half to two-thirds the amount of breast milk they were taking in at age six months, and they will be eating three meals per day plus snacks. At one year old, breast milk still provides considerable nutrition and fluids but the bulk of a child’s nutrition comes from food. A one-year old child should be eating a wide variety of foods, including soft fruits and vegetables, starchy foods, protein foods like eggs, beans, and soft meats and cheese and yogurt.

19. I’m only wearing bras now that are easily moved for breastfeeding. And none of them have wiring. How much can I expect my boobs to sag after breastfeeding?

The good news is that a lack of underwire bras isn’t going to cause sagging breasts. The bad news is that it’s the hormones of pregnancy, not breastfeeding or lack of underwire bras, that actually causes breasts to lose elasticity, so there would be some breast sagging caused by pregnancy, even if you hadn’t breastfed at all.

It’s virtually impossible to grow a human being inside your body without having your body change, so rather than feel like you’ve lost your “ideal” body, consider embracing your new shape as a sign of the new life you’ve created.

20. How do you prevent mastitis?

Mastitis is a breast infection leading to fever, body aches, and fatigue. A mom with mastitis will have symptoms similar to the flu. Mastitis can lead to abcess and needs to be treated by a physician right away.

Some people are more prone to mastitis than others, but the best you can do to prevent mastitis is to take excellent care of yourself:

• Avoid wearing a tight-fitting bra.
• Nurse often and completely empty your breasts. Use a breast pump if you feel your baby is unable to drain your breasts.
• Drink plenty of fluids (At least two liters per day).
• Eat well (three meals plus snacks daily).
• Avoid smoking.
• Get plenty of rest. Sleep when your baby sleeps and say “yes” when people offer to help with errands or household chores.

21. What suggestions do you have for a first-time mom who had a breast reduction 10 years ago? The stats are 50/50 on being able to produce following a reduction but, I want to make sure I’m taking the right precautions in my diet and any other methods that could assist in bringing that milk down for my baby!

A phone call to your surgeon’s office should help you determine whether or not your milk ducts were severed during your breast reduction. If precautions were taken to keep your milk ducts intact, you have a much better chance of producing a full milk supply.

At birth, nurse frequently, drink plenty of water and eat a well-balanced diet, and monitor your child’s wet and poopy diapers as any new mom would. Be sure to let your pediatrician know about your breast reduction surgery; they may want to keep a closer eye on your child’s weight to be sure that breastfeeding is going well.

22. I have nipple piercings. Can I breastfeed?

Yes, you can. You will need to remove the piercing to nurse, and it’s possible that you will have a large amount of milk or no milk at all that flows from the pierced area.

If the piercing is relatively new, it will need to be completely healed before you nurse to avoid the introduction of bacteria from your baby’s mouth into the wound from the piercing.

23. I still breastfeed my 15-month-old baby in the AM, PM, and during the occasional night waking (maybe once per week). During those night awakenings, it seems like she’s genuinely hungry or needs comfort, though I’d like to move away from this if I can. How can I make sure she’s going to bed with a full tummy that will sustain her through the night? This is especially hard when she doesn’t always want to eat much dinner (hello, picky eating phase!).

The best thing you can do to ensure she’s full at night is to give her a high-calorie bedtime snack. Think carbs plus fat & protein. Here are a few ideas:

• Cheese and crackers
• Quick bread (banana bread, zucchini bread, or blueberry muffin) with butter
• Banana or apple slices with peanut butter
• Chopped hard boiled egg and avocado bites

24. I’m a little embarrassed to ask this, but is it normal to feel negative emotions while breastfeeding or pumping? Emotions such as a feeling of disgust or even anger. I don’t have these horrible feelings towards my son at all, but it’s strange that I feel them at all when I think breastfeeding is such a beautiful act. Do these feelings ever lighten up?

A small percentage of people experience Dysphoric Milk Ejection Reflex (D-MER). This is a wave of negative emotions that usually occurs just around the time of milk letdown, and it may be related to temporary hormonal changes. The negative feelings can range from mild sadness to intense anger. For about half of people with D-MER, these feelings persist until breastfeeding stops. For the other half, these feelings stop around the time their menstrual cycle returns, even if they’re still nursing.

If this sounds like what you’re experiencing, reach out to a lactation consultant with experience in D-MER. It may be helpful to contact the lactation center at your nearest teaching hospital.

25. Can you talk about post-weaning depression?

Some lactating parents are thrilled to wean because they get their bodies back to themselves. Others feel a loss of connection to their babies, and they experience a sense of grieving for their child’s infancy, especially if this is their last planned baby. Both feelings are normal. If you feel depressed or down after weaning (or anytime) and your depression lasts more than two weeks, consult a licensed mental health care provider who can support you.

26. When do you know you need to ask for help?

Parenting is hard work, and for many people, so is breastfeeding. An hour with the right lactation consultant may help you fix a problem you’re really struggling with at home and it may also give you the opportunity to talk out your feelings about whether or not you want to keep breastfeeding. There’s no wrong reason to ask for help, but here are some definite reasons to make an appointment with an IBCLC:

• Your baby isn’t gaining weight as well as your doctor would like.
• Your baby doesn’t seem satisfied between feedings.
• You’re unsure if your baby is latching correctly.
• You are more than 2 weeks postpartum, and you have sore nipples.
• You have cracked or bleeding nipples.
• You have breast pain.
• You’ve been diagnosed with mastitis.
• You’ve been advised to wean but you don’t feel ready.
• You want to wean and you need help.
• You feel exhausted or unsure about your breastfeeding experience.
• You need help transitioning back to work/pumping.