Guide for New Parents

• Caring for Your Baby While You are With Us
• Caring for Your Baby at Home
• Feeding Your Baby
  • For Breastfeeding Mothers
  • For Bottle/Formula-Feeding Mothers
  • For Breastfeeding and Bottle-feeding Mothers

Caring for Your Baby While You are With Us

During your stay, your nurses will help care for your baby, answer any questions you may have, and provide you with the skills and information you will need to care for your baby. If you have any questions or concerns, please speak with your nurses - they are here to help you in any way possible.

To ensure that you have the information you need to care for yourself and your baby when you go home, we offer a variety of classes. We encourage you and your partner to attend these classes before going home. We also encourage you to watch the Newborn Channel during your stay for postpartum and newborn educational programs. It is available 24 hours-a-day through the hospital television system at no additional cost. You may also view videos via the hospital’s On-Demand television system. Refer to your bedside guide for instructions or ask your nurse for more information.

Caring for Your Baby at Home

Once you bring your baby home, you should limit the number of people that visit. This is a special time for you to bond with your new family. Family and friends can help you by running errands and doing household chores but this is your special time to get to know your new baby. Be sure that visitors and siblings wash their hands before holding your baby. If they have a cold or have been exposed to illness, they should not visit. It is normal for your baby to lose weight in the first few days before starting to gain weight. Most babies regain their birth weight a couple of weeks after he or she was born, then double it by six months and triple it in one year.

Sleeping

Always place your newborn on his or her back when putting your baby to sleep. The American Academy of Pediatrics states that sleeping on his or her back is the safest position for your newborn to sleep. Sleeping in this position has been proven to lower the risk of Sudden Infant Death Syndrome (SIDS). Do not place pillows, stuffed animals, toys, a heavy comforter, or anything else in the crib with your baby. These items could suffocate or choke your newborn. Using bumper pads in the crib is not recommended. When putting your baby to sleep, it is important that your baby stays warm, but do not overdress him or her. Sleeping patterns may not become well established for some months, which is why it is so important to sleep as much as you can. Nap when your baby naps. You will soon develop a bedtime and nap routine for your baby. Some babies like to be bathed or massaged before bedtime. This may be a perfect time for you or your partner to spend with the baby.

“Tummy time” is also important for the development and strengthening of the baby’s shoulders and arms. While your baby is awake and well attended, position the baby on his or her stomach. However, remember to always place your baby on his or her back for sleep.

Crying

Crying is your baby’s way of communicating with you. For many babies, there is a different cry for “I’m hungry,” “I need my diaper changed,” “Pick me up,” and “I want a hug.” You will soon learn your baby’s cry. You will get to know what position and activities your baby likes for comforting. Babies love it when you speak and sing to them. You will learn to tell when your baby has “had enough.” Getting to know your baby is a very exciting experience. Many parents notice their baby has a fussy period in the evening. This is not uncommon. Some think it is the baby “blowing off steam” (releasing excess energy after experiencing all the excitement of the day). Check to be sure that she or he is not hungry, does not have a wet diaper, and is not in pain. You may find that holding your baby or taking him or her for rides in the car helps to settle the baby. Infant massage can sometimes calm a fussy baby.

Bathing

You may be nervous or anxious about giving your baby a bath. The first bath may seem intimidating but it could also be full of laughter. As with most anything else, bathing your baby gets easier with practice. Many babies love bath time and it may become a relaxing ritual before bedtime. Be sure the area is free of drafts and choose a time when you are not hurried. Have all your supplies ready ahead of time, such as cotton balls; a soft washcloth; clean, warm water in a tub or sink; mild soap; and a towel. When bathing your baby, you can place him or her in a tub by supporting the baby’s head and bottom. Begin washing your baby from top to bottom.

• Gently wipe with clean water from the inside to the outside corner of each eye with a clean washcloth or cotton balls.
• Wipe his or her face with a washcloth.
• Dampen your baby’s hair/scalp with water and gently rub in baby shampoo. Rinse by pouring water over the baby’s head while avoiding the eyes.
• Support your baby’s head and neck with your hand under the chin and gently lean him or her forward to wash the back. Rinse with clean water.
• Wash from top to bottom, bathing the diaper area last.
• Be sure to clean well between the skin folds. For girls, be sure to wipe from front to back. For circumcised boys, clean the healed penis the same way as the rest of the body. For uncircumcised boys, do not retract the foreskin. Bathe the area and rinse.
• When finished, lay your baby on a clean towel and quickly dry off before diapering and dressing.

NOTE: Never leave your baby unattended during bath time.

Diapering

Gather your supplies including a clean diaper, baby wipes, a diaper pail and petroleum jelly or diaper rash ointment. Lay your baby on the changing table and unfasten the tabs. Place a cloth under the baby so he or she will not soil the surface. Gently grasp your baby’s ankles and elevate as you take off the diaper.

If your baby has a full portion of the diaper to clean the area before you wrap the used diaper into a bundle for disposal. Clean the area with wipes or a damp washcloth. Always wipe from front to back and be sure to clean between the folds of skin. Apply petroleum jelly or diaper rash ointment to your baby’s bottom. To put on a clean diaper, hold your baby’s ankles lifting his or her bottom and slide the back of the clean diaper under your baby’s bottom, lowering the legs. Pull the front of the diaper up between the legs and attach the tabs to each side. Redress your baby and wash your hands.

Cutting Your Baby’s Nails

Trimming your baby’s nails may seem scary at first. Try filing your baby’s nails with a nail file during the first few weeks when the nails are tiny and soft. After that, you can use nail clippers or roundtipped scissors. This is best accomplished when your baby is soundly sleeping.

Taking Your Baby’s Temperature

It is not necessary to take your baby’s temperature regularly. If your baby is not acting like himself or herself or feels very warm to touch, you may want to take the temperature before calling your pediatric care provider. The two ways to measure the temperature are axillary (under the arm) and rectally.

Measure the temperature using the axillary method first. Place the thermometer under the arm and hold the arm in place. If his or her temperature is higher than 100.3 degrees, your pediatric care provider may want you to take a rectal measurement. Do not use a mercury thermometer to check your baby’s temperature - always use a digital thermometer.

To measure a rectal temperature, wash your hands and the thermometer and then dab a little petroleum jelly (Vaseline®) on the end and press the “on” button. Lay your baby on his or her back on a firm surface, lift his or her legs and gently spread the cheeks. Use both hands, one for the thermometer and the other to hold your baby securely. Gently insert the tip about one half inch into the baby’s rectum. Hold it in place until it beeps, then slowly withdraw and read it. Notify your pediatric care provider of a rectal temperature over 100.3 degrees.

Warning Signs

Please call you pediatric care provider if you notice the following:

• Your baby seems ill or is not acting like himself or herself;
• Your baby is not eating well or refuses feedings;
• Your baby’s rectal temperature is over 100.3 degrees;
• Your baby has less than six wet diapers in 24 hours;
• Your baby is still passing meconium at three days of age;
• Your baby’s skin has a yellow tint, which is moving down from the baby’s face to the legs;
• Your baby is very sleepy and difficult to wake;
• Your baby is vomiting repeatedly;
• Your baby is crying excessively with no known cause;
• You notice an unusual or severe rash on your baby;
• Your baby has frequent or excessive loose stools;
• Your baby has no stool in 24 hours during the first week of life.
  

Feeding Your Baby

Feeding your baby will be one of the most satisfying experiences of early parenthood. It is a time to be close, to nurture and communicate with your baby in your own special way. Whether you choose to breastfeed or bottle-feed your baby is your decision. Parents choose each method for different reasons. The method you choose should be one that is right for you and your baby and the one that makes you and your partner comfortable.

For Breastfeeding Mothers

Breast milk contains all the nutrients needed for your baby’s growth and development and is perfectly matched to meet his or her needs. There are many breastfeeding benefits for your baby. Extensive research has demonstrated that breast milk provides optimal health benefits to both the newborn and the mother.

Breastfed babies may also have less risk for developing:

• diarrhea or constipation;
• ear infections;
• asthma;
• diabetes;
• leukemia;
• respiratory infections;
• allergies.

Some breastfeeding benefits for mother include:

• faster postpartum recovery;
• cost-efficient;
• convenient;
• reduces risk of breast, uterine, and ovarian cancer;
• quicker weight loss after birth.

There are many resources available to you to learn about breastfeeding. Brigham and Women’s Hospital offers breastfeeding classes while you are in the hospital, teaching and assistance from your nurse, and if needed, a lactation consultation. You can also get information from your health care providers. Additional resources can be found at the back of this guide.

Preparing to Breastfeed/Feeding Cues:

If you are unsure of whether or not your baby is ready to feed, look for signs (cues) that he or she may be hungry. Your baby may open his or her mouth wide like a yawn with tongue down and forward over the bottom gum (rooting). Your baby may start smacking his or her lips and thrust the tongue. Your baby may also bring his or her hands up to the mouth. You may also notice fluttering eyes and rapid eye movement with your baby’s eyes closed. Crying, which is a very late feeding cue, can also be a sign that your baby is hungry. If your baby is crying, it is important to calm the baby before trying to feed him or her.

Positioning your baby for feeding:

• You should be relaxed and comfortable. Support your back, feet and arms. (Your head should be supported in side-lying).
• Support your baby’s head and body at the level of the breast. Pillows are usually helpful with the “cradle” and “football” positions to support the arm that is holding your baby’s head and body.
• Turn your baby completely on his or her side with nose, chin, chest, abdomen and knees touching you (cradle and side-lying).
• Make sure your baby’s head is in a neutral position (hip, shoulder and ear aligned).
• Keep your baby’s body close to you by placing your hand and arm along your baby’s back for support.
• Support your breast with cupped hand (“C” hold) with thumb and fingers kept well back from the areola.

Latch-on:

• You will first express drops of colostrum/milk.
• Your baby then roots and opens his or her mouth wide (like a yawn).
• Your baby’s tongue should be over the lower gum, cupped around your nipple and areola.
• Your baby’s lips should be visible and flanged outward.
• Your baby’s lips should cover 3/4” – 1” of areola (usually most or all of areola). The entire nipple will be deep in your baby’s mouth.
• You should not hear any clicking or smacking sounds.
• You will notice your baby’s cheeks are round with no dimpling.
• You should NOT experience any pain after your baby has latched on, only a sensation of pulling, tugging, and/or pressure.

Suck and Swallow:

• Your baby’s jaw should be moving in rhythmic motion.
• Your baby sucks slowly and deeply with short pauses.
• You may feel any of the following normal occurrences in your body: uterine cramping, increased bleeding, thirst, breast ache or tingling, relaxation, sleepiness.
• During every feeding, you should see and hear your baby swallowing and/or see milk in his or her mouth.

A breastfeeding mother should never experience blisters, bruising or cracks on her nipples. The skin should remain intact and the nipples should retain their original shape and color, although they may be elongated.

Cracks, blisters or bruising indicates that the baby is not positioned correctly or latched on properly. Please call your pediatric or obstetric care provider for help if you experience any of the above symptoms.

Common Questions about Breastfeeding

Breastfeeding may be a new experience for you, therefore we have compiled a list of frequently asked questions about breastfeeding to help you better prepare for this skill. If you need more information or have additional questions, please do not hesitate to ask your nurse, obstetric care provider, or pediatric care provider.

Will my baby show any cues that she or he is hungry?
Yes. Hunger signs may include awakening, fluttering eyes, lip smacking noises, bringing hands to the mouth, thrusting his or her tongue, rooting, or trying to suck.

How often should I feed my baby?
By three to four days old, your baby should feed eight to 12 times in 24 hours or on demand. Some babies will feed every one and a half to two hours; others feed every three to four hours.

How long should I breastfeed during each feeding?
Initially, your baby may actively suck for only five to 10 minutes. After the first few days, breastfeed at least 10 minutes or longer until your breast feels softer and your baby seems content. This will allow for the baby to get the richer hindmilk. Sometimes your baby may breastfeed on only one breast. If this happens, start on the opposite breast at the next feeding.

When will my breast milk come in?
Roughly two to five days after giving birth, your breasts will begin to fill with milk - feeling firmer and warmer. As your milk changes from colostrum (thin, initial breast milk) to a transitional milk, its color will change from yellow to light yellow or whitish yellow. Your mature milk, which comes in about two weeks after the birth of your baby, will also be thin and may have a bluish-white color.

What does breastfeeding feel like?
Once you position the baby directly facing your chest and place the nipple/areola in the baby’s mouth, she or he will latch onto the nipple and areola. If you have positioned your baby correctly, with each suck you will feel pulling, tugging, and/or pressure on the breast. Breastfeeding should not hurt.

What is a normal feeding pattern?
Babies suck in bursts and every baby has his or her own unique style and rhythm. You want to feel about six to 10 rhythmic sucks followed by an audible swallow, then a pause. Your baby’s suck and swallow pattern will slow as she or he swallows the richer milk at the end of each feeding.

How do I know if my baby is getting enough?
As your milk supply increases within two to five days after the birth, you should notice:

• a sense of fullness in your breast before feeding;
• that your baby is swallowing while breastfeeding;
• that your breasts are softer after a feeding;
• a tightening or tingling in the breast as your milk “lets down” or releases (you may also feel relaxed and sleepy);
• possible leaking from one breast while the baby is feeding from the other;
• possible uterine cramps the first few weeks while breastfeeding.

In the first 24 hours after your baby’s birth, he or she should have one wet diaper and one with stool (bowel movement). By day two, he or she should have two wet diapers and one to two stools. By day three, he or she should have three wet diapers and one to three stools, and by day four, he or she should have four wet diapers and one to four stools.

When your milk supply has increased or by six days of age, your baby should have:

• eight to 12 feedings in 24 hours;
• at least six to eight wet diapers every 24 hours. Urine will be pale yellow, not dark tea-colored. Hint: If you use disposable diapers and are unsure if the diaper is wet, place a tissue in the diaper;
• At least two to three soft, yellow, seedy stools every 24 hours. During the first weeks the baby may have a bowel movement with most feedings;
• Quiet, contented periods after breastfeeding.

My baby is a week old and seems to want to breastfeed all of the time! Is this normal?
This is normal due to “growth spurts,” which are predictable periods when the breastfed baby will want to feed more frequently than before. Growth spurts occur at two to three weeks, six weeks, three months and six months. This frequent feeding may last for 24-72 hours. During these times, it is important to feed your baby on demand - as much as she or he wants. Breastfeeding on demand will meet your baby’s needs; water or formula supplements are not necessary. As your baby feeds more frequently, your body will respond by producing more milk. When growth spurts end, your baby will want to feed less often.

What help is available to me?
In the hospital, your nurse can help you with feeding at the bedside. The lactation consultants conduct daily breastfeeding classes and can consult in your room if you are having problems. After you go home, please refer to the Resources section on page 38 of this guide for organizations you can call for breastfeeding support.

Will breastfeeding help me lose weight?
Women who choose to breastfeed may find it easier to lose weight because their bodies burn 200-300 calories of stored fat each day to provide the energy needed to breastfeed during the first three months. If you decide to breastfeed, you can expect to lose weight gradually if you maintain a healthy, well-balanced diet. Starting a reduced-calorie diet while breastfeeding is not recommended-it can impact your ability to produce milk and deprive you of much-needed energy. (Remember, 30 percent of the weight you gain during pregnancy is the result of fluid accumulation; you will most likely lose that weight over time regardless of your calorie intake.)

How much should I eat while I am breastfeeding?
While breastfeeding, you should consume at least 1,800 calories each day, which is the minimum amount you will need to produce an adequate supply of milk and meet your nutritional needs. As a rule, it is recommended that you consume 300-500 calories more than you would if you were not breastfeeding. Be sure to maintain a well-balanced diet that includes protein, carbohydrates, fruits and vegetables.

How do I know that my baby is getting enough fat and calories to gain weight?
Breast milk in all its stages is perfect for your baby. The combination of “foremilk” (beginning of the feeding) and “hindmilk” (end of feeding) is just the right blend of fat, carbohydrates, proteins and nutrients for your baby.

What should I do if my baby seems sleepy and does not regularly awaken for feedings ...loses interest easily ... does not vigorously breastfeed?
Watch for cues that your baby is hungry as described on the previous page, especially the eyes fluttering. This rapid eye movement indicates that the baby is in a light sleep state and may awaken more easily to breastfeed. During the day, be alert to your baby’s feeding cues or wake your baby every two and a half to three hours to encourage at least eight to 12 feedings in 24 hours. Try waking your baby by unwrapping blankets, stimulating rooting by stroking the baby’s mouth or encouraging baby to suck on a clean finger before bringing your baby to your breast. It may be helpful to change your baby’s diaper or try burping your baby. At night, it is not necessary to awaken your baby - unless your pediatric care provider recommends it or your baby is not feeding eight to 12 times in 24 hours.

My baby seems frantic when we begin feedings. What can you suggest?
Begin feedings when your baby is first showing early cues. Do not wait until your baby cries or he or she may become too frantic to suck. Use slow, gentle movements and provide a quiet environment. Provide skin-to-skin contact. To decrease the time from “latch” to “let down,” massage your breast for two to four minutes and express a few drops prior to putting baby to breast. If your breasts are very full or engorged, soften your areola by expressing milk so that baby can easily latch on. Change the diaper between breasts or after a feeding.

I am a vegetarian. Can I breastfeed my baby?
As long as your diet is well balanced and not too restrictive, your breast milk will provide your baby with the necessary nutrients. Many vegetarians have difficulty getting enough protein, calcium, vitamin D and vitamin B-12, so take special care to incorporate foods with these nutrients into your diet. Getting enough vitamin B-12 is particularly challenging for vegetarians because it can only be found in animal products. Good sources include yeast, soymilk, cereal and other soy products that are B-12 fortified.

Can I have caffeine while I am nursing?
Because caffeine is passed on to babies through breast milk, you should limit the amount of caffeine you consume to one or two eight-ounce servings per day. In addition to helping you stay hydrated and sleep better, avoiding caffeine will prevent the irritability and poor sleep habits that it can cause in babies. The caffeine in your breast milk will reach its highest level one hour after you ingest it - try to time your baby’s feedings so they occur before you drink a caffeinated beverage.

Can I drink alcohol?
You should abstain from drinking alcohol while you are breastfeeding your baby. Alcohol can be passed on to babies through breast milk and can negatively affect your ability to let down or release milk.

Can I use aspartame?
Studies show that aspartame products (e.g., NutraSweet® and Equal®) are safe to use while breastfeeding. However, sugar-free drinks offer no nutrients and often include caffeine, so they should be consumed in moderation. For a tasty, low-calorie drink, mix four ounces of your favorite juice with seltzer water and ice.

Can I exercise if I am breastfeeding my baby?
Yes! Make it a point to exercise regularly. In addition to helping you achieve a healthy weight and improve your cardiovascular fitness, exercise stimulates milk production. Be sure to speak with your obstetric care provider before you begin an exercise plan.

Are there foods I should avoid eating?
Most women who are brestfeeding can eat a wide variety of foods without any problems. However, some babies are more sensitive to certain food proteins, spices, or dairy products. If your baby seems fussy after you have eaten a different type of food, try to avoid that food until your baby’s digestive system has developed a bit more.

My nipples have become sore from breastfeeding. Is there anything I can do to treat them?
The best way to prevent nipple damage (trauma) is correct positioning and latching at the breast. When you begin to breastfeed, your nipples may become somewhat sore and tender. Expressing colostrum/breastmilk after each feeding and rubbing it into your nipples will soothe and condition them and help with the healing process. Colostrum contains anti-infective properties that will protect your nipples from bacterial growth. Avoid using soap and washing your nipples between feedings. Taking a daily shower is all you need to do. If your nipples become cracked and/or are bleeding, repositioning your baby will prevent further damage. If you need additional help, call your obstetric care provider.

What do I do when my breasts get very full?

• Shower or apply warm compresses to your breasts, massage them gently and express milk to soften the areola.
• Find a comfortable chair, relax and begin breastfeeding.
• Make sure your baby is properly positioned and latched well onto your breast.
• Feed your baby for at least 10 minutes or until your breast softens and your baby is in a content state.
• Gently massage and compress (squeeze) your breasts when your baby pauses between sucking bursts; this will increase the amount of milk your baby takes during the feeding.
• Continue to watch your baby for signs of feeding cues or feed your baby at least every two to three hours (eight to 12 feedings in 24 hours).

How do I prevent/treat breast engorgement?
Two to five days after your baby is born, your milk supply will begin to increase. Some mothers may experience a condition called engorgement where their breasts become very hard, swollen, inflamed and painful. It is important to treat engorgement quickly. Excessive fullness may inhibit the let-down reflex and also flatten your nipples making it difficult to establish a correct latch, which would then contribute to nipple damage and soreness.

Prevention: Establish early, frequent feedings. Your baby should be breastfeed eight to 12 times or an average of every 11/2 - 3 hours in a 24-hour period. Avoid supplements of formula or water for three to four weeks unless your pediatric care provider instructs you to do otherwise. (Limit the use of a pacifier.) Use a breast pump to pump your breasts if your baby cannot breastfeed or if he or she misses a feeding.

Treatment:

• Take pain-relieving medication as directed by your obstetric care provider.
• Shower to relax. Gently massage your breasts and hand-express some milk to soften the areola.
• Find a comfortable room with minimal distractions. Play soft music and use calming images to decrease stress.
• Feed your baby for 15-20 minutes or until the breast softens. Using breast massage and compression during the feeding will enhance milk removal. Offer the second breast. If your baby does not feed on the second side, pump that breast for two to five minutes or until the breast is softer and you are more comfortable. Begin the next feeding on this breast.
• Do not go longer than three hours during the day without either breastfeeding your baby or pumping your breasts. If your baby is unable to latch effectively and pumping does not facilitate milk release and breast softening, lie flat on your back, elevate your breasts with towels and apply ice to your breasts to decrease swelling.
• Continue cold treatments in between feedings until your milk begins to flow, as well as for your comfort.
• Wear a well-fitting, supportive bra without an underwire.

Engorgement usually resolves within 24-48 hours. Please contact a lactation consultant or your obstetric care provider if engorgement continues and you are unable to feed your baby at least eight times in 24 hours.

Get Your Calcium

It is particularly important for you to get 1,200 mg of calcium each day while you are breastfeeding. Your body will route calcium to your milk supply before it will use the calcium to fortify your bones. If you do not consume enough, your baby will still receive calcium through your breast milk, but your body will not. As a result, your bone density may decrease - putting you at increased risk for osteoporosis.

Recommended Nutrition Plan for Breastfeeding Mothers

You should consume a minimum of 1,800 calories each day while you are breastfeeding. Although you are probably eager to get back to your pre-pregnancy weight, it is crucial that you consume the nutrients you need to sustain yourself and produce milk for your baby. The following nutrition plan will help you achieve this.

Breakfast Sundae
1 small banana
4 oz. low-fat yogurt, any flavor
1/2 cup whole-grain cereal
Sliced strawberries or other fruit
Peel banana. Split and place in dish. Top with yogurt and sprinkle cereal and fruit on top.

Fruit Smoothie
*3 cups low-fat milk
1 ripe banana
1 cup strawberries
Blend in food processor or blender until smooth.

* This recipe works well if you substitute flavored soy or Lactaid® milk, which are great alternatives for women who are vegetarians or lactose intolerant.

Using a Breast Pump

For some breastfeeding mothers, situations or circumstances may cause the need for you to electronically pump your breasts for milk. For example, you may need to provide breast milk for your premature or sick baby; remove milk when your baby breastfeeds ineffectively; increase your milk supply with added stimulation; help pull out flat or inverted nipples; relieve engorgement; or provide breast milk when you are at work or away from your baby.

Just like starting to breastfeed, pumping your breasts is a learning experience. In the first day or two after the birth of your baby, you may see only a few drops of colostrum. However, in three to 10 days, your breasts will produce plenty of milk. Anxiety, worry, exhaustion and high expectations may affect your milk supply and your “let-down” reflex.

To increase and maintain your supply of breast milk, consider these suggestions:

• Find a quiet place.
• Try to pump at the same time and place each session.
• Listen to relaxing music or use childbirth breathing exercises.
• Use a telephone answering machine so you are not disturbed, but can hear important messages.

To enhance your “let down” reflex:

• Make sure you are warm and comfortable.
• Take a warm shower.
• Apply warm cloths to your breasts.
• Massage your breasts for three minutes.
• Stimulate your nipples by gently rolling or rubbing them.
• To pump both breasts at the same time and shorten pumping time, use an electric double-breast pump.

If you are collecting milk because your baby is hospitalized, you need to pump as frequently as your baby would feed, about eight to 12 times in 24 hours. Pump your breasts at night if you wake up and your breasts are very full or if you have noticed a drop in your milk supply.

If you plan to return to work, it is important to breastfeed frequently in the first month to establish your milk supply. A few weeks before returning to work, start pumping and storing your breast milk. If you are collecting milk for another caregiver to feed your baby, pumping depends on your baby’s feeding schedule. If your baby feeds frequently, you may be able to pump a little milk after some feedings. If your baby has a long sleep period during the night, you may be able to pump more milk in the morning when most mothers find they have more milk.

Tips for Using a Breast Pump

Wash your hands thoroughly and, on a clean surface, get all your equipment ready. Make sure all the necessary parts are correctly connected to the pump.

Sit in a comfortable chair, with your neck, shoulders and back well supported. If you can, rest with your feet up. Have a glass of water or juice located within reach. Moisten the flange with warm water or handexpressed drops of milk. Center your nipple in the flange. The flange should form a tight seal around dark area surrounding your nipple.

Set the pump on the LOWEST pressure setting. Turn the machine on. Then, slowly increase the pressure to where you are most comfortable.

If you are using a single-breast pump set-up, pump one breast for about five to seven minutes and then pump the other side. Repeat this sequence one or two more times until the flow of milk slows and only drops of milk are expressed. If you are using a double-breast pump set-up, pump both breasts about 10-20 minutes or until the flow of milk slows and only drops of milk are expressed.

NOTE: Always shut the machine off before taking the flange away from your breast.

After pumping, rub a few drops of milk on your nipples and areola and keep your nipples exposed to air until dry. This lubricates the nipple and helps to prevent and treat any soreness.

Cleaning Equipment After Use In the hospital: Use one kit for 48 hours only. After each use, disconnect all pump parts that come in contact with your milk. Rinse milk out first with cool water. Wash in hot, soapy water (castile soap will be given to you) and rinse well several times. Place cleaned parts on clean paper towels and cover with clean paper towels. Allow to air dry. If the overflow filter and tubing come in contact with milk, ask your nurse to replace these parts.

At home: Sterilize the reusable kit at least once a day. All parts that come in contact with milk should be boiled in water for 20 minutes or washed in your dishwasher. If the baby is not going to be fed right away, milk should be pumped directly into a sterile container or transferred to a sterile container for storage. If the overflow filter or tubing comes in contact with milk, clean those parts according to the manufacturer’s directions.

Solutions to Common Temporary Problems

When pumping, some women may experience nipple soreness, which will ease with time. To manage sore nipples:

• Massage your breasts before pumping to start the milk flow.
• Start on the least sore side first.
• Use the lowest pressure setting that effectively removes your milk.
• Be sure the flange fits well, is centered and positioned correctly. If it still causes pain, you may need to try another brand.
• Pump more frequently and for shorter periods of time.
• After pumping, apply expressed milk to nipples and allow them to air dry.
• Avoid putting creams, oils and lotions on your nipples as these may slow healing.

If you notice a decrease or change in your milk supply:

• Eat well-balanced meals. Drink when you are thirsty; do not wait until your mouth is dry.
• Pump at least eight to 12 times in 24 hours. Maintain a routine or pump more times per day for shorter periods of time. Skipped or fewer pumping sessions will lower your milk supply.
• Find time to rest and decrease tension. Taking care of the baby, housework and/or going back to work can make you very tired.
• If you have been ill, your milk supply will increase as you get better.
• If you started new medications, check with your obstetric care provider. Some drugs slow milk production.

NOTE: Your milk supply may change even after several weeks or months of pumping. Also, if your baby’s condition in the hospital worsens, it is common to see a decrease in the milk supply. When your baby’s condition improves, your milk supply will increase.

Collection, Storage and Use of Breast Milk

Only store breast milk that you have just pumped. DO NOT store or reuse any milk unused during a previous feeding; bacterial growth is a serious risk. Mature breast milk looks bluish-white and thin. When it is refrigerated or frozen, the richer milk rises to the top and may look layered or curdled. Shake gently when defrosted and it will mix together.

Containers. The storage container should be clean. If your baby is in the hospital, check with the nurses to see what type of container they suggest or if they provide them. Suggested containers are glass or plastic bottles with solid caps to provide an airtight seal.

If using disposable bottle liners, be sure to double-bag the liners in case a tear occurs. Fold over the edges, and use a twist or rubber band to secure. Then, freeze the bag in a paper cup to keep it from spilling.

Filling Containers. If possible, pump directly into the storage container. Do not fill the container to the top because milk expands when frozen. To avoid discarding and wasting any milk your baby does not drink in a feeding session, store your milk in smaller volumes, i.e. two ounces rather than six ounces. Then, if your baby needs more, you can defrost small amounts.

Labeling Containers. Label each container with your name and date of pumping. If your baby is in the hospital, write the name of any medications you might be taking or illnesses you have had on the label.

Storage. Unless you plan to use your milk within one hour of expressing, refrigerate or freeze it as soon as possible. Store milk in the back of the refrigerator or freezer where it is the coldest. If you are away from home, use insulated food containers packed with ice or cold packs. Milk will keep about 48 hours in the refrigerator. Use refrigerated breast milk as much as possible, keeping frozen milk as a backup. Frozen milk will keep three months in the freezer of a refrigerator/freezer or six months in a deep freezer unit.

Using Stored Milk. When taking stored milk out of the refrigerator or freezer, check the dated label and use the oldest milk first. When you defrost frozen milk, use it within 24 hours.

Thawing. To thaw frozen milk, place the container in a pan of warm water (not on a stove) - making sure the water does not touch the bottle cap. Never use a microwave to thaw or warm milk. Not only can microwaves destroy nutrients in the milk, they also can heat unevenly resulting in hot spots that can burn your baby during feeding. Thawing breast milk at room temperature for any time period is not recommended.

Transporting. To transport refrigerated milk, use ice or a cold pack. DO NOT use ice when transporting frozen milk. Pack frozen milk tightly in a cooler, using a clean towel or styrofoam beads to fill the extra space. Because wet ice is warmer than the frozen milk, it can thaw the milk some, permitting the growth of harmful bacteria.

If you are having difficulty with or have further questions about breastfeeding, call your obstetric care provider or your pediatric care provider.

For breast pump rental information at Brigham and Women’s Hospital, call (617) 732-7092.

SUGGESTED READING
For more information about breastfeeding, we recommend: “The Breastfeeding Book,” by William Sears, MD and Martha A. Sears, RN, 2000 and “The Womanly Art of Breastfeeding,” 7th ed. LaLeche League International, 2004.

For Bottle/Formula-Feeding Mothers

If you have made the decision that bottle-feeding is the best choice for you, there are many things to know about cleaning the utensils and preparing the formula properly.

Types of Formula

Brigham and Women’s Hospital uses pre-packaged, ready-to-use formula prepared by commercial formula companies. Your nurse will ask you and/or your pediatric care provider which brand of formula to use to feed your baby. Formulas that are available for home use come in three different varieties: ready-to-feed, concentrate, and powder.

• Ready-to-feed formulas come already mixed with water in a single can or individual bottles. This is fed without any other preparation to your baby.
• Concentrated formulas must be mixed with an equal amount of water. For example, a 13-ounce can of concentrate must be mixed with 13 ounces of water to make 26 ounces of formula. It can then be poured into bottles.
• Powdered formula also comes in a can. Follow the directions on the can for the exact amounts of powder and water to mix.

NOTE: Be aware of which type of formula you are using, and make sure to read all the directions on the container.

Keep in mind the following tips when using formula:

• Buy and use the formula before the expiration (“use before”) date that is printed on the can.
• Do not use damaged or dented cans.
• Read the directions on the label carefully.
• Store powdered formula with the cover on in a cool, dry place and use within one month of opening.
• After feeding the baby a bottle, throw away any formula that is left in the bottle since once it has been in your baby’s mouth, it has come into contact with his or her saliva and bacteria can grow in the formula.
• If you do not put all the liquid formula in bottles, cover the opened can of liquid formula and store it in the refrigerator for no more than 48 hours.
• Store unopened cans of formula at room temperature.

Step-By-Step Formula Preparation

The following steps should be taken to clean yourn equipment and to prepare bottles of formula, either for a 24-hour supply or as single bottles if you prefer.

• Wash your hands.
• Wash bottles and nipples with hot, soapy water (using a bottle and nipple brush), rinse well, and air-dry. If you have a dishwasher, you can use it to sanitize the bottles, nipples and utensils. The nipples should be placed on the top rack in the dishwasher so that they do not melt. Do not use the energy saving or no-heat cycle. It is not necessary to sterlize the equipment. Washing the parts as described above is fine.
• Wash the top of the unopened can of formula and the can opener with hot, soapy water and rinse with hot water.
• Shake concentrated and ready-to-feed cans well before opening or using.
• Use a pointed can opener to puncture a complete opening on one side of the can; on the opposite side put a smaller opening in the can to allow air to escape while you pour.
• Add to the clean bottles either the powdered formula (use the instructions on the can for the amount of powder and the amount of water to use), or equal amounts of concentrated formula and water, or ready-to-feed formula with no added water.
• Place the nipples on the bottles tip down (handle as little as possible), put the caps on and tightly screw on the rings. Store the bottles in the refrigerator until needed, but not more than 48 hours.

Temperature of Formula

If you prepare formula for your baby in advance, be sure it is refrigerated. Formula that has been refrigerated does not have to be warmed up for your baby, but most infants prefer it at least at room temperature. Remember that your baby will get used to whichever temperature formula you give him or her and will expect that temperature for all feedings.

To warm formula, stand the bottle in a few inches of warm water for a few minutes, gently rotating the bottle occasionally for even warming. Do not leave a bottle to warm at room temperature. It will take too long and may result in the growth of bacteria. NEVER HEAT BOTTLES IN A MICROWAVE OVEN. They can overheat the milk in the center of the bottle. Even if the bottle feels comfortably warm to your touch, the milk in the center can burn your baby’s mouth. The easiest way to test the temperature is to shake a few drops on the inside of your wrist.

Feeding Position

It is important for your baby to be physically close to you while bottle-feeding since this is a time for interacting and bonding with your baby. Place your baby in a feeding position by cradling him or her in a semi-upright position (the head and shoulders are higher than the waist) while supporting the head. Do not feed your baby when he or she is flat or lying down and never prop a bottle in your baby’s mouth.

Babies have a natural instinct, called rooting, to turn toward a touch on their lips or cheek. Touching your baby’s mouth or cheek with the bottle nipple will cause a hungry baby to turn toward the nipple and open his or her mouth. This is the time to put the nipple in the baby’s mouth making sure the nipple is placed on the tongue. To prevent your baby from swallowing air, tilt the bottle so that the formula fills the nipple. Look for bubbles in the bottle as the baby sucks. This will let you know that the baby is able to draw out the formula when sucking. If there are no air bubbles, loosen the cap slightly and try again.

Amount of Formula

In the beginning, babies take about a half to one ounce of formula at each feeding. Their stomachs are about the size of a walnut and cannot hold more than that. Small babies may want to rest every three to four minutes and may need to take smaller amounts more frequently. The amount of formula your baby takes will increase gradually as the baby grows. You may wish to check with your pediatric care provider for the appropriate amount of formula for your baby.

Generally, you should feed your baby every three to four hours during the day or six to eight times in 24 hours. If your baby does not seem to take very much formula and then falls asleep either before or after burping, do not try to feed your baby more. It is best to feed your baby on demand.

Do not encourage your baby to finish the bottle if he or she is not interested. If your baby is still sucking enthusiastically when the bottle is empty, offer more formula. (It is wise to prepare several one-ounce bottles for this reason when you prepare your bottles in advance.) You never need to wake a baby at night for a feeding unless your pediatric care provider has told you to do so.

It should take your baby about 15-20 minutes to finish a bottle. It may take longer to feed a young or smaller baby who needs rest periods than it will an older, more practiced baby. A strong and vigorous baby will not tire from sucking as quickly as a young, smaller baby. If, on more than one occasion you notice it is taking your baby more than 30 minutes to feed, tell your pediatric care provider. Early in a feeding while the baby is very hungry, he or she will suck much faster than later on when he or she is almost full. As your baby gets older, he or she will want more formula at each feeding. Each week your baby will take about a half to one ounce extra per bottle. At the same time, your baby will gradually decrease the number of feedings in a 24 hour period from six to eight feedings initially to four to six feedings by the end of three months. Be aware of your baby’s intake. Your pediatric care provider will probably ask how much formula your baby takes. You will know that the baby is getting enough to drink if your baby has six to eight wet diapers in 24 hours by the time he or she is six days old and has one to two bowel movements a day.

For Breastfeeding and Bottle-feeding Mothers

Burping your baby

Babies may swallow air during feedings so be sure to burp your bottle-fed baby often - after every half to 3/4 of an ounce of formula in the first few days. If you are breastfeeding, burp your baby before you switch to the second breast and also when your baby is done feeding. If your baby does not burp after a couple of minutes of trying, resume feeding. A few of the best burping positions are:

• Over the shoulder: Drape your baby over your shoulder and gently pat or rub your baby’s back.
• On the lap: Sit your baby upright, lean his or her weight forward against the heel of your hand, and gently pat or rub your baby’s back.
• Lying down: Place baby stomach-down on your lap and gently rub or pat his or her back.

Keep a clean burping cloth over your clothing to avoid being soiled by the baby spitting up.