What does a breastfeeding mother and baby need besides each other? Clearly, they need time and proximity so they can adjust their relationship from a continuous but unconscious provision of warmth, comfort and nutrition by mother of baby to a deliberate but more intermittent provision of those same requirements for baby by the mother. Mother needs the support of those around her to meet her physical and emotional needs while she meets those of the new baby. And this process takes time to develop its rhythm. Like new dancing partners, the dyad must become comfortable and intuitive in their actions, developing trust and coordination over time.

But — what if a separation must occur. Mom can no longer be ever-present to meet her baby’s needs. Or what if baby or mother has a physical issue that affects milk supply or delivery? How can we provide a substitute for both mom and baby that doesn’t undermine the breastfeeding relationship? The market steps in to offer its solutions: bottles, pacifiers and breast pumps! These tools offer and purport to be a temporary solution to bridge the separation on a short term basis, but often present their own challenges to mother and baby.

So, how do we select when presented these “solutions?” First, understand the basic physiology of breastfeeding. How do mothers make and release milk? How do babies obtain that milk? What is the biology that we are trying to mimic? What are the properties of the man-made materials that we use to create these tools? Over the years, inquiring minds have looked at various products on the market to try to determine how these products work and to what degree they either simulate breastfeeding or offer less interference with breastfeeding when used. The problem is, most of the methods used to test products don’t truly match what a baby does when they use the products. Ultrasound studies may show the mechanics baby uses on a bottle, for instance, but can’t really measure the baby’s adaptation to the materials or how the baby changes flow rates by altering the quality or actions used during sucking. Only a very sophisticated real-time system using pressure gauges, ultrasound and sequential weight checks can adequately assess the way a bottle performs for a particular baby. And even that can’t determine how a baby is adapting and accommodating to the bottle.

Also, keep in mind that the way a bottle is offered and the position that the baby is held affects the way baby accepts the bottle and the way it works. Babies who are breastfeeding well use their tongues to create vacuum and control the flow of the breast. When babies are held on their backs to feed from the bottle, gravity may push the flow and cause baby to react by altering the way they use their tongue.

Pacifiers

Some fairly good research has found that pacifiers introduced after the first two weeks and limited to less than 2 hours use during the day do not appear to inhibit milk supply or shorten breastfeeding. In this study, a one-piece pacifier with a rounded nipple and slight flange at the base was used for all babies in the study.(1) In this study, all babies were healthy babies with no identified risk factors such as tongue-tie etc. Early introduction of pacifiers may interfere with baby’s learning curve where he identifies and correlates sucking and swallowing with latching to the breast. Pacifiers are made of materials much firmer than mother’s breasts and do not conform to the baby’s palate. This imprinting period can last up to 6 weeks. An analogy I have sometimes used is this: introducing a pacifier is like giving a young teen porn – it is artificial, highly stimulating, and does not resemble the real shape, feel or action of the real thing. Ear, nose and throat specialists who work with babies with tongue and lip-ties have noted that babies who have used pacifiers a great deal can have issues learning how to open widely and actively extend the tongue to latch onto the breast. If possible, delay pacifiers until they are absolutely necessary, after comfortable and effective breastfeeding is established, and then limit use to less than two hours daily. Avoid orthodontic, flat or bulbous pacifiers.

A skilled IBCLC can assess a baby’s sucking technique, evaluate suck strength and make recommendations for supplementation methods if needed. They can offer suggestions to help the nursing couple to address and overcome any issues encountered.  They can also evaluate mom’s supply and make recommendations for techniques, equipment and supplements as needed.  They can communicate with other healthcare providers to coordinate breastfeeding and family-friendly care.

Bottles

The research that has been done on bottles includes direct ultrasound and indirect flow studies using a pump setup to mimic the vacuum levels babies use on bottles.(2) Some bottles will deliver nearly an ounce in a minute! This fast of a flow rate will cause a baby to take too much at a time from a bottle, may cause gassiness and fussiness and spitting up. Some bottles will deliver a fast rate of flow if the baby bites on the nipple. When babies must use a bottle and the flow rate or method of obtaining the milk (compression instead of sucking) varies from what is normal during breastfeeding, it can cause bottle or breast rejection. Bottles that drip when held sideways do not necessarily flow fast when baby is sucking. And, bottles that don’t drip, are not necessarily slow flowing when used by the baby. Generally, 5 ounce Newborn Dr. Brown’s bottles with regular size neck, not wide-mouthed, Special Needs Feeders, used with the small line lined up with baby’s nose, Calma feeders, and Munchkin Latch bottle are considered slow-flow, non-compression bottles. Bottles not recommended include Avent, Tommee-Tippee, Momma original, Evenflo original, and many others. This list is subject to change, however, as manufacturers constantly change or quit making products over time. The best way to test a bottle is to buy one only, try squeezing the nipple where baby’s gums would go to check for compression, and offer to baby.

When bottles are recommended for supplementation, it is a good idea to have a lactation consultation to evaluate the baby’s suck and mother’s supply. This can help in choosing the right bottle or another method for supplementation that can help preserve the breastfeeding relationship.

Check out my hand-out on using a bottle under resources.

Pumps

When I started nursing my first baby in the early 70’s, and needed to go back to school, the best you could do for a breast pump  was one of these: This thing was hard to clean and could only hold maybe an ounce. Needless to say, not too many moms used them for very long or with much success. By my second child, this kind of pump was available.  A little better, still not great.  Fortunately, I was able to delay returning to work until he was over a year and I didn’t need to pump. By my third, the first electric piston pumps were available in hospitals.  They looked like this:    For the everyday working mom, manual pumps were still the only option. By 1987, when I opened the first Outpatient Lactation Service in Nashville, heavy duty hospital pumps were available for rental.  Battery pumps also became available, like this:but weren’t super comfortable or effective. By 1989, along came a lighter weight rental pump  This pump could do both breasts at once and was portable! By mid-1990’s the first Pump In Style, a lightweight single user pump that could double pump was available for purchase.  Medela continued pioneering work in the lab, building on the work of Egnell and Whittlestone, trying to design a pump that would be efficient, effective and yet portable and quiet. Variable speed and vacuum pressures were investigated and the Symphony was invented in 2003.

 Medela as well as many other manufacturers have since built and sold breast pumps of various sizes, colors and technologies. There is a huge market of mothers who realize that breast milk is what babies need but have to be away from their babies and need to provide that milk when they are apart.

So how do you choose an effective pump that’s right for you? First of all, look at your need. Have you established a good milk supply with a healthy nursing baby? Milk supply peaks at about 4 weeks postpartum and regulates at about 8 weeks. Minimum requirements for babies from 1-6 months is about 750 ml per day. That’s about 25 oz. Research has shown that a breast pump needs to be able to remove at least 70% of mom’s available supply to maintain production. More complete removal can increase production over time. Less complete removal will decrease production. This is a normal process and is how breastfeeding works when a baby nurses. If a mom only needs to be away from her baby on an occasional basis, any pump that gives her some relief and removes some milk is useful, as when she and baby are together again, the baby can remove the extra milk left behind.  Or if a mom is very full and needs some extra relief, a simple vacuum “pump” (really more of a milk catcher than an actual pump) such as the Haaka is inexpensive and can do an adequate job for many moms. The Harmony pump by Medela, is a simple single manual pump that can be used.  Many moms find this pump especially useful as an emergency pump when they are traveling or away from their baby because it is quiet, light and portable. For moms returning to work and needing to pump quickly, Medela, Spectra, Ameda and many other companies sell pumps. You can look at Amazon reviews. Here is the FDA’s review of breast pumps.

If you have a low milk supply, a baby in the NICU or you are in the hospital, a hospital rental-grade breast pump is the best type of pump for helping increase supply. The pump needs to be able to stimulate a let-down and then apply enough vacuum to empty your breasts quickly when you have a let-down. The flanges should fit your nipple. Medela.com has information on choosing right sizes of flanges. There are YouTube videos available and several blogs. Here’s one: http://www.medelabreastfeedingus.com/tips-and-solutions/13/choosing-a-correctly-fitted-breastshield.  Look into hand-on pumping, do hand-expression after milk flow has stopped, and gentle breast massage before pumping. Some moms find that using coconut oil (if you are not allergic) inside the breast flanges improves comfort. In addition, hands-on pumping can help improve milk-removal, thus improving supply.  http://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html

What if you don’t feel let-down? Milk squirting or fast-dripping into the pump flange is the best sign of let-down. But constant staring at the bottles can inhibit let-down! Playing music, drinking something warm, looking at a picture of your baby and even letting the baby nurse on one breast while pumping on the other, if possible, can help your body learn to respond with let-down. Let-down is essential as the breast pushes the milk out with tiny muscles around the milk collection areas towards the nipple. Vacuum created by the baby or the pump stimulates your brain to release the hormones that cause the muscles to contract and the hormone that causes milk to be produced for the next feeding session.

Some hints for effective pumping include: warming the breasts before pumping (studies have shown up to 50% more milk obtained that way), make sure your pump flanges fit your breast (consider new Personal Fit flanges by Medela, switching the pump rhythm from “stimulation mode” to “expression mode” within 60 seconds to take advantage of the hormone surge and get milk out more quickly, increasing the sucking pressure to optimal levels (maximum comfort vacuum is best).  Using soft silicone flanges can increase compression of the breast which can sometimes slow drainage of the breast. Duckbill style valves on the bottom of pumping flanges can fail or gradually decrease the vacuum the pump is creating which also can affect supply. The pump should cycle about 60 times a minute during expression phase and twice that during stimulation phase.

Pumping is one of those things that moms do to get by. It is never the best option, but in some cases it is the ONLY option a mom has to provide her milk for a baby who can’t yet do the job or when mom and baby are separated by employment or illness. It is hard work for many moms, but it is something only YOU can do, as your milk is the milk best suited for YOUR baby!

(1)Does the Recommendation to Use a Pacifier Influence the Prevalence of Breastfeeding? Jenik AG, Vain NE, Gorestein AN, Jacobi NE, Pacifier and Breastfeeding Trial Group J Pediatr. 2009;155:350-354 (2) Comparison of Flow Rates between Commercial Bottles Karen Gromada, IBCLC unpublished communication.

Sometimes, despite doing all the right things, there’s just not enough milk to totally sustain a baby with exclusive, mama-only, straight from the tap, breastfeeding.  Whatever the reason – genetic, environmental, iatrogenic, mother-baby separation, illness, etc., all that can be done has been done and there’s still not enough. What to do?

1. Realize that breastfeeding is more about the relationship than it is about the volume of milk. Once a baby has made the connection between mom and comfort at the breast, the volume of milk obtained is not as important as the emotional connection that occurs. This is an important concept to grasp. Many babies nurse 3 or even more years. Older babies get a full diet of family-friendly foods, still need and want that connection with mom. But it’s not about the volume of milk, it’s about getting mom’s undivided attention and the feeling of security at the breast.
2. For a baby to make that connection between breastfeeding and safety in the arms of mama, breastfeeding needs to continue even when full breastfeeding does not provide all the baby’s nutritional needs. Giving up breastfeeding for breast pumping may seem like a solution to address issues of low supply when a baby is an inefficient feeder for some reason, but exclusive pumping does not allow for that connection and interaction to continue. Think hard before you give up direct breastfeeding.
3. If supplementation is required, and donor milk is available, use that to support baby’s nutritional needs as long as possible. If baby is able to breastfeed well enough, use a lactation aid at breast as much as possible for supplementation. If supplementation must be done away from the breast, use bottles in a manner that supports baby-led feeding.  See other posts for more information on selecting pumps and bottles that may interfere less with continuing the at-breast feeding bond.
4. Recognize that babies use suckling time at the breast to help with digestion, to comfort and settle. Large volumes of milk are not needed, or even desired for this activity. Breastfeed your baby after supplementing to allow for this benefit. Breastfeed whenever possible instead of giving a pacifier. Some people call this “comfort-feeding.” In the early days, combine comfort-feeding with skin-to-skin care to build the connection between you and baby.
5. Accept the fact that breastfeeding length and milk volumes do not have to correlate. Adoptive mothers may not have a full supply of milk, but they can still breastfeed. Mothers of toddlers aren’t exclusive breastfeeders, but they can still breastfeed. Mothers with insufficient glandular tissue may not be able to provide 100% of their babies nutritional needs, but they can still breastfeed.

There has been a lot of discussion among the medical community about the impact of tongue and lip restrictions on breastfeeding and oral health in general. Over my now almost 50-year career of nursing and lactation support, this discussion has grown from a “no big deal, just fix it” question to an “it’s an imagined problem” to where things stand now – with camps saying it’s overdiagnosed to camps saying that it’s underdiagnosed and undertreated. There are many social media groups for both moms and professionals discussing the issue and in some cases, strong battle lines are drawn. Here is my opinion.

Personally, I have had two children with restricted lingual frenulums. One received a revision at 5 days by the old GP that delivered her. The other delivered many years later, was not diagnosed and was not treated. I nursed them both, the first for 10.5 months (in a day when everyone bottle-fed) and the second 3.5 years. Both had dental issues later in life.  That’s my personal experience and occurred before I was a board certified lactation consultant. My experience says that with a genetic capacity for excellent milk supply and determination, breastfeeding can happen for some moms with babies with oral restrictions, but sometimes it can’t. There was no Facebook back then with thousands of mothers looking for support that they can’t find in their local medical community. I survived. Does that make it ok to not treat oral restrictions?

Professionally, over the course of my career, I have helped thousands and thousands of women breastfeed.  Some of the most difficult cases have been with babies with oral restrictions. And many of these have additional difficulties to overcome, some as secondary issue caused by the oral restrictions, some separate but equally challenging issues. Below are some of my conclusions.

Oral restrictions affect muscles in the body. Babies use their whole bodies to breastfeed. Sucking is the mechanism by which babies get nutrition, comfort and explore their world. When that is disturbed by difficulties of attachment due to weakness or inability to move the tongue (which is another muscle), their world is turned upside down. Compassion and understanding go a long way to increasing patience with a baby who doesn’t understand and who is biologically driven to nurse. All babies want to nurse, but oral restrictions impeded their ability to do with ease.

First, it is important to note that muscle tension can affect tongue effectiveness, giving an appearance of restriction. That is why it is important to have an experienced diagnostician who can distinguish between a mechanical restriction (like a tongue-tie) versus muscles in tension preventing movement and range of motion. Proper diagnosis is the first key to dealing with inhibited tongue function.

Next, if a mechanical restriction is diagnosed, an experienced and knowledgeable provider is the second key in improving function. The provider must know how to do a complete release and be able to show the parents what that looks like when it is accomplished, and give proper guidance for post-revision care. In some babies, there are benefits to doing pre-release physical therapy, occupational therapy, etc. if baby is showing signs of compensation that can be helped even before release is done.

The third key is effective and consistent after care done once the baby’s restrictions is released. Babies who can’t suck effectively, often develop muscle tension in other places than the tongue as they try to compensate for poor tongue function. This can result in lots of tension, pulling away from the breast, biting, etc. Some babies will develop or may have accompanying torticollis, high body tone, etc.  Body work, physical therapy, effective and frequent tummy time, baby-wearing, and skin to skin care can help calm and relax a baby. This must be done in a pattern that is effective and rewarding for baby.  Some babies need care from a speech language therapist. If baby is being supplemented, the choice of supplementation device may change as baby improves. See my post for more information on the impact of devices on breastfeeding competency. Protect your milk supply while working on any latch issues as supply is driven by the degree and frequency of emptying the breast. See the link above for more information on that as well.

A lactation consultant should reevaluate baby after a release because latch techniques may need adjustments once baby has full range of motion of the tongue. It takes time to work through and retrain baby to latch comfortably and effectively. Most moms report it takes 2-4 weeks. Follow-up assessment during this time is important to make sure healing is progressing and function is improving. The IBCLC can further refer to body workers, speech therapy, physical therapy as needed.

Above all, when taking the journey through breastfeeding difficulties, including oral restrictions, remember that the breast is and should be not a battle ground but a sanctuary for babies. Keep baby close and comfortable (that’s skin to skin care). Keep baby at the breast, even if you have to supplement away from the breast. Breastfeeding can be an after meal snack even if your supply is low. Your journey may not be easy, but your bond can be strong as you work through challenges.

Research shows that the number one reason for moms not meeting their breastfeeding goals is low supply. Research shows that milk supply is heavily dependent on what happens in the first 3 days.  Here are a few tips that will protect your supply and ease baby’s transition from womb to world.

What To Know:

1. Babies are not born knowing that sucking is related to hunger satiation. Sucking is a reflex that brings comfort first, food second. Babies do not know hunger before birth.
2. Caring for babies skin to skin provides warmth, moisture and transfer of protective good bacteria from mom to baby. Research has shown that babies cared for this way have less jaundice, better sugar levels, better temperature maintenance and fewer infections than those cared for away from mom’s skin. Delaying bathing to allow time for vernix (the thick creamy coating in skinfolds and coating skin) helps baby absorb good bacteria from mom. This is especially important for babies who have delivered by Cesarean Section.
3. Most babies, when placed on mom’s chest immediately after birth, will begin crawling, searching and rooting activities within the first hour after delivery. Interestingly, mother’s milk is most readily available at that time due to birth hormones. Babies who get this early dose of colostrum are protected from low blood sugar and the gut is provided a protective layer of mother’s helpful bacteria. This early latch also starts the milk production process and helps prevent delays in milk coming in.
4. Baby’s first sucking experiences help develop baby’s sucking behavior. Finding the breast for herself while crawling on her belly encourages a wide-open mouth and tongue forward. Repeated practice sessions – offering the breast with early feeding cues whenever baby demonstrates those – helps the imprinting process. Leaving baby’s hands unwashed and uncovered helps baby find her way to the breast.
5. Frequent feedings in the first 100 hours (10-12 per 24 hours) encourages a more rapid transition from colostrum to milk production. Tight swaddling may interfere with natural feeding rhythms.
6. Feeding both breasts, and repeating as necessary, helps a baby associate sucking with obtaining milk.
7. IV fluids, blood pressure issues etc. can cause the areola around the nipple to be firm and make latching more difficult for the baby. Reverse pressure softening and areolar expression can remedy this and make latching easier.
8. When babies are latched well, you should be able to hear a few swallows, even in the first day of nursing.
9. What goes in must come out: that means a baby who is getting milk from the breast will have wet diapers and poop. This starts at one a day and increases by an additional wet and poop for each day of life. By 5 days, a baby should be wetting 6-8 times and pooping 3-5 times per day.
10. Nipple tenderness should be resolved by day 5.

What To Expect:

First 24 Hours: Baby should nurse within two hours, if placed skin to skin with mom and allowed to remain there.  Some babies will sleep 4-6 hours and then begin nursing every 1.5-3 hours.  Some babies do not take the recovery sleep. Babies may nurse for a few minutes, others for half an hour.

Second 24 Hours: Babies should start waking up more, nursing for longer periods. During the second night of life, babies may nurse more frequently and seem hungrier, wanting to nurse off and on all night. Milk often comes in after this frequent nursing period. Switching breasts frequently and breast compression helps protect nipples and improves supply.

Third 24 Hours:  Milk volumes increase, breasts become firmer. Nursing sessions should last 10-30 minutes. Be sure to nurse both breasts, changing breasts whenever baby starts to fall asleep.

What To Do:

1. Keep mother and baby together, 24 hours a day. Do not separate unless medically necessary.
2. Put baby on mom’s chest immediately after birth. Mom’s head should be raised so she can see and follow her instincts to help baby with latch. Delay bathing for at least the first 24 hours. When bath is done, leave hands unwashed.
3. GIVE THE BABY TIME. Don’t worry if baby doesn’t immediately latch to the nipple. Let her fuss a bit, move back and forth to seek the nipple and find it herself. Do not force the nipple into her mouth or push her head onto the nipple. Do not push on her back. Baby has natural instincts to feed that are most active when he is on his belly and feels supported by mom’s body.
4. If mom’s areola is firm or nipple appears flattened, perform Reverse Pressure Softening and/or Areolar Expression to help baby draw nipple far back onto his tongue. 
5. Use breast compression to keep milk flowing if baby seems to fall asleep quickly after latching. This is a firm but gentle squeezing of the breast a few inches back from the nipple. Squeeze and hold while baby is drinking; release while he rests and repeat until baby is not swallowing.
6. Change breasts every few minutes when baby slows down on sucking and swallowing. Repeat breasts until baby is satisfied and asleep.

1. If your baby is too sleepy to latch (this can happen from medications mom is given during labor), express directly into baby’s mouth or hand-express colostrum and syringe or spoon feed to baby. This will help prevent low blood sugar for the baby and prevent unnecessary formula supplementation. Breast milk is more effective at increasing baby’s blood sugar than formula because it is self-digesting. Do this every 2 hours until baby shows interest and starts latching by himself. 
    
2. If your baby has not started latching by 12 hours after birth, ask for a hospital breast pump and begin pumping as well as manual expression to give your supply a jump start. If your baby begins latching but is still having difficulty after 24 hours (causing nipple pain, no swallowing), start pumping. Pump 10 times/day the first three days, then 8 times/day after that until baby is doing well.  Research shows that moms who begin hand-expressing AND pumping in the first two hours when baby is unable to nurse well, have twice as much milk at 10 days as those who delay.  WATCH THIS VIDEO: http://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html
3. Avoid pacifiers and bottles until baby is latching well. It usually takes about 2 weeks for babies to imprint at the breast.
4. Keep track of baby’s output. The My Medela App is free and will help you keep track of feedings and baby’s wets and poops.
5. If you are still having trouble with latch or have nipple damage after the 5th day or you have cracked or bleeding nipples, get hands-on individual help.
6. Laid-back breastfeeding with mom comfortably supported and baby’s weight on her and not a pillow should be practiced throughout breastfeeding. If mom has a sore neck and shoulders from breastfeeding, it’s a sign that she is not comfortable and is working too hard. Babies take at least 6 weeks past their due date to become automatic breastfeeders and to have more control over their head and neck muscles.

If you have time and resources, please take a comprehensive prenatal breastfeeding class. Prenatal Classes help get the whole family on the same page and reduce stress. Classes are offered in many locales, including Nova Birth Services at (615) 669-6399 and most Maternity Hospitals. 

1. Use a Dr. Brown’s 4 oz with standard (not wide-mouth) bottle. The valve in the Dr. Brown’s bottle encourages baby to suck and not remove milk by compression. Shorter, wider bottles encourage biting.
2. Put baby on her side in a flexed position, propped with her head higher than her bottom. Her neck should be naturally curved with the chin sticking out a little. Her head should be lined up with her body, not turned to one side or the other. If your baby is older, you can sit baby upright on your lap, supporting her head behind the neck with one hand. Don’t put her in the crook of your arm or on your forearm – this may lean her back too far, causing the milk to come out of the bottle more quickly when she is not sucking. Remember, baby’s back should be rounded, not arched, hips flexed and chin forward in either position.
3. Tilt the bottle so milk is NOT in the nipple at first. This will not cause baby to swallow air, but instead get her used to sucking a few sucks without milk, like breastfeeding. Use the nipple of the bottle to tease the baby’s lips, stroking from the top lip to the bottom, trying to get her to stick the tongue out over the bottom lip and open very wide. Stroke down gently from the center of the top lip to the center of the bottom lip. Be patient, as it may take several strokes at first for her to get the idea.  When she starts to get the tongue out, tilt the nipple towards her palate and encourage her to take it in all the way to the back of her tongue. Baby’s tongue should cover her gums and be over her bottom lip  This will encourage her to suck, not bite, the bottle. Her lips should flange out, touching the nipple collar. If she doesn’t take the nipple in very far, gently twist and work it back further onto her tongue until her lips touch the collar. If she gags, take the bottle out and start over. The tip of the nipple should rest on the back of baby’s tongue (like the breast nipple during breastfeeding) and not in the front of her mouth. If baby does not close mouth and cup tongue around the nipple, try supporting her chin with a finger and pressing upward. Do not tip the bottle up and completely fill the nipple as this will cause milk to flow too quickly. Air in the nipple will not cause gassiness! Babies swallow air when milk is flowing too quickly and they attempt to breathe and swallow at the same time.
4. When baby is older and stronger, you can hold baby in sitting position. Cross your legs or put one foot up on a stool to allow your leg to help support baby’s back. Hold the bottle as level as possible, just allowing milk to come into the nipple. This puts baby in charge and encourages her to use her tongue correctly.
5. After 30 seconds or so of swallowing, tilt the bottle back so milk is not in the nipple. Allow baby to rest and catch her breath. As baby begins to empty the bottle, you can lean her head back slightly, but no more than 45 degrees. On her side, you can turn her slightly upward to keep milk in the bottle nipple tip.
6. If your baby is using the side position, you may find she is more efficient on one side than the other. If that is true, use the best position for majority of feeding but finish on the other side. You may also try lying on your back with her lying across your chest.
7. Watch for swallowing (slight pause in the open-close motion of sucking). Help her to pace herself by removing the bottle if she seems to be pushing it with her tongue, does not pause to breathe, milk is spilling out of her mouth or she needs to burp. It should take her 15-20 minutes to finish a bottle.
8. Some babies require chin support to get started especially if they have been using bottles that have short nipples, wide bases and where milk comes when baby bites down on the bottle teat. Keep working with above techniques until baby gets the hang of sucking instead of biting the bottle nipple.
9. Offer the breast after feeding for comfort-nursing as often as possible. This will help improve digestion and keep baby interested in breastfeeding.

Note: Baby is on mom’s lap with her butt against mom’s stomach, not sitting upright. Baby’s head is higher than her bottom. Bottle nipple is tilted up and milk only half-fills the nipple. Both lips are flanged out and touch the collar of the bottle.

Baby-Led Bottle-Feeding by Jane Kershaw Revised 12/2021

Adapted from “Bottle-Feeding as a Tool to Reinforce Breastfeeding by Dee Kassing, BS, MLS, IBCLC. J Human Lact 18(1), 2002

Strategies for Moms Anticipating Breastfeeding Difficulties

This page is designed for moms who have previously experienced breastfeeding difficulties or have been informed by a skilled provider that they MIGHT have difficulty breastfeeding. These strategies do NOT guarantee that mom will avoid these problems, but serve as a sample of actions that moms have taken that have proven successful in their breastfeeding journey.

Flat or Inverted Nipples

A flat nipple is one that, when the areola is compressed about an inch behind the nipple, flattens out and appears level with the surround areola or becomes thick and barely protrudes past the surface.  An inverted nipple pulls behind the surface of the areola and may pull inward into the breast.

Prenatally:  Try Supple cups starting at least 8 weeks before delivery. Check out  for product information. Begin using these as per instructions. Consider purchasing softshells for inverted nipples  to wear over the supple cups to allow longer periods of wearing to help correct the condition prior to delivery.

After Delivery: Try Latch Assistant by Lansinoh. This can be used on the nipple itself or placed over a nipple shield (if needed) to draw the nipple out or to pull inside the shield before latching.

Supple cups can also to be used in the same way.

History of Latch difficulties with delayed or slow onset of Stage 2 of lactogenesis.

Research has shown that optimal breast stimulation and expression of colostrum during the first 72 hours after delivery can double milk output at 10 days.

1. Initiate breastfeeding within the first hour after delivery with mom in laid-back position, using biological nurturing approach. See:  for more basic tips.  If areola is tight (feels like your chin or the end of your nose), use reverse pressure softening and areolar expression to increase nipple availability before baby latches.  Once baby has latched, remain reclined throughout the feeding. Mother to recline at feeds for 6-8 weeks. Reclining means mom is leaned back between 15-70 degrees (not straight up) with her back and neck and arms supported.  Baby’s weight is on mom’s body not away from her on a pillow.  Mom should not have to push on baby’s head or back for her to reach the breast. Switch breasts when baby starts to pause a lot (usually every 5 minutes or so). At 24 hours, begin softening and expression before every feed, even if you don’t think your areola is firm.
2. Ask for a hospital breast pump to be brought to you right away, along with syringes for milk collection. If your baby is not latching well by 12 hours, begin using breast pump in addition to hand-expressing. 
3. Offer the breast every 2 hours until 10:00 at night, and then every 3 hours during the night. If baby is too sleepy to latch, hand express about 10 minutes. If baby isn’t latching consistently by 24 hours, but you are not separated, add pumping for 15 minutes to help speed up onset of milk production. Give any colostrum to the baby by finger-feeding. This is for first 3 days of life. Pump early, pump often!
4. If your baby cannot latch to the breast or stops latching, ask for a small and a large nipple shield. Try both to see if baby can latch to either. Ask for demonstration from your care provider.  If you have not started pumping yet, begin doing so. Pumping in the first 3 days should be about 15 minutes using the Symphony initiation program. Once your milk starts coming in, use the maintenance program and move the vacuum up to at least 10 bars on the screen up to maximum comfort vacuum (a bit uncomfortable but not painful).  Ask for written instructions for pump use. Plan on taking a rental pump home from hospital if needed. Remember milk does not start squirting until Day 7 after delivery.
5. Check baby’s suck using your thumb to see if baby is drawing your thumb back to the back of her tongue or is only “peanut butter sucking” on the tip of your thumb. Sometimes a little suck training before latch can correct what is just a habit baby has at birth.
6. If no comfortable strong latch is obtained, plan to see a lactation consultant around 4th-5th day (optimal time when milk surge normally begins and baby is more alert).
7. Monitor baby’s weight loss. If mom’s milk is not coming in quickly, have donor milk or ready to feed formula available for early supplementation as needed. Many organizations recommend hydrolyzed formula if human milk is not available.  If supplementation is needed in the hospital after the first day, ask for oral syringes and a feeding tube for easier finger feeding or at breast supplementation. If long-term supplementation is required, a Dr. Brown’s bottle and side-lying baby-led bottlefeeding technique can be used. 

Breastfeeding Assistive Devices 

• Latchassist by Lansinoh
• Hydrogels by Medela (2 pkgs)
• Nipple shields 20 and 24 (if not obtained from hospital)
• Bacitracin
• Medela Harmony manual pump
• Haaka milk collector
• Tube top – makes a comfortable holder for nursing pads, can be used as a pumping bra
• Dr. Brown’s 4 oz regular newborn bottle (not glass, not wide mouth)
• Microwave sterilizer bag (if you have a microwave)

From Hospital

• Oral syringes
• Pump kit
• Rental pump
• Feeding tube (used for finger-feeding or at breast supplementation)

A Word of Encouragement

DID YOU KNOW? 

In a study conducted with moms with history of breastfeeding difficulties, that 95% of them had success with following births – even if the previous breastfeeding experience was not what was expected or planned? This just validates that every breastfeeding experience is unique with a unique baby and a mom with a different (and growing) skill set! It’s just like childbirth – each birth, each mother-child relationship is different, but all are valuable!