Every mother’s experience with breastfeeding is different. Whether this is your first baby or you are an experienced mom, each baby is unique. Breastfeeding will be a learning process.

Your baby is learning how to:

• Latch.
• Suck.
• Swallow.

You are learning how to:

• Position your baby to feed.
• Observe and follow his or her hunger cues.
• Manage your breast milk supply and breast health.

First Days and Weeks

Milk Coming In

At birth, your breasts will make a thick, yellowish substance called colostrum. Colostrum is packed with nutrients and other important substances that help your baby start building up his or her immune system. There will not be a lot of this liquid at first, but the amount will gradually increase over the first couple of days. Most babies will get all the nutrition they need through colostrum during the first few days of life. As you begin breastfeeding, your baby’s sucking will tell your body to start making milk. For most mothers, this thinner, whiter form of milk comes in by about 3 days after birth, but may take longer for first-time moms. You may notice your breasts feeling full, hard, and warm as this happens. Your baby may begin to want to breastfeed more frequently around this time. If you are concerned about your milk coming in, talk to a lactation consultant or your doctor or nurse.

Did You Know?

Pacifiers and your baby.

If you are breastfeeding your baby, you may want to wait to use a pacifier until breastfeeding is well-established. At that time, using a pacifier for naps and at bedtime can help reduce the risk of Sudden Infant Death Syndrome (SIDS).

Leaking

Your breasts may feel full and leak. Over time, the leaking may slow down as your body gets used to breastfeeding. If your breasts leak, you may find it helpful to put disposable or cloth pads in your bra.

Engorgement

Over the first few weeks after birth, your breasts may become larger, firm, warm, and uncomfortable as your body adjusts to making milk. This is called engorgement. As your breasts get used to filling and emptying as you feed your baby, this should improve. Feeding your baby frequently should help to prevent severe engorgement and relieve discomfort.

Sore Nipples

During the first few weeks of breastfeeding, your nipples may be sore or sensitive as they adjust to your baby’s sucking. If you have cracked or damaged nipple skin, or pain that is not improving over the first 1–2 weeks, talk to a lactation consultant or your doctor or nurse.

Pain While Breastfeeding

Although your breasts and nipples may be tender or uncomfortable, once your baby is well-latched, breastfeeding should not be painful. Sometimes pain can happen if you have an improper latch, a milk duct that is clogged with milk (plugged milk duct), a breast infection (mastitis), or other issues. If you have pain while breastfeeding, especially with a fever, talk with your doctor or nurse to figure out why.

As Your Baby Gets Older

Teething/Biting

You can continue to breastfeed once your baby starts to get teeth. Babies use their tongues, not their teeth, to breastfeed. If your baby is latched well and sucking, you should not feel the teeth while your baby is feeding. Once in a while babies might bite the nipple or breast, especially when they are teething. Talk to a lactation consultant for tips on how to teach your baby not to bite.

Refusing to Breastfeed

Sometimes babies will suddenly stop wanting to breastfeed. Many times it is hard to know why this happens. Refusing to breastfeed is usually temporary and your baby will start breastfeeding again within a few days. Some reasons your baby may refuse breastfeeding include teething, illness, stress, a change in environment such as a new childcare situation, or a major change in routine. This usually does not mean your baby is ready to wean.

To help your baby return to breastfeeding:

• Keep offering your baby the breast or breast milk from a bottle if bottle feeding.
• Spend extra time cuddling and holding your baby.
• Offer the breast in quiet spaces and when your baby is sleepy or relaxed.
• Pump or express milk frequently to keep your breast milk supply up until your baby starts breastfeeding again.

Distracted Breastfeeding

Your baby is starting to notice all the things going on around him or her. This can mean that your baby might get distracted while breastfeeding. Help your baby focus by turning off the TV, dimming the lights, or feeding in a quiet place.

Weaning

Although breastfeeding is recommended until your baby is at least 12 months old, weaning may happen before then. Learn about when and how to wean your baby from breastfeeding.

Your breastmilk helps your baby grow healthy and strong from day one.

• Your first milk is liquid gold. Called liquid gold for its deep yellow color, colostrum (coh-LOSS-trum) is the thick first milk that you make during pregnancy and just after birth. This milk is very rich in nutrients and includes antibodies to protect your baby from infections.

  Colostrum also helps your newborn's digestive system to grow and function. Your baby gets only a small amount of colostrum at each feeding, because the stomach of a newborn infant is tiny and can hold only a small amount.

• Your milk changes as your baby grows. Colostrum changes into mature milk by the third to fifth day after birth. This mature milk has just the right amount of fat, sugar, water, and protein to help your baby continue to grow. It looks thinner than colostrum, but it has the nutrients and antibodies your baby needs for healthy growth.

The thin, yellow, serous fluid secreted by the mammary glands during pregnancy and immediately postpartum before lactation begins. It consists of immunologically active substances, white blood cells, water, protein, fat, and carbohydrates.

There are three phases of breast milk. Each one is vital in nourishing your baby.

PHASE 1: COLOSTRUM

This is the thick first milk your breasts make while you are pregnant and just after birth. Moms and doctors may refer to it as "liquid gold" for its deep yellow color and because it is so valuable for your baby. Colostrum is very rich in nutrients and has antibodies to protect your baby from infections. Colostrum also helps your baby's digestive system grow and work well.

PHASE 2: TRANSITIONAL MILK

Transitional milk comes when mature breast milk gradually replaces colostrum. You will make transitional milk from 2-5 days after delivery until up to 2 weeks after delivery. You may notice that your breasts become fuller and warmer and that your milk slowly changes to a bluish-white color. During this time, your breast milk changes to meet your baby's needs. Nursing often, removing milk well, and relieving engorgement will help with milk production.

PHASE 3: MATURE MILK

About 10-15 days after birth, you start making mature milk. Like each phase of breast milk, it has all the nutrients your baby needs. The amount of fat in mature milk changes as you feed your baby. Let your baby empty your first breast before switching to the other breast during a feeding. This will help your baby get the right mix of nutrients at each feeding.

Yes. Your breastmilk changes in the days after birth and continues to change as your baby grows. Learn what will happen with your milk, your baby, and you in the first few weeks.

Birth

Milk: Your body makes colostrum (a rich, thick, yellowish milk) in small amounts. It gives your baby early protection against diseases.

Baby: Your baby will probably be awake in the first hour after birth. This is a good time to breastfeed your baby.

You (Mom): Let your baby begin the process of searching for your nipple. This baby-led way of breastfeeding can help your baby get a good latch.

First 12 to 24 hours

Milk: Your baby will drink about 1 teaspoon of colostrum at each feeding. You may not see the colostrum, but it has what your baby needs and in the right amount.

Baby: It is normal for the baby to sleep heavily. Labor and delivery are hard work! Some babies like to nuzzle and may be too sleepy to latch at first. Feedings may be short and disorganized.

You (Mom): Your body is still making colostrum. Take advantage of your baby's strong instinct to suck and feed upon waking every couple of hours to help your milk come in faster.

Next 3 to 5 days

Milk: Your mature (white) milk takes the place of colostrum. It is normal for mature milk to have a yellow or golden tint at first.

Baby: Your baby will feed a lot, at least 8 to 12 times or more in 24 hours. Very young breastfed babies do not eat on a schedule. It is okay if your baby eats every 2 to 3 hours for several hours, then sleeps for 3 to 4 hours. Feedings may take about 15 to 20 minutes on each breast. The baby's sucking rhythm will be slow and long. The baby might make gulping sounds.

You (Mom): Your breasts may feel full and leak. (You can use disposable or cloth pads in your bra to help with leaking.)

First 4 to 6 weeks

Milk: White breastmilk continues.

Baby: Your baby will now likely be better at breastfeeding and have a larger stomach to hold more milk. Feedings may take less time and may be farther apart.

You (Mom): Your body gets used to breastfeeding. Your breasts may become softer and the leaking may slow down.

Introduction

The breasts of pregnant women change in size and appearance due to the effects of the hormones estrogen and progesterone. Alveolar cells of the breast begin to secrete colostrum in the twelfth to sixteenth week of pregnancy. This is called lactogenesis I. Colostrum is a thick, yellowish-white fluid which can be expressed from the breast by the third trimester. Milk secretion is suppressed during pregnancy by estrogen and progesterone.

Colostrum has more protein and fewer carbohydrates and fat than mature breast milk. Colostrum is rich in secretory immunoglobulin A (IgA), which helps to protect the infant from infection. Colostrum also helps to establish a normal gut microbiome in the infant. The bowel is considered sterile at birth.

Human colostrum is the ideal food for human newborns and is preferable over formula or milk from other animals. The proportions of nutrients in human milk are different than other animals and therefore suited better for humans. Although formula simulates human milk as much as possible, the components of colostrum and mature milk, such as immunoglobulins, leukocytes, as well as antioxidants, enzymes, and hormones, give colostrum and mature human milk many advantages over formula. This often is vitally true with preterm infants who are much more vulnerable to infection and greatly benefit from receiving colostrum and human milk.

This article highlights the knowledge needed by the interprofessional team in managing female patients who are currently lactating or will be lactating in the future.

Structure and Function

The function of the breasts is to produce milk to nourish infants. The purpose of colostrum is to provide low-volume milk that helps the newborn as they learn to regulate the suck, swallow, and breathe cycle during feeds. Colostrum has an important role in providing immunity as well as nutrition to the newborn and helps in establishing a healthy gut microbiome, which can have long-term, beneficial effects.

Embryology

Female breast development in the fetus begins in the fourth week of gestation. By 16 weeks, the smooth muscle of the nipple and areola are present, and the epithelial cells develop into mammary buds. These will branch out into alveoli and ducts, which will create the mammary system. The mammary gland continues to develop throughout childhood until puberty, when there is a rapid proliferation of ducts and alveoli. The hormones that influence each menstrual cycle also increase the proliferation and growth of the mammary tissue.

Blood Supply and Lymphatics

The breast has a high level of vascularization, including the internal mammary and lateral thoracic arteries. There also are numerous lymphatic vessels in the breast and axilla. The lymphatic vessels follow the lactiferous ducts and converge near the nipple. Lymphatic fluid can accumulate during the engorgement phase of breastfeeding, usually 3 to 5 days postpartum, and contribute to the visible distention of the breasts. The components of milk are synthesized in the alveoli, including protein, fat, and carbohydrates, or are retrieved from maternal plasma (vitamins and minerals).

Nerves

The posterior pituitary releases oxytocin in response to an infant suckling at the breast. The nipple and areola have a high level of sensory nerve endings. The release of oxytocin causes the milk ejection reflex (MER), also referred to as the letdown reflex. The myoepithelial cells surrounding the alveoli will contract and propel milk forward through the lactiferous ducts and out through the nipples. The mother often feels a tingling sensation. Infant suckling also stimulates prolactin (from the Greek root word meaning "for milk"). Prolactin levels rise during pregnancy, drop shortly before birth, and then rise again after birth. Prolactin levels double with infant suckling.

Physiologic Variants

Factors that can affect prolactin release and subsequent milk production include breast stimulation, sleep, stress, and pregnancy. Medications that act as stimulants include neuroleptic drugs, thyroid-releasing hormone, metoclopramide, estrogens, phenothiazines, norepinephrine, histamine, and acetylcholine. Medications that are suppressors include L-dopa, ergot preparations, clomiphene citrate, pyridoxine, monoamine oxidase inhibitors, and prostaglandins E and F.

Many physiologic variables can affect breastfeeding and, therefore, the intake of colostrum. This can be divided into maternal factors and infant factors. Maternal factors include the size and shape of the nipples, breast development during puberty and pregnancy, mammoplasty (reduction or augmentation); other breast surgery; fibrocystic changes; breast cancer, obesity, and concurrent medical problems in the mother. Factors in the infant that can affect breastfeeding include gestational age at birth; ankyloglossia (tongue-tie); cleft lip or palate; other physical malformations; infections; oral-motor dysfunction (abnormal suck); and various diseases, such as congenital heart disease, cystic fibrosis, inborn errors of metabolism, intestinal malabsorption syndrome, neurological disorders, renal disease, and thyroid disease.

Nipple size and shape are probably the most common factor affecting the first days of breastfeeding when the infant receives colostrum. A more erect nipple encourages the newborn to latch and suck. Flat or inverted nipples can make it more difficult for the mother and infant to learn how to breastfeed. Nipple shields can be used but have shown limited success. Another common factor is the infant's wakefulness and ability to suck. The best way to promote breastfeeding is skin-to-skin time with the mother within 5 minutes of birth and lasting for at least 1 hour. This helps the infant physiologically adjust to extrauterine life and helps them to find the nipple by smell and tactile stimulation. This skin-to-skin time also helps establish normal skin flora on the newborn to protect them from pathologic bacteria. Successful breastfeeding within an hour of birth sets the stage for improved breastfeeding experiences in the coming days.

Surgical Considerations

The role of the interprofessional team in evaluating and treating women is critical. As mentioned, surgical procedures on the breast can influence breast milk production and ejection. The main factors include the type of surgery performed, whether neural or ductal pathways were disturbed, and the amount of breast tissue removed. Breast augmentation usually does not interfere with full breastfeeding, but breast reduction surgery often leads to the inability to breastfeed. Some breast reduction surgery involves completely removing the nipple and then reattaching it after excess breast tissue is removed; this will interfere with nerve and ductal pathways. The pedicle technique involves keeping the nipple attached, and tissue around this pedicle is removed. This has a somewhat higher chance of allowing breast milk production and ejection to occur. Breast surgery for benign tumors or cancer also can affect the ability of the breast to produce milk.

Clinical Significance

The interprofessional team should consider the age and future wishes of the patient whenever breast surgery is considered. Patients should be counseled on the risks and benefits of the surgery or other treatment of the breasts and their influence on future breastfeeding so that they can make informed decisions about their treatment. The healthcare team should also consider the use of medications and their effect on the colostrum, the breastfeeding process, and the suckling newborn. The patient needs to be counseled thoroughly on the indications, interactions, and possible adverse effects for themselves and their baby. The health care team needs to educate women about the importance of colostrum for their newborns and encourage/support women in their early breastfeeding experiences to improve breastfeeding outcomes and newborns' health.

Other Issues

Colostrum, the initial milk produced by the breast during pregnancy, can be expressed during the third trimester and begins to be secreted in larger volumes after birth. Lactogenesis II begins at 2 to 3 days postpartum and is often called transitional milk. This milk gradually changes from colostrum to mature milk. The quantity of milk increases rapidly. The immunoglobulins and proteins decrease, and the lactose, fat, and calories increase. Lactogenesis III is mature milk and replaces the transitional milk. This milk is more bluish-white and not as thick. Mature milk contains 20 kcal/ounce and nutrients specific to meet the needs of the growing infant. It continues to have immunoglobulins and other antibacterial components.