At first – skin contact

Use continuous skin-to-skin contact, low-pressure help as needed.  Even non-latching babies will move readily to the breast on their own, if kept on the mother’s chest (especially if birth medications were not used).  Many of these self-directed babies will go on to breastfeed with little or no help.

If birth was medicated – express colostrum by the end of the first hour

Continue constant skin-to-skin care.  Anecdotally, there is often much more colostrum available for that first feed than there is at subsequent feeds.  Normally, of course, the baby would take that large meal himself.  If a non-latching baby had labor medications, it is likely that he’s going to need help for a while.  Getting a larger volume of colostrum now may mean less risk of formula supplementation later.  At this very early stage, a pump may work, but hand expression is far less of an intervention.

By about 6 hours – begin hand expression

Continue skin-to-skin care.  Hand express colostrum into a plastic spoon, spoon-feed baby every 2-3 hours and when either wakes at night.  If possible, have an assembly line, with one spoon being filled while another is being fed to baby.  Babies take very little food their first day, and it’s possible to get a fair amount into a baby rather quickly this way, so that mother and baby can resume cuddling.  Milk removal is as important as giving the milk to the baby.

By 24 hours, or sooner – continued hand expression and perhaps pumping

Continuous skin-to-skin contact.  Think of Day 2 as “calibration day,” when the breast begins to prepare for its future output.  Continue hand expression and consider initiating pumping with a hospital grade pump, 8-10 times in 24 hours.  Don’t expect much from pumping at first – perhaps just drops on the flange, which can be wiped up with a finger and put on the baby’s lips.  Continue to hand express into a spoon as long that’s more effective; the thick, sticky quality of colostrum and its relatively low volume make it difficult for a pump to extract it at first.  Once pumping becomes more effective, end sessions with hand expression.  The extra removal and massage will mean even more milk in days to come.  Feed with dropper, syringe, or cup.

Continue skin-to-skin care.  Pump 8 or more times in 24 hours, finishing with hand expression.  Consider a nipple shield to facilitate latching.  If the nipple shield is unsuccessful or doesn’t allow for adequate milk transfer, consider using a bottle to expedite feeds.  Once milk volume increases, the bottle may be the least stressful way to manage feeds that don’t take place at breast.  If milk volume hasn’t yet increased, hand expression may still be a more effective tool than pumping.  A pump is often faster than hand expression once volume has increased and milk is thinner, but should not replace it completely.

After discharge – nipple shield/bottle, pump, hand expression, help, patience, confidence

Continue skin-to-skin care as much as possible.  Express 8 or more times per 24 hours, tapering off when baby begins to nurse.  Try gradually to have one, then two feedings ahead in the refrigerator, to allow a “sanity cushion”.  This will take some time; pumping 10 times a day for a day or two will help.  Seek help from a breastfeeding specialist.  If the baby isn’t nursing, continue to pump with hand expression a minimum of 8 times a day for the first 2 weeks (10 is terrific but difficult, 6 is a bare minimum), to “set the thermostat high”.  It’s easier to down-regulate a too-large supply than to up-regulate a too-low supply.  Babies sometimes take weeks to breastfeed effectively, but they can virtually all get there, if the mother keeps her supply going.  If we can teach a tiger to jump through a flaming hoop, we can certainly help a baby do what he is already designed to do!

Diane Wiessinger, MS, IBCLC   www.normalfed.com