Three Basic Rules for Successful Breastfeeding
Three Basic Rules for Successful Breastfeeding
Help your breastfed baby gain weight and have satisfying feedings. Maximize your milk supply while enjoying breastfeeding more!
[Note: The fundamental “three rules” for solving breastfeeding problems were developed by Linda Smith, IBCLC. Other rules were developed by IBCLCs Karen Kerkhoff Gromada, Barbara Wilson-Clay, and Diane Wiessinger, but Rules 1 and 2 (“feed the baby” and “protect the milk supply” have always the same, no matter whose teaching you follow. ]
A Well-Fed Newborn Baby Is:
- Easy to wake and keep awake during feedings most of the time
- Actively sucks and swallows (you should be able to hear the swallows)
- Looks satisfied after nursing
- Is content to feed every 2–3 hours (more frequent feeding can be normal during growth spurts, and for a few hours once a day, but for newborns, it may show ineffective feedings)
- Has moist lips and obvious saliva inside of the mouth
- Loses no more than 4% in the first 24 hours of life and 7% by 48 hours of life (for vaginally birthed babies); 5% and 8%, respectively, for cesarean-born babies).* See the Newborn Weight Loss Tool to evaluate your baby's loss/gain; a well-fed baby is above the yellow line on the graph (more explanation here)
- Gains about an ounce/day (after Day 4)
- Is back to birth weight by Day 10
- Has 6–8 wet diapers a day, light or pale yellow urine
- Has 3–5 dirty diapers a day (can be fewer than this depending on their age)
- Softens your breasts after feeding
Source: Fed is Best, forthcoming from BenBella Publishing (2023)
*While a 10% weight loss has recently been considered acceptable, this 2014 lecture by Christina Smillie, MD, IBCLC, explains why this is actually excessive weight loss and can result in breastfeeding problems, such as the ones discussed in this article [content warning: infant harm] by Jody Segrave-Daly, RN, IBCLC (retired).
Feed the Baby
If your goal is exclusive breastfeeding, a full milk supply will be necessary, and a well-fed baby has plenty of energy to stimulate the breasts effectively. A baby who isn’t getting enough calories will not have strength and stamina to empty your breasts well, and will often sleep more to conserve energy. This can lead to a permanent reduction in milk supply.
If your milk supply is currently low (which will be addressed in Rule 2: Optimizing Your Milk Supply), the most important thing to do is to make sure your baby is getting enough milk to fully meet their body's needs and gain weight appropriately. The earlier you start this process, the best chance of success* you will have.
Skip to Infant Milk Calculator for how much milk your baby needs
*You define “success” for your own and your baby’s breastfeeding experience.
When a newborn is not showing signs of being well fed, and is
- gaining weight slowly or hardly at all
- usually unsatisfied after breastfeeding
- sleepy (or fussy) at the breast most of the time
- having more than twelve or fewer than eight breastfeeds a day
- usually feeding for a long time (>40 min) and very frequently (<2 hourly),
there may be an issue with either your milk supply or their ability to transfer the milk that you have. (It should go without saying that neither are your fault.)
Note: sometimes these are signs of an underlying medical problem; always check with your pediatrician if your baby is not feeding well.
If your baby typically has a worried expression on their face while breastfeeding, often with a furrowed brow, this can be a sign they're not getting enough milk.
Occasional cluster feeding is normal for babies who are gaining weight well, but when your baby is nursing all the time and still not gaining, they (and your breastfeeding relationship) would benefit from increasing your baby's calories and hydration.
Many people think pumping, bottles, or formula use should be a last resort; that you always need to wait until “breastfeeding is established,” a term which is somewhat vague, or until your milk supply increases enough to be sufficient. However, when it comes to a baby with clear signs of unsatisfied hunger, a little help is needed. The average newborn burns about 300–400 calories/day (120 kcal/kg/day), which is provided by this much milk. To provide the energy to meet their daily needs, plus extra for growth, it is important to feed them until satisfied every time. An underweight baby will need more calories to catch up.
Rule number one for solving the problem is to feed the baby to satisfaction at each and every feeding. There is no advantage of waiting until your baby shows late signs of low breast milk intake, such as dehydration or persistent lack of weight gain. Keeping your baby well fed is an investment in their future energy to breastfeed well. Breast compressions will help your baby drink more while breastfeeding:
Source: International Breastfeeding Center. Used with permission.
There are many ways to supplement that will not disrupt breastfeeding; click here to learn more.
Optimize Your Milk Supply
Optimize Your Milk Supply
Simply put, a full milk supply usually makes breastfeeding much easier. A full supply is defined as the amount of milk it takes for your baby to lose no more than 4–7% of their birth weight (5–8% for c-section babies; see the NEWT for specifics),* then gain about an ounce a day from Day 4 to four months of age. This is usually accomplished by at least 25–27 oz (750–800 ml) of milk production per day by Day 14, and 30–35 oz (900–1050 ml) or more by Day 40.
*While a 10% weight loss has recently been considered acceptable, this 2014 lecture by Christina Smillie, MD, IBCLC, explains why this is excessive weight loss that can result in breastfeeding problems.
With a full supply, your baby will not have to work that hard to take large gulps of milk, will stay awake without you having to constantly stimulate them, and will become satisfied after feedings and gain weight appropriately.
To know if you are producing this amount, you can do one of these two things: (1) 24 hours of weighted feeds with a scale accurate to 2 g (you will probably have to rent it, as most commercial scales do not have this level of accuracy); (2) pump and bottle-feed for 24 hours with a high-quality double electric breast pump.
You may have heard that babies are more effective than pumps at emptying the breasts. For most mother–baby pairs, pumping is in fact just as effective as the baby; this scientific review of evidence on breast pumps reported that “a healthy breastfeeding infant removes approximately 80% of the total ingested human milk volume in 5 minutes, and an efficient breast pump removes 85% of the available milk in the breast in 15 minutes.”
So the baby may be quicker, but the end result is about the same.
(Occasionally a mother who is exclusively breastfeeding and not used to pumping will have a hard time getting milk to flow with a pump, but for the majority of mothers, pumping provides a good estimate of milk production.)
As mentioned above, when your baby is not getting enough to eat, they will not have the energy or patience to suck vigorously and calmly at the breast. They may fall asleep within a few minutes, come off and cry repeatedly, or even fight you when you put them to the breast. Your baby does not hate you or your breasts; they’re not telling you they don’t want you to breastfeed overall; your body is not broken or defective. It can just be frustrating to the baby when they’re trying hard and not getting their hunger/thirst satisfied quickly enough.
There is usually a solution to low milk production, and it is (almost) always to empty the breasts more frequently and thoroughly. (Note that the breasts are a constantly running milk factory and can never be 100% emptied. Aside from feeding the baby sufficiently, establishing your milk supply is the most time-sensitive aspect of breastfeeding success.
Babies can learn to latch at a more relaxed pace and can often learn to latch even after a few months go by, but in the first 14 days after birth, your body is actively trying to figure out how much milk to make, based on how much is taken out of the breasts and how frequently. After that, it may be more difficult (or even not possible) to develop a full milk supply. Everyone is different though; the only way to know for sure is to try.)
How to Increase Milk Production
Every 3* hours:
(1) Breastfeed for about 15 min (or until baby stops swallowing, whichever comes first).
(2) Other parent or support person bottle-feeds baby
(3) Mother pumps her breasts about 15 minutes.
*Please feel free to customize this to meet your own needs, and take a look at a modified version that prioritizes your sleep (self-care is important in helping your body be well enough to produce milk).
Feeding in this way is called “triple feeding,” because you are doing three things—breast, bottle, and pumping. It is a typical plan for babies who are not breastfeeding well, and/or mothers who have a low milk supply. I suggest trying this plan for 3–4 days, and if it is not working for you, get more individualized advice by scheduling an appointment. It is not a long-term solution, because it is hard.
Keep in mind that mothers who are pumping while others bottle feed the baby sometimes feel isolated and disconnected from their baby—it can feel like your only role is to be a milk provider while everyone else gets the fun and bonding. Make sure you get time to snuggle and you can also bottle-feed when you wish. Time with you is more important to your baby than the number of ounces of milk you produce.
Source: Kristin Coghlan. Used with permission.
What About Foods, Drinks, and Supplements?
Many cultures have foods, drinks, and herbs they use to help with milk production. While none of these have been studied sufficiently in humans, the dairy industry has research on foods that improve milk yield in cows, so it's possible. Trying various culturally recommended foods is unlikely to be harmful, but be wary of companies that sell expensive herbal blends and cookies; there is no regulation or evidence of effectiveness and safety.
The Academy of Breastfeeding Medicine states that because "current research of both pharmaceutical and herbal galactogogues [milk boosting substances] is still relatively inconclusive and all agents have potential adverse effects," they "cannot recommend any specific galactogogue at this time."
Remember, Oversupply is a Thing!
As a milk factory, many mothers' breasts are capable of producing more than one baby needs. Much more. Oversupply sounds like a good problem to have—however, it can actually be so difficult that some mothers choose to stop breastfeeding, due to constantly leaking breasts, practically drowning the baby at feedings, frequent uncomfortable engorgement, and baby often being gassy and miserable due to lactose overload. (Reducing supply is usually not usually hard though, so don’t feel like you have to stop breastfeeding if you don’t want to!)
What if Nothing Works?
Unfortunately, not everyone can produce a full milk supply, just like not everyone can get pregnant or give birth vaginally. If for biological or logistical reasons, you cannot increase your supply sufficiently, you can still breastfeed with supplementation. If your supply is very low, this technique may help you establish a mutually enjoyable breastfeeding relationship in spite of it. You are not alone, and it is not your fault:
This is often a devastating blow to mothers who had wanted to exclusively breastfeed. It’s important to understand that your baby will not be harmed (most babies thrive) drinking properly prepared formula, and your bond with your baby will be just as strong. Human milk has many wonderful qualities—but science milk is pretty amazing too, and being improved all the time. It’s still normal and ok to be sad and grieve your loss. No one should minimize your feelings.
After Rules 1 and 2 are satisfied, the third and perhaps most difficult rule needs to be addressed—fixing the breastfeeding problem.
Rule 3: Fix the Breastfeeding Problem
Rule 3: Fix the Breastfeeding Problem
Unfortunately without evaluating you and your baby directly, I can't tell you how to fix your specific problem, so you will have to follow Rule 3 by working with a lactation consultant. Make sure while you are following Rules 1 and 2, you are working on positioning and latching your baby optimally. If you have concerns about oral ties, please read this.
There are many sources from which you can find information about all manner of breastfeeding problems. The difficulty is knowing what information or expert you can trust. I recommend asking friends and family who have been successful with breastfeeding, interviewing several lactation consultants, speaking with your pediatrician, and reading evidence-based websites like the ones listed at the bottom of this page. Trust your instincts also; there will be plenty of people who say everything is fine, but if it feels like it’s not, listen to your gut and get help.
Interview several lactation consultants, and ask local mom friends for recommendations. Be wary of advice you find on the internet (says the person giving advice on the internet); run things by your pediatrician, who knows your baby and their specific health needs best.
Remember that the earlier you get help, the easier and more successful you are likely to be in solving the problem and meeting your goals. Getting Rules 1 and 2 addressed are the most time sensitive. But fixing the breastfeeding problem—especially if it is causing you physical or emotional pain—is important too, because you are important!