Birth and Immediately After

• Immediate skin-to-skin and baby-initiated breastfeeding without interruption for 30-60 minutes

• If IV fluids were given during labor, consider using a 24-hr weight instead of an immediate birth weight when measuring for weight loss/weight gain

• Consult an International Board Certified Lactation Consultant (IBCLC) to help with initial latch

• Frequent nursing and skin-to-skin, no less than every two hours from the start of each feed. If not nursing, milk should be expressed every two to three hours

• Both breasts should be offered at each feed

• If there is a history of low supply or if baby doesn’t latch well or latch assistance devices such as nipple shields are needed, consider hand expressing or pumping colostrum/milk for 10-15 minutes following a feeding 

It is often evident soon after birth if supplemental formula/milk/colostrum is needed. If baby loses more than 7% of birth weight (10% if IV fluids were used), begin supplementing quickly.

Other reasons to begin supplementing include:

• Slow/no weight gain: Baby should reach birth weight by two weeks and gain approx 5.5 - 8.5 oz per week for the first four months — see average weight gain link below

• Output concerns: lack of wet diapers, diapers not wet enough, brick dust in the diaper, passing meconium on Day 4 or later — see table below

• Nursing concerns: A poor latch and/or mother/infant separation

• Certain medical conditions: Including, but not limited to, jaundice or low blood sugar

Bottle feeding, supply line (SNS) feeding, syringe, cup, and spoon are all acceptable methods of supplement. If using bottles, select the slowest flow nipples and use a pace feeding method to avoid the development of a flow preference.

Average Reported Intake of Colostrum By Healthy,
Term Breastfed Infants 

Time             Intake 

1st 24 hours        2–10 ml/feed

24–48 hours        5–15 ml/feed

48–72 hours        15–30 ml/feed

72–96 hours 30-60 ml/feed

Source: ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017

Adequate Diaper Output - First 6 Weeks

Day 1: 1 wet diaper, meconium stool
Day 2: 2 wet diapers, dark stool
Day 3: 4+ wet diapers, brown/light brown stool
Day 4 - 6 weeks: 6+ wet diapers; 3-4+ yellow stools

A sufficiently wet diaper for a young baby is 3 tablespoons or 45mls. For an older baby, 4-6 tablespoons or 60-90mls. If baby is far exceeding the number of wet diapers on the chart, this amount may be slightly less. Pour water into a clean diaper so you can compare and get used to the weight. 

Source: KellyMom. More on what to expect when nursing a newborn

Average Weight Gain for Breastfed Babies (U.S. units)

Average Weight Gain for Breastfed Babies (metric units)

Establishing Supply

THE FIRST RULE IS TO FEED THE BABY.
You may have heard that introducing supplement will prevent you from establishing a good supply. But a baby who has enough energy to nurse effectively will help your supply far more, as long as you are continuing to remove milk when giving supplement. Babies who do not get enough milk in the early days can sleep more than usual and even act content in an effort to conserve energy. It is therefore important to monitor diaper output as well as growth trajectory.

• Until reaching birth weight, baby should feed 10-12+ times in a 24 hour period

• Baby should be woken to eat every two hours during the day as needed and should no be allowed to go more than one four hour stretch between feeds at night

• Baby should gain approximately 0.6 - 1.2 oz per day, or what is appropriate for baby’s age

  • Average Weight Gain for Breastfed Babies (U.S. units)

  • Average Weight Gain for Breastfed Babies (metric units)

• Do not panic if you need to offer supplement!

• Once baby has passed birth weight and are gaining well, baby can be allowed to sleep for longer periods, but you should still aim for 8-12+ feeds per 24 hour period.

• It is best to offer smaller supplements throughout the day and feed baby on demand, to satiation. Supplements should be offered in conjunction with nursing and pumping, as applicable, rather than by themselves in place of nursing or pumping. For example, it is better to give a smaller amount after every nursing session than a large feed at bedtime. 

Pump/Nurse Frequently
In order to bring in a full supply, most parents need to remove milk via nursing or pumping 10-12 times per 24 hours for the first six weeks. Low supply parents will often pump for an additional 10-15 minutes after nursing during the early weeks to signal increased demand. When combined with bottle feeding as well, this is called triple feeding. It may be especially helpful if baby does not transfer milk well, but can be emotionally and physically grueling and is not recommended to continue past 1-2 weeks unless no other options are possible or desired by the parent (e.g. at-breast supplementation, nursing only, exclusive pumping, combined nursing/pumping in the same feed).

MOTN (Middle of the Night) Removals
Prolactin, one of the most important hormones for milk production, peaks in the early morning hours, and most parents will find that this is the time period during which they produce the most milk. Decreasing removals during these hours will usually lead to decreased milk production, especially if MOTN removals are dropped in the first 6-8 weeks of life.

Find a Supportive Provider
If you are struggling with supply, finding an LC/IBCLC that you like and trust and working closely with this individual or another medical professional to monitor weight gain can be very helpful. Weight checks are recommended one or two times per week until supply is established.

• Find an IBCLC

• If you are struggling to find a supportive lactation consultant, contact us and we may be able to provide suggestions depending on your location

Evaluate Potential Oral Issues
Tongue and lip ties, as well as other oral dysfunction, can prevent baby from removing milk effectively. Consider having baby evaluated by a knowledgeable provider such as a pediatric dentist with Tethered Oral Tissues (TOTs) training.

Take Care of You!
Remember, stress and sleep deprivation can have an impact on supply too. A happy, healthy parent is what your baby needs most, so you may find that choosing to implement some, but not all, best practices is best for your mental health.