Evidence-based tips for breastfeeding moms: A guide for the science-minded

© 2008-2014 Gwen Dewar, Ph.D., all rights reserved

Breastfeeding may be natural, but it isn’t automatic (Volk 2009).

Here are some tips for breastfeeding moms, based on research by lactation experts, anthropologists, and social scientists.

For more evidence-based information about breastfeeding, see this collection of Parenting Science articles.

1. Don’t be bamboozled by the myth of instinctive nursing: Breastfeeding is a skill that must be learned — by mothers and babies

You might assume that effective breastfeeding techniques are in some way “hardwired” into the human brain. How else would our ancestors have survived?

But if you take a look at our closest living relatives — the nonhuman primates — you’ll notice that first-time mothers are less competent about breastfeeding, and sometimes they manage very poorly indeed (Hrdy 1999; Smith 2005; Volk 2009).

This is especially true for animals that have been raised in captivity and denied prior opportunities to handle infants and watch other mothers nurse; which, if you think about it, is the situation that many first-time human mothers find themselves in.

So mothers have to learn breastfeeding, and human babies do too.

Yes, babies are born with a sucking reflex. Studies also show that newborns are attracted to the scent of their mothers’ breasts (Varendi and Porter 2001). But, as I note below, human breasts are tricky.

The best way to extract milk isn’t through straightforward suction or the squeezing of nipples. Instead, babies need to put pressure on the areola, and to do this they must latch on in just the right way. It takes practice, and you’ll probably know when your baby is doing it wrong, because it hurts.

None of this means you have to be tutored by an expert. Experienced mothers and lactation experts can be very helpful, but so can trial-and-error. The important point is that breastfeeding is not automatic.

2. Make sure the baby is properly latched

In the early days of breastfeeding, women often experience sore nipples. They may also feel a tugging, pins-and-needles sensation during the let-down or milk ejection reflex. But they shouldn’t be experiencing acute pain every time the baby begins to nurse. If you experience this sort of pain, your baby is probably not latching on correctly. Other signs of a poor latch include

  • Sounds of the baby gulping air
  • Dimpled or sucked-in cheeks

The baby should have more than the nipple in her mouth. She should take in a lot of breast tissue as well, so that the nipple is far in the back of the baby’s mouth and the baby can press on the areola during feeding. As noted above, it may be this pressure on the areola that is most important for the flow of milk (Woolridge 1986).

If you suspect a bad latch, gently detach your baby (by slipping your finger in his mouth to break the suction) and start over:

  • Tickle the side of the baby’s mouth to stimulate the gaping reflex
  • When the baby’s mouth is wide open, insert the breast deep into the baby’s mouth so that the nipple ends up being far in the back

3. Breastfeed on demand, particularly during the newborn period

To ensure an adequate milk supply, and a satisfied baby, feed your baby on cue and for as long as he shows an interest. Let your baby decide when to switch breasts. Restricting a baby’s time at the breast may deprive him of the more nutritious, higher-fat hind milk associated with softer, emptier breasts.

To review the scientific basis for breastfeeding on demand, see my articles on the infant feeding schedule and breastfeeding on demand.

4. Experiment with different breastfeeding positions

Thoughts of breastfeeding might conjure up images of the “cradle” hold, in which the infant’s head is held in the crook of the mother’s arm. But there are many alternative positions to this position, some of which your baby might prefer, and varying positions can help you cope with clogged milk ducts and mastitis (see below).

For an instructional guide to breastfeeding positions, and more tips for breastfeeding moms, see The Mayo Clinic’s website.

5. Watch out for clogged milk ducts and take steps to prevent mastitis.

One of the many channels delivering milk can become blocked, either at the site of the nipple pore or deep inside the breast. When this happens, the area will be sore or painful, and you will usually be able to feel a hard lump. When the area becomes inflamed, the condition is called mastitis, and may be accompanied by fever and flu-like symptoms.

If you think you have mastitis, you should consult your physician. In some cases the site becomes infected and requires antibiotics. But you can do a lot to prevent mastitis:

  • If you have a clogged duct or mastitis, don’t back off breastfeeding. To get better, you need to empty your breast. Discontinuing the flow of milk will contribute to engorgement and increase your risk of complications. 
  • Attend to those hard lumps right away. Massage or squeeze the area to force the milk to flow in the direction of your nipple. Some women are prone to more frequent lumps. With vigilance, these can be managed before they cause illness.
  • If you notice that an area of your breast is consistently left undrained after nursing, investigate different breastfeeding positions. Different positions put demands on different ducts.
  • Be careful with the manual breast pump. A study of 946 breastfeeding women found that use of a manual breast pump strongly predicted mastitis (Foxman et al 2002).

6. Don’t feel that breastfeeding is an “all or nothing” proposition.

Many agencies, including the World Health Organization, recommend exclusive breastfeeding for the first six months. And some people talk about breastfeeding as if it’s an all-or-nothing proposition? But is it?

Numerous studies suggest that babies experience fewer gastrointestinal infections when they are exclusively breastfed for 6 months or more. Babies may also suffer fewer respiratory infections. But it’s not yet clear that long-term, exclusive breastfeeding offers any special advantages with regard to growth, intelligence, behavior, or body mass index later in life (Kramer and Kakuma 2012). Not if your baby is otherwise well-fed.

For example, some researchers tracking babies over time have found modest links between exclusive breastfeeding and children’s IQs, with larger effects for children who breastfed longer (Jedrychowski et al 2012). But in other cases, researchers have failed to find any significant differences between exclusive and partial breastfeeders. Breastfeeding was linked with a cognitive advantage, but there was no dosage effect (McCrory and Murray 2013).

7. Consider safe co-sleeping

Throughout most of human history and in most cultures, babies have slept with their mothers close at hand. You might wonder if co-sleeping will deprive you of even more sleep, but studies show that moms who share beds with their infants enjoy the same total sleep time as mothers who don’t (McKenna et al 1999). Many co-sleeping moms find co-sleeping to be less disruptive because they don’t have to wake “all the way up” to breastfeed their babies.

But there are important safety concerns. In particular, beds designed for Western adults include features that are hazardous for babies–features like soft mattresses, loose bedding, and crevices in which babies can become trapped. And some people–like smokers or people who are very tired–shouldn’t sleep on the same surface with a baby.

For these reasons, many researchers recommend that parents co-sleep by keeping their babies on a separate sleeping surface, like a “side car” style bassinet.

For scientific information about co-sleeping–and safety guidelines–check out my article about bed sharing with infants.

In addition, check out the website for Dr. James McKenna’s Mother-Baby Behavioral Sleep Laboratory of Notre Dame University. McKenna is an anthropologist and world-renowned expert on infant sleep, sudden infant death syndrome, and breastfeeding.

8. Realize that “sleeping through the night” is a Western ideal

Some books or websites offering tips for breastfeeding moms seem to imply that failure to “sleep through the night” is a pathology. Although medical problems are sometimes the cause of lost sleep, the truth is that short sleeping bouts are biologically normal—-for both adults and babies.

Western culture is enamored with the idea of sleeping for 7-8 hours at a stretch, and babies are expected to conform to this pattern within a few months of birth. But there is no biological basis for this expectation. At best, older babies might learn to sleep for 4-5 hours at a time. Parents who claim their babies sleep longer are usually unaware that their babies have awakened during the night.

And cross-cultural evidence strongly suggests that the idea of sleeping through the night—-for adults or babies–is a Western peculiarity. In non-Western cultures, people sleep in shorter intervals, and are less regular about the timing of sleep (Worthman and Melby 2002).

Although knowing this won’t solve all your sleeping troubles, it may help to realize that there is nothing wrong with you or your baby if you aren’t sleeping like logs. In fact, long bouts of deep sleep may put babies at increased risk of SIDS (McKenna et al 1999). As Western sleep researchers are becoming aware of the anthropological evidence, they are coming to revise their notions about sleep disorders.

Read more in my article about night wakings.

9. Dangerously sleep deprived? Consider occasional bottle-feeding.

Should you accept that offer from a friend to babysit (and bottle feed) while you take a long nap? Lactation experts discourage new moms from bottle feeding babies for the first 3-4 weeks. The fear is that supplemental feeds will lead to a decreased milk supply and endanger successful breastfeeding in the long-term. Some workers also worry about “nipple confusion”—the idea that babies will become accustomed to the ease of sucking milk from a bottle and will subsequently reject the more challenging human breast.

But mothers need to weigh these risks against the risks of severe sleep deprivation. Sleep deprivation parents are more accident-prone and at higher risk for developing postpartum depression. An occasional 3-4 hour breastfeeding break is unlikely to imperil your breastfeeding success, and may have crucial benefits.

10. If you have a breast pump, use it wisely

The breast pump is an essential device for breastfeeding women who must spend many hours away from their babies. Unfortunately, however, pumping can interfere with the natural feedback process between mom and baby.

Pumping too frequently can lead to milk overproduction, which can lead to painful, engorged breasts, clogged milk ducts, and infections (see #5 above). It may also make the milk too quickly for suckling babies to deal with.

Just as importantly, full breasts can interfere with the quality of your milk supply. When breasts are full, the milk that comes out is low-fat “foremilk.” Only when breasts are soft—more empty—do breasts start to produce the higher-fat hind milk. Babies presented with full breasts may fill up on low-fat milk, which can cause colic and gastric problems (Woolridge 1995). Such babies may also have to feed more frequently to get enough calories.

11. Don’t stress about giving equal time to each breast

If your baby feeds from one breast more often than another, you will develop a certain asymmetry in milk productivity. But guess what? You’re probably a bit asymmetrical anyway. Michael Woolridge and his colleagues have measured asymmetries in breast milk output among mothers with no “obvious bias in breast use” (Woolridge 1995).

The preoccupation with switching breasts may be a Western quirk. Most babies develop a preference for one breast, and—-in many cultures—-it’s not uncommon for babies to feed from only one breast at each feeding (Woolridge 1995). This may increase the baby’s fat intake (see discussion above).

12. Check your vitamin D levels

Research suggests that the standard recommended daily dose of vitamin D is inadequate for many lactating mothers, and as a result their babies may suffer from vitamin D insufficiency.

In one study that monitored both mothers and infants, the authors concluded that “with limited sun exposure, an intake of 400 IU/day vitamin D(3)” in mothers “supplied only extremely limited amounts of vitamin D to the nursing infant via breast milk” (Wagner et al 2006).

Other studies have found that doctors could remedy vitamin D deficiency in nursing infants by prescribing much higher levels of vitamin D to their mothers (e.g., Kovac 2008; Marshall et al 2013; Oberhelman et al 2013).

The upshot? You don’t want to put yourself on megadoses of vitamin D, because too much D is toxic. But you should discuss vitamin D levels with your physician, and pursue treatment if you or your baby is diagnosed with an insufficiency.

13. Consume the “good” fats

Breast milk is the original baby food, but we should remember that it evolved in the context of a Paleolithic diet.

Dietary surveys of hunter-gatherers around the world–as well as archeological remains–suggest that our ancestors ate far more vegetable foods and consumed much leaner meats than is typical among many modern populations (Eaton et al 1999). Their diets were low in cholesterol and sodium, and biased in favor of a particular kind of fat. Instead of taking in large quantities of saturated fats, hunter-gatherers ate more polyunsaturated fatty acids(PUFAs), like omega-3 fatty acids, which are important for brain development.

There is reason to think these dietary differences are consequential to babies. For instance, several studies suggest that infants who are breastfed by mothers consuming Western diets high in saturated fat are more liable to develop high cholesterol and blood pressure levels later in life (Leeson et al 2001; Mott et al 1991). And researchers speculate that omega-3 fatty acids in breastmilk may help compensate for dietary fat imbalances babies experienced during gestation (Bernard et al 2013). A heathful maternal diet — that includes more PUFAs and fewer saturated fats — may therefore benefit your baby.

Fish oil is an excellent source of PUFAs. However, because some fish are contaminated with dangerously high levels of mercury, you must be cautious about which fish you eat. The USDA offers these guidelines regarding the choice of fish.

14. Avoid caffeine and alcohol, and check the safety of medications and herbal remedies

Caffeine can make your baby irritable and sleepless. And contrary to the old wives’ tale, alcohol actually decreases a woman’s milk production (Mennella 2001). It also interferes with a baby’s ability to sleep (Mennella and Gerrish 1998).

Many ingested foods and supplements can be transferred to an infant through breast milk. Some of these are reasonably safe, others are not (American Academy of Pediatrics Committee on Drugs 2001). Lactation consultants and pediatricians can advise you on the safety of specific substances.

More reading

In addition to the links above, see my article about the composition of breast milk. It provides nutritional information and offers other tips for breastfeeding moms.

References: Tips for breastfeeding moms

There are thousands and websites, articles and books featuring tips for breastfeeding moms. Here are some select publications.

Kathleen Huggins’s bestseller, The Nursing Mother’s Companion (2005: Harvard Common Press) has been in print for over 20 years and is now in its 5th edition. Many mothers love its explicit and comprehensive problem-solving approach. It includes a guide to nursing positions, safe medications, and many other tips for breastfeeding moms.

Another source of tips for breastfeeding moms is Janet Tamaro’s humorous, non-preachy, best-selling book, So That’s What Those Are For, 3rd edition (2005: Adams Media).

You can find more tips for breastfeeding moms among the scientific publications I cited in this article:

American Academy of Pediatrics Committee on Drugs. 2001. The Transfer of Drugs and Other Chemicals Into Human Milk. Pediatrics 108: 776-789.

Bernard JY, De Agostini M, Forhan A, de Lauzon-Guillain B, Charles MA, Heude B; EDEN Mother-Child Cohort Study Group. 2013. The dietary n6:n3 fatty acid ratio during pregnancy is inversely associated with child neurodevelopment in the EDEN mother-child cohort. J Nutr. 143(9):1481-8.

Eaton SB, Eaton SB III, Konner MJ. 1999. Paleolithic nutrition revisted. In: Evolutionary Medicine, WR Trevathan, EO Smith and JJ McKenna (eds). Oxford: Oxford University Press.

Hrdy SB. 1999. Mother nature: Maternal instincts and how they shape the human species. New York: Pantheon Books.

Jedrychowski W, Perera F, Jankowski J, Butscher M, Mroz E, Flak E, Kaim I, Lisowska-Miszczyk I, Skarupa A, and Sowa A. 2012. Effect of exclusive breastfeeding on the development of children’s cognitive function in the Krakow prospective birth cohort study. Eur J Pediatr. 171(1):151-8.

Kovacs CS. 2008. Vitamin D in pregnancy and lactation: maternal, fetal, and neonatal outcomes from human and animal studies. Am J Clin Nutr.  88(2):520S-528S.

Kramer MS and Kakuma R. 2012. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2012 Aug 15;8:CD003517.

Leeson CPM, Katterhorn M, Deanfield JE and Lucas A. 2001. Duration of breastfeeding and arterial distensibility in early adult life: population based study. BMJ 322: 643-7.

Oberhelman SS, Meekins ME, Fischer PR, Lee BR, Singh RJ, Cha SS, Gardner BM, Pettifor JM, Croghan IT, and Thacher TD. 2013. Maternal vitamin D supplementation to improve the vitamin D status of breast-fed infants: a randomized controlled trial. Mayo Clin Proc. 88(12):1378-87.

Marshall I, Mehta R, and Petrova A. 2013. Vitamin D in the maternal-fetal-neonatal interface: clinical implications and requirements for supplementation. 26(7):633-8.

McKenna J, Mosko S, and Richard C. 1999. Breastfeeding and mother-infant co-sleeping in relation to SIDS prevention. In: Evolutionary Medicine, WR Trevathan, EO Smith and JJ McKenna (eds). Oxford: Oxford University Press.

McCrory C and Murray A.The effect of breastfeeding on neuro-development in infancy. Matern Child Health J. 17(9):1680-8.

Menella JA and Gerrish, CJ. 1998. Effects of exposure to alcohol in mother’s milk on infant sleep. Pediatrics 101(5):21-25.

Mennella JA. 2001. Alcohol’s Effect on Lactation. Alcohol Research & Health 25(3):230-234.

Mott GE, Jackson EM, McMahan CA, and McGill HZ. 1990. Cholesterol metabolism in adult baboons is influenced by infant diet. J Nutrition. 120:243–251.

Smith HJ. 2005. Primate parenting. New York: Harvard University Press.

Wagner CL, Hulsey TC, Fanning D, Ebeling M, Hollis BW. 2006. High-dose vitamin D3 supplementation in a cohort of breastfeeding mothers and their infants: a 6-month follow-up pilot study. Breastfeed Med. 1(2):59-70.

Woolridge MW. 1986. The ‘anatomy’ of infant sucking. Midwifery 2:164-171.

Woolridge MW. 1995. Baby-controlled breastfeeding: Biocultural implications. In: Breastfeeding: Biocultural perspectives. P. Stuart-Macadam and KA Dettwyler (eds). New York: Aldine deGruyter.

Worthman CM and Melby M. Toward a comparative developmental ecology of human sleep. In: Adolescent Sleep Patterns: Biological, Social, and Psychological Influences, M.A. Carskadon, ed. New York: Cambridge University Press, pp. 69-117.

Varendi H and Porter RH. 2002. The effect of labor on olfactory exposure learning within the first postnatal hour. Behav Neurosci. 116(2):206-11.

Volk AA. 2009. Human breastfeeding is not automatic: Why thats so and what it means for human evolution. Journal of Social and Cultural Evolutionary Psychology3: 305-314.

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Content of “Tips for breastfeeding moms” last modified 2/14