Love, Starts from Breastfeeding...

(Content revised 10/2021)

To Expectant Parents…

Dear Mum and Dad,

I'll meet you soon!

While you are busy preparing my cot and other things, have you thought of giving me the most precious gift to help me grow strong and healthy? Yes! That's breastfeeding!

I am growing day by day in Mum's womb. I hope when I am born I can breastfeed, while Mum cuddles me warm and safe. I would get all the nourishment I need and the unique natural antibodies and living immune cells.

Some parents choose to feed their babies with formula milk. Formula milk comes from cow's milk, and is no comparison to the natural milk from Mum. Formula milk does not have antibodies, nor will it adjust its nutrients according to my needs. It might pose other risks as well.

I hope you can take some time and read this booklet carefully, and learn why breastfeeding helps me for years to come. I can't wait to enjoy Dad being next to Mum while I breastfeed.

From your beloved baby …

Table of contents

Chapter 1 - Breastfeeding is the Foundation of Life

As recommended by the World Health Organisation, babies should be exclusively breastfed in the first 6 months. Solid food should be introduced gradually at around 6 months old to cater for their nutritional needs. Continue to breastfeed up to 2 years old or beyond.

Benefits of breastfeeding

Babies

  • It reduces the risk of:
    • Diarrhoea
    • Chest infections
    • Respiratory tract infections
    • Middle ear infections
    • Obesity
    • Future diabetes
  • It helps:
    • Digestion
    • Accepting new food

Builds a close relationship between mother and baby

Mothers

  • It reduces the risk of:
    • Breast cancer and ovarian cancer
    • Bleeding after delivery
    • Diabetes
  • It helps body slimming
  • It saves time and money
  • It is convenient, and protects the environment

* Preterm, sick, jaundiced babies need breastfeeding even more!

* Reduces the risk of necrotising enterocolitis in premature babies

Contains natural antibodies that enhance immunity

During pregnancy, antibodies are transferred to the baby via the placenta. However, these antibodies will be gone by about 6 months after birth. In the first 2 to 3 years of life, babies can easily pick up infections due to their immature immune systems. Breastmilk contains natural antibodies, living immune cells, enzymes, etc that timely reduce the risk of infection.

Exclusive breastfeeding provides all the energy and nutrition babies need in their first six months of life

Offers comprehensive nutrition that promotes development

Breastmilk is a living fluid. Mothers are able to produce breastmilk with a varied combination of nutrients that are specific and meet their babies' needs at different stages of growth. Nutrients in breastmilk, such as omega-3 fatty acid (e.g. DHA) and taurine, help babies develop their brain, eyes and the digestive system etc. Different ingredients are added to formula milk to imitate breastmilk. Currently there is insufficient evidence to indicate these ingredients are beneficial to babies' long term health.

Exclusive breastfeeding

In exclusively breastfed babies, antibodies and other components in the breastmilk protect their gut, reducing their risk of infection

Unnecessary supplementation with formula milk or water will reduce the babies' desire for breastfeeding, resulting in a decrease in breastmilk production

Direct breastfeeding

The benefits of breastfeeding are not limited to the composition of breastmilk…

  • During breastfeeding and skin-to-skin contact, both mum and baby release "love hormone" (oxytocin) which enhances bonding with each other:
    • For babies: It stimulates emotional, intellectual and brain development to build happy and confident kids
    • For mothers: It relaxes their body and mind, boosts happiness and nurtures their motherly love
  • Direct breastfeeding helps with responsive feeding
  • The baby takes the lead on the breast and does not overeat, thereby reducing the risk of future obesity and diabetes
  • Suckling on breast promotes oral muscle development and reduces malocclusion (such as protruding teeth)

Some mothers wish to know the exact amount of milk consumed by their babies and give up direct breastfeeding. However, the milk consumed varies between babies and between feeds. Responding to the babies' cues would better satisfy their physical and psychological needs

Raising a smart and happy Kid

Connecting and interacting with your bump promotes your baby's brain development

At around 20 weeks, the unborn baby begins to hear and tunes in to the mother's attentive love.

Expectant parents can interact more with the baby before birth by:
  • Gently stroking the bump
  • Sensing the baby's movement
  • Talking to her
  • Singing a song
  • Listening to music with her (Don't play the music directly on the bump)

Invite elder brothers or sisters to bond with the bump. This helps build a close and loving relationship in the family.

Connecting with your baby

After the baby arrives, parents can:

  • Engage in skin-to-skin contact with their baby
  • Room-in with the baby
  • Observe and respond to the baby's needs by feeding responsively, cuddling, holding, talking to and singing to her...

When babies are kept close to their parents and their needs are responded to, they will become happy and confident children and adults

A close and loving relationship between parents and babies:
  • When babies feel loved, they release "love hormone" instead of stress hormone
  • These help build the babies' brain and lay foundation for their lifelong health
  • It also releases "love hormone" in the parents, which boosts bonding and parenting skills
  • Babies will feel secure, stay calm and cry less

Getting ready for breastfeeding since pregnancy

Your breasts begin to prepare for lactation about the time you get pregnant, and begin to produce colostrum at around the second trimester

Did you know?

Changes in breasts begin in pregnancy

Expectant mothers may feel breast fullness and notice darkening of nipples and areolae, some even leaking of small amounts of milk. Some may have small accessory breasts under their armpits. Sebaceous glands may appear as small bumps around the areolae

Throughout pregnancy and lactation, sebaceous glands (also known as Montgomery Glands) may increase in size and number, giving off

  • Oil: lubricates nipples and areolae
  • Anti-infective property : keeps germs away
  • The mother's scent : help lead the baby to the breast

Do not wash your nipples off with soap before each breastfeeding

Did you know?

Size of breasts does not affect the milk production

Even if the breasts are relatively small, the amount of breastmilk produced is not affected, although they may store less milk per feed. Your baby will increase the frequency of feeding, if needed, to maintain the total daily breastmilk intake

Mothers with flat or inverted nipples can breastfeed successfully

To suckle and get milk properly, a baby draws the nipple and most of the areola into her mouth and not just the nipple

Watch video

Successful breastfeeding requires the concerted effort of the mother, the baby and the family, to learn, adapt and overcome challenges together

  • Some babies may not suckle effectively. There may be excessive weight loss, dehydration or severe jaundice
  • Some mothers may feel frustrated because of doubts and stress, while others may experience sore nipples, blocked ducts or mastitis due to inappropriate breastfeeding skills

Expectant parents should prepare early, familiarise themselves with breastfeeding knowledge and seek family support. Most mothers can successfully breastfeed their babies if they sHow to feed your babyarly should difficulties arise.

Please read "How To Feed Your Baby It's Your (Informed) Decision [Combo Set]"

Antenatal talks, Breastfeeding coaching and Breastfeeding support groups

The longer a baby is breastfed, the more health benefits the mothers and their babies will have

Chapter 2 - Breastfeeding is the Best Start for Your Baby

Your baby has to adapt to the new world outside the womb. As he grows and develops, he will give out signals to indicate his needs. Parents should observe, understand and satisfy their baby's physical and psychological needs.

Intimate skin-to-skin contact

In the delivery room:

Within the golden first hour, immediate skin-to-skin contact until the end of the first feed from the mother's breast

  1. Lies on mum's bare chest
  2. Smells and seeks
  3. Gazes at mum
  4. Approaches the breast
  5. First colostrum feed!

Watch video

  • It extends the heartwarming attachment between you and your baby, keeps him warm, steady his heart rate and breathing, and provides a sense of security
  • Exposure to the beneficial bacteria from your skin helps the growth of his normal flora
Tips

Mother-friendly childbirth practices such as skin-to-skin contact are in place in many hospitals. Please inquire at your birthing hospital for details

Frequent skin-to-skin contact with your baby:
  • Helps milk flow and reduces breastfeeding difficulties
  • Comforts your baby (especially when he cries)
  • Enhances bonding between you and your baby

Dad : I feel blessed!

Baby : This is so sweet!

Mum : It makes direct breastfeeding easier!

During breastfeeding and skin-to-skin contact with your baby, please note that:
  • Mother can adopt a semi-reclined or sitting position, instead of lying on the bed
  • The baby's mouth and nose should not be covered
  • Pay attention to the baby's skin colour and breathing
  • Mother should put the baby back in his crib if she feels sleepy

Responsive feeding

Parents' prompt response to the baby's needs is crucial to the baby's brain development. It also helps establish a mutual loving and trusting relationship

Watch video

  • Start feeding your baby when he gives early hunger cues
    • Stirring
    • Mouth opening
    • Turning head, seeking / rooting
  • Stop feeding once your baby shows signals of fullness
    • Signs of fullness: suckles slowly, relaxes arms and feet, releases the breast, looks satisfied or falls asleep
  • Whether feeding breastmilk or formula milk, let the baby decide when to start or stop
  • Feeding does not require a strict schedule, and the amount taken by the baby each time may not be the same

Crying or fussing is a relatively late hunger cue

  • Do not wait to feed your baby until he is very hungry and cries. This may affect his suckling
  • Although the mouth is wide open, his tongue curls up and hinders proper attachment!
  • You can calm your baby with skin-to-skin contact before feeding him

Breastfeeding responsively not only provides nutrition, but also fosters love, comfort and reassurance between mother and baby

Mum:Direct breastfeeding satisfies the baby's and my physical and psychological needs

Baby:I want to be close to my mum more often

  • A directly breastfed baby cannot be overfed
  • Breastfeeding becomes the first action when responding to a baby's various needs. Suckling the breast fulfills a baby's need to feel close to and loved by his mother, bringing a sense of security
  • Mother can offer her breast to comfort and care for her baby when he is crying, distressed, fuzzing, lonely, or unsettled e.g. after vaccination
  • Aids direct breastfeeding and enhances milk production
  • A mother can offer her breast to meet her own physical and psychological needs. For example:
    • When she wants to cuddle with her baby
    • Before she goes out
    • When her breasts feel full
  • As the baby grows, mother may respond to his needs in other ways

    Parents unable to directly breastfeed their baby should also respond to his needs in a timely manner

Breastfeeding day and night

Frequently feed your baby to meet his needs day and night for the first few weeks of his life

  • It can fill his very small stomach
  • This allows him to grow quickly
  • Keeping the new baby close to his parents day and night helps him to feel secure and loved
  • Removing milk from the breasts frequently will increase milk production
  • More milk-producing hormone is secreted at night
  • Prevents milk stasis like engorgement, blocked ducts etc

Rooming-in

Keep your baby close in a cot day and night by the side of your bed:

  • You can respond to his needs and reach him easily
  • You can get to know while bonding with your new baby, and support his brain development
  • It boosts your confidence to care for your baby
  • It reduces the risk of Sudden Infant Death

Safe Sleep Sweet Dreams

Tips :

Many hospitals support rooming-in, keeping mothers and babies in the same room. Please discuss with your birthing hospital for details

Coping with night feeds

  • Keep the room fairly dark and quiet
  • Place the cot next to your bed so that you can respond to his needs before he starts crying
  • You may consider to feed your baby whlist lying in bed
  • Prepare the required items in the room beforehand
Tips for Partners:
  • Support mum, praise her and acknowledge her efforts
  • Encourage and help mum to get as much rest as possible. Help to change nappies, burp and bathe the baby, etc
  • When it's breastfeeding time, bring her drinks and snacks, pass her cushions and bring the baby to her

Keep your baby close, respond to his cues

Mothers and babies learn and adapt together day and night
  • As you breastfeed your baby according to his needs, your milk production and feeding skills will improve
  • Your baby will also gradually settle into a feeding rhythm that is right for you both

Tips to increase milk supply

Start breastfeeding as early as possible

Immediately after birth, start skin-to-skin contact and breastfeed your baby, so he can start to learn suckling before your milk "comes in"

Responsive feeding

Your newborn needs to be fed frequently because his stomach is very small. Recognise his early hunger cues and feed him without restricting schedule or amount

Feeding at night

Your baby cannot tell day from night when asking for a feed. It is convenient to feed him by keeping him close in a cot next to your bed. You have more milk-producing hormone at night. Hence night feeds help boost milk supply

Ensure proper attachment and suckling

If your baby attaches and suckles properly, he will get enough milk and prevent your nipples from getting sore. Seek help from healthcare professionals if you have any problem with breastfeeding

Ensure effective removal of breastmilk

Having skin-to-skin contact before breastfeeding can enhance milk flow. However, if your baby does not suckle well, express the retained milk after breastfeeding

Pain relief

Any kind of "pain", including wound and breast pain, can diminish the milk flow. You can relieve the pain by using painkillers (paracetamol is compatible for lactating mothers), applying a cold compress on your breasts, or adopting a comfortable breastfeeding position

Getting adequate rest

Nap while your baby sleeps, get your family or helper to do the housework, simplify the chores, and minimise guest visits in order to have more rest time

Balanced diet

Maintain a balanced diet so you have enough nutrients to ensure the quality of your breastmilk. Keep yourself well hyrated with water and broth

Tips

It may take a few days or several weeks to see the increase in milk supply

You can do it!

Do not supplement with water or formula milk lightly

Giving water or formula milk will fill up your baby's tiny stomach, reduce his desire to feed at the breast, and lead to decreased milk production.

Do not use pacifiers or bottles sparingly

Sucking the teat is different from suckling at the breast. Teats may affect some babies' ability (especially preterm babies) to learn and master effective breastfeeding. If you wish to use teats, you may consider using them when effective breastfeeding is established.

Avoid excessive expression of breastmilk

Excessive expression may cause over-production of breastmilk. Your breast become engorged and the risk of blocked duct and mastitis increases.

Breastmilk is a living substance
It changes feed by feed and day by day to accommodate the growth of your baby

Making milk to match the baby's needs

Baby starts suckling at the breast

  • Effective suckling and frequent feeding
  • Most breastmilk has been removed
  • Message from the breasts
    • Less milk left = high demand
  • Gradual rise in milk production
  • Increase milk supply

Baby starts suckling at the breast

  • Ineffective suckling or infrequent feeding
  • Most breastmilk is left in the breast
  • Message from the breasts
    • Much left-over = low demand
  • Gradual reduction in milk production
  • Decrease milk supply

Chapter 3 - Breastfeeding Makes Every Moment Count

Feeding Journey

First day after delivery

Mum : I can

  • Breastfeed my baby as early as possible. Do not wait until the milk "comes in"
  • Feed according to my baby's needs. Breastfeed at least 3-4 times on the first day
  • Approach healthcare professionals for breastfeeding coaching to assess whether my baby attaches properly
  • Put my baby's cot beside my bed, so I can easily observe my baby's needs and readily respond
  • Sleep at the same time as my baby sleeps and minimise guest visits to get as much rest as possible

If you cannot directly breastfeed your baby:express milk within 2 hours of delivery and frequently afterwards, so that you can feed your baby with colostrum and prevents delayed "come-in"

Watch video

Understanding colostrum

  • Your breasts begin to produce colostrum since the second trimester of pregnancy
  • You will not feel breast fullness with the small amount of colostrum
  • The scanty thick colostrum helps your baby learn how to coordinate suckling, swallowing, and breathing
  • Colostrum, full of antibodies, is the baby's first dose of "natural vaccine"

Watch video

Baby : Understand me

Activity Most alert in the first 2 hours after birth; then becomes sleepy in the next 10 hours (may wake up once or twice in-between)
Size of stomach About 5-7ml
Around the size of a marble, nicely matching the amount of colostrum
Feeding pattern Requires at least 3-4 times on the first day (Babies normally have enough reserve to cope with their needs)
Soiled nappies At least once, dark green sticky meconium
Wet nappies At least 1
Weight Mild physiological weight loss
Newborn jaundice Generally not present

*The information in the above table is based on a healthy full-term baby.

2 to 4 days after delivery

Mum : I can

  • Put my baby's cot next to my bed, so I can easily observe my baby and respond to his needs
  • Do not restrict feeding frequency. Feed my baby when early feeding cues are observed. Baby generally needs 8-12 feeds a day
  • Encourage let-down reflex before feeding
  • Baby usually needs to feed on both breasts at this stage
  • Proactively approach healthcare professionals for breastfeeding coaching to assess whether my baby attaches and suckles properly.
  • Monitor my baby's wet and soiled nappies to ensure he is taking in enough milk
  • Exclusively breastfeed my baby. Refrain from supplementing with formula milk or water lightly
  • Get as much rest and naps as I can. Limit guest visits
  • Eat well and drink enough water or broth
About "milk comes in"
  • A copious production of breastmilk results from change in hormone level and leads to hard, swollen, and painful "engorged" breasts
  • Breast engorgement impede milk flow, hindering your baby's attachment. The swelling will gradually subside within 12-24 hours
  • To help with the milk flow, you can:
    • Start early and breastfeed frequently
    • Express a small amount of milk to soften the areola. This helps your baby to attach and suckle
    • Apply a cold compress to your breast using an ice pack, cold towel, or cabbage leaf
    • Take painkillers, such as paracetamol

If your breast engorgement exceeds 24 hours or milk does not "come in" on the 4th day after delivery, seek advice from healthcare professionals as soon as possible

Baby : Understand me

Activity Compared to the first day, I am more alert and active, and wake easily. I cannot tell day from night. I use different signals, even crying, to express my needs (Please read the following page, “Crying Baby”)
Size of stomach About 22-27ml
Around the size of a ping pong ball
Feeding pattern Usually need at least 8-12 feeds in the first few days (Babies' stomach is still small and therefore requires frequent feeding)
Soiled nappies Meconium
Changes to dark brown on day 3 & 4 and then yellowish
At least twice a day
Wet nappies On Days 1 & 2, at least 1-2 times a day
On Days 3 & 4, at least 3-4 rather heavy nappies a day
Weight Physiological weight loss continues. Some babies may start to regain weight from Day 4 onwards
Newborn jaundice Level of a pigment called bilirubin in the blood increases, resulting in a yellow discolouration of the skin and eyes
Points to note with newborn jaundice
  • Visit Maternal and Child Health Centre within 1-2 days after being discharged from hospital or follow up as scheduled
  • Make sure your baby is taking enough breastmilk. It can reduce the risk of severe jaundice
  • Do not feed additional water, glucose water or formula milk

Mini Interlude (1): "The 2nd Night"

Mum: "My baby slept well yesterday, but tonight he's clingy and falls asleep after suckling for just a short while. When I take him off the breast, he cries! Is my breastmilk not enough?"

Baby: "Mum's chest is best!"

  • Having rested for a day, today I feel much more alert. This is such an exciting and interesting world:
    • I am surrounded by bright lights, noises, and weird smells…
    • I am wrapped up and left to lie alone in the cot…
    • Now and then unfamiliar uncles and aunties touch me…
  • Mum's chest is warm and safe. I am so blessed listening to her heartbeat and voice

Healthcare professional: "This is the baby's adaptation period."

  • The delivery process has tired your baby out. After taking a full-day rest, your baby will become active on the second day of life, especially at night
  • The sleep cycle of newborn babies is very short. They wake up easily
  • As babies have a small stomach and colostrum is easily absorbed, babies will feel hungry in an hour or even less. Hence they need frequent feeding
  • Frequent suckling helps increase milk production
  • Babies find it easier to adapt to the exciting new world and learn to feed from breast when mothers hold the baby in skin-to-skin contact and offer her breast frequently

Mum : "My dear baby, for you I will!"

From 5 days after delivery to 1 month

Mum : I can

  • Keep my baby close in the same room, to understand and readily respond to his needs
  • Offer my breast whenever my baby shows early hunger cues. Breastfeeds can be long or short and at varying times in the day. As a rough guide, babies generally need 8-12 feeds a day
  • Feed my baby with one breast first until it is soft, then offer the other breast. He may take it when he is not satisfied
  • Monitor my baby's wet and dirty nappies to ensure he is getting enough milk
  • Rest and take naps when my baby sleeps in short stretches. Maintain a balanced diet and drink lots of water or broth

Tips

  • Bring my baby to the Maternal and Child Health Centre or other clinics to review his health and feedings
  • Arrange a "breastfeeding coaching" with healthcare professionals, to check if he attaches and suckles properly

Seizing "calibration period"

In the first 3 to 5 weeks, your milk supply tailors to your baby's needs:

  • If milk is not taken from the breast, it will produce substances that suppress milk production
  • With your baby's effective and frequent suckling, your breasts will make enough milk to provide for his needs
  • Some mothers need to add-on milk expression to keep up the milk production
  • On the other hand, if too much milk is made, such that a mother frequently feels breast engorgement, she needs to down regulate the milk production

The more you feed, the more milk you make!

Baby : Understand me

Activity Sleeps in bursts with short cycles comprising of quiet and active sleep. Stirs and wakes up easily. Not able to tell day from night.
Size of stomach Day 7-10
Size of a large chicken egg
Around 60-80ml
Feeding pattern
  • Frequency and duration varies. Babies generally feed well with at least 8-12 times in 24 hours, and mostly feed for about 10-40 minutes each time
  • As stomach grows, breastfeeding skills improve, and the milk supply optimises, most babies feed around 7-8 times in 24 hours approaching 1 month of age
  • "Cluster feeding":some babies, whether breastfed or formula-fed, may have lots of frequent feeds close together during certain periods of a day, more common in the evening or at night, and may then sleep for longer stretches of 4-5 hours.
Soiled nappies Normal stool texture

Loose, pasty, soft and seedy

The stool can be yellowish, greenish, or brownish. There can be big variations to the frequency and texture. Usually at least twice a day, but can be up to 7-8 times due to the mild laxative effect of breastmilk

Wet nappies At least 5-6 heavy and wet nappies a day (equivalent to around 3 tablespoons or 45ml of water in a dry nappy)
Weight Regains birth weight in around 1-2 weeks, and then steadily puts on weight
Newborn jaundice Level of bilirubin normally stabilises in around 1 week and then gradually drops

Prolonged jaundice may occur in some breastfed babies, and can last more than a few weeks. Usually this is not severe and does not affect the baby's health. Please continue to follow up according to the recommendations of medical professionals

3 months old, I can arrange day-time naps and establish a good bedtime routine.

Mini Interlude (2): "Crying Baby"

Mum: "My baby keeps crying except when he is feeding or sleeping. If I pick him up whenever he cries, I might spoil him and make him more clingy. What should I do?"

Please read "Parenting Series 3 - Baby's crying" booklet

Baby: “Mum and Dad, while I'm trying my best to adapt to this world, I need lots of attention from you!”

  • hungry
  • wet nappy
  • tummy ache
  • too hot
  • too many visitors
  • lonely
  • I am not sure what I want yet
  • I wish my mum and dad to care for me!

Healthcare professional:"You will not spoil your crying baby when you promptly attune to him. Instead, you are building a loving relationship and a stronger brain for your confident and happy child."

  • Every baby is unique. Their temperament, sensitivity and response to the environment are different
  • When your baby cries, you can :
    • Cuddle him and put him skin-to-skin on your chest
    • Offer your breast
    • Sing and talk to him
  • Letting your baby "cry it out" will activate his stress hormones, make him doubt his carers, and become anxious and clingy
  • Some babies may cry intense bouts without apparent reasons, and can be daunting without an evident soothing measure. Fortunately, this condition mostly resolves when babies reach 3-4 months of life

Tips:

Please be patient and accept the baby's cries while trying out various comforting methods with love

After the first month

Mum : I can

  • Readily respond to my baby's needs
  • Prevent blocked milk ducts or mastitis, by not letting milk back up in the breasts for too long
  • Fully breastfeed my baby for 6 months, without adding formula milk or water
  • Introduce solid food to my baby at around 6 months old. Continue breastfeeding until 2 years old and beyond, or as long as my baby wishes to
Understanding "Maintenance phase"
  • Following the calibration period in the first 3-5 weeks, milk production becomes steady. Mothers experience less apparent sensation of breast fullness
  • Although milk production does not increase significantly for the next few months, exclusive breastfeeding can meet all the growth needs of babies in their first 6 months

Tips

If you often feel your breasts refill and engorge quickly, you may be suffering from oversupply, and are at more risk of developing blocked ducts and mastitis (Please read Chapter 8)

  • Interact with my Baby
  • When my baby reaches about 2-3 months old, I can arrange day-time naps and establish a good bedtime routine. Encourage my baby to fall asleep on his own (Please read "The Lullaby 1: Developing Regular Sleep Patterns" booklet)
  • Starting at about 6 months old, if my baby wakes up in the middle of the night, I will wait and let him learn to soothe himself to fall asleep, instead of responding straight away (Night feeding is normally not needed)

Tips

If you often feel your breasts refill and engorge quickly, you may be suffering from oversupply, and are at more risk of developing blocked ducts and mastitis

If you encounter any breastfeeding difficulties (including blocked duct or mastitis), reach out to the following resources.

  • Maternal and Child Health Centres / Lactation Clinics at your birthing hospital
  • Breastfeeding hotlines
  • Breastfeeding peer support scheme
After the first month

Understand me

Activity :

  • More awake and active during the daytime, and sleeps longer at night. Hence feeding becomes more concentrated during the daytime
  • Sleeping needs and patterns vary among babies

Feeding pattern :

  • Gradually develops a feeding routine and the feeding frequency decreases.

    The milk intake needed by each baby is unique. It also changes with growth, metabolism, and activity level at different stages of life

    Here are some examples of changes in appetite:

    • "Growth spurt": Your baby may seem insatiable and feed more frequently than usual, and thus pass more wet nappies. This may last a few days to over a week. Stay calm and follow his lead, then your milk supply will boost to keep up with his growth needs
    • "Tired of milk": As months pass by, growth slows down, and the amount of milk taken by your baby plateaus or slightly reduces. As long as he is active, playful and comfortable, you can feel reassured. Do not force-feed your baby. Consider feeding him in a quiet corner as he is curious and easily distracted
    • "Quitting night feeds": Babies will stop taking milk at night, according to their needs. Since the 3rd month of age, babies gradually develop routine daytime and nighttime activities. At around 6 months old, about half of the babies can sleep for 6 hours at night. Even if they wake up in the middle of the night, they often fall asleep by themselves

Stools :

After 1 month of age, breastfed babies have fewer stools, or even none for several days. This pattern is normal as long as the baby is well with no vomiting or bloating, the stool is soft, and the baby passes "wind" every day

Some exclusively breastfed babies may have more frequent stools. This is fine as long as the stool is not watery or frothy and the baby is active

Reach out to healthcare professionals or visit the Maternal and Child Health Centre if in doubt

Weight :

Weight gain will be slower after the first 2 to 3 months and babies may feed less. So, observe your baby's hunger and fullness cues and avoid overfeeding

Is my baby getting enough milk?

Parents could observe the following conditions to ensure their babies have enough milk:

  1. Contented baby
  2. Adequate wet nappies

    As a rough guide, if a baby is passing a wet nappy after each feed, he is getting abundant milk

  3. Sufficient stools
  4. Weight gain

Even if they have taken enough milk, some babies may:

  • Cry in bouts
  • Frequently wake up
  • Change their feeding pattern for example more or longer feeds, demanding the second breast each feed

It reflects the normal fluctuation and needs of the growing baby.

Please read:

Chapter 4 - Practical Breastfeeding Skills

Let-down reflex

  1. Milk cells produce breastmilk. It is then stored mostly in tiny sacs and scarcely in milk ducts
  2. The sacs are wrapped by muscles that can act like little pumps
  3. As your baby starts to suckle, "love hormone" (oxytocin) is released, and signals are sent out
  4. Upon receiving the signals, muscle pumps contract and the milk ducts widen
  5. Milk is then squeezed into the main ducts, and ejected out from the nipple

A good let-down reflex enables smooth milk flow

Factors enhancing let-down reflex:
  • Free of pain
  • Skin-to-skin contact
  • Effective suckling
  • Look at, listen to, smell and touch your baby
  • Being confident
  • At ease
  • Adequate rest
Factors suppressing let-down reflex:
  • Pain
  • Separating from baby
  • Ineffective suckling
  • Doubtful
  • Negative mood
  • Tiredness

Let-down occurs a few times during a feed or an expression. When it appears, some mothers may feel:

  • Tingling sensation in the breasts
  • Spraying out of milk
  • Milk leaking from the breasts
  • Uterus cramping (especially in the early weeks following childbirth)

Some mothers may not notice these signs, but all are encouraged to carry on the "Prelude" and prompt let-down.

Prelude to breastfeeding

To improve milk flow, prompt your let-down reflex before direct breastfeeding or milk expression by:

  • Skin-to-skin contact with your baby
  • Gentle breast massage
  • Warm compress on breast (apply less than 3 minutes)
  • Relax yourself by listening to music, taking a warm shower, thinking of your baby, looking at his photos or videos
  • Back massage by your partner or a family member

Livestream :

Let's gear up with these short videos
Practical skills:

Get ready for comfortable breastfeeding

Wash your hands before holding your baby!

Breastfeeding in a comfortable position prevents muscle strain and helps milk flow

  • Your back, forearms and legs must be well supported
  • Do not put too many clothes on your baby, else he cannot get close to you for breastfeeding

Expose your baby's chest for intimate skin-to-skin contact, it helps bring him close to your breast, and keeps him warm

Tips

As your baby grows in size, you may adjust the way how you hold and support his body parts

Proper breastfeeding position:

I. Often used positions
Best for Method
Transitional hold

(Best for Beginners)

Mum :

First-time mums

Baby :

Learning to latch-on and suckle

  • Support your baby's head and neck with one palm
  • Direct him to feed on the opposite breast
Football hold Mum:

Large breasts, inverted nipples, had a Caesarean section, blocked duct

Baby:

Preterm, weak at suckling, reluctant to feed

  • Support your baby's head and neck with one palm, tucking his body and feet under your arm
  • Lift the baby to feed on the same side
Cradle hold Baby:

Skilled at latching and suckling

  • Support your baby's head and neck with your forearm, allowing his head to tilt back
  • Feed from the breast on the same side
Side-lying position Mum:

Night feeding, tired mums

Baby :

Skilled at latching and suckling

Let your baby lie on his side
Semi-reclined position Mum:

Oversupply of breastmilk

Baby :

Reluctant to feed

Put the baby tummy down on your already laid-back body, gluing to your breast by gravity

II. Holding your baby close

  • Keep the baby's head and body in a straight line, so his neck is neither twisted nor bent forward
  • Hold your baby close: let him face your breast, and his tummy touching yours
  • Support behind your baby's neck and shoulders, such that his head is able to tilt back
  • Let your baby's nose level with and point to your nipple

Tips

Proper positioning helps with the baby's attachment, facilitates effective suckling and avoids nipple injury

III. Bringing your baby to the breast

  1. Once your baby's head has tipped back, wait for the wide gape, then quickly bring him to the breast, chin leading and touching your breast first

    If your baby's mouth is close, gently brush his top lip to encourage him to open his mouth

    The nipple points towards the back of the roof of baby's mouth

  2. Let his bottom lip touch the breast well away from the nipple base, his top lip will then attach to your breast

Good attachment

If your baby attaches well, he will get a large mouthful of breast including the nipple and most areola. You can see:

  • Mouth is wide open, as if yawning
  • Bottom lip flanges out
  • Chin indents your breast
  • Your areola is more visible above his top lip than below his bottom lip

Effective suckling

If your baby suckles well, you can see:

  • Rounded cheeks while suckling
  • Initial rapid sucks turning to rhythmic, slow deep sucks with occasional pauses. You may even hear the swallows

    Deep suck: His jaw lowers down

  • He comes off your breast and looks content after getting enough milk
Proper attachment and suckling, you can notice:
  • Breastfeeding is comfortable and not painful
  • Your breast becomes soft after feeds
  • Your nipple is the same shape when your baby releases it as the start:

    The nipple resumes its shape or is slightly elongated

Ineffective attachment and suckling

Improper attachment:

  • Mouth is not wide open
  • Lip is pointing forward or turning in
  • Chin / bottom lip is not touching your breast
  • Your areola is more visible below his bottom lip than above his top lip

Suboptimal suckling:

  • Cheek is drawn in and dimpled
  • Your baby makes clicking or smacking noises instead of swallowing sounds

Ineffective attachment and suckling, you can notice:

  • Breastfeeding is painful
  • Your breast remains full after feeds, increasing the risk of blocked ducts
  • Your nipple is pinched or blanches when your baby releases it:

    The nipple is flattened. You should ask for professional guidance

Let's practise breastfeeding

Tips

If your baby is not attaching properly, or your nipple is painful, slip your finger into the corner of his mouth, gently take him off from the breast and try again

Tips for practising breastfeeding

  • Feed responsively whenever he signals early hunger cues
  • Perform "Prelude to breastfeeding": stimulate the let-down reflex with skin-to-skin contact, etc
  • Try different breastfeeding positions and practise proper positioning to hold your baby
  • Check whether your baby has proper attachment and suckling
  • Arrange breastfeeding coaching with healthcare professionals for any difficulties

It takes time and practice for both baby and mum to get used to each other and learn together!

Strategies that sustain breastfeeding

Breastfeeding will become easier if you have mastered the above skills. The following tips help you to keep up with breastfeeding:

  • Get support from your family, help them understand that longer breastfeeding brings more health benefits for you and your baby
  • Feed responsively
  • Familiarise yourself with milk expressing skills
  • Seek help as soon as possible if you encounter problem(s) with breastfeeding
  • Fit breastfeeding into your life
  • Prepare for breastfeeding before returning to work
  • Join breastfeeding peer support scheme in the community (Please refer to those as recommended by your hospital or Maternal and Child Health Centre)

Out and about with your baby

Many mothers keep on breastfeeding their babies while continuing their usual social activities

  • Breastfeeding at restaurants
  • Breastfeeding at shopping malls
  • Breastfeeding when taking public transport
Benefits of breastfeeding anytime, anywhere:
  • Promptly respond to the baby's needs
  • Helps the baby feel secure in unfamiliar environment
  • Prevents breast engorgement or blocked milk ducts
Convenient clothes for breastfeeding
  • Tops with concealed nursing access
  • Soft, wireless bra
  • Straps that can be undone with one hand
  • Nursing shawl or muslin
Research before venturing:

Locate the breastfeeding babycare facilities and "breastfeeding friendly premises" near the destination

  • If you prefer private lactating rooms, search for "List of Babycare Facilities in Government Premises" from the Department of Health website http://s.fhs.gov.hk/vggcd
  • You are welcome to breastfeed your baby anywhere in these Breastfeeding Friendly Premises, recognisable by the speacial logo www.SayYesToBreastfeeding.hk

Combining breastfeeding with work

Mothers can continue to breastfeed after returning to work, given a strong family support and adequate preparation. Before you resume work, discuss with the management about your intention and the support you require, so as to express milk at work.

"An Employee's Guide – to Combining Breastfeeding with Work" booklet

"Employers' Guide – to Establishing Breastfeeding Friendly Workplace" booklet

Transition in the last two weeks before returning to work:
  • Practise hand expressing
  • If you choose to use a breast pump, read the product manual to see how it works, and practise using it

    What You Need to Know about Breast Pump

  • Learn how to handle expressed breastmilk
  • Let your baby get used to feeding methods other than direct breastfeeding
    • Caregivers should feed only the rightful amount and at times to match with the baby's hunger and satiety cues. This can avoid overfeeding your baby while you are at work. Otherwise, your baby will be discouraged to feed on your breasts and in turn reduce your milk supply

Stack up or dwindle down your milk:

Depending on the lactation breaks when returning to work:

  • If your baby is satisfied each day from you and the breastmilk expressed during lactation breaks, reserve of 1-2 days worth of milk is usually adequate (Express after feeding your baby once per day e.g. in the morning, collect over the last 2 weeks of maternity leave for the stash)
  • If you are unable to express as much at work, progressively reduce your feed or expression within the presumed working hours, in order to prevent breast engorgement (Gradually lengthen the interval and drop off one session every few days over the last 2 weeks of maternity leave)-

Tips

Some working mothers start early and pump lavishly to stock up a freezer stash of breastmilk. This oversupply status, coupled with inadequate expression during work, will substaintially increase the risk of breast engorgement pain and blocked ducts

Baby : I love fresh milk from my mum!

The composition and antibodies in breastmilk change to meet your baby's needs at different times. We recommend giving your baby fresh breastmilk, instead of stocking up too much

Rehearsal:

Practise in the last couple of weeks before resuming work, by replacing direct feeds with expression within the planned working hours

Scenario 1: Within working hours, lactation breaks equate the feeds of your baby

  • Use a couple of weeks to practise replacing direct breastfeeding with expressing milk. Let your baby get used to being fed by the caregiver

Scenario 2: Within working hours, lactation breaks are less than the feeds of your baby

Method 1 : Make use of your non-working hours (lunch time, breaks, before or after work), or shorten the duration of each lactation break, in order to have more lactation breaks

Method 2 : If you are fairly sure about the fewer number of lactation breaks, gradually lessen your expression over 1- 2 weeks

Example :

There will be 2 lactation breaks within working hours. During this time slot, the baby is currently feeding on breast 3 times. Aim to adjust to 2 expressions progressively

  • During the last week, express milk 30 minutes later than the usual time you breastfeed your baby, followed by a further delay of 30 minutes 3 days later. When you return to work, you can express milk twice at work, and directly breastfeed your baby at home

Baby : I want to be feed on my mum when she's not at work!

Breastmilk production may decrease if you have few or no lactation breaks during work. If you wish to maximise your milk supply:

  • Directly breastfeed your baby whenever you are at home, you may express milk on the other breast while doing so
  • At weekends and holidays, directly breastfeed your baby whenever he is hungry, instead of expressing on schedule
  • Some babies may drink less from bottle. Offer only the amount he needs from bottle, and allow him to feast from breast
  • Do not force your baby to quit night feeds. If your baby does not feed at night time, express once before you sleep

If the expressed breastmilk cannot provide for your baby, supplement with formula milk while limiting the amount to what is necessary for him

Chapter 5 - Let's Learn About Breastmilk Expression

When to express when breastfeeding

  • Your baby is away from you:

    With a goal to maximise your milk production, expressing has to be effective and frequent, with at least 8 times in 24 hours including once at night especially in the first couple of weeks after childbirth

    You may need to occasionally express when you are temporarily away from your baby too

  • You have engorged breast:

    Express a small amount of breastmilk, so that your areola softens for easier attachment

  • You return to work:

    Start your preparation about 2 weeks before returning to work

  • Blocked ducts / mastitis:

    If your baby refuses to suckle or the blockage persists after feeding, express as much of the retained milk as you can

  • When milk supply cannot meet your baby's need:

    Express after direct breastfeeding can provide breastmilk for your baby while increasing milk production. As your baby improves in feeding on the breast, decrease the number of expressions to avoid over production of breastmilk

Tips

  • Excessive expressing may cause oversupply of milk and increases the risk of mastitis
  • You do not need to check your milk supply by expressing. Instead, monitor the baby's wet and dirty nappies to ensure she is getting enough milk

Expressing milk by hand

Every breastfeeding mother should know how to hand express, prudent in almost all situations

  1. Wash your hand thoroughly before expressing milk, and prepare a clean container with a wide opening
  2. Prelude for breastfeeding
  3. Place the thumb and index fingers (in a C shape) 3cm from the base of your nipple
  4. Press the fingers towards the chest and compress the deeper breast tissue, then release. Repeat the 'compress and release' action
  5. If the milk does not flow smoothly, you may compress different parts of your breast around your areola to drain the breast thoroughly
  6. You can massage your breast gently every now and then to improve milk flow
  7. When milk flow slows down, switch to the other breast. Keep swapping for a few times until both breasts become soft. The entire process normally takes around 20 to 30 minutes
  8. At the end of an effective expression, breasts become soft

Do not rub the skin

Expressing milk by breast pump

Please read the "What You Need to Know about Breast Pumps" booklet and the product user manual

Tips

Hand expressing or pumping milk should not cause any pain. Reach out for healthcare professionals if you are painful

Storing expressed breastmilk

Store breastmilk properly in clean air-tight milk storage bags or bottles

Store in small portions which are close to the typical amount consumed by your baby each feed, to avoid wasting milk that might not be finished

Regarding the best anti-bacterial property and nutrient quantity, breastmilk freshly expressed is preferable to refrigerated, and refrigerated is better than frozen

Recommendation in human milk storage:
Storage condition/temperature Recommended storage time
Freshly expressed breastmilk Thawed milk taken from freezer
Freezer

(-18°C or colder)

Within 6 months Do not refreeze
Refrigerator (4°C) Up to 4 days Up to 1 day (count from the time when it is completely thawed)
Insulated cooler bag

with frozen ice packs

Up to 24 hours -
Room Temperature (25°C or colder) Up to 4 hours 1-2 hours

Label milk with the date it was expressed. Plan on when the milk will be used, and store milk either in the back of the freezer or upper shelf of the refrigerator, not the door

  • If you do not plan to use freshly expressed breastmilk within 4 days, freeze it right away
  • If you wish to top up frozen breastmilk:
    • Do not directly add in warm freshly expressed milk
    • Chill the freshly expressed breastmilk in the refrigerator for about an hour before adding into the frozen milk
    • To avoid defrosting the frozen milk, its amount must be more than that of the chilled breastmilk

Did you know?

Breastmilk may layer out after chilling, and the creamy yellowish fat rises to the top. Gently swirl and mix the layers before feeding

Expressed breastmilk can sometimes smell different, due to chemical reactions between the enzymes and fats in the breastmilk. Provided your expressed breastmilk does not smell sour or rancid and is stored properly, it is safe to feed to your baby

Tips

If you are storing breastmilk for premature or ill babies, please consult medical professionals in the hospital

Thawing or re-warming breastmilk

Breastmilk can be thawed or re-warmed once only, use the oldest milk first

Thawing frozen milk :

Thaw milk overnight in the chilled compartment of refrigerator. Alternatively, run frozen milk under running water

Re-warming milk :

Milk can be served cold, room temperature, or warm. If needed, place the sealed container into a tub of warm water below 40°C (Test the temperature of the milk using the back of your hand. If it feels warm, then the temperature is right)

Do not heat breastmilk directly on the stove or in the microwave. Overheating will destroy the nutrients. Microwaving also creates hot spots that can burn your baby's mouth

Tips

Warm thawed breastmilk must be consumed within 2 hours, discard any leftover afterwards

Reference: Proper Storage and Preparation of Breast Milk. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services (2019)

Feeding baby with expressed breastmilk

Once started feeding, the breastmilk should be finished within 2 hours

Follow your baby's lead, stop feeding when she shows cues of fullness. Apart from bottles, you may feed your baby with other methods

Feeding expressed breastmilk using a cup
  • Hold your baby in a semi-reclined position
  • Tilt the cup slightly and rest on the edge of your baby's bottom lip, so the milk touches her lips
  • Let your baby suck or lap up the milk inside the cup
  • Allow your baby to pace her drinking. Do not pour milk into her mouth
  • Expect some milk to leak from the corner of your baby's mouth while she drinks

Tips

Cup feeding is the preferred way of feeding premature babies, and babies with nipple preference

Sterilising feeding equipment

All feeding equipment (small cups, spoons, milk bottles, teats, etc.) must be washed and sterilised after use

Please read Guide to Bottle Feeding

Chapter 6 - Healthy Diet for Lactating Mums

To provide nutrition for your growing baby, aim for a well-balanced diet of nutrient-dense whole foods that are rich in iodine, folic acid and omega-3 fatty acid, (including DHA and EPA). Take an iodine-containing prenatal multivitamin / mineral supplement as well

Please read Healthy Eating During Pregnancy and Breastfeeding

Eat healthy while breastfeeding

  • Prioritise food variety :
    • Include meat and poultry, fish, eggs and dairy products every day
    • Choose whole-grain foods like brown rice, oatmeal and whole-wheat bread
    • Eat abundant vegetables and fruits
    • Drink plenty of water, broth or unsweetened beverages
  • Get adequate nutrients :
    • Omega-3 fatty acids : Consume fish in moderation, or take a DHA supplement
    • Iodine : Consume iodine-rich foods and take an iodine-containing supplement
    • Calcium : Consume milk, calcium-fortified soymilk and tofu made with calcium salt etc
    • Iron : Consume red meat, poultry, fish, dark green leafy vegetables and dried beans
  • Avoid over-eating
  • Limit the intake of fat, trans fat and sugars. Remove the oil from soup
  • Avoid eating large predatory fish and fish with high levels of methylmercury
  • Do not smoke or drink alcoholic beverages
  • Consult a registered Chinese medicine practitioner before taking traditional herbal medicine or health tonics

Omega-3 Fatty Acids Facts

  • Omega-3 fatty acids include DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid). DHA is important for the development of the brain and the eyes of your baby
  • Oily fish like salmon, sardine, mackerel, eel and yellow croaker are rich in DHA. Fish in the local market such as golden thread, Pacific saury and pomfret also contain a moderate level of DHA
  • Consider taking DHA supplement if you do not eat fish

Iodine Facts

You cannot "eat" to obtain enough iodine, even with fish every day! (http://s.fhs.gov.hk/iodineen)

  • Iodine is critical for normal metabolism and thyroid gland function
  • The baby relies on sufficient iodine for growth and development. A lack of iodine damages a developing brain
  • The WHO recommends pregnant and lactating women to consume at least 250 micrograms iodine a day to meet the demands of their babies before and after birth
  • Local pregnant women are not getting enough iodine from their diet. To ensure adequate intake of iodine, pregnant and lactating women should:
    • Take an iodine-containing prenatal multivitamins / multimineral every day. Check its iodine content from the supplement you choose. Seek advice from doctors, nurses, pharmacists or dietitian if in doubt
    • Use iodised salt in place of table salt for cooking. Store the salt in a tight and coloured container, and add it just before serving
    • Consume iodine-rich foods such as seafood, marine fish, eggs, milk and dairy products. You can choose seaweed snacks with lower sodium and fat

Daily Meal Plan for Lactating mums

Food Group Servings per day Example(s) of a serving
Grains 4-5 1 bowl of rice or rice noodles; 1¼ bowls of noodles; 1½ bowls of macaroni or spaghetti
Vegetables 4-5 ½ bowl of cooked vegetables; 1 bowl of uncooked vegetables
Fruit 3 1 medium size apple or orange (approximate size of a lady's fist); 2 kiwi fruits; ½ cup of diced fruits
Meat and alternatives 6-7 40g raw meat/fish/chicken;

1 chicken egg; ¼ block of firm tofu;

6-8 tablespoons of cooked beans

Milk and alternatives 2 1 cup of low-fat milk or calcium-fortified soy milk; 2 slices of processed cheese; 1 carton(150g) of yogurt
Oils, sugars, salt in moderation Limit to 2 teaspoons of oil per meal; no more than 5g (1 teaspoon) of salt per day
Fluids 10 A cup of water or one bowl of thin soup

* 1 bowl = 250-300ml, 1 cup = 240ml

Should a breastfeeding mother avoid certain foods?

  • Does it protect the baby against allergies?

    Recent studies have not found a lower risk of allergies in children whose mothers restricted their diets during breastfeeding. Unless you or your baby have some type of food allergy, you should not avoid certain foods during breastfeeding. If you suspect your baby is allergic to the foods you ingested, consult your doctor for advice.

  • Can I drink coffee or tea?

    Too much caffeine can affect babies' central nervous system and may keep them awake. Lactating mothers should limit caffeine-containing drinks. Try decaffeinated coffee or tea as alternatives.

  • Can I drink alcoholic beverages?

    Alcohol has adverse effects on health and can affect judgement. Alcohol may decrease milk production and affects baby's development. Lactating mothers are recommended not to drink alcoholic beverages.

Tips for the vegetarian breastfeeding mothers :

  • Vitamin B12
    • Essential for the development of brain and nervous system, and production of red blood cells in babies
    • Vitamin B12 can be obtained from milk, cheese, yogurt, eggs or food with added vitamin B12 (such as breakfast cereals, soymilk, and nut beverages)
    • Take vitamin B12 supplements if you do not eat eggs or dairy products, since plant foods do not provide vitamin B12
  • Omega-3 Fatty Acids
    • Mothers may take flaxseed, walnuts or use vegetable oils which are high in alpha-linolenic acid (ALA), to increase the conversion to DHA in the body. However, the capability of this conversion to DHA varies. Therefore, vegetarian mothers can consider taking DHA supplements

Chapter 7 - Questions from Mothers

(1) Do breastfed babies need supplements?

  • Vitamin D
    • Vitamin D supports healthy bone development and immune function
    • Babies get limited vitamin D from breastmilk only, in particular when their mothers have low vitamin D levels
    • Exposing a larger area of skin of your baby to sunlight helps her body to produce adequate vitamin D
    • If your baby only gets limited sun exposure or is at higher risk for vitamin D deficiency, a daily dose of 10 micrograms (mcg) or 400 International Units (IU) of vitamin D supplement can help maintain adequate vitamin D level. If you are concerned, please consult your doctor or pharmacist
    • Babies are not able to obtain sufficient vitamin D from breastmilk alone even if the mother takes vitamin D supplement. It is more effective to bring your baby outdoors to create vitamin D from direct sunlight

    Please read Parents information: Vitamin D

  • Iron

    When healthy and term infants reach around 6 months old:

    • The iron stored in the infant's body is almost used up, but its demand has increased considerably. Although better absorbed, iron in breastmilk is limited, and breastmilk alone cannot meet the growing infant's needs
    • Babies should eat adequate amounts of iron-rich food every day :
      • Iron-fortified rice cereal or wheat cereal
      • Iron in meat, fish and egg yolk is easier to be absorbed
      • Green leafy vegetables and dry beans. Iron is better absorbed when vitamin C-rich fruits are eaten together
      • When your baby eats a variety of iron-rich food like meat, egg yolk and green leafy vegetables every day, you can gradually replace the iron-fortified cereal with congee
    • If the baby does not eat enough iron-rich foods every day, she may need supplements. Please consult your doctor or pharmacist if you have this concern

(2) My 1-month-old baby still has jaundice. Should I switch to formula milk?

Jaundice of some breastfed babies may persist longer and usually subside within 2 to 3 months. This is termed "breastmilk jaundice", which is mild and does not harm the baby.

However, there are other sinister causes for prolonged jaundice, like the rare but severe congenital bile duct obstruction. It will dreadfully impair the baby's liver if not treated early. Therefore, your jaundiced baby needs to undergo check-up and blood tests.

On the contrary, if only formula milk is used to bring down bilirubin levels, important medical conditions cannot be ruled out. If the tests return to be normal, you can be assured and continue breastfeeding your baby to provide the optimum nutrition and protection.

(3) Should I stop breastfeeding while taking medicine?

Most over-the-counter medicines like cold medicine, pain relievers, and most antibiotics, are compatible with breastfeeding. A few exceptions like anti-cancer drugs, radio-active materials and some immune system suppressants, are contraindicated while breastfeeding. In general, only a small amount of breastfeeding-compatible medicine passes into the milk, and can be eliminated quickly by healthy term babies. Also, the medication dosage prescribed when your baby gets sick is much higher than the dose passed in the breastmilk.

Moreover, if you are taking medicine for cold, flu, vomiting, or diarrhoea etc, and continue to breastfeed while adopting proper infection control measures, your breastmilk will contain antibodies to reduce her risk of getting the same bug.

Unnecessarily stopping breastfeeding or discarding your expressed milk denies your baby of precious breastmilk, and can reduce your milk production. Some babies may not suckle the breast properly after they were fed with bottles of formula.

Before taking any medicine, consult your doctor to search from the credible medical resources, for possible impact on the breastfed babies or milk production.

Please read Frequently Asked Questions about Breastfeeding

Chapter 8 - Breastfeeding Challenges and Solutions

Breastfeeding is a learned skill for both your baby and you, and is not always easy. During the breastfeeding journey, some mothers may give up after encountering a few setbacks. If mothers can identify problems early and manage them duly while working on their feeding skills, breastfeeding will become easier.

Sore nipples

It is a common breastfeeding challenge. Expect a little bit of nipple tenderness during the first few days of breastfeeding. The tenderness may build up in the first few minutes of suckling or pumping, and will lessen as the breastfeeding journey continues

If your nipple pain is persistent or worsening, it is usually because your baby is not attached properly at the breast, or you are not using the breast pump appropriately. The most effective solution plausible is enhanced feeding skills and correct use of breast pump

If your nipples crack, or are continually painful, reach out for an assessment by healthcare professionals as soon as you can

Nipple injury

Causes:

The baby does not attach properly or the nipples are rubbed by the breast shields when pumping

Solution:

1. Nipple care and pain relief methods

  • Only wash your breasts when you bath or shower as usual each day. Excessive cleaning of nipples can strip the natural anti-germ oil, leading to dry and cracked nipples
  • After feeding, dab a little expressed milk onto your nipples then let them air-dry
  • Consider patting on ultra-pure lanolin or hydrogel on the nipples to provide moisture barrier and promote healing
  • Take painkiller if needed

2. Improve breastfeeding technique

  • Seek breastfeeding coaching from healthcare professionals :
    • Improve breastfeeding skills and ensure proper attachment and suckling
    • Learn different breastfeeding positions and find the most suitable one for you and your baby
  • If a breast pump is used, make sure the size of breast shield fits the nipple, the position of breast shield is correct, the suction level is comfortable, and the duration of pumping is appropriate

What You Need to Know about Breast Pumps

Tips for direct breastfeeding/expressing when nipple is sore/injured
  • Feed your baby when he shows early hunger cue
  • Prelude for Breastfeeding
  • Start on the unaffected (or less painful) breast, and switch to the other side after the let-down reflex occurs
  • If you feel persistent pain during breastfeeding, slip a finger into the corner of your baby's mouth, gently remove him from the breast, and try again

Blocked ducts and Mastitis

Causes:

Ineffective milk drainage from the breasts leads to stasis of milk, that can cause blockage of milk ducts or even breast inflammation (mastitis). Bacterial infection may then set in. These situations may occur at any time during the lactation period

Situations that may result in milk stasis:
  • Abrupt reduction in the frequency of breastfeeding / milk expression (e.g. missed a feed)
  • Improper milk expression
  • Localised pressure on the milk ducts : sleeping on the breast, wearing wired or tight bras, pressing breast shields too hard on the breasts when pumping
  • Too much breastmilk
  • Blocked nipple pore: white spots on nipples
  • Fatigue or stress
  • Ineffective suckling of baby

Cracked nipples can serve as a portal of entry for bacteria, and increase the risk of mastitis / breast abscess

Symptoms:
Blocked Ducts Mastitis
Breast and/or areola lump is present, pain or swelling may appear near the lump extremely painful hard lump and swelling that persist
Over-lying skin may have mild redness marked redness and may feel hot
Body Temperature may have low grade fever fever (usually higher than 38.5℃)
Other - chills, fatigue, aches

Tips:

If the milk can be drained effectively:

  • Blocked milk ducts usually improve within 24-48 hours. If the lump is large, red, hot and very painful, or if you develop high temperature (>38.5°C), you are suffering from mastitis and should reach out for medical advice

Management:

1. Seek medical help as soon as possible
  • You may approach the Lactation Clinic of your birthing hospital (if applicable), Maternal and Child Health Centre or other healthcare personnel.
2. Improve milk flow
  • Ensure proper latching of the baby and expression of milk, so frequent effective drainage of breasts can occur
  • When the let-down reflex occurs, gently massage the affected area toward the nipple. Do not press too hard to avoid breast injury

Tips for Breastfeeding when there is blocked ducts and mastitis

  • Practise responsive feeding; so as to frequently breastfeed your baby or express milk from the affected breast each time
  • Prelude to breastfeeding e.g. skin-to-skin contact, warm showers to encourage the let-down reflex
  • If the milk flow is not smooth :
    • Start feeding your baby with the unaffected breast first. Once let-down reflex appears and milk flow improves, switch him to the affected side
    • Try different feeding positions so that baby's chin can be placed near the blocked area
  • With the rather superficial location in the breast, milk ducts can easily be blocked by pressure. Mothers with large breasts could lift up their breasts during breastfeeding and milk expression, and check whether the affected area is being compressed
3. Medication
  • Taking pain relievers like paracetamol and nonsteroidal anti-inflammatory drug (NSAID) at scheduled times can effectively alleviate pain, stimulate let-down reflex and improve milk flow
  • If there are obvious symptoms of mastitis, mothers need to complete a course of prescribed antibiotics, which usually takes 10-14 days. It relieves the symptoms and prevents abscess formation
    • Mastitis usually improves in 48-72 hours after antibiotic treatment. However, if the lump persists or pain worsens, it may have developed into an abscess. Seek medical help as soon as possible! Approximately 3% of mastitis will develop into an abscess

Mothers can continue to breastfeed their babies while taking breastfeeding-compatible drugs like painkillers and antibiotics

4. Others
  • Get adequate rest and lots of fluids
  • Apply cold compress to the breast after breastfeeding or milk expression to relieve swelling and pain
  • Some mothers choose to take lecithin supplements "to decrease the stickiness of milk", but its medical evidence is limited
  • Physiotherapy may help to reduce swelling, inflammation and pain
5. Prevent recurrence
  • Solve and manage the cause(s) of milk stasis, so as to prevent recurrence
Tips

If breast lump persists during the lactation period, seek help from a doctor to rule out other medical causes

Overabundant milk supply

Condition when a mother produces more milk than her baby needs

Causes:
  • Mother is exceptionally capable of producing milk
  • Improper feeding method overstimulates milk production, for instance, switching to the other breast when the first breast is not yet soft
  • Expressing milk more than the baby's daily need
Symptoms:
  • The breasts refill soon after feeding. The mother may experience engorgement and pain at times
  • The milk flows at fast rate and makes the baby choke or splutter at the breast, or even push it away
  • The baby is often ravenous, and passes watery or explosive frothy stool
Management:
  • Feed responsively, so as to match your baby's needs
  • Down-regulate milk supply (takes a few days or a week, and stop when milk supply is at the right amount for your baby)
    • If you directly breastfeed your baby :
      • Arrange daytime into a few cycles, each lasts around 3-4 hours. When your baby cues for feeding, offer the same breast during a cycle, alternating breasts each cycle
      • Ad lib feeding from both breasts overnight
    • If you expresses milk for your baby : gradually reduce the frequency or amount of milk obtained from each expression, until the total amount of expressed milk meets the daily need of your baby
    • If the breasts become too uncomfortably full : express small volumes of milk for comfort and prevention of blocked ducts
    • Watch out for blocked ducts and monitor your baby's nappies and body weight for feeding adequacy
  • Managing a fast let-down:
    • Make use of gravity by feeding in a semi-reclined position
    • Temporarily apply pressure using a "scissors-hold" with the first and second fingers of your free hand, easing up on the pressure and varying positions during the feed
    • If the areola is too swollen, express a small amount of milk to help your baby attach on the breast
  • Apply a cold compress to relieve the engorgement discomfort
  • Reach out for breastfeeding coaching or consult a healthcare personnel
Risks:

Mothers who have breastmilk oversupply are more prone to blocked milk ducts or even mastitis

Understanding "Foremilk" and "Hindmilk"

  • "Foremilk" describes the milk available when your baby starts feeding, and provides ample nutrients. As your baby continues to suckle and drain your breast, more fat globules enter and gradually increases the fat content in the milk, this is termed "hindmilk" which largely provides energy
  • Foremilk and hindmilk cannot be defined by the length of feed nor the content of milk
  • Let your baby consume as much milk as he desires, without cutting off one breast before it is drained. If he is not satisfied after finishing the first breast, offer him the other breast. This can ensure him getting a balanced nutrition and all the benefits of breastmilk
  • If a mother produces too much milk, her baby becomes full just when the foremilk fills his stomach
    • As foremilk is easily absorbed, the baby feels hungry again very soon and requests feeding frequently
    • Digesting foremilk within a short period of time builds up gas, leading to wind, abdominal colic and watery or explosive frothy poos

Accessory (extra) breast tissue

Refers to the breast tissue that appears along the milk ridge from armpits to groins, apart from the "main" breasts on the chest area. It is a fairly common developmental variation that takes place before birth. Extra nipples that resemble moles may also occur

Accessory breast tissue appears as a lump under the skin, increasing in size and/or producing milk in response to the hormones during pregnancy and lactation

After milk "comes in", the tissue may swell and become painful. It usually regresses within one week, and resolves after stopping breastfeeding

Solution:
  • Continue to breastfeed
  • Do not compress the accessory tissues
  • Apply a cold compress or take painkillers to relieve swelling and discomfort
  • Consult your doctor if there are symptoms of inflammation

White bleb on nipple

When the opening of milk duct (nipple pore) is blocked by overgrowth of skin or small amount of thickened milk, it forms a whitish or yellowish spot on the nipple. It can persist for days or weeks, often until the skin eventually breaks and the hardened material can escape

Solution:
  • Soak your nipple in warm water to soften the skin before feeding your baby. Let your baby suckle, and the blockage may be released upon suction
  • If it persists, apply moist heat on your nipple again, and lightly rub it with a wash towel, or open the pore with a sterile needle. Then gently squeeze the area behind the white bleb with your fingers to remove dried milk substance from the milk ducts
Tips:

If there is no improvement after the above measures, seek help from the Maternal and Child Health Centre, or your family doctor

Thrush

Fungal infection may occur at any time, but usually when breastfeeding is established, or when the mother has recently taken antibiotics

Symptoms:
  • Pain
    • Intermittent: may last more than one hour
    • Mostly present around the nipple. Can spread to breast or even the back or shoulders
    • Feels like pins and needles, stabbing pain or burning
    • Mostly happens after feeding, pumping or throughout feeding or pumping
  • The nipple may appear normal or have the following symptoms:
    • Pink or flaky skin
    • Cracked and heals slowly
    • Red itchy patch around nipple
    • White bleb (may be more than one)
    • The baby may develop oral thrush or nappy rash
Solution:
  • Seek help from health care professionals:
    • Apply antifungal cream (or take oral medicines) as prescribed by the doctor. The treatment course takes at least two weeks to complete. Use the prescribed antifungal treatment for your baby at the same time to avoid re-infecting one another
    • Take painkillers as needed
  • Maintain hygiene:
    • Wash hands frequently, especially before breastfeeding or after changing nappies
    • Keep nipples dry. Use a breathable breast pad and change it regularly
    • Items that come into direct contact with your breasts and baby's mouth including bras, teethers and pacifiers should be washed and sterilised (like boiling for 20mins) after use and stored in a dry cool place
  • Adjusting your mood, getting adequate rest, having a balanced diet and engaging in appropriate exercises can all help enhance your immunity
  • Mothers may consider cutting down on sugary food, refined carbohydrates (like rice and white bread), yeasty foods (like bread, alcohol and mushrooms) and dairy products
Tips:

Mothers can carry on breastfeeding while being treated for thrush, but expressed milk should be consumed within one day

Useful hotlines and websites

If you have problem(s) with breastfeeding, please seek advice from the organisations below as soon as possible:

Family Health Service, Department of Health

  • Visit Maternal and Child Health Centres
  • Call the Breastfeeding hotlines 3618 7450

Hotline services provided by hospitals under the Hospital Authority: (Applicable to mothers who delivered at these hospitals. Please call before seeking medical attention)

Prince of Wales Hospital

3505 3002 (24-hour recorded message)

Pamela Youde Nethersole Eastern Hospital

2595 6813 (Monday to Friday:2:00pm to 3:30pm)

Queen Elizabeth Hospital

3506 6565 (Monday to Friday:2:00pm to 5:00pm)

United Christian Hospital

2346 9995

(9:00am to 6:00pm, after 6:00pm recorded message only)

Tuen Mun Hospital

2468 5702 (9:00am to 9:00pm, recorded message)

Queen Mary Hospital

7306 9687 (8:00am to 8:00pm)

Kwong Wah Hospital

3517 2175 / 3517 8909 (24-hour postpartum hotline)

Princess Margaret Hospital

2741 3868 (24-hour recorded message)

Baby Friendly Hospital Initiative Hong Kong Association
2838 7727 (9:00am to 9:00pm)

Hong Kong Breastfeeding Mothers' Association
2540 3282 (24-hour recorded message)

Your Pediatrician / Obstetrician / Family Doctor

Watch video

Highly Recommended:

  • Raising a Smart and Happy Kid
  • Responsive Feeding
  • Breastfeeding Day and Night
  • Feeding Journey

Family Health Service

Website: www.fhs.gov.hk

24-hour information hotline: 2112 9900

Contents of this brochure will be updated from time to time. Please refer to the website of Family Health Service, Department of Health, for the latest information.