Infant Feeding

No matter how you choose to feed your baby, there are some risks involved. You can lower the risks associated with different feeding methods and keep your baby safe by using the following strategies.

Risk of illness with formula feeding

To reduce this risk:

• If you are supplementing with formula, offer your baby as much of your own expressed milk as possible and switch back to human milk feeding as soon as possible
• Hold your baby skin-to-skin to help them develop good gut bacteria
• Prepare and store formula safely to avoid the risk or water-borne illnesses and contamination

Risk of less responsive feeding or overfeeding with a bottle

To reduce this risk:

• Learn about cue-based feeding which helps you respond to signs of hunger, stress and being satisfied
• Gently offer the bottle nipple to your baby only in response to feeding cues
• Respond to your baby and avoid forcing them to finish a bottle
• Learn to communicate with your baby with eye-to-eye contact, smiles and using your voice
• Hold your baby close while feeding and switch the arm you use to hold your baby

Risk of formula contamination

To reduce this risk:

• Check for information on formula recalls
• Wash and dry all feeding items properly
• Learn about using safe water for preparing formula

Risk of reduced human milk supply with formula or bottle feeding

To reduce this risk:

• Use hand expression or pumping to keep up your milk supply if you plan to switch back to breast/chestfeeding
• Get support or advice from a professional such as a lactation consultant

Risk of dehydration or not getting enough with breast/chestfeeding

To reduce this risk:

• Learn the signs that your baby is getting enough human milk and talk to your health-care provider if your baby might not be getting enough
• Learn how to hand express and give your baby your expressed milk by spoon or cup after feedings if you do not think they have fed well
• Meet with a health-care provider for support until your baby is gaining weight well and you feel confident

Risk of dehydration or not getting enough with formula feeding

To reduce this risk:

• Determine if you are using a ready-to-feed (does not need to be mixed with water) or concentrated formula (needs to be mixed with water)
• Follow the instructions on the package carefully to add the right amount of water
• Learn how much formula your baby should have during each feed and within each 24-hour period based on your baby's age
• Learn cue-based feeding when bottle feeding

Risk of illness from breast/chestfeeding in certain circumstances

While most people can breast/chestfeed safely, there are certain infectious medical conditions or medications that can be passed to the baby through human milk. If you are in this situation, you may want to consider:

• Using a safe, affordable and sustainable human milk replacement
• Talking to your health-care provider about the current recommendations and available options

Adapted from Baby Friendly Initiative Strategy Ontario (2017): Informed Decision Making

Baby-led latching describes the natural and simple way that a newborn finds your nipple to begin feeding within the first hour of life. It is encouraged immediately after the baby is born during skin-to-skin care as baby is most alert at this time. It can also be useful as your baby learns to breast/chestfeed.

To encourage baby-led latching:

• Use skin-to-skin care with the lactating parent to help the baby find the breast or chest
• Start with a calm baby who is placed vertically with their tummy on your upper chest, between your nipples
• Be comfortable and lean back a little
• Expect your baby to begin to bob or peck by moving their head up and down while looking for your breast
• Support your baby’s head and neck, shoulders and bottom as they move to find the nipple
• Expect your baby to find the nipple, push their chin into your breast and reach up to the nipple with an open mouth
• Continue to support your baby’s bottom, back and shoulders while this happens ( your nurse may also help you to support this practice)
• Settle into a more comfortable position for feeding once your baby is latched on

For more information about positioning and baby-led latching, please visit the following resources:

• Breastfeeding Matters – An Important Guide to Breastfeeding for Women and their Families
• Global Health Media: Attaching your baby at the breast video
• Stanford University: Breastfeeding in the first hour video
• International Breastfeeding Centre: Breastfeeding videos
• Toronto Public Health: Learning to breastfeed
• Health Link BC: Breastfeeding positions video
• More Milk Sooner – Latching video

Putting your baby to your breast/chest as soon as possible is the best way to begin feeding. If your baby does not latch, you can use hand expression or a pump to stimulate milk production.

Hand expression

Hand expression is a way to remove milk from your breast or chest using only your hands. It is useful for new parents who are breast/chestfeeding to learn how to hand express. When used along with directly feeding your baby, hand expression can increase milk production. Hand expressing a small amount of milk from a full breast can also help your baby to latch.

In the first few days after birth, you produce a thicker and stickier version of milk called colostrum. It is hard to collect colostrum with a breast pump, so using hand expression can help your baby get more colostrum. Colostrum is low in fat and high in carbohydrates, protein and antibodies to strengthen your baby’s immune system and help keep them healthy. Your baby only needs a small amount of colostrum and it can be measured in teaspoons rather than ounces. Colostrum is extremely easy to digest, which helps your baby to pass frequent stools (poop) in the form of meconium (dark stool) and reduces the risk of jaundice.

Your expressed milk offers many important benefits, especially if your baby is born prematurely or is sick. If you plan to breast/chestfeed, but are separated from your baby, we encourage you to start hand expression early and to start pumping within six hours of birth.

The research tells us that breast/chestfeeding and hand expression should begin within one hour of birth. You can continue every three hours or so for the first 24 hours. To increase your milk supply, you can both hand express and feed your baby at your breast or chest. Feed your baby directly first and then hand express. You can then feed your baby the expressed milk as well.

Hand expression is an effective way to express milk, boost your milk supply and collect milk for your baby. You can ask your nurse to help you with hand expression. 

If you are interested in hand expressing milk before your baby is born, please see the following resources for more information and speak with your care team. 

• More Milk Sooner-How to hand express
• Health Link BC: Hand expressing breastmilk video
• Le Leche League Canada: Prenatal colostrum expression

It is possible to express your milk before your baby arrives. This is called antenatal hand expression (AHE). It involves stimulating your breast/chest tissue and expressing colostrum by hand in the final weeks of pregnancy (typically after 37 weeks).

Why is AHE important?

Hand expression in late pregnancy helps your body produce more colostrum and milk.

Some babies need extra milk in the early days, and colostrum is the preferred supplement for your baby.

These include babies:  

• Whose birth parent has diabetes or other complex medical conditions
• With complex health conditions (such as cardiac complications or cleft lip)
• Born early or with low birth weight
• Who are multiples (such as twins or triplets)

What is colostrum?  

Colostrum is the thick, often gold-coloured fluid that you produce first during your pregnancy and before your milk comes in.

Although colostrum is low in volume, it is highly nutritious and easy to digest. 

Benefits for the parent and baby

For the parent, AHE helps to:

• Increase milk production and long-term milk supply
• Increase parental confidence and success in infant feeding and bonding
• Protect against postpartum mood issues
• Prevent breast/chest tissue engorgement and discomfort in the postpartum period

For the baby, AHE provides more colostrum, which:

• Is packed with protective antibodies, vitamins, and minerals
• Helps to build the baby’s immune system and gut flora to protect against allergy and disease

How to hand express

1. Wash your hands with soap and water.
2. Apply warm compresses and gently massage your breasts/chest tissue from the outside towards the nipple.  
3. Place your fingers in a C-shape on your breast/chest two finger-widths away from the nipple.
4. Press back towards your chest wall while applying pressure with fingertips to compress breast/chest tissue.
5. Relax your hands on breast/chest tissue.  
6. Move fingers around the breast/chest tissue to express different areas and then switch to the other side to repeat the steps 

Watch a video on hand expression on the Stanford Education website.

Collection and storage

Collect your colostrum into a clean cup or spoon and draw it up using a syringe.

Label syringes with your name, date and time at the end of each session.

Store syringes in a freezer-safe bag in the freezer.

When transporting, store syringes in a cooler bag with a freezer pack.

Bring only enough for a 24-hour period (that is, a few syringes with amounts between one and 15 mL).

Any unused colostrum should be discarded if it:

• Has been used at a previous feed 
• Is left at room temperature for more than one hour
• Has thawed from freezer to fridge for over 24 hours

Your expressed human milk can be stored (immediately after expression) as follows, unless your care provider has said otherwise:

• At room temperature for six hours
• In the fridge for six days
• In the freezer for six months

Colostrum Collection Kits can be purchased at the Sinai Shop. 

Frequency

Hand expression should be done twice daily for five to 10 minutes at a time while alternating between both sides of your breast/chest each session.  

What to expect

The average amount of colostrum collected is five mL. Even if you do not see any drops, AHE stimulates the cells that make milk. This helps to produce more milk sooner after birth.  

Safety and considerations

Please discuss with your health-care provider whether or not AHE is safe for you.

If you notice any cramping during AHE, stop and talk to your health-care provider about whether you should continue.  

Using a pump is another way to express your milk. Before you decide to buy or borrow a pump, it is important to know that some pumps should not be shared. Talk to a lactation consultant about which pump is best for you.

You can rent or buy a pump from several places, including the Sinai Shop at Mount Sinai. You will also need to buy a double pump collection kit. Sterile kits (for immediate use) can be purchased online or in person at the Sinai Shop or in the Postnatal Ambulatory Clinic (PNAC).

If you are pumping for a baby with special needs, like a premature baby or a baby who is unable to breast/chestfeed, a hospital-grade electric pump is recommended.

Tips for using a pump include:

• Pump each side for no longer than 20 minutes
• Try double pumping of both sides at the same time to produce more milk and save time
• Remember that pumping should not hurt or be uncomfortable and you can adjust the suction pressure on the pump for your comfort
• Make sure your nipple is placed in the centre of the flange (the part of the pump that goes around your nipple)
• If your baby has not latched yet, start to pump six hours after the birth (together with hand expression)
• If you and your baby are separated, double pump every two to three hours for 20 minutes, up to eight times a day
• If you have a low supply of milk and you need to supplement breast/chestfeeding, double pump for 10-15 minutes after each feed

Expressed milk is the best choice for supplementing a breast/chestfeeding baby. Freshly expressed human milk can be kept at room temperature for up to four hours. If you plan to store your milk for longer, keep it in the refrigerator. Offer expressed milk when your baby is ready to feed. If you do not have enough, talk to your health care team, lactation consultant or health-care provider to develop a feeding plan.

For more information about pumping and storing milk, please visit the following resources:

• CDC: Breast Milk Storage and Preparation
• Kelly Mom: What should I know about buying a new or used breastpump?
• Kelly Mom: Establishing and maintaining milk supply when baby is not breastfeeding
• Women’s Health: Pumping and storing breastmilk
• La Leche League: Pumping milk

Cluster feeding is part of a baby's normal feeding pattern in the first days after birth, also known as cue-based feeding. Babies will have two or three hours of quiet alertness after being born. Then they go into a deep sleep to help them recover from birth. This is followed by an increase in your baby’s wakefulness and feeding cues called cluster feeding.

Cluster feeding does not mean that your baby is not getting enough milk. It is not a medical indication that you should supplement your baby's feeds with formula.

Cluster feeding is:

• A normal response to babies using up stored energy they had from before birth
• Expected 24 to 48 hours after birth
• Comforting and reassuring to your baby
• A way to boost your milk production, especially at night when your hormone levels are higher

Allowing your baby to cluster feed as much as possible will help your mature milk come in. It will comfort your baby and help you make more milk in the future. If you are feeling exhausted, giving your baby expressed milk is a good first step to take.

If your baby is not getting enough milk directly from your breast or chest, you can give also give them your expressed milk or infant formula. This is called supplementing.

You can read more from La Leche League about how to tell if your baby is getting enough milk. Please talk to your health-care provider if you are concerned.

If your baby needs supplementing, try using your own expressed milk first. You can use hand expression or a pump to collect the milk.

If your baby is still not getting enough milk, supplementing with formula may be needed. You might need to supplement with expressed milk or formula for the following medical reasons:

• Low blood sugar (glucose) levels
• Jaundice (if the baby is too sleepy to feed well at the breast)
• Meconium (black and sticky) stools continue after the fourth day
• Not feeding well at the breast or chest  
• Too much weight loss (despite frequent feeds)
• Your milk has not increased (or "come in") by the fourth day
• Dehydration (not enough wet diapers) 

Please talk to your nurse, lactation consultant or health-care provider if you think you need to supplement your infant feeding. The most important thing is to ensure that your baby is fed. 

How much to supplement

Newborn babies have small stomachs that gradually stretch to hold more milk over the first week. You can learn more about the size of your newborn's stomach from La Leche League.

You can use the following as a guide for how much expressed milk or formula you need to supplement:

The first 24 hours: 2-10 mL

24 to 48 hours: 5-15 mL

48 to 72 hours: 15-30 mL

72 to 96 hours: 30-60 mL

For more information on your milk supply, please visit the following resources:

• Global Health Media: Is your baby getting enough milk video
• Global Health Media: Increasing your milk supply video

For more information about supplementing, please visit the following resources.

• Healthlink BC: What you need to know about supplementing your baby with formula

If you are giving your baby a small amount of expressed milk or formula, try using a small cup or a spoon to feed your baby. If your baby needs more expressed milk or formula than is reasonable to feed with a cup or spoon, a method of feeding called paced bottle feeding is recommended.

Paced bottle feeding

Paced bottle feeding slows the flow of the milk and allows your baby to be in control of how fast and how much they feed. This is also called baby-led bottle feeding. 

This method reduces the risk of overfeeding your baby and may make it easier for babies who are also trying to breast/chestfeed. Paced bottle feeding is a good approach for any baby who is bottle feeding.

For more information on paced bottle feeding, please visit the following resources:

• Region of Peel: How to bottle feed your baby video
• Paced bottle feeding video 

It is important to learn how to safely prepare and store formula, as well as how to sterilize bottles and equipment.

Please note that powdered formulas are not recommended for your baby’s first two months because there is a risk of introducing bacteria when preparing it. For the first two months, we encourage parents to use ready-to-feed liquid formula.

When preparing formula, remember to thoroughly wash your hands, sterilize your feeding equipment and follow the formula package preparation instructions  carefully.

For more information about using formula, please visit the following resources:

Baby-Friendly Initiative Strategy Ontario: Safely preparing infant formula video

Health Canada: Preparing formula

Your milk is the ideal food for your preterm baby. Your colostrum and milk are unique to your baby and will change over time to meet the needs of your baby.

Your milk provides protein for growth and development and antibodies that protect your baby from infection.

Breast/chestfeeding also lowers your baby’s risk of various health issues, including:

• Ear infections
• Lung and breathing issues
• Diarrhea
• Diabetes
• Obesity
• Some childhood cancers
• Sudden infant death syndrome (SIDS) 

In addition to providing the ideal food for you baby, breast/chestfeeding lowers your own risk of breast cancer, ovarian cancer, type 2 diabetes and high blood pressure.
 

Learn how we support your infant-feeding decisions.

Our baby-friendly promise for NICU families 

Sometimes, early preterm babies may need extra nourishment to help them grow. Your health-care team may recommend fortifying your expressed milk with human milk fortifier, nutrients or fats.

Preterm babies may not be able to directly breast/chestfeed at first. However, your milk and skin-to-skin contact are very important for them. You can express milk by hand or pump until your baby is strong enough to feed directly from your breast or chest.

The Rogers Hixon Ontario Human Milk Bank offers pasteurized human donor milk by prescription only to eligible families with critically ill preterm infants in the Mount Sinai NICU.

When your baby is ready, a lactation consultant with expertise in helping preterm babies can help you with breast/chestfeeding.

For more information on feeding your baby in the NICU, please visit the following resources. 

La Leche League: The importance of breastfeeding for a premature baby

Global Health Media: Breastfeeding your small baby video

After you go home with your baby, you may need support with infant feeding if:

• Your baby has jaundice
• Your baby is not gaining enough weight
• Your baby sleeps through feeds or does not wake up for feeds at least every four hours.
• You need to supplement your breast/chestfeeding with formula
• You have sore nipples
• You have blocked ducts that do not get better with feeding, expressing or pumping.
• You have a fever or generally feel unwell
• You are using a lactation device or nipple shield

Breast/chestfeeding can be challenging, and many things can affect your success. Please seek help and support when you need it. Be patient with yourself. It is okay to ask for help.  

The following resources provide in-person and/or virtual infant feeding support:

• The Postnatal Ambulatory Clinic at Mount Sinai
• La Leche League Canada
• City of Toronto Breastfeeding Clinics
• Health 811 (formerly Ontario Telehealth): Call 811 to receive help in 110 languages (direct TTY number 1-866-797-0007)