Breastfeeding and bottle feeding

The keys to successful breast-feeding are getting the baby in the right position and ensuring the mother is comfortable. When the side of the cheek is touched or stroked, a young baby searches automatically for the nipple (this is called rooting), but they may need help in latching on for the first few feeds.

When sucking, the baby's lips should form a seal around the areola (pigmented part of the nipple). This will make the tip of the nipple rest against the baby's palate (roof of the mouth). One of the main signs of good latching on and feeding is that the baby responds with rhythmical sucking motions. A health visitor or midwife can offer support in showing parents the signs of good feeding.

At the end of the feed, if the baby does not doze off and let go of the nipple, they should not be pulled off the breast; instead, the suction effect of their lips should be broken with the mother's finger tip inserted into the side of their mouth.

A feeding baby has to breathe through their nose, so time and patience are needed if they have a cold. Premature babies often do not suck well but they benefit from breast-milk, so again patience is essential. Some babies are born with a tooth (or several teeth); this is said to make no difference to breast-feeding, though a few mothers find it painful.

A mother's comfort during feeds is vital, whether sitting or lying down. The atmosphere should be as relaxed as possible; a telephone answering machine and someone to look after any other children are useful luxuries.

The customary advice is to let the baby suck at each feed for as long as they want. However this is not always practical: if a baby goes on sucking for an hour or so, the mother's nipples can become sore, or she may simply have to get up and go to work, or see to her other children.

If time at the breast has to be limited, it is best to feed little and often. This approach can make all the difference between success and failure with breast-feeding.

The breasts do not have to be drained at each feed. Starting and completing a feed from one breast ensures the baby receives the "hind milk" (that milk produced towards the end of the feed). This is higher in fat content than the "fore milk" (the milk produced at the start of the feed) and satisfies the baby's appetite. However some babies prefer to feed from both breasts at each feed and will be equally satisfied. A baby feeding well will normally feed for 20-30 minutes, but it should always be remembered that the time spent feeding will vary considerably.

Some babies prefer to feed from both breasts, and the mother can start with a different side at each feed (a tissue inside the relevant bra cup helps those whose memory is unreliable). Between sides, one can usefully change the baby's nappy, especially if they need rousing for the second half of their feed, but strict hygiene is obviously vital.

The more a baby sucks, the more milk is produced later. Feeding "on demand", whenever the baby is hungry, is therefore the rule because this ensures a match between demand and supply. There are exceptions: premature babies may have to be woken and offered feeds every three hours, say, while mothers of twins find a routine essential and often breast-feed both babies at once even if only one of them is hungry.

No special preparation is necessary, apart from normal hygiene and ensuring that after a feed the nipples are kept dry. Some commercial creams can relieve soreness but a midwife, health visitor or breast-feeding advisor should be asked first about the suitability of the product. The mother may also find that by expressing a little fresh breast milk, and rubbing it around the nipples, the tenderness can be relieved.

Nipple shields are sometimes useful for those with soreness, but they have to be sterilised each time and many experts believe they are of limited use and can even confuse a baby.

She can usually eat whatever she wants, unless she notices that a particular food upsets her baby later (this sometimes happens with oranges and very spicy foods). She should eat as much as she feels hungry for; this is not the time to diet.

Fluids should be taken in plentiful quantities, but alcohol is best limited to the occasional glass. Avoiding excess caffeine is also wise. Many women get thirsty while breast-feeding and like to keep a glass of water or juice at hand during feeds.

Many drugs can pass into breast-milk and affect the baby. This does not mean that a woman should miss out on treatment she needs, but she and her doctor must take great care with the choice of drugs.

• The occasional paracetamol seems safe but aspirin is usually best avoided
• Most of the commonly prescribed antibiotics are safe for breast-feeding mothers, but not all
• The same is true of anti-depressants which are sometimes needed for post-natal depression
• The woman should always tell the doctor (or pharmacist) that she is breast-feeding as otherwise this fact can be overlooked

The first three days or so after delivery the breasts do not produce milk but a thin fluid called colostrum which is rich in sugar, protein and antibodies. Sometimes the milk is produced literally overnight, painfully distending the breasts which are then said to be engorged. If the areola is swollen too, the baby will be unable to suck until some of the excess milk is eased off by hand first. The mother can do this herself especially if she takes a hot bath with plenty of flannels over her breasts. This method is generally not advised for bottle feeding mothers and should be guided by their midwife or health visitor.

Engorgement does not usually last long. If it does, advice from the midwife or breast-feeding adviser should be sought.

If a nipple is sore, especially if there is a searing pain when the baby sucks, it may be cracked. The best remedy for this is to expose the nipple to the air as much as possible. If there is a lot of pain, it is better to express milk until the crack heals instead of feeding the baby from that side.

Cracking can be prevented by proper latching on and by limiting the length of each feed if the nipple is sore. Women with fair skin tend to have more sensitive nipples.

If the breasts themselves are sore, they may be engorged. Or, if pain is localised, the problem could be a blocked duct, or an infection which needs antibiotics. It can be hard to distinguish between the two, so a midwife, physician or breast-feeding advisor should be asked to help identify the problem at an early stage.

If there is pain, redness on the breast and flu-like symptoms the mother should consult the doctor as soon as possible, even if it is a call outside the normal surgery hours.

With breast-feeding it is hard to tell how much milk the baby is getting; the proof is in whether they are putting on weight. Losing weight in the first week after birth is normal for most babies born at term, but they usually regain their birth weight by 10 days (maximum three weeks). Thereafter an average weight gain is just under 200g (7 oz) a week.

A baby who is not getting enough breast milk may also be short of fluid, and the nappy may be dry when it should be wet. Dehydration is serious in babies and a doctor should be consulted if nappies are dry at two or more feeds in 24 hours.

Mothers sometimes worry that their baby will be under-nourished simply because they have small breasts, especially if they have been told that they will never succeed at breast-feeding because of it. This worry is counterproductive and unwarranted. Bra size has very little to do with the amount of glandular tissue in the breast, and almost any woman of any size can usually breast-feed successfully.

The drawback is that a breast-fed baby who takes bottles of formula milk will suck less at the breast, so the production of the mother's milk will decrease as a result.

Women often ask about giving bottles to supplement breast-milk. It is often possible to avoid bottles by increasing milk production; by drinking plenty of fluid, feeding the baby more often and taking rest as much as possible. However there are times when a woman genuinely cannot produce more milk, or does not want to try, in which case it is best to supplement the baby's intake with a bottle, especially if the baby's weight gain is poor.

A good time to introduce a bottle is the early evening, a time of day when many mothers produce less milk. The bottle should be offered just after a breast-feed, not before (unless the mother is trying to stop breast-feeding altogether; this process usually takes at least a week or two).

A breast-pump is used to drain milk when the baby is not there to suck - because for instance the child may be in Special Care, or the mother is at work. Pumps are also useful for relieving engorged breasts. A hand-operated pump, available from chemists, is satisfactory for occasional use. However if a woman intends to feed her baby her expressed breast-milk on a regular basis, electrical or battery operated pumps are available. Electrical pumps can be hired (see support organisations listed at the end of this factsheet or ask the midwife or local maternity unit).

Expressed milk can usually be kept in the fridge for up to 24 hours, or in the freezer for about two weeks. However expressing milk alone, and not breast feeding the baby will diminish the milk supply, sometimes dramatically.

The technique of bottle-feeding is simpler, but the preparation is much more complicated. It is important to:

• use sterilised equipment (including the measuring scoop, and the plastic knife or spatula used for levelling off each measure, and a plastic bottle cleaning brush)
• ensure that the hole in the teat is neither too small nor too large
• make feeds up to the right concentration (neither too strong nor too weak)
• offer the feed at the right temperature

Bottles and other equipment can be sterilised either with cold water and sterilising tablets or fluid, or with a purpose-bought steam sterilising unit. There are specialised microwave sterilisation units available. All these methods are good but the hands have to be clean too, or the whole point of sterilising is lost.

Before making up formula, some parents rinse off the sterilising solution from the bottle; if this is done, it should be with freshly boiled water, not tap water.

If the parent (or other adult preparing feeds) has an infection, scrupulous hygiene is even more vital. It is always important not to touch the tip of the teat (the bit that enters the baby's mouth) or to place any sterilised objects on the kitchen work-top.

Instructions for making up formula differ slightly from one make to another and can be found on the individual packets. The directions should always be followed carefully.

Some common mistakes include:

• packing powder too tightly into the scoop (this makes the feed too concentrated and can seriously dehydrate a baby)
• losing count of the number of scoops during preparation
• forgetting to stir the milk or shake the bottle
• placing the powder in the bottle before putting in the freshly cooled water

Perhaps surprisingly, big babies need more. As a rough guide, every 24 hours the average requirement is around 150 mls of formula milk for every kilogramme of the babys weight (2-3 fluid oz for every pound).

Obviously feeds have to be given throughout the day (and night), usually on demand when the baby is hungry. With the average baby this is often around every four hours.

Bottle-fed babies may need extra fluid, so cooled boiled water should be offered in hot weather or if running a temperature.

Bottles can be prepared up to 24 hours in advance and kept in the fridge until needed (with the top of the bottle sealed with a disc, rather than left just with a teat on it). Cold bottles can be reheated in an electrical bottle-warmer, or just in a jug of hot water. Using a microwave oven is not a good method because it can create hot areas within the formula which could burn the baby.

Some babies (especially older babies) are happy with cool formula milk, but it is best to heat it to body temperature, especially for a small or premature baby. Formula which is too hot is very dangerous and can even kill: heat can cause the lining of a baby's throat to swell and thereby block off their breathing completely.

The temperature of the milk must always be tested before offering the bottle to the baby. It's traditional for the bottle to be inverted so that a few drops fall onto the inside of the feeders wrist (inverting the bottle is far better than shaking it because this also tests whether the teat is letting out enough milk).

As with breast-feeding, the parent should be comfortable and relaxed. This is a good time to hold the baby close and speak to them.

The bottle itself should be held so that only formula enters the baby's mouth, not air. If the bottle is drained completely, it means larger feeds should be made up. Otherwise the baby will inevitably gulp air which could cause them to have pain later.

A baby should never be left propped up with the bottle, or left unsupervised to feed, as choking could occur. There is also the risk that feeding very slowly from bottles can damage teeth, leading to cavities.

The baby should be supported upright and helped to bring up any wind. Any formula left in that bottle should be thrown away; germs grow in milk, so a good rule is to discard formula which has been reheated 45 to 60 minutes previously.

All feeding equipment, especially teats, should be thoroughly cleaned using a bottle brush (which must only be used for this purpose, washed and sterilised daily) and warm soapy water ensuring all milk traces are removed.

If salt is used to clean the teats and not thoroughly rinsed off, excess sodium from the salt can cause a build up which is bad for babies.

Therefore all feeding equipment must be washed thoroughly before sterilising.