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Infant Feeding

Deciding how to feed your baby is an important decision and there are many things to consider. We encourage you to learn the facts about breast/chestfeeding, as well as the use of human milk and infant formula, so your infant feeding decision is informed. We also encourage you to discuss your thoughts, feelings, concerns and questions about feeding your baby with your family and your health care provider.

Ways to feed your infant include:

  • Breastfeeding: baby feeds directly from breasts (often the term used by women when feeding their infants)
  • Chestfeeding: baby feeds directly from the chest (often the term used by transgender men who have chosen to have a baby and lactate)
  • Human milk feeding: expressed human milk fed to infant via bottle or alternate feeding method
  • Formula feeding: infant formula fed via bottle or alternate feeding method

Human milk is different than infant formula. Infant formula is a commercial product, usually cow-milk based. Both feeding options have benefits and associated risks. Speak to your health care provider about risks associated with infant feeding, and how to minimize these.

Human milk:

  • Supports a baby’s growth and development
  • Changes according to a baby’s nutritional needs
  • Is recommended up to two years and beyond as it provides the older baby with important nutrients and some immune protection

Breast/Chestfeeding:

  • Helps babies cope better with painful procedures (e.g., during immunizations)
  • Provides an additional way to connect emotionally

Infant Formula:

  • Increases risk of diarrhea, ear infections, chest infections, obesity, diabetes and Sudden Infant Death Syndrome (SIDS)
  • Is associated with an increased risk of health concerns such as postpartum bleeding, type 2 diabetes, breast cancer, and ovarian cancer for birth parents

The Mount Sinai team seeks to make sure you have access to infant feeding information that is up-to-date, accurate and evidence-based. We will also support your decision by educating you and assisting you as much as possible when your baby arrives and while you are in hospital. Please visit the following link for more information on infant feeding decision making: 

The infant feeding timeline was created to help you navigate feeding in the first 48 hours after birth. This timeline is used for education and it serves as a reminder about what is considered normal infant feeding behaviours and patterns. Your nurse will help you navigate your infant’s feeding behaviours and patterns during your hospital stay, but it is also helpful to have some understanding of these things before your baby is born. The following link provides comprehensive information on breast/chestfeeding:

Skin to Skin involves the placement of your baby in an upright position, on you or your partner’s chest with no clothing or blankets placed between the infant and the parent.

The following video provides more guidance:

Potential risk associated with infant feeding
(not in the NICU)

Reduce the potential risk by

Increased risk of illness with formula feeding
  • Offer your infant as much human milk as possible and return to full breast/chest/human milk feeding as soon as possible
  • Hold your infant skin-to-skin to optimize exposure to their microbes to colonize the infant’s gut, produce a healthy microbiome and promote physiological benefits
  • Prepare and store formula safely to reduce the risk of food and water-borne illnesses

Increased risk of less responsive feeding with bottle feeding
  • Be familiar with cue-based feeding which helps in responding to signs of hunger, stress and satiation
  • Offer a bottle only in response to feeding cues by gently inviting your infant to take the bottle nipple
  • Be responsive to your infant and avoid forcing their infant to finish a bottle as formula/bottle-fed infants are at risk of over feeding
  • Use eye-to-eye contact with your infant to build early communication and responsiveness to one another. Include smiles and vocalization
  • Hold your infant close and try to alternate which arm is used to hold your infant while feeding

Increased risk of formula contamination due to manufacturing errors, improper cleaning of equipment and/or impure water
  • Be knowledgeable about where to access information about formula recalls. The Government of Canada website lists safety concerns and recall alerts. A parent may sign up for alerts on recalls
  • Ensure proper washing and drying techniques of all equipment used for feeding your infant
  • Be knowledgeable about safe water selection when preparing formula

Reduced human milk supply with formula and/or bottle feeding
  • If formula or a bottle is going to be used and you would like to return to full breast/chestfeeding, consider the following:
    • Learn how to establish and maintain your milk supply. This may include hand expressing, pumping or both
    • Get advice and support from a knowledgeable professional who can assist you to return to breast/chestfeeding

Increased risk of dehydration/inadequate calories if your infant is not breast/chestfeeding effectively
  • Learn how to identify sufficient milk transfer at each feeding
  • Learn how to recognize the signs that your infant is getting an adequate amount of human milk. Also know about signs when you need to talk to your health care provider (HCP)
  • Learn how to hand express early and give expressed human milk by spoon or cup after feedings, especially if you do not feel confident that your infant has fed well
  • Have an experienced HCP teach you how to assess adequate milk transfer in the first few days. This will help build your confidence
  • Ensure you have support and follow-up from an experienced HCP until you feel confident with feedings and your infant is showing an adequate weight gain pattern

Increased risk of dehydration/inadequate calories if your infant is not being fed the correct amounts or dilution of formula
  • If you are formula feeding, know how to correctly identify the type of formula you are using e.g., ready to serve vs. concentrate formula
  • Carefully follow package directions when reconstituting formula to ensure correct dilution of formula
  • Learn about appropriate amounts of formula per feed and per 24-hour period based on the age of your infant
  • Know how to use cue based feeding when bottle feeding formula

Increased risk of illness from direct breast/chestfeeding when the following are considerations

  • Maternal HIV
  • Herpes simplex virus type 1 (HSV-1)
  • Using medication that is contraindicated while breast/chestfeeding
  • Infants with galactosemia
  • Infants with maple syrup urine disease (MSUD)
  • Infants with phenylketonuria
  • Use a human milk replacement that is acceptable, feasible, affordable, sustainable and safe
  • Speak to your HCP and get up-to-date recommendations if you have any of these conditions

Adapted from Baby Friendly Initiative Strategy Ontario (2017) Informed Decision Making: Having Meaningful Conversations Regarding Infant Feeding Retrieved from on March 12 2021

Mount Sinai seeks to support you in your infant feeding goals. The evidence tells us that there are certain steps that we can take to support your success with breast/chestfeeding. Our Promise is made up of these steps.

Baby-led latching is natural and simple and can be encouraged immediately after the baby is born. It can also be useful as your baby learns to breastfeed, if your baby is not breastfeeding well and if your nipples are sore or painful. 

To encourage ‘Baby-led latching’:

  • “Skin to skin care with the lactating parent will help facilitate baby led latching by encouraging the baby to be oriented to the breast/chestfeeding and ensuring the infant is within proximity of the breast/chest and by calming the infant”
  • Start with a calm baby who is placed vertically with their tummy on your upper chest, between your breasts
  • Be comfortable, lean back a little
  • Your baby will begin to bob or peck while looking for your breast
  • Support your baby’s head and neck, shoulders and bottom as they move to find the nipple
  • In time, your baby will find the nipple, push their chin into the breast and reach up to the nipple with an open mouth
  • It will help to continue to support the baby’s bottom, back and shoulders while this happens
  • Once baby is latched, you and your baby can settle into a more comfortable position

This video shows you how baby-led latching happens in the first moments after birth.

Learning to position and latch your infant takes time, for you and your baby.

The following tips might be helpful: 

  • Have your baby skin to skin, close to your body
  • Position your baby so the nose is at the nipple
  • Allow your baby to reach up towards the nipple with an open mouth, so the head is slightly extended or tilted back
  • Use the base of your hand behind the shoulders to direct the baby up to the breast
  • Support the head with your fingers
  • Make sure your baby’s ear, shoulder and hip are in a straight line
  • Baby’s mouth will be wide open with lips flanged

These resources might be helpful to review before baby is born, and then again after baby is born.

Putting the infant to breast/chest as soon as possible is the best way to initiate breast/chestfeeding. If the infant cannot/does not latch, then hand expression can help stimulate milk supply.

If you’re interested in expressing milk before your baby is born, please speak to your care team. For more information on Antenatal Hand Expression, see this pamphlet.

Hand expression of breast milk is a technique that is valuable for every new breastfeeding mother to learn. In addition to feeding your baby at the breast, hand expression of breast milk has been shown to increase milk production. It can also be very helpful when a breast is very full.  A small amount of hand expression from a full breast can assist a baby to latch more successfully.

Learning the skill of hand expression early in your breastfeeding experience can allow for better availability of colostrum in the first days because the breast pump may not easily collect this thicker, stickier version of breast milk. Colostrum is low in fat, and high in carbohydrates, protein, and antibodies to help keep your baby healthy. Colostrum is extremely easy to digest, it is low in volume (measurable in teaspoons rather than ounces), but high in concentrated nutrition for the newborn. Colostrum has a laxative effect on the baby, helping him pass his early stools, which aids in the excretion of excess bilirubin and helps prevent jaundice.

Your expressed breast milk offers many important benefits and is especially important if your baby is born prematurely or is sick.  If you are separated from your infant, and you plan to breastfeed, we encourage early hand expression of breast milk.

The research tells us that hand expression should begin within 1 hour of the birth and continue regularly, every 3 hours or so, for the first 24 hours.  You will also be encouraged to do regular breast pumping at intervals similar to the timing a baby may feed if going to the breast.  It is also okay to hand express or pump as well as feed your baby at the breast with the goal of increasing milk supply. It is usually advised that you breastfeed first and then pump or hand express, collecting your expressed breast milk to supplement the feed at the breast. Hand expression is an effective means of expressing milk, boosting milk supply and collecting milk for an infant. Ask your labour and delivery and your postpartum nurse to help you with hand expression. 

Expressing human milk with a pump

Another way to express your milk is to use a pump. When considering whether to purchase or borrow a pump, it is important to know there are some pumps should not be shared. Please visit the following link for more information on making a safe pump choice:

Before making a purchase it is advised that you check with a lactation consultant to determine what type of pump will meet your individual needs. 

You can rent or purchase a pump at a number of locations, including Mount Sinai at the Sinai Shop. You will need to also purchase a single-use collection kit. Sterile Kits (for immediate use) can be purchased online at the link above, or in person at the Baby Shop (Monday to Friday 10am to 4:30pm) or in PNAC (Monday to Sunday 10am to 4pm). 

If you are pumping for a late preterm or a preterm infant, a hospital-grade electric breast pump is recommended if you are pumping for a baby with special needs, such as a premature infant or a baby who is unable to breastfeed. If you are pumping milk for a baby in the NICU, please see the following links for more information:

Points to remember when using a pump:

  • Pump each breast for no longer than 30 minutes. Double pumping (both breasts at the same time) will save time and often yields more milk.
  • Pumping should not be uncomfortable and should not hurt
  • Make sure your nipple is placed in the centre of the flange
  • Begin pumping six hours after birth if your infant has not/cannot latch. In this case, hand expression can begin one hour after birth, and can happen with pumping as advised by the Lactation consultant
  • If you and your baby are separated - double pump every two to three hours for 30 minutes (up to eight times a day)
  • If you have a low supply and your baby is breast/chestfeeding, but requires supplementation, double pump for 10-15 minutes after each feed

These links may provide additional information on pumping and milk storage:

Expressed breast milk is the optimum choice for supplementation of the breastfeeding infant. Your expressed breast milk should always be refrigerated and given to your infant when they are ready to begin feeds.  If there is not enough breast milk, your team will discuss with you what options might be available.

Clusterfeeding is part of the normal pattern a baby has in the first days after birth. Following the initial quiet alert stage in the first two or three hours after birth, baby goes into a deep sleep to help recover from labour. This period of deep sleep is followed by increased wakefulness and increased nursing demands. This is called "clusterfeeding." Clusterfeeding is often interpreted as an indication "that baby is not getting any milk or is getting an insufficient amount" of milk. Research has shown that this is a time in the early postpartum period, when mothers will resort to using supplemental formula. Clusterfeeding is not a medical indication for formula supplementation.

Some important points to remember:

  • Clusterfeeding usually occurs 24 to 48 hour after birth
  • This is a normal reaction to reduction of colostrum and brown fat reserves baby has made during pregnancy
  • The neurological system of a healthy, full term newborn is immature at birth and is somewhat disorganized in its behaviours. Baby seeks comfort and familiarity and breastfeeding offers this
  • Prolactin is the hormone responsible for making milk. It is at its highest levels at night and increases with more frequent feeding. Night feeds are particularly important to establish the milk supply and to increase milk volumes

Allowing baby to feed as much as possible at the breast during this time period of clusterfeeding will help the more mature milk to come in, will comfort baby and will positively influence future milk production.  If parents become exhausted in this period of time, feeding mom’s own expressed milk is the first line of defense.

One of the reasons parents feel they need to introduce formula when they are breastfeeding is because they think they do not have enough milk for their growing infant.

The Best Start “Breastfeeding Your Baby Poster” is a guide that outlines the signs that feeding is going well, and can be a source of reassurance when you are feeling uncertain. 

Watch the following videos to hear more about how you know you have enough milk, or how you can increase your supply.

How do you safely supplement a breastfeeding baby?

If a baby requires supplementing, our first advice is to use mom’s own milk to do so. Hand expression and /or pumping can assist you in collecting your own milk to supplement your baby. Using formula when you are breastfeeding your baby can be a very difficult decision. These resources may also be helpful in making this decision:

The use of formula is sometimes medically indicated when your milk is not enough in volume for your baby. Extra breast milk or formula may also be indicated for medical reasons such as: 

  • Low blood sugar (glucose) levels
  • Jaundice treatments (if the baby is too sleepy to feed well at the breast)
  • Meconium stools continue after the fourth day
  • Late preterm baby who is not feeding well at the breast
  • Excessive weight loss (despite frequent, effective feeds)
  • Mother’s milk has not increased by the fourth day
  • Dehydration (not enough wet diapers)

Ask your nurse or lactation consultant about supplementing your infant. Above all, your infant must be fed. We want you to be informed so that you can make the best decisions for your infant, but you may also find it helpful to get the opinion and support of experts. 

Recommended volumes for supplementing

The chart below is a guide for supplementing your infant’s feed:

Age

Per feed ml

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

More information about a baby’s stomach capacity in the early days can be found here.

When is a bottle needed?

Paced bottle feeding is a method of feeding your baby that mimics breastfeeding. It is also known as ‘Baby-led bottle feeding’ and is a method of feeding that can help minimize the negative impact bottle feeding may have on the baby who is also breastfeeding or trying to breastfeed. It is an acceptable method of supplementing breastfeeding when volumes of expressed milk or formula that are recommended exceed what might be reasonable to feed by cup or spoon. 

Paced bottle feeding is also the recommended method of feeding if you choose to exclusively formula feed by bottle.

The following video can help you learn how to pace bottle feed your baby:

Using Formula

It is important to know how to safely prepare and store formula as well as how to sterilize bottles and equipment. It is important to note that powdered formulas are not considered sterile, and can be subject to contamination recalls. We encourage our patients to consider using the premixed liquid formula or the concentrated liquid formula in the first two months of life. In addition to good hand hygiene and proper sterilizing of equipment when preparing formula, we encourage parents to always follow the package directions for reconstituting formula.

These resources are helpful for any parent who is considering formula for full feeds or as a supplement:

Why is breast milk important for preterm babies?

Breast milk is the ideal food for all babies and vital for preterm babies. A mother’s milk is especially suited to her own baby.

Your colostrum and breast milk are unique to your baby. Your breast milk adapts to meet the needs of your baby and changes over time.

Preterm breast milk is very important for:

  • Growth and development and is especially suited to the needs of preterm babies
  • Providing protein for brain growth
  • Providing antibodies to protect preterm babies from infection

Babies who are not breastfed are at a higher risk for:

  • Ear infections
  • Lung and breathing issues
  • Diarrhea
  • Diabetes
  • Overweight and obesity
  • Some childhood cancers
  • Sudden Infant Death Syndrome

An early preterm baby may need extra nourishment to support their growth needs. This may include adding human milk fortifier, nutrients and/or fat to the expressed breast milk. Although preterm babies may not be able to breastfeed in the beginning, skin-to-skin contact and breast milk are very important for them. Until premature babies are able to feed directly from the breast, mothers can express and pump their milk to feed to their baby.

The evidence tells us that there are certain steps that we can take to support your success. Our Promise made up of these steps, has been modified to acknowledge the very specific challenges that a parent might have when feeding a baby in the NICU.

You will have access to a Lactation Consultant with specialized knowledge in initiating and maintain a milk supply and encouraging a preterm baby to the breast when they are ready.

For information on pumping milk for a baby in the NICU, please refer to the “Hand Expression and Pumping” section

These resources are helpful for feeding your baby in the NICU:

Our Postnatal Ambulatory Clinic (PNAC) is staffed by a team of registered nurse/lactation consultants who provide breast/chest/human milk feeding support services to Mount Sinai patients.

Once you go home with your infant, you may require additional breastfeeding support. 

After discharge, get help with your breast/chestfeeding if:

  • You are supplementing your breast/chestfeeding infant with formula
  • You have sore nipples
  • You have blocked ducts that are not relieved by frequent feeding, hand expression or pumping
  • You have a fever or you are generally not feeling well
  • You are using a lactation device or nipple shield
  • Your infant is sleeping through feeds, not waking for feeds at least every four hours, not peeing or pooping enough, is jaundiced or is not gaining appropriate weight

There can be many circumstances that influence your breast/chestfeeding success. It is important to be patient with yourself, your body and your infant and it is ok, and encouraged, that you seek help if you need it. To determine if breast/chestfeeding is going well, this poster may help you monitor how breast/chestfeeding is progressing with your baby.

These resources may also be helpful for breast/chestfeeding:

In-Patient Education

Helpful breastfeeding education class to guide you

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