Breastfeeding Initiation: Your Questions Answered

Jenny Murray, BSN, RN / October 2019


By now, you’ve heard the importance of providing opportunities for mothers to breastfeed (or pump, if needed) within a timely manner after birth to establish future milk supply. There are many questions circulating about this process, so today I’ll answer a few of the larger ones.

Every mom who desires to breastfeed should begin her breastfeeding journey in an optimal manner – ideally beginning to breastfeed within the first hour after birth, and with frequent and repeated skin-to-skin contact.1 Research shows what happens in the beginning sets mom (and baby) up for long term success.

Q: “I know this is important, but a mother who has just given birth is exhausted and is anxious to show off her newborn. Why should we set this kind of expectation for her?”

A: For mom to meet her long-term breastfeeding goals, there is compelling evidence that shows a lot has to happen in the first few days, beginning in the first few hours after birth. The success of building her milk supply depends on secretory activation, or the lactogenesis II phase, that focuses upon stimulation and the frequent emptying of the breast.1,2 After this onset of lactogenesis, continued milk removal drives more milk production.2

Q: What does all of that mean?

A: Once an infant and placenta are delivered, there is a dramatic decline in progesterone. Prolactin levels will increase with this fall in progesterone. Keeping the prolactin levels elevated in the first few days following birth sets the foundation for adequate milk volumes later. Prolactin levels are elevated by an infant sucking, and we know through research that a newborn’s sucking behavior enhances the onset of a copious milk supply.1,3 With the low volume of colostrum, the intermittent sucking pattern by the newborn and increased vacuum levels provided by the infant provide stimulation to the prolactin receptors. If mom is unable to breastfeed, or an infant provides inadequate stimulation, it is important to stimulate secretory activation through breast expression by using a breast pump.4 Medela’s Symphony PLUS Initiation technology was designed, based on research, to provide this kind of stimulation.1

Q: “A mom may feel anxious about this type of breastfeeding work in the beginning. I hear many moms say they’ll work on it when they get home in a more comfortable setting. Wouldn’t they prefer to do that?”

A: While the rates of initiation have increased over the years, the rates of exclusive breastfeeding extending to 3 and 6 months are dramatically declining.  We have all heard the mom who says she quit breastfeeding because “I didn’t have enough milk.”  Supporting early stimulation increases her chances of building a milk supply that supports mom and baby. In turn, this gives her the confidence she needs to continue to breastfeed or pump.

In one study by Parker et al, 60% of mothers of very low birth weight (VLBW) infants who initiated pumping within the first hour were still lactating 6 weeks post-delivery compared to the 20% of mothers who initiated after 6 hours.1

Q: How can we support moms as early as possible? 

A: It all begins with education. All moms want what is best for their baby, so if she chooses to breastfeed, it is important to help her set realistic expectations with supportive care and education.

It’s best if education starts in the hospital, and it is imperative that nurses understand the “why” behind the importance of early stimulation. They should also be aware of any risk factors that may contribute to the need for mom to pump. How we interact with mom can affect her long-term breastfeeding success.   

All mothers who desire to breastfeed should receive evidence-based care that allows the infant to begin breastfeeding soon after delivery and continue to frequently breastfeed. This is not always possible though, especially for a preterm or sick infant who is admitted to the NICU. There are other risk factors that can also contribute to suboptimal lactation or inadequate stimulation.1,5 These include:

  • First time mom
  • Mom over the age of 30
  • C-section
  • Increased BMI
  • Twin gestation
  • Late pre-term infant

Case:  “A 35-year-old, G1P0 mom was just admitted to L&D.  She desires to breastfeed. She will be having a c-section for placenta previa. The baby is 35 weeks. How do I give her every chance to meet her breastfeeding goals?”

This mom has several risk factors that we know put her at risk for suboptimal lactation. If the infant is stable, breastfeeding should be combined with pumping using Medela Initiation Technology. This will provide mom with the crucial stimulation needed to meet her breastfeeding goals.

It is very important to explain to mom the importance of early stimulation and how it can affect long term success for her and her baby. If she does not have the right education and support early on, it could create anxiety, depression, and an overall negative birthing experience. This disappointment of not meeting breastfeeding goals for baby can leave lasting scars.

When we understand how to help our children, we do whatever we can to do what is best for them. Armed with supportive education, this can help increase mom’s chances of meeting her goals, while fulfilling what we know is the very best medicine for an infant – mother’s own milk.

Learn more about The Moms’ Room: A program designed to empower moms to reach their goals, help them connect with other moms, and to get the support they need. It starts as early as 6 weeks prenatal and extends through 2 years postnatal.

Learn more about breastfeeding initiation and the build and maintain phases.


  1. Parker LA, Sullivan S, Krueger C, Mueller M. Association of timing of initiation of breastmilk expression on milk volume and timing of lactogenesis stage II among mothers of very low-birth-weight infants. Breastfeed Med. 2015;10(2):84-91.
  2. Rhodes, J.  Improving Delayed Lactogenesis and Suppressed Lactation in At-Risk Mothers White Paper.  2017.
  3. Meier, P.P., Engstrom J.L., Janes, J.E., Jegier, R.J., Loera, F.  Breast pump suction patterns that mimic the human infant during breast feeding: greater milk output in less time spent pumping for breast pump-dependent mothers with premature infants.  Journal of Perinatology.  2012; 32(2):102-110.
  4. Rhodes, J.  Initiation Support Strategies to Optimize Maternal Milk Volumes.  Neonatal Intensive Care.  2017; 30(2):33-36. 
  5. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics. 2003; 112(3 Pt 1):607-619.


About the Author

Jenny Murray, BSN, RN, began her career 18 years ago as a neonatal nurse in neonatal intensive care. She has since served in a variety of nursing leadership roles within the NICU. Her experience in those roles has driven her love for education and research, especially educating and supporting clinicians in the advancing, innovative world of neonatology. Jenny currently works as a Clinical NICU Specialist for Medela LLC.