Making a Choice
Deciding how you will feed your baby can be a hard decision. You’ll really only know the right choice for your family when your baby comes.

Many women decide on one method before the birth and then change their minds after their baby is born. And many women decide to breastfeed and supplement with formula because they find that is the best choice for their family and their lifestyle.

While you’re weighing the pros and cons, talk to your doctor or lactation consultant. These health care providers can give you more information about your options and help you make the best decision for your family

Before you give birth
During pregnancy, the following things can prepare you for breastfeeding.

·         Prenatal care. It is important to take good care of yourself and your baby. Babies who are born early (premature) have a harder time breastfeeding.

·         Talk to your doctor and lactation consultant. Make sure they know your plan to breastfeed.

·         Breastfeeding items. Plan ahead by purchasing the items you need. These can include a nursing pillow, nursing bra, and covers. Check into breast pumps.

The Basics of Breastfeeding
Breastfeeding is very healthy for you and your baby. Breast milk is commonly the only nutrition your baby needs for the first 6 months after birth.

After 6 months, you will start to feed your baby other foods in addition to breast milk. We recommend you continue to breastfeed your baby for at least the first 12 months. Breastfeeding is natural, but can sometimes be challenging. You and your baby may need a little help, especially in the beginning. It will generally get better with time and practice.

To get ready to breastfeed:

·         Make a plan for after your baby is born and talk with your doctor or lactation consultant about breastfeeding.

Once your baby is born:

·         Let your doctor know you want skin-to-skin contact with your baby right away.

·         Nurse whenever your baby is hungry.

·         And always ask for help if breastfeeding is difficult.

·         After your baby is born

Babies are born and placed skin-to-skin as soon as possible. This quick, close contact is now recognized to promote many health benefits.

·         Skin-to-skin contact also helps babies start breastfeeding, which provides the exact nutrients your baby needs plus many more advantages. We strongly encourage women to nurse their babies, and if you choose to breastfeed my certified lactation consultant, Kristy can help you get started.

·         Breastfeeding offers many benefits to your baby. Breast milk contains the right balance of nutrients to help your infant grow into a strong and healthy toddler and it has antibodies to help protect your infant against common childhood illnesses and infections. Babies who are breastfed are less likely to have allergies, asthma, or diabetes, or become overweight.

·         Breastfeeding has benefits for you as well. It’s cheaper than using formula. No bottles to wash or formula to mix. It helps your uterus go back to normal size after stretching out during pregnancy, delay your periods from returning and help you lose weight faster. However, don’t count on breastfeeding to prevent pregnancy. Breastfeeding helps you bond with your baby. Women who breastfeed have lower risks of type 2 diabetes, breast cancer, ovarian cancer, high blood pressure, and heart disease.

·         Women who don’t have health problems should try to give their babies breast milk for at least the first six months of life. Most women with health problems can breastfeed. There are rare exceptions when women are advised not to breastfeed because they have certain illnesses. Some medicines, illegal drugs, and alcohol can also pass through the breast milk and cause harm to your baby. Check with Dr. Wyman if you have concerns about whether you should breastfeed.

·         If you are having problems with breastfeeding, contact a Kristy my lactation consultant.

Breastfeeding information and tips:
Once your baby is born, your breasts will start to fill up. At first, your body will produce a “pre-milk,” called colostrum. This could be thin and watery or thick and more yellow-colored. The pre-milk has a slower flow to help your baby learn to nurse. After 3 to 4 days of nursing, your real breast milk will come in.

Most babies are ready to eat 1 to 2 hours after birth. Below is a guide on how to breastfeed.

1.    Wash your hands before each feeding.

2.    Place your baby in one of the breastfeeding positions (outline below).

3.    Put the thumb of your free hand on top of your breast and your other fingers below.

4.    Touch your baby’s lips to your nipple until your baby opens their mouth wide.

5.    Put your nipple all the way in your baby’s mouth and pull your baby close to you. This lets your baby’s jaw squeeze the milk ducts under your areola (nipple).

Latching on:
When your baby is latched on, both lips should pout out and cover nearly all of your areola. Your baby’s jaw should begin to move back and forth and your baby may make low-pitched swallowing noises instead of smacking noises. If you feel pain while your baby is nursing, your baby may not be latched on.

Your baby’s nose may touch your breast during nursing which is okay due to the design of your baby’s nose to allow air to get in and out. If you are concerned that your baby can’t breathe, gently press down on your breast near your baby’s nose to allow more room to breathe. Your baby should not have to turn their head or strain their neck to nurse.

Breastfeeding holding positions:
You can hold your baby in a number of ways. Some of the most common positions are:

·         Cradle. Put your baby’s head in the crook of your arm. Support your baby’s back and bottom with your forearm. Your baby should be lying facing you. Your breast should be right in front of your baby’s face.

·         Side-lying. While lying down, place your baby alongside you. Your baby should be facing you. Pull your baby close to you so they can latch on. You can use a pillow to prop up, if needed. You do not want to fall asleep while nursing laying down (or any other) position.

·         Football. Tuck your baby under your arm, along your side. Their head should be resting in your hand. Support your baby’s body with your forearm. Your baby should be facing you.

·         Cross-cradle. Hold your baby with the opposite arm of the breast you are using. Support your baby’s head and bottom with the palm of your hand and forearm. Your baby should still be lying facing you. This position can help premature babies or babies who have a weak suck. It provides added head support.

Feeding Information:
Feed your baby as often as they want to be fed. Learn how to tell when they are hungry. Crying can be a sign of hunger, but it may be too late. Babies who are crying or are upset have a harder time latching on. Watch out for early signs of hunger. Your baby may:

·         make sucking motions

·         turn toward the breast if they are being held

·         put their hands in their mouth

·         become excited or alert.

After birth, they may be hungry 8 to 12 times a day or more. This number may decrease over time or increase during a growth spurt. Growth spurts occur at about 2 weeks and 6 weeks of age and again at about 3 months and 6 months of age.

Let your baby eat until they are satisfied. This may be for about 15 to 20 minutes at each breast. Try to have your baby nurse from both breasts at each feeding. Make sure your baby finishes one breast before starting the other. Your baby should let go on their own once they are done.

Do not limit the time you let your baby nurse. It may keep your milk ducts from completely emptying. This can decrease your milk flow and make it harder for your baby to latch it on. It also can cause swelling and pain. Applying a cold compress before nursing can ease discomfort.

Enough Milk:
Your baby is getting enough milk if they:

·         act satisfied after each feeding.

·         gain weight consistently after the first 3 to 7 days after birth. (Your baby may lose a little weight during the first week after being born.)

·         has about 6 to 8 wet diapers a day.

·         has about 2 to 5 or more stools a day at first. This number may decrease to about 2 stools or less a day.

Sometimes babies fall asleep while nursing. If you think your baby is asleep and hasn’t finished nursing, here are some tips to try:

·         You can squeeze your breast to make more milk flow

·         undress your baby and rub the back

·         tickle the feet

·         burp your baby

·         try changing your baby’s diaper or switching to the other breast

Babies who latch on incorrectly may fall asleep at the breast. If this happens, break the suction and reposition your baby onto your breast to include both your nipple and areola. You can break the suction by slipping your finger in the side of your baby’s mouth (between the gums) and then turning your finger a quarter turn to break the suction. (If you just pull your baby off your breast, it will likely startle your little one and hurt your breasts as well.)

After you’ve broken the suction, try to burp your baby and switch your little one to the other breast. A lactation consultant can show you the right latch method and help you with any questions or concerns you might have.

Milk supply:
If you think your baby needs more milk, increase the number of feedings a day. It’s important for you to get plenty of rest and eat right. Give your body time to catch up to your baby’s demands.

Do not replace breast milk with baby formula or cereal. This can make them lose interest in breast milk. It also will decrease your milk supply. You should not give your baby solid foods until about 6 months of age.

Breastfeeding Challenges
It’s easier to prevent sore nipples than it is to treat them. The main cause of sore nipples is when your baby doesn’t latch on the right way. You need to start over to correct this. To take your baby off your breast, release the suction by putting your finger in the corner of your baby’s mouth between the gums. Switch breasts and try to breastfeed again.

Other ways to help prevent and heal sore nipples are:

·         Make sure your baby is sucking the right way. If the sucking hurts, your baby’s mouth may not be in the right position.

·         Offer your baby the less sore of your two nipples first. Your baby’s sucking may be less forceful after the first few minutes.

·         If possible, position cracked or tender parts of your breast at the corner of your baby’s mouth. This way the spots get less pressure during feeding.

·         Change positions.

·         Let your nipples air dry between feedings. Let the milk dry on your nipples instead of wiping it off.

·         Wash your nipples daily with warm water. Do not use soap or lotion that may contain alcohol. This can dry out your skin.

·         Rub lanolin on your nipples to help soothe them.

·         Avoid bra pads lined with plastic. Change bra pads between feedings to keep your nipples dry.

·         Discharge milk with your hand until the let-down reflex occurs. This can help make your milk flow easier so your baby sucks less hard.

Your baby’s nursing sessions are either very short or extremely long. Breastfeeding sessions that are consistently briefer than about ten minutes during the first few months may mean that your baby isn’t getting enough milk and that not enough milk is being removed to stimulate your ongoing milk production. Sessions that last consistently longer than about fifty minutes may mean that your baby isn’t receiving enough milk due to ineffective suckling or low milk production.
Your baby still seems hungry after most feedings. Baby may not be ingesting enough milk. Consult your pediatrician. Meanwhile, double-check baby’s latch-on and position at the breast to try to increase the milk your baby is getting.

Your newborn frequently misses nursing sessions or sleeps through the night. Frequent feedings around the clock are a necessary part of breastfeeding a new baby. Your baby requires a feeding every few hours to gain sufficient weight to thrive. If your newborn sleeps longer than four hours a night, wake your baby up and encourage baby to nurse. You don’t hear frequent swallowing when your baby nurses after your milk supply has come in. Your baby will probably swallow occasionally at the beginning of nursing, more frequently as session continues,  and less frequently again near the end. Swallowing is an excellent sign that your baby is actually ingesting milk, and its absence should prompt you to call your pediatrician at once. (Remember, though, that you may not be able to hear your baby swallowing in the early colostrums sipping days.)
By two weeks of age, your baby is under her birth weight or hasn’t started gaining at least 5 to 7 ounces per week since your milk came in. Inadequate weight gain is one of the strongest indicators that a baby is not getting enough milk.

After seven days, your baby has fewer than six wet diapers and four stools per day, baby’s urine is dark yellow or specked with red, or stools are still dark rather than yellow and loose. If you or your pediatrician is concerned about your child’s milk intake, you might want to keep a written record of your baby’s wet diapers and bowel movements during the early days to be sure baby is progressing properly.

After five days, your milk hasn’t come in or your breasts don’t feel as though they’re filling with milk. If you feel this way, have your baby weighed by your pediatrician immediately. This is the most precise way to tell whether she is ingesting enough milk. You may also want to have your breasts examined by a lactation consultant.
You experience severe breast engorgement. Hard, painful breasts may prevent your baby from latching on correctly and discourage both of you from nursing. You may need to express milk manually or with an electric breast pump until your breasts have softened somewhat. Severe, unrelieved engorgement can decrease your milk supply.
The fullness and hardness of your breasts don’t decrease by the end of a feeding. Your baby may not be drinking enough milk or may be suckling ineffectively.
Severe pain interferes with breastfeeding. Your baby is probably not latching on correctly. If you have severe nipple pain or significant cracking of the nipples that makes it too painful to nurse, consult your physician or lactation specialist. She can check for a nipple or breast infection such as mastitis and help you with any problems with latching on. You may need to start breastfeeding on the less sore side or even use an electric breast pump until your nipples have healed. Your lactation specialist can show you how to do this.
After a week or two, you don’t notice the sensations associated with your milk let-down reflex. Though this may not indicate a problem at all, it could mean that your milk production is low. Ask your baby’s pediatrician to evaluate her and observe your breastfeeding technique. Your lactation consultant can help assess the situation, too.

When to see your doctor
Call your doctor if you have:

·         a red, sore, or painful spot on your breast

·         painful engorgement (overfull breasts)

·         a fever or if you feel achy. These may be signs of an infection.

You also should call your doctor if your baby is losing weight for no apparent reason.

Your diet while breastfeeding:

What foods to eat:
The best diet is well balanced and has plenty of calcium. A balanced diet includes eating from all 5 food groups. You should get 5 servings of milk or dairy products each day. It is okay to eat foods that were restricted while you were pregnant. These will not make your baby sick.

If you do not eat meat or dairy, you can get calcium from foods such as broccoli, sesame seeds, tofu, and kale.

You should eat about 500 extra calories per day. Make sure you drink extra fluids as well. Continue to take a prenatal vitamin so your body gets enough nutrients.

What foods to avoid:
Certain foods can bother your baby. They may make them fussy or gassy. Pay attention to what you eat and how your baby acts after feedings. Stop eating foods that affect them. These may include spicy foods, broccoli, or milk.

Some babies react to cow’s milk that is in your diet. Symptoms can include gas, vomiting, diarrhea, rash, or colic. Your baby also can have an allergic reaction to something you eat. Common foods are eggs and peanuts. They may get a rash or have trouble breathing. Contact your doctor right away if your baby has any of these signs.

Limit your intake of caffeine and alcohol. These can get into your milk. Do not have more than a couple cups of coffee, tea, soda, or other caffeine. Do not have more than one alcoholic drink. Avoid drinking either less than 2 hours before a feeding.

Some medicines can get into your milk. This includes over-the-counter drugs and prescriptions, such as antidepressants and birth controls. Do not take anything without talking to your doctor first. Smoking also is bad for breastfeeding. The chemicals and smoke can get it your milk. Smoking can cause you to make less milk. If you smoke, try to quit.

When can I start pumping: 
Some women who breastfeed start pumping soon after their baby is born to build up their milk supply if they’re not producing enough milk. This also can be helpful if a mom wants to store milk in the freezer for when she returns to work.

But it’s a good idea to wait to introduce a bottle to your baby. Some experts feel that pumping and giving bottles too early might cause “nipple confusion,” leading a baby to decide that the bottle is the quicker, better option than the breast. While some babies have this confusion, others have no problem moving between a bottle and the breast.

If you’re returning to work after maternity leave, try to start pumping a couple of weeks beforehand. If you wait until the day before you go back to work, you may be frustrated to find that your body doesn’t respond to the pump. In fact, it may take some practice and patience before you’re able to produce enough milk without your baby’s help. It also may take time for your baby to get used to taking a bottle.

Depending on how heavy their milk flow is, some women can fill a bottle in one pumping session, while others may need to pump more to get a full bottle.

Though pumping might be frustrating at first, it can help you get some much-needed rest and let your partner and other family members bond with and feed the baby. It also allows you to continue to provide breast milk for your baby when you return to work or are away.

Kinds of pumps:
Do your research and consult with your lactation specialist who is available to assist you with detailed instructions and be there for you if you have difficulty.

Which kind of breast pump to use is up to you. Here’s what’s available:

·         Manual pumps. Manual pumps are smaller than electric pumps and more discreet. They are cheaper than electric pumps. A manual pump is fine for occasional pumping, but usually not for returning to work because many moms find that the effort required for manual pumps is too much and it takes too long to draw out milk.

·         Electric pumps. Despite their expense, electric can be easier to use than manual ones because they don’t require much physical effort. And many models let you pump both breasts at once, which is a real time-saver and may increase your milk supply.

Some women find the noise of the electric pumps to be a little much. And though they often come in easy-to-carry bags (such as backpacks or arm bags), the weight and bulk can be a bit cumbersome.

Also keep in mind where you might be using the pump. Some electric pumps can be plugged in or battery-operated; others can’t. So, unless you want to have to find a comfortable spot and an electrical outlet every time, you might want one that offers both options. It’s also important to consider a back-up method, such as a battery-operated or manual pump, in case of a power outage.

Find out which type of pump (if any) your insurance will help pay for. If you don’t have the money to buy a pump or don’t receive one as a gift, contact the governmental organization Women, Infants, and Children (WIC) to find out about their pump program and to see if you qualify.

Making pumping easier:
As with nursing, it’s important to be comfortable when pumping.

Often, women’s milk will “let down” (or start to be released) when they see or hear their babies cry. So, when faced with an object instead of the welcoming face of your little one, you may find it hard to pump.Try relaxing in a comfortable chair or couch and don’t stress out too much about producing enough milk.

If your breast just doesn’t seem to fit the pump correctly, the pump may come with different sized flanges or you can buy a smaller or larger flange to place over your breast. (The flange is the plastic cup that goes over the nipple and areola when you pump.)

Also, just like when you’re nursing, it’s important to place the breast shield of the pump correctly over your breast, covering your nipple and areola (not just the tip of your nipple), and getting a good seal. If you place the pump incorrectly, it can be uncomfortable and you’ll be much less likely to get the milk you need. And if you’re using an electric breast pump, make sure to adjust the speed and suction to the level that’s comfortable for you to help prevent unnecessary discomfort.

Storing breast milk:

These apply to full term, healthy breastfeeding babies:

·         Fresh breast milk can stay SIX hours at normal room temperature.

·         Breast milk that has been pumped or expressed by hand can stay in the refrigerator for SIX days

·         Milk can be frozen (in a side-by-side or top/bottom) for SIX months

·         And in a deep freeze without frequent opening of the door, for ONE year

·         To thaw frozen milk, you can move it to the refrigerator (it takes 24 hours to thaw), then warm by running warm water over the bag or bottle of milk and use it within the next 24 hours. If you need it immediately, then remove it from the freezer and run warm water over it until it’s at room temperature. Do not refreeze it. Once your baby has started to drink from the bottle, you should use it within 1 hour.

Baby milk intake first week: 

Remember, the size of the full-term baby’s stomach at birth is the size of a small cherry or a shooter marble. By day three, it will grow to the size of a walnut or ping pong ball, by day seven, to the size of an apricot, and day 30, to the size of the baby’s fist or a large chicken egg. Your stomach is the size of your fist, or a softball. How much does each of these hold?

·         Day One: 3 to 5 milliliters per feeding, or 1/2 to 1 teaspoonful

·         Day Three: 22 to 27 milliliters or 0.75 to 1 ounce

·         Day Seven: 45 to 60 milliliters or 1.5 to 2 ounces

·         One Month: 80 to 150 milliliters or 2.5 to 5 ounces

Diaper count:

What goes in must come out, says the old adage. Breastfed babies have very frequent stools in the early weeks. Remember that breast milk is very easy for your little one to digest, and he or she will be pooping out whatever he or she doesn’t need for immediate growth. Here’s what you should expect to see:

·         Day one to day two: Black, sticky, odorless meconium

·         Day two to three: Green, less sticky, and still odorless transitional

·         Day three to four: Yellow, seedy, runny breast, milky stools with a rather sweet, yeasty odor.

How many?

·         Day one: 1 wet, 1 stool (or more!)

·         Day two: 2 wet, 2 stools (or more!)

·         Day three: 3 wet, 3 stools (or more!)

·         Day four, when a copious milk supply begins: six or more wet and four or more stools.

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Babies first bottle: 
If possible, you should have someone else give your little one the bottle at first. This is because babies can smell their mothers and they’re used to receiving breast milk from mom, not a bottle. So try to have someone else give a breastfed baby the first bottle.

Also consider either being out of the house or out of sight when your baby takes that first bottle, since your little one will wonder why you’re not doing the feeding as usual. Depending on how your baby takes to the bottle, this arrangement may be necessary until he or she gets used to bottle feeding.

Breast milk and formula:
Although breast milk is the best nutritional choice for infants, in some cases, breastfeeding (or exclusive breastfeeding) may not be possible or an option. Your baby’s health and happiness is, in large part, determined by what works for you as a family. So if you need to supplement, your baby will be fine and healthy, especially if it means less stress for you.

Lactation professionals recommend waiting until a baby is about 3 weeks old before offering artificial nipples of any kind (including pacifiers).

Starting formula:
If you’re using formula because you’re not producing the amount of milk your baby needs, nurse first. Then, give any pumped milk you have and make up the difference with formula as needed.

If you’re stopping a breastfeeding session or weaning from breastfeeding altogether, you can begin to replace breastfeeding with bottle feeds. As you do this, pump to reduce uncomfortable engorgement so you will not have problems with plugged ducts or mastitis. As you eliminate nursing sessions, your milk supply will decrease and your body will begin to adapt to produce enough milk to accommodate your new feeding schedule.

Starting your breastfed baby on formula can cause some change in the frequency, color, and consistency of the stools (poop). Be sure to talk your doctor, though, if your baby is having trouble pooping.

If your baby refuses formula alone, you can try mixing some of your pumped breast milk with formula to help the baby get used to the new taste.

All About Formula Feeding
Commercially prepared infant formulas are a nutritious alternative to breast milk, and even contain some vitamins and nutrients that breastfed babies need to get from supplements.

Manufactured under sterile conditions, commercial formulas attempt to duplicate mother’s milk using a complex combination of proteins, sugars, fats, and vitamins that aren’t possible to create at home. So if you don’t breastfeed your baby, it’s important to use only commercially prepared formula and not try to make your own.

Besides medical concerns that may prevent breastfeeding, for some women, breastfeeding may be too difficult or stressful. Here are other reasons women may choose to formula feed:

Convenience. Either parent (or another caregiver) can feed the baby a bottle at any time (although this is also true for women who pump their breast milk). This allows mom to share the feeding duties and helps her partner to feel more involved in the crucial feeding process and the bonding that often comes with it.

Flexibility. Once the bottles are made, a formula-feeding mother can leave her baby with a partner or caregiver and know that her little one’s feedings are taken care of. There’s no need to pump or to schedule work or other obligations and activities around the baby’s feeding schedule. And formula-feeding moms don’t need to find a private place to nurse in public.

Time and frequency of feedings. Because formula is less digestible than breast milk, formula-fed babies usually need to eat less often than breastfed babies.

Diet. Women who opt to formula feed don’t have to worry about the things they eat or drink that could affect their babies.

Formula Feeding Challenges
As with breastfeeding, there are some challenges to consider when deciding whether to formula feed.

Lack of antibodies. None of the antibodies found in breast milk are in manufactured formula. So formula can’t provide a baby with the added protection against infection and illness that breast milk does.

Can’t match the complexity of breast milk. Manufactured formulas have yet to duplicate the complexity of breast milk, which changes as the baby’s needs change.

Planning and organization. Unlike breast milk formula feeding your baby requires planning and organization to make sure that you have what you need when you need it. Parents must buy formula and make sure it’s always on hand to avoid late-night runs to the store.

And it’s important to always have the necessary supplies (like bottles and nipples) clean, easily accessible, and ready to go.

Expense. Formula can be costly. Powdered formula is the least expensive, followed by concentrated, with ready-to-feed being the most expensive.

Possibility of producing gas and constipation. Formula-fed babies may have more gas and firmer bowel movements than breastfed babies.

If your baby has a hard time adjusting to this new form of feeding, just be patient and keep trying
When should I introduce solid foods and juice?
For babies who are exclusively breastfed, doctors recommend waiting until a baby is about 6 months old. But some infants may be ready sooner.

When is baby ready to eat solids foods:

·         are interested in foods

·         hold up their heads well, and sit up with little or no help

·         have the oral motor skills needed to eat

·         usually weigh twice their birth weight, or close to it

Wait until your baby is at least 4 months old and shows these signs of readiness before introducing solids. Babies who start solid foods before 4 months are at a higher risk for obesity and other problems later on. They also aren’t coordinated enough to safely swallow solid foods and may choke on the food or inhale it into their lungs.

When the time is right, start with a single-grain, iron-fortified baby cereal (rice cereal has traditionally been the first food for babies, but you can start with any you prefer). Start with 1 or 2 tablespoons of cereal mixed with breast milk, formula, or water. Another good first option is an iron-rich puréed meat. Feed your baby with a small baby spoon, and never add cereal to a baby’s bottle unless your doctor recommends it.

At this stage, solids should be fed after a nursing session, not before. That way, your baby fills up on breast milk, which should be your baby’s main source of nutrition until age 1.

When your baby gets the hang of eating the first food, introduce a variety of other foods, such as puréed fruits, vegetables, beans, lentils, or yogurt. Wait a few days between introducing new foods to make sure your baby doesn’t have an allergic reaction.

Experts recommend introducing common food allergens to babies when they’re 4–6 months old. This includes babies with a family history of food allergies. In the past, they thought that babies should not get such foods (like eggs, peanuts, and fish) until after the first birthday. But recent studies suggest that waiting that long could make a baby more likely to develop food allergies.

Offer these foods to your baby as soon as your little one starts eating solids. Make sure they’re served in forms that your baby can easily swallow. You can try a small amount of peanut butter mixed into fruit purée or yogurt, for example, or soft scrambled eggs.

Note: There is no benefit to offering fruit juice, even to older babies. Juice can fill them up and leave little room for more nutritious foods, promote obesity, cause diarrhea, and even put a baby at an increased risk for cavities when teeth start coming in.