Breastfeeding and Other Foods
Breastmilk is the only food your baby needs until at least 4 months of age and most babies do very well on breastmilk alone for 6 months or more. There is no advantage to adding other sorts of foods or milks to breastmilk before 4 to 6 months, except under unusual or extraordinary circumstances. Many of the situations in which breastmilk seems to require addition of other foods arise from misunderstandings about how breastfeeding works, and/or originate from a poor start at establishing breastfeeding.
Supplementing during the first few days
It is thought by many that there is "no milk" during the first few days after the baby is born, and that until the milk "comes in" some sort of supplementation is necessary. This idea seems to be born out by the fact that babies, during the first few days, will often seem to feed for long periods and yet, not be satisfied. However, the key phrase is that "babies seem to feed" for hours, when in fact, they are not really feeding much at all. A baby cannot get milk efficiently when he is not latched on properly to the breast. When the mother's milk becomes more plentiful, after 3-7 days, the baby may do well even if he is not well latched on. But during the first few days, if the baby is not latched on properly, he cannot get milk easily and thus may "seem to feed" for very long periods. There is a difference between being "on the breast" and breastfeeding. The baby must latch on well so he can get the mother's milk which is there in sufficient quantity for his needs, as nature intended. If a better latch, and compression (Handout #15 Breast Compression) do not get the baby breastfeeding, then supplementation, if medically needed, can be given by lactation aid (handout #5 Lactation Aid). The lactation aid is a far better way to supplement than finger feeding or cup feeding, if the baby is taking the breast. And it is much, much better than using a bottle. But remember, getting the baby well latched on first works most of the time and no supplements will be needed.
Breastmilk is over 90% water. Babies breastfeeding well do not require extra water, even in summer. If they are not breastfeeding well, they also do not need extra water, but require that the breastfeeding be fixed. Babies do not need extra water even in hot weather.
It seems that breastmilk does not contain much vitamin D. We must assume this is as nature intended, not a mistake of evolution. The baby stores up vitamin D during the pregnancy and he will remain healthy without vitamin D supplementation, unless you yourself were vitamin D deficient during the pregnancy. Vitamin D deficiency in pregnant women in Canada is rare. Outside exposure also gives your baby vitamin D even in winter, even when the sky is covered. An hour or so of outside exposure during a week gives your baby more than enough vitamin D even if only his face is exposed, even in winter.
Under unusual circumstances, it may be prudent to give the baby vitamin D. For example, in situations where exposure of the baby to ultraviolet rays of the sun is not possible (Northern Canada in winter, or if the baby is never taken outside), giving the baby extra vitamin D would be advised. Vitamin D drops are expensive.
Breastmilk contains much less iron than formulas, especially the iron enriched formulas. Actually, this seems to give the baby extra protection against infection, as many bacteria require available iron in order to multiply. The iron in breastmilk is very well utilised by the baby (about 50% is absorbed), while being unavailable to bacteria, and the breastfed full term baby does not need any additional iron before about 6 months of age. However, introduction of iron containing foods should not be delayed much beyond 6 months of age.
Solid Foods (see also handout #16 Starting Solid Foods)
Breastfed babies normally do not require solid foods before 6 months of age. Indeed, many do not require solid foods until 9 months or more of age, if we can judge by their weight gain and iron status. However, there are some babies who will have great difficulty learning to accept solid food if not started before 7-9 months of age. Because the six month old baby will also soon need to have an additional source of iron, it is generally recommended and convenient that solids be introduced around 6 months of age. Some babies show great interest in grabbing food off the table by 5 months, and there is no reason not to allow them to start taking the food and playing with it and putting it in their mouths and eating it.
It has been the habit of physicians to suggest that babies be started first on cereals and then other foods be added. However, the 6 month old is far different from the 4 month old. Many 6 month old babies do not seem to like cereal if it is introduced at this time. Do not push the baby to take it, but offer other foods, and perhaps try again when your baby is a little older. But if he refuses, do not worry he will be missing something. There is nothing magic about cereal and babies do fine without it. Anyhow, your baby may soon be eating bread. The best way for the baby of getting additional iron is by eating meat.
There is no good reason why a baby needs to eat or be introduced to only one food per week, or why vegetables should be started before fruits. Anyone worried about the sweetness of fruit has not tasted breastmilk. The six month old can be given almost anything off his parents' plate that can be mashed with a fork.
Far fewer feeding problems will occur if a relaxed approach to feeding is taken.
Breastmilk, cow's milk, formula, outside work and bottles (see also handout #17 What to feed the baby when the mother is working outside the home)
A breastfeeding baby who is older than about 4 months will not likely take a bottle if he has not already gotten used to one. This is no loss or disadvantage. At about 6 months or even younger, the baby can start learning to use a cup, and usually will be quite good at drinking from a cup by about 7-8 months of age, if not sooner. If the mother is returning to paid work at about 6 months, there is also no need to start bottles or formula. In this situation, solids may be started somewhat earlier than 6 months of age (say 4 or 5 months of age), so that by the time the mother is working outside the home, the baby can be getting most of his food and liquid off a spoon when the mother is not with him. As he gets older, the cup may be used more and more for liquids. You and the baby can manage without his taking bottles. Do not try to starve the baby into taking a bottle if he refuses to accept one. Your baby is not being stubborn, but does not know how to use an artificial nipple. He also may not like the taste of formula, which is understandable.
Though there has been a lot of publicity recently about not giving babies cow's milk until at least 9 months, this does not really apply to breastfeeding babies. The breastfeeding baby can take some of his milk as cow's milk after about 6 months of age, especially if he is starting to take substantial amounts of a wide variety of solids as well. Goat's milk is an alternative. Many breastfeeding babies will not drink formula because they do not like the taste. Actually, the breastfeeding baby can get all the milk he needs from the breast without his requiring other sorts of milk, even if he is nursing only a few times a day.
My 4 month old is hungry on breast only. Solids or Formula?
There is no advantage in this situation of giving formula by bottle and there may be some disadvantage. Even at this age a baby may start to prefer the bottle if he seems not to getting enough from the breast (if, in fact, he will accept a bottle). It would be preferable in this circumstance to give solids off a spoon rather than to give formula in a bottle. (Frequently, however, this situation can be remedied differently by improving the breastfeeding—get help). If you wish to mix formula with solids, that does not cause the same sort of problem as giving it in a bottle. If the baby seems hungry after breastfeeding, feed him solids off a spoon. However, it may be possible with a simple techniques, to get the baby gaining well, and/or to be satisfied with breastfeeding alone. Check with the clinic.
Written by Jack Newman, MD, FRCPC
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