JBR Admin

JBR Admin

Friday, 15 February 2008 17:56

When the baby refuses to latch on

When the baby refuses to latch on

Why would a baby refuse to take the breast?

There are many reasons a baby might refuse to latch on. Often there is a combination of reasons. For example, a baby might latch on even with a tight frenulum if no other factors come into play, but if, for example, he is also given bottles early on, this may very well change the situation from "good enough", to "not working at all".


  1. If the mother's nipples are particularly large, or inverted, or flat, these nipple variations make latching on more difficult, not usually impossible.
  2. Some babies are unwilling to nurse, or suck poorly as a result of medication they received during the labour. Narcotics are responsible for many such situations, and meperidine (Demerol) is particularly bad as it stays in the baby's blood for a long time and affects the way he sucks for several days. Even morphine given in an epidural may cause the baby to be unwilling to nurse or latch on, since medication from an epidural definitely does get into the mother's blood, and thus into the baby before he is born.
  3. Vigorous suctioning at birth may result in babies not sucking properly and not wanting to latch on. There is no need to suction a healthy, full term baby at birth.
  4. Abnormalities of the baby's mouth may result in the baby's not latching on. Cleft palate, but not cleft lip, causes severe difficulties in latching on. Sometimes the cleft palate is not obvious, affecting only the part inside the baby's mouth.
  5. A tight frenulum (the whitish tissue under the tongue) may result in a baby having difficulty latching on. This is not, strictly speaking, considered an abnormality, and thus, many physicians do not believe that it can interfere with breastfeeding, but they are misinformed.
  6. A baby learns to breastfeed by breastfeeding. Artificial nipples interfere with how the baby takes the breast. Babies are not stupid. If they get slow flow from the breast (as is expected in the first few days of life) and rapid flow from the bottle, they will not be confused many will figure it out quite quickly.


However, one of the most common causes of babies' refusing to latch on arises from the misguided belief that babies in the first few days must breastfeed every 3 hours, or on some sort of schedule. This results in anxiety on the part of the staff when a baby has not fed, for example, for three hours after birth, which results, frequently, in babies being forced to the breast when they are not ready yet to feed. When the baby is forced into the breast, and kept there by force, when the baby is not interested or ready, we should not be surprised that some babies develop an aversion to the breast. If this misguided approach then results in panic, and "the baby must be fed", alternative feeding methods (the worst of which is the bottle) are then used, resulting in worsening of the situation and the beginning of a vicious circle.

There is no evidence that a healthy full term newborn must feed every three hours during the first few days. There is >no evidence that they will develop low blood sugars if they don't feed every three hours (the whole issue of low blood sugars has become a mass hysteria in newborn nurseries which, like all hysterias, has a legitimate basis for developing, perhaps, but actually causes more problems than it prevents, including the problem of many babies getting formula when they don't need it, and being separated from their mothers when they don't need to be, and not latching on). Babies should be together, skin to skin with their mothers, 24 hours a day. When they are ready, most will start looking for the breast. Having the baby with the mother skin to skin immediately after birth, and allowing the baby and the mother the time to "find" each other, will prevent most situations of the baby not latching on. Having the baby and mother together for 5 minutes though, is not the answer. The mother and baby should be together until the baby latches on, without pressure, without time limits ("we've got to weigh the baby, we've got to give the baby vitamin K etc these procedures can wait!). This might take 2 hours or more.

But the baby is not latching on!

Okay, so how long can we wait? There is no obvious answer to that. Certainly, if the baby has shown no interest in nursing or feeding by 12 to 24 hours after birth, it may be worthwhile to do something, mostly because hospital policies usually require the mother to be discharged by 24 to 48 hours. What?


  1. The mother should start expressing her milk, and that milk (colostrum), either alone, or mixed with sugar water, should be fed to the baby, preferably by finger feeding. If it is difficult get colostrum (often hand expression works better than a pump in the first few days), then sugar water alone is fine for the first few days. Most babies will start sucking, and many will wake up enough to attempt going to the breast. As soon as the baby is sucking well, finger feeding should be stopped and the baby tried at the breast. Finger feeding is essentially a procedure to prepare the baby to take the breast, not primarily a method to avoid the bottle, though it will do that too.
  2. Before discharge, early, competent help needs to be arranged so that the mother and baby are getting help by day four or five at the latest. Many babies not able to latch on in the first few days will latch on beautifully once the mother'smilk supply has increased substantially as it does around day 3 or 4. Getting help at this time avoids the negative associations with the breast that many babies develop as time goes on.
  3. A nipple shield started before the mother's milk becomes abundant (day 4 to 5) is bad practice. Starting a nipple shield before the mother's milk "comes in" is not giving time a chance.


I'm home from hospital. The baby won't latch on. What do I do?

The single most important factor influencing whether or not the baby latches on is the mother's developing a good milk supply. If the mother's supply is abundant, the baby will latch on by 4 to 8 weeks of life no matter what. What we try to do at the clinic is get the baby latching on earlier, so that you won't have to wait that long. So, it is more important you keep up your supply, than avoid a bottle. The bottle interferes, and it is better you use other methods (such as a cup) if you can, but if you feel you have no choice, you should do what you need to do.


  • Learn how to get the best position and latch from an experienced lactation specialist (see also handout When latching). As the baby comes onto the breast, compress the breast so that the baby gets a gush of milk. Try the baby on the breast he seems to prefer, not the one he resists more.
    • If the baby latches on, he will start sucking and start drinking (get information on how to know a baby is actually getting milk at the breast - see handout #4. Is my baby getting enough milk?).
    • If the baby doesn't latch on, don't try to keep him on the breast; it won't work. He will either get hysterical or "go limp". Move him away from the breast and start again. It is better to go on-off, on-off several times than to push him into the breast when he hasn't latched on.
    • If the baby goes to the breast and sucks once or twice, he hasn't latched on a little; he hasn't latched on at all.
  • If the baby refuses the breast, don't keep at it until he's angry. Try finger feeding a few seconds to a minute or two, and try again, perhaps on the other side. Finger feeding is to prepare the baby to take the breast, not primarily to avoid a bottle.
  • If the baby doesn't latch on, finish the feeding with whatever method you find easiest.
  • Using a lactation aid at the breast may be helpful, but often requires an extra hand.
  • At about two weeks after birth, a change in what you have been doing often seems to send a message to the baby that "there's more than one way to do this". If you have been finger feeding only, a change to a cup or bottle will sometimes work, or using a nipple shield will often work. If you have been bottle feeding only, switching to finger feeding (before attempting the baby at the breast only, as you may not, at this point, manage finger feeding only) may work.


How to maintain and increase milk supply

  • Express your milk as often as is practical, at least 8 times a day, using a reliable pump that expresses both breasts at the same time. Using compression while pumping increases the efficiency of pumping and increases the milk supply (another hand is helpful, but mothers have rigged up the pump so that they don't have to hold onto the tubing or flanges while pumping and thus can compress without help).
  • If the baby hasn't latched on by day 4 or 5, start fenugreek and blessed thistle to increase milk flow. See handout #24. Miscellaneous treatments. Domperidone may also be useful. See handouts 19a and 19b, Domperidone 1 and 2.
  • Do not use a nipple shield until the milk supply is well established (at least 2 weeks after the baby is born).

Do not get discouraged. Even if your milk supply is not up to the needs of your baby, many babies will still latch on. Get good help. Do not do this on your own.

Written by Jack Newman, MD, FRCPC
May be copied and distributed without further permission

Friday, 15 February 2008 17:49

Slow weight gain after the first few months

Slow weight gain after the first few months


Sometimes, babies who are doing very well with breastfeeding alone for the first few months, start not to gain as well after 2 to 4 months just with breastfeeding. This may be normal, because breastfed babies do not grow along the same growth curves as formula fed babies, and it may appear that they grow too slowly, when in fact, it is the formula fed baby who is growing too quickly. Breastfeeding is the normal, natural way of feeding infants and small babies. Using the formula feeding baby as the normal is irrational and leads us to make errors in advising mothers about feeding and growth.

In some cases, an illness in the baby may result in slower weight gain than is expected. Supplementing with formula does not cure the illness, and may rob the baby of the beneficial effects of exclusive breastfeeding. You can tell when a baby is getting milk and when he is not (see below). If he is not, it is unlikely the baby has an illness, and more like the mother's milk supply is down.

However, the most common cause of unusually slow weight gain is that the mother's milk supply has decreased.

Why would your milk supply decrease?


  1. you have gone on the birth control pill. If you have, stop the pill. There are other ways of preventing a pregnancy besides hormones.
  2. you are pregnant.
  3. you have been trying to stretch out the feedings, or "train" the baby to sleep through the night. If this is the case, feed the baby when he is hungry or sucking his hand.
  4. you are using bottles more than occasionally. Even when the milk supply is well established, frequent bottles teach the baby a poor latch at a time when the baby expects rapid flow. With slow flow, the baby may pull away from the breast, decreasing time at the breast even more, and decreasing breastmilk even more.
  5. an emotional "shock" can, occasionally, decrease the milk supply.
  6. sometimes an illness, particularly when associated with fever can decrease the milk supply. So can mastitis. Illness in the mother does not usually decrease milk supply.
  7. you are doing too much. You don't have to be a super mother. Let the housework go. Sleep when your baby sleeps. Let the baby nurse while you sleep.
  8. some medications may decrease milk supply--some antihistamines (e.g. Bendryl), pseudephedrine (e.g. Sudafed).
  9. a combination of some of the above.
  10. sometimes the milk supply decreases, particularly around 3 months for no obvious reason.


One more reason requires a little more explanation. In the first few weeks, babies tend to fall asleep at the breast when the flow of milk is slow (this slowing of the flow occurs more rapidly if the baby is not well latched on). The baby will suck and sleep and suck, without getting large quantities at this point, but the mother may have a letdown reflex (milk ejection reflex) from time to time and the baby will drink more. When the mother's supply is abundant, the baby usually gains fine, though he may spend long periods on the breast despite the mother's abundant supply.

However, by the time babies are 6 or 8 weeks of age, younger sometimes, many babies start to pull away from the breast when the flow slows down, often within a few minutes of starting nursing. The mother will then likely put the baby to the other side, but then the baby will do the same thing. He may be hungry still, and may refuse the breast preferring to suck his hand. He won't get those extra letdown that give him a few extra gushes of milk that he would have had if he had stayed on the breast. So he drinks less, and the supply also decreases because he drinks less, and the flow slows even earlier in the feeding (because there is less milk) and you see what may happen. It doesn't always happen this way, and many babies may gain even if the do spend only a short period of time on the breast, but still pull off and suck their hands because they want more sucking. If the weight gain is good, there is no need for concern.

The way to prevent this is to get a good latch from the very first. However, many mothers are being told the latch is good even if it isn't. A better latch can help, sometimes even at a late date. Using compression will often keep a baby drinking (see protocol for increasing the intake of breastmilk by the baby).Sometimes domperidone will increase the milk supply significantly. Do not use it if you are pregnant, however (see handout on domperidone).

How do you know the baby actually drinks at the breast

When a baby is getting milk (he is not getting milk just because he has the breast in his mouth and is making sucking movements), you will see a pause at the point of his chin after he opens to the maximum and before he closes his mouth, so that one suck is (open mouth wide-->pause-->close mouth). If you wish to demonstrate this to yourself, put your index or other finger in your mouth and suck as if you were sucking on a straw. As you draw in, your chin drops and stays down as long as you are drawing in. When you stop drawing in, your chin comes back up. This pause that is visible at the baby's chin represents a mouthful of milk when the baby does it at the breast. The longer the pause, the more the baby got. Once you know about the pause you can cut through so much of the nonsense breastfeeding mothers are being told. Such as: Feed the baby twenty minutes on each side. A baby who does this type of sucking (with the pause) for twenty minutes straight might not even take the second side. A baby who nibbles (doesn't drink) for 20 hours will come off the breast hungry.

Written by Jack Newman, MD, FRCPC
May be copied and distributed without further permission

Sunday, 26 June 2005 16:43

How Breast Milk Protects Newborns

How Breast Milk Protects Newborns

Some of the molecules and cells in human milk actively help infants stave off infection.

Doctors have long known that infants who are breast-fed contract fewer infections than do those who are given formula. Until fairly recently, most physicians presumed that breast-fed children fared better simply because milk supplied directly from the breast is free of bacteria. Formula, which must often be mixed with water and placed in bottles, can become contaminated easily. Yet even infants who receive sterilized formula suffer from more meningitis and infection of the gut, ear, respiratory tract and urinary tract than do breast-fed youngsters.

The reason, it turns out, is that mother's milk actively helps newborns avoid disease in a variety of ways. Such assistance is particularly beneficial during the first few months of life, when an infant often cannot mount an effective immune response against foreign organisms. And although it is not the norm in most industrial cultures, UNICEF and the World Health Organization both advise breast-feeding to "two years and beyond." Indeed, a child's immune response does not reach its full strength until age five or so.

All human babies receive some coverage in advance of birth. During pregnancy, the mother passes antibodies to her fetus through the placenta. These proteins circulate in the infant's blood for weeks to months after birth, neutralizing microbes or marking them for destruction by phagocytes-immune cells that consume and break down bacteria, viruses and cellular debris. But breast-fed infants gain extra protection from antibodies, other proteins and immune cells in human milk.

Once ingested, these molecules and cells help to prevent microorganisms from penetrating the body's tissues. Some of the molecules bind to microbes in the hollow space (lumen) of the gastrointestinal tract. In this way, they block microbes from attaching to and crossing through the mucosa-the layer of cells, also known as the epithelium, that lines the digestive tract and other body cavities. Other molecules lessen the supply of particular minerals and vitamins that harmful bacteria need to survive in the digestive tract. Certain immune cells in human milk are phagocytes that attack microbes directly. Another set produces chemicals that invigorate the infant's own immune response.

Breast Milk Antibodies

Antibodies, which are also called immunoglobulins, take five basic forms, denoted as IgG, IgA, IgM, IgD and IgE. All have been found in human milk, but by far the most abundant type is IgA, specifically the form known as secretory IgA, which is found in great amounts throughout the gut and respiratory system of adults. These antibodies consist of two joined IgA molecules and a so-called secretory component that seems to shield the antibody molecules from being degraded by the gastric acid and digestive enzymes in the stomach and intestines. Infants who are bottle-fed have few means for battling ingested pathogens until they begin making secretory IgA on their own, often several weeks or even months after birth.

The secretory IgA molecules passed to the suckling child are helpful in ways that go beyond their ability to bind to microorganisms and keep them away from the body's tissues. First, the collection of antibodies transmitted to an infant is highly targeted against pathogens in that child's immediate surroundings. The mother synthesizes antibodies when she ingests, inhales or otherwise comes in contact with a disease-causing agent. Each antibody she makes is specific to that agent; that is, it binds to a single protein, or antigen, on the agent and will not waste time attacking irrelevant substances. Because the mother makes antibodies only to pathogens in her environment, the baby receives the protection it most needs-against the infectious agents it is most likely to encounter in the first weeks of life.

Second, the antibodies delivered to the infant ignore useful bacteria normally found in the gut. This flora serves to crowd out the growth of harmful organisms, thus providing another measure of resistance. Researchers do not yet know how the mother's immune system knows to make antibodies against only pathogenic and not normal bacteria, but whatever the process may be, it favors the establishment of "good bacteria" in a baby's gut.

Secretory IgA molecules further keep an infant from harm in that, unlike most other antibodies, they ward off disease without causing inflammation-a process in which various chemicals destroy microbes but potentially hurt healthy tissue. In an infant's developing gut, the mucosal membrane is extremely delicate, and an excess of these chemicals can do considerable damage. Interestingly, secretory IgA can probably protect mucosal surfaces other than those in the gut. In many countries, particularly in the Middle East, western South America and northern Africa, women put milk in their infants' eyes to treat infections there. I do not know if this remedy has ever been tested scientifically, but there are theoretical reasons to believe it would work. It probably does work at least some of the time, or the practice would have died out.

An Abundance of Helpful Molecules

Several molecules in human milk besides secretory IgA prevent microbes from attaching to mucosal surfaces. Oligosaccharides, which are simple chains of sugars, often contain domains that resemble the binding sites through which bacteria gain entry into the cells lining the intestinal tract. Thus, these sugars can intercept bacteria, forming harmless complexes that the baby excretes. In addition, human milk contains large molecules called mucins that include a great deal of protein and carbohydrate. They, too, are capable of adhering to bacteria and viruses and eliminating them from the body.

The molecules in milk have other valuable functions as well. Each molecule of a protein called lactoferrin, for example, can bind to two atoms of iron. Because many pathogenic bacteria thrive on iron, lactoferrin halts their spread by making iron unavailable. It is especially effective at stalling the proliferation of organisms that often cause serious illness in infants, including Staphylococcus aureus. Lactoferrin also disrupts the process by which bacteria digest carbohydrates, further limiting their growth. Similarly, B12 binding protein, as its name suggests, deprives microorganisms of vitamin B12. Bifidus factor, one of the oldest known disease-resistance factors in human milk, promotes the growth of a beneficial organism named Lactobacillus bifidus. Free fatty acids present in milk can damage the membranes of enveloped viruses, such as the chicken pox virus, which are packets of genetic material encased in protein shells. Interferon, found particularly in colostrum-the scant, sometimes yellowish milk a mother produces during the first few days after birth-also has strong antiviral activity. And fibronectin, present in large quantities in colostrum, can make certain phagocytes more aggressive so that they will ingest microbes even when the microbes have not been tagged by an antibody. Like secretory IgA, fibronectin minimizes inflammation; it also seems to aid in repairing tissue damaged by inflammation.

Cellular Defenses

As is true of defensive molecules, immune cells are abundant in human milk. They consist of white blood cells, or leukocytes, that fight infection themselves and activate other defense mechanisms. The most impressive amount is found in colostrum. Most of the cells are neutrophils, a type of phagocyte that normally circulates in the bloodstream. Some evidence suggests that neutrophils continue to act as phagocytes in the infant's gut. Yet they are less aggressive than blood neutrophils and virtually disappear from breast milk six weeks after birth. So perhaps they serve some other function, such as protecting the breast from infection.

The next most common milk leukocyte is the macrophage, which is phagocytic like neutrophils and performs a number of other protective functions. Macrophages make up some 40 percent of all the leukocytes in colostrum. They are far more active than milk neutrophils, and recent experiments suggest that they are more motile than are their counterparts in blood. Aside from being phagocytic, the macrophages in breast milk manufacture lysozyme, increasing its amount in the infant's gastrointestinal tract. Lysozyme is an enzyme that destroys bacteria by disrupting their cell walls.

In addition, macrophages in the digestive tract can rally lymphocytes into action against invaders. Lymphocytes constitute the remaining 10 percent of white cells in the milk. About 20 percent of these cells are B lymphocytes, which give rise to antibodies; the rest are T lymphocytes, which kill infected cells directly or send out chemical messages that mobilize still other components of the immune system. Milk lymphocytes seem to behave differently from blood lymphocytes. Those in milk, for example, proliferate in the presence of Escherichia coli, a bacterium that can cause life-threatening illness in babies, but they are far less responsive than blood lymphocytes to agents posing less threat to infants. Milk lymphocytes also manufacture several chemicals-including gamma-interferon, migration inhibition factor and monocyte chemotactic factor-that can strengthen an infant's own immune response.

Added Benefits

Several studies indicate that some factors in human milk may induce an infant's immune system to mature more quickly than it would were the child fed artificially. For example, breast-fed babies produce higher levels of antibodies in response to immunizations. Also, certain hormones in milk (such as cortisol) and smaller proteins (including epidermal growth factor, nerve growth factor, insulinlike growth factor and somatomedin C) act to close up the leaky mucosal lining of the newborn, making it relatively impermeable to unwanted pathogens and other potentially harmful agents. Indeed, animal studies have demonstrated that postnatal development of the intestine occurs faster in animals fed their mother's milk. And animals that also receive colostrum, containing the highest concentrations of epidermal growth factor, mature even more rapidly.

Other unknown compounds in human milk must stimulate a baby's own production of secretory IgA, lactoferrin and lysozyme. All three molecules are found in larger amounts in the urine of breast-fed babies than in that of bottle-fed babies. Yet breast-fed babies cannot absorb these molecules from human milk into their gut. It would appear that the molecules must be produced in the mucosa of the youngsters' urinary tract. In other words, it seems that breast-feeding induces local immunity in the urinary tract.

In support of this notion, recent clinical studies have demonstrated that the breast-fed infant has a lower risk of acquiring urinary tract infections. Finally, some evidence also suggests that an unknown factor in human milk may cause breast-fed infants to produce more fibronectin on their own than do bottle-fed babies.

All things considered, breast milk is truly a fascinating fluid that supplies infants with far more than nutrition. It protects them against infection until they can protect themselves.



The Author: JACK NEWMAN founded the breast-feeding clinic at the Hospital for Sick Children in Toronto in 1984 and serves as its director. He has more recently established similar clinics at Doctors Hospital and St. Michael's Hospital, both in Toronto. Newman received his medical degree in 1970 from the University of Toronto, where he is now an assistant professor. He completed his postgraduate training in New Zealand and Canada. As a consultant for UNICEF, he has worked with pediatricians in Africa. He has also practiced in New Zealand and in Central and South America. Further Reading MUCOSAL IMMUNITY: THE IMMUNOLOGY OF BREAST MILK. H. B. Slade and S. A. Schwartz in Journal of Allergy and Clinical Immunology, Vol. 80, No. 3, pages 348-356; September 1987.

IMMUNOLOGY OF MILK AND THE NEONATE. Edited by J. Mestecky et al. Plenum Press, 1991.

BREASTFEEDING AND HEALTH IN THE 1980': A GLOBAL EPIDEMIOLOGIC REVIEW. Allan S. Cunningham in Journal of Pediatrics, Vol. 118, No. 5, pages 659-666; May 1991.

THE IMMUNE SYSTEM OF HUMAN MILK: ANTIMICROBIAL, ANTIINFLAMMATORY AND IMMUNOMODULATING PROPERTIES. A. S. Goldman in Pediatric Infectious Disease Journal, Vol. 12, No. 8, pages 664-671; August 1993.

HOST-RESISTANCE FACTORS AND IMMUNOLOGIC SIGNIFICANCE OF HUMAN MILK. In Breastfeeding: A Guide for the Medical Profession, by Ruth A. Lawrence. Mosby Year Book, 1994.

SCIENTIFIC AMERICAN December 1995 Volume 273 Number 6 Page 76
Scientific American (ISSN 0036-8733), published monthly by Scientific American, Inc., 415 Madison Avenue, New York, N.Y. 10017-1111. Copyright 1995 by Scientific American, Inc. All rights reserved. Except for one-time personal use, no part of any issue may be reproduced by any mechanical, photographic or electronic process, or in the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted or otherwise copied for public or private use without written permission of the publisher. For information regarding back issues, reprints or permissions, E-mail This email address is being protected from spambots. You need JavaScript enabled to view it. .

Written by Jack Newman, MD, FRCPC
May be copied and distributed without further permission

Sunday, 26 June 2005 16:42

Risks of Artificial Feeding

Risks of Artificial Feeding

(Studies done mostly in affluent societies)

Risks to infant and child


1. Walker M. A fresh look at the risks of artificial feeding. J Hum Lact 1993;9:97-107 2. Cunningham AS, Jelliffe DB, Jelliffe EFP. Breastfeeding and health in the 1980: a global epidemiologic review. J Pediatr 1991;118:659-66

Cognitive Development:

CD (review): Andraca I, Uauy R. Breastfeeding for optimal mental development. Simopoulos AP, Dutra de Oliveira JE, Desai ID (eds): Behavioral and Metabolic Aspects of Breastfeeding. World Rev Nutr Diet. Basel, Karger, 1995;78:1-27

CD (review): Gordon N. Nutrition and cognitive function. Brain and Development 1997;19:165-70

CD-1: Morrow-Tlucak M, Haude RH, Ernhart CB. Breastfeeding and cognitive development in the first 2 years of life. Soc Sci Med 1988;26:635-9

CD-2: Taylor B, Wadsworth J. Breastfeeding and child development at five years. Dev Med Child Neurol 1984;26:73-80

CD-3: Lucas A, Morley R, Cole TJ, Lister G, Leeson-Payne C. Breastmilk and subsequent intelligence quotient in children born preterm. Lancet 1992;339:261-4

CD-4: Nettleton JA. Are n-3 fatty acids essential nutrients for fetal and infant development. J Am Diet Assoc 1993;93:58-64

CD-5: Rogan WJ, Gladen BC. Breastfeeding and cognitive development. Early Hum Dev 1993;31:181-93

CD-6: Silver LB, Levinson RB, Laskin CR, Pilot LJ. Learning disabilities as a probable consequence of using chloride-deficient infant formula. J Pediatr 1989;115:97-9

CD-7: Willoughby A, Moss HA, Hubbard VS, Bercu BB, Graubard BI, Vietze PM, et al. Developmental outcome in children exposed to chloride deficient formula. Pediatrics 1987;79:851-7

CD-8: Wing CS. Defective infant formulas and expressive language problems: a case study. Language, Speech and Hearing Services in Schools 1990;21:22-7

CD-9: Crawford MA. The role of essential fatty acids in neural development: implications for perinatal nutrition. Am J Clin Nutr 1993;57(suppl):703S-10S

CD-10: Temboury MC, Otero A, Polanco I, Arribas E. Influence of breastfeeding on the infant's intellectual development. J Pediatric Gastroenterol Nutr 1994;18:32-36

CD-11: Pollock JI. Longterm associations with infant feeding in a clinically advantaged population of babies. Dev Med Child Neur 1994;36:429-40

CD-12: Makrides M, Neumann MA, Byard RW, Simmer K, Gibson RA. Fatty acid composition of brain, retina and erythrocytes in breast and formula fed infants. Am J Clin Nutr 1994;60:189-94

CD-14: Anderson GJ, Connor WE, Corliss JD. Docosohexaenoic acid is the preferred dietary n-3 fatty acid for the development of the brain and retina. Pediatr Res 1990;27:87-97

CD-15: Neuringer M, Connor WE, Lin DS, Barstad L, Luck S. Biochemical and functional effects of prenatal and postnatal fatty acid deficiency on retina and brain in rhesus monkeys. Proc Natl Acad Sc USA 1986;83:4021-5

CD-16: Florey C Du V, Leech AM, Blackhall A. Infant feeding and mental and motor development at 18 months of age in first born singletons. Int J Epidem 1995;24 (Suppl 1):S21-6

CD-17: Wang YS, Wu SY. The effect of exclusive breastfeeding on development and incidence of infection in infants. JHL 1996;12:27-30

CD-18: Greene LC, Lucas A, Livingstone BE, Harland PSEG, Baker BA. Relationship between early diet and subsequent cognitive performance during adolescence. Biochem Soc Trans 1995;23:376S

CD-19: Riva E, Agostoni C, Biasucci G, Trojan S, Luotti D, Fiori L, et al. Early breastfeeding is linked to higher intelligence quotient scores in dietary treated phenylketonuric children. Acta P diatr 1996;85:56-8

CD-20: Niemel A, J A-L. Is breastfeeding beneficial and maternal smoking harmful to the cognitive development of children? Acta diatr 1996;85:1202-6

CD-21: Rodgers B. Feeding in infancy and later ability and attainment: a longitudinal study. Devel Med Child Neurol 1978;20:421-6

CD-22: Horwood LJ, Fergusson DM. Breastfeeding and later cognitive and academic outcomes. Pediatrics 1998;101:p. e9

CD-23: Paine BJ, Makrides M, Gibson RA. Duration of breastfeeding and Bayley's mental developmental Index at 1 year of age. J Paediatr Child Health 1999;35:82-5


Neurologic Outcome

N-1: Lanting CI, Patandin S, Weisglas-Kuperus N, Touwen BCL, Boersma ER.Breastfeeding and neurological outcome at 42 months. Acta Paediatr 1998;87:1224-9




SIDS-1: Mitchell EA, Scragg R, Stewart AW, Becroft DMO, Taylor BJ, For RPK, et al. Results from the first year of the New Zealand cot death study. NZ Med J 1991;104:71-6

Insulin Dependent Diabetes:

Working Group on Cow's Milk Protein and Diabetes Mellitus of the American Academy of Pediatrics. Infant feeding practices and their possible relationship to the etiology of diabetes mellitus. Pediatrics 1994;94:752-4


JD-1: Karjalainen J, Martin JM, Knip M, Ilonen J, Robinson BH, Savilahti E, et al. A bovine albumin peptide as a possible trigger of insulin-dependent diabetes mellitus. N Eng J Med 1992;327:302-7

JD-2: Mayer EJ, Hamman RF, Gay EC, Lezotte DC, Savitz DA, Klingensmith J. Reduced risk of IDDM among breastfed children. Diabetes 1988;37:1625-32

JD-3: Virtanen SM, Rasanen L, Ylanen K, Aro A, Clayton D, Langlholz B, et al. Early introduction of dairy products associated with increased risk of IDDM in Finnish children. Diabetes 1993;42:1786-90

JD-4: Virtanen SM, Rasanen L, Aro A, Lindstrom J, Sippola H, Lounamaa R, et al. Infant feeding in Finnish children over 7 yr of age with newly diagnosed IDDM. Diabetes Care 1991;14:415-17

JD-5: Gerstein HC. Cow's milk exposure and type I diabetes mellitus. Diabetes Care 1994;17:13-9

JD-6: Kostraba JN, Cruickshanks KJ, Lawler-Heavner J, Jobim LF, Rewers MJ, Gay EC, et al. Early exposure to cow's milk and solid foods in infancy, genetic predisposition, and risk of IDDM. Diabetes 1993;42:288-95

JD-7: Parez-Bravo F, Carrasco E, Gutierrez-Lapez MD, Marta‚­nez MT, Lapez G, Garcia‚­a de los Rios M. Genetic predisposition and environmental factors leading to the development of insulin-dependent diabetes mellitus in Chilean children. J Mol Med 1996;74:105-9

JD-8: Gimeno SGA, De Souza JMP. IDDM and milk consumption. Diabetes Care 1997;20:1256-60

JD-9: Hammond-McKibbon D, Karges W, Gaedigk R, Dosch H-M. Immunological mechanisms that link cow milk protein and insulin dependent diabetes: a synopsis. Can J Allergy and Clin Immunol 1997;2:136-46


Cow milk Allergy and Intolerance:

CM-1: Ha st A. Importance of the first meal on the development of cow's milk allergy and intolerance. Allergy Proc 1991;12:227-32



Respiratory Illness:

RI-1: Pullan CR, Toms GL, Martin AJ, Gardner PS, Webb JKG, Appleton DR. Breastfeeding and respiratory syncytial virus infection. Br Med J 1980;281:1034-6


RI-2: Chiba Y, Minagawa T, Mito K, Nakane A, Suga K, Honjo T, Nakao T. Effect of breastfeeding on responses of systemic interferon and virus-specific lymphocyte transformation with respiratory syncytial virus infection. J Med Virology 1987;21:7-14

RI-3: Wright AL, Holberg CJ, Martinez FD, Morgan WJ, Taussig LM. Breastfeeding and lower respiratory tract illness in the first year of life. Br Med J 1989;299:946-9

RI-4: Porro E, Indinnimeo L, Antognoni G, Midulla F, Criscione S. Early wheezing and breastfeeding. J Asthma 1993;30:23-8

RI-5: Burr ML, Limb ES, Maguire JM, Amarah L, Eldridge BA, Layzell JCM, Merret TG. Infant feeding, wheezing, and allergy: a prospective study. Arch Dis Child 1993;68:724-28

RI-6: Pisacane A, Graziano L, Zona G, Granata G, Dolezalova H, Cafiero M, et al. Breastfeeding and acute lower respiratory infection. Acta Padiatr 1994;83:714-18

RI-7: Beaudry M, Dufour R, Marcoux S. Relation between infant feeding and infections during the first six months of life. J Pediatr 1995;126:191-7

RI-8: Okamoto Y, Ogra PL. Antiviral factors in human milk: implications in respiratory syncytial virus infection. Acta Padiatr Scand Suppl 1989;351:137-43

RI-9: Downham MAPS, Scott R, Sims DG, Webb JKG, Gardner PS. Breastfeeding protects against respiratory syncytial virus infections. Br Med J 1976;2:274-6

RI-10: Wright AL, Holberg CJ, Taussig LM, Martinez FD. Relationship of infant feeding to recurrent wheezing at age 6 years. Arch Pediatr Adolesc Med 1995;149:758-63

RI-11: Yue Chen. Synergistic effect of passive smoking and artificial feeding on hospitalization for respiratory illness in early childhood. Chest 1989;95:1004-07

RI-12: Wilson AC, Forsyth JS, Greene SA, Irvine L, Hau C, Howie PW. Relation of infant diet to childhood health: seven year followup of cohort of children in Dundee infant feeding study. Br Med J 1998;316:21-5 (also shows higher blood pressure in formula fed children)

RI-13: Oddy WH, Holt PG, Sly PD, Read AW, Landau LI, Stanley FJ, Kendall GE, Burton PR. Association between breastfeeding and asthma in 6 year old children: findings of a prospective birth cohort study. Br Med J 1999;319:815-9

RI-14: Caesar JA, Victora CG, Barros FC, Santos IS, Flores JA. Impact of breastfeeding on admission for pneumonia during postneonatal period in Brazil: nested case-control study. Br Med J 1999;318:1316-20 RI-15: Pisacane A, Impagliazzo N, De Caprio C, Criscuolo L, Inglese A, da Silva MCMP. Breastfeeding and tonsillectomy. Br Med J 1996;?:? RI-16: Lapez-Alarcan M, Villalpando S, Fajardo A. Breastfeeding lowers the frequency and duration of acute respiratory infection and diarrhea in infants under 6 months of age. J Nutr 1997;127:436-43


Otitis Media:

OM-1: Saarinen UM. Prolonged breastfeeding as prophylaxis for recurrent otitis media. Acta Pediatr Scand 1982;71:567-71


OM-2: Teele DW, Klein JO, Rosner B. Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective cohort study. J Infect Dis 1989;160:83-94

OM-3: Duncan B, Ey J, Holberg CJ, Wright AL, Martinez FD, Taussig LJ. Exclusive breastfeeding for at least 4 months protects against otitis media. Pediatrics 1993;91:867-72

OM-4: Owen MJ, Baldwin CD, Swank PR, Pannu AK, Johnson DL, Howie VM. Relation of infant feeding practices, cigarette smoke exposure and group child care to the onset and duration of otitis media with effusion in the first two years of life. J Pediatr 1993;123:702-11

OM-5: Harabuchi Y, Faden H, Yamanaka N, Duffy L, Wolf J, Krystofik D. Human milk secretory IgA antibody to nontypeable H mophilus influenza: Possible protective effects against nasopharyngeal colonization. J Pediatr 1994;124:193-8

OM-6: Aniansson G, Alm B, Andersson B, Hakansson A, Larsson P, Nyla O, et al. A prospective cohort study on breastfeeding and otitis media in Swedish infants. Pediatr Infect Dis J 1994;13:183-8

OM-7: Paradise JL, Elster BA, Tan L. Evidence in infants with cleft palate that breast milk protects against otitis media. Pediatrics 1994;94:853-60

OM-8: Sassen ML, Brand R, Grote JJ. Breastfeeding and acute otitis media. Am J Otolaryn 1994;15:351-7

OM-9: Dewey KG, Heinig J, Nommsen-Rivers LA. Differences in morbidity between breastfed and formula fed infants. J Pediatr 1995;126:696-702 (risk also increased in FF infant for diarrhea)

OM-10: Scariati PD, Grummer-Strawn LM, Fein SB. A longitudinal analysis of infant morbidity and the extent of breastfeeding in the United States. Pediatrics 1997;99:e5


Risks for the premature baby:

P-1: Lucas A, Cole TJ. Breastmilk and neonatal necrotizing enterocolitis. Lancet 1990;336:1519-23


P-2: El-Mohandes AE, Picard MB, Simmens SJ, Keiser JF. Use of human milk in the intesive care nursery decreases the incidence of nosocomial sepsis. J Perinatol 1997;17:130-4

P-3: Daniels L, Gibson R, Simmer K. Selenium status of preterm infants: the effect of postnatal age and method of feeding. Acta Pædiatr 1997;86:281-8 (M:23)

P-4: Uauy RD, Birch DG, Birch EE, Tyson JE, Hoffman DR. Effect of dietary omega-3 fatty acids on retinal function of very low birth weight neonates. Pediatr Res 1990;28:485-92 (M:18)

P-5: Lucas A, Morley R, Cole TJ, Lister G, Leeson-Payne C. Breastmilk and subsequent intelligence quotient in children born preterm. Lancet 1992;339:261-4 (CD: 3)

P-6: Bishop NJ, Dahlenburg SL, Fewtrell MS, Morley R, Lucas A. Early diet of preterm infants and bone mineralization at age five years. Acta Paediatr 1996;85:230-6

P-7: Carlson SE, Rhodes PG, Ferguson MG. Docosahexaenoic acid status of preterm infants at birth and following feeding with human milk or formula. Am J Clin Nutr 1986;44:798-804

P-8: Foreman-van Drongelen MMHP, van Houwelingen AC, Kester ADM, Hasaart THM, Blanco CE, Hornstra G. Long-chain polyunsaturated fatty acids in preterm infants: status at birth and its influence on postnatal levels. J Pediatr 1997;126:611-8

P-9: Bier JB, Ferguson AE, Morales Y, Liebling JA, Oh W, Vohr BR. Breastfeeding infants who were extremely low birth weight. Pediatrics 1997;100:p e3


Childhood Cancer:

CC-1: Schwartzbaum JA, George SL, Pratt CB, Davis B. An exploratory study of environmental and medical factors potentially related to childhood cancer. Med pediatr Oncol 1991;19:115-21


CC-2: Davis MK, Savitz DA. Graubard BI. Infant feeding and childhood cancer. Lancet 1988;2:365-8

CC-3: Freudenheim JL, Marshall JR, Graham S, Laughlin R, Vena JE, Bandera E, et al. Exposure to breastmilk in infancy and the risk of breast cancer. Epidemiology 1994;5:324-31

CC-4: Shu XO, Linet MS, Steinbuch M, Wen WQ, Buckley JD, Neglia JP, Potter JD et al. Breastfeeding and the risk of childhood acute leukemia. J Nat Cancer Institute 1999;91:1765-72


Gastrointestinal Disease and Infections:

GI-1: Koletzko S, Sherman P, Corey M, Griffiths A, Smith C. Role of infant feeding practices in the developement of Crohn's disease in childhood. Br Med J 1989;298:1617-8


GI-2: Greco L, Auricchio S, Mayer M, Grimaldi M. Case control study on nutritional risk factors in celiac disease. J Pediatr Gastroenterol Nutr 1988;7:395-8

GI-3: Duffy LC, Byers TE, Riepenhoff-Talty M, La Scolea L, Zielezny M, Ogra PL. The effects of infant feeding on rotavirus-induced gastroenteritis. A prospective study. Am J Pub Health 1986;76:259-63

GI-4: Hanson LA, Lindquist B, Hofvander Y, Zetterstrom R. Breastfeeding as a protection against gastroenteritis and other infections. Acta Pediatr Scand 1985;74:641-2

GI-5: Ruiz-Palacios GM, Calva JJ, Pickering LK, Lopez-Vidal Y, Volkow P, Pezzarossi H, et al. Protection of breastfed infants against Campylobacter diarrhea by antibodies in human milk. J Pediatr 1990;116:707-13

GI-6: Cruz JR, Gil L, Cano F, Caceres P, Pareja G. Breastmilk anti-Escherichia coli heat labile toxin IgA antibodies protect against toxin-induced infantile diarrhea. Acta Pediatr Scand 1988;77:658-62

GI-7: Gillin FD, Reiner DS, Wang C-S. Human milk kills parasitic intestinal protozoa. Science 1983;221:1290-2

GI-8: France GL, Marmer DJ, Steele RW. Breastfeeding and Salmonella infection. Am J Dis Child 1980;134:147-52

GI-9: Haffejee IE. Cow's milk-based formula, human milk and soya feeds in acute infantile diarrhea: A therapeutic trial. J Pediatr Gastroenterol Nutr 1990;10:193-8

GI-10: Lerman Y, Slepon R, Cohen D. Epidemiology of acute diarrheal diseases in children in a high standard of living rural settlement in Israel. Pediatr Infect Dis J. 1994;13:116-22

GI-11: Howie PW, Forsyth JS, Ogston SA, Clark A, Du V Florey C. Protective effect of breastfeeding against infection. Br Med J 1990;300:11-6

GI-12: Duffy LC, Riepenhoff-Talty M, Byers TE, La Scolea LJ, Zielezny MA, Dryja DM et al. Modulation of rotavirum enteritis during breastfeeding. Am J Dis Child 1986;140:1164-8

GI-13: Haddock RL, Cousens SN, Guzman CC. Infant diet and salmonellosis. Am J Pub Health 1991;81:997-1000

GI-14: Scariati PD, Grummer-Strawn LM, Fein SB. A longitudinal analysis of infant morbidity and the extent of breastfeeding in the United States. Pediatrics 1997;99, June 1997;e5 (also for otitis media)


Urinary Tract Infection:

UT-1: Pisacane A, Graziano L, Mazzarella G, Scarpellino B, Zona G. Breastfeeding and urinary tract infection. J Pediatr 1992;120:87-9




MA-1: Labbock MH, Hendershot GE. Does breastfeeding protect against malocclusion? An analysis of the 1981 child health supplement to the national health interview survey. Am J Prev Med 1987;3:227-32


MA-2: Palmer B. The influence of breastfeeding on the development of the oral cavity: A commentary. J Hum Lact 1998;14:93-8


Formula as a heavy metal cocktail:

HM-1: Koo WWK, Kaplan LA, Krug-Wispe SK. Aluminum contamination of infant formulas. J Parenteral Enteral Nutrition 1988;12:170-3


HM-2: Davidsson L, Cederblad , Lannerdal B, Sandstr A B. Manganese absorption from human milk, cow's milk and infant formulas in humans. Am J Dis Child 1989;143:823-7

HM-3: Dabeka RW, McKenzie AD. Lead and cadmium levels in commercial infant foods and dietary intake by infants 0-1 year old. Food Additives and Contaminants 1988;5:333-42


Other Contamination due to bottle feeding:

C-1: Mytjens HL, Roelofs-Willemse H, Jaspar GHJ. Quality of powdered substitutes for breastmilk with regard to members of the family Enterobacteriacea. J Clin Microbiol 1988;26:743-6


C-2: Biering G, Karlsson S, Clark NC, Jonsdottir KE, Ludvigsson P, Steingrimsson O. Three cases of neonatal meningitis caused by Enterobacter sakazakii in powdered milk. J Clin Microbiol 1989;27:2054-6

C-3: Westin JB. Ingestion of carcinogenic N-nitrosamines by infants and children. Arch Environmental Health 1990;45:359-63



A-1: Lucas A, Brooke OG, Morley R, Cole TJ, Bamford MF. Early diet of preterm infants and development of allergic or atopic disease: randomized prospective study. Br Med J 1990;300:837-40


A-2: Kajosaari M, Saarinen UM. Prophylaxis of atopic disease by six months' total solid food elimination. Acta Pediatr Scand 1983;72:411-14

A-3: Ellis MH, Short JA, Heiner DC. Anaphylaxis after ingestion of a recently introduced hydrolyzed whey protein protein formula. J Pediatr 1991;118:74-7

A-4: Saarinen UM, Kajosaari M. Breastfeeding as prophylaxis against atopic disease: prospective follow-up study until 17 years old. Lancet 1995;346:1065-69

A-5: Saylor JD, Bahna SL. Anaphylaxis to casein hydrolysate formula. J Pediatr 1991;118:71-4

A-6: Marini A, Agosti M, Motta G, Mosca F. Effects of a dietary and environmental prevention programme on the incidence of allergic symptoms in high atopic risk infants: three years' followup. Acta PA diatr 1996;Suppl 414 vol 85:1-19



M-1: McJunkin JE, Bithoney WG, McCormick MC. Errors in formula concentration in an outpatient population. J Pediatr 1987;111:848-50


M-1a: Abrams CAL, Phillips LL, Berkowitz C, Blacket PR, Priebe CJ. Hazards of overconcentrated milk formula. JAMA 1975;232:1136-40

M-1b: Potur AH, Kalmaz N. An investigation into feeding errors of 0-4 month old infants. J Trop Pediatr 1995;41:120-2

M-1c: Green HL, Moyer VA. Improper mixing of formula due to reuse of hospital bottles. Arch Pediatr Adolesc Med 1995;149:97-9

M-1d: Coodin Fj, Gabrielson IW, Addiego JE. Formula fatality. Pediatrics 1971;47:438-9

M-1e: Wilcox DT, Fiorello AB, Glick PL. Hypovolemic shock and intestinal ischemia: a preventable complication of incomplete formula labeling. J Pediatr 1993;122:103-4

M-2: Specker BL, Tsang RC, Ho ML, Landi TM, Gratton TL. Low serum calcium and high parathyroid hormone levels in neonates fed "humanized" cow's milk-based formula. Am J Dis Child 1991;145:941-5

M2a: Jochum F, Fuchs A, Menzel H, Lombeck I. Selenium in German infants fed breastmilk or different formulas. Acta Paediatr 1995;84:859-62

M-3: Kramer MS. Do breastfeeding and delayed introduction of solid foods protect against subsequent obesity? J Pediatr 1981;98:883-7

M-4: Dick G. The etiology of multiple sclerosis. Proc Roy Soc Med. 1976;69:611-5

M-4b: Pisacane A, Impagliazzo N, Russo M, Valiani R, Mandarini A, Florio C, Vivo P. Breastfeeding and multiple sclerosis. Br Med J 1994;308:1411-2

M-5: Birch E, Birch D, Hoffman D, Hale L, Everett M, Uauy R. Breastfeeding and optimal visual development. J Pediatr Ophthalmol Strabismus 1993;30:33-8

M-6: Makrides M, Simmer K, Googin M, Gibson RA. Erythrocyte docosahexaenoic acid correlates with the visual response of healthy, term infants. Pediatr Res 1993;34:425-7

M-7: Sullivan SA, Birch LL. Infant dietary experience and acceptance of solid foods. Pediatrics 1994;93:271-77

M-8: Cochi SL, Fleming DW, Hightower AW, Limpakarnjanarat K, Facklam RR, Smith JD, et al. Primary invasive Hæmophilus influenza type b disease: A population-based assessment of risk factors. J Pediatr 1986;108:887-96

M-9: Arnold C, Makintube S, Istre GR. Day Care Attendance and other risk factors for invasive Hamophilus influenza type b disease. Am J Epidemiol 1993;138:333-40

M-9a: Takala AK, Eskola J, Palmgren J, Rannberg P-R, Kela E, Rekola P, MA PH. Risk factors of invasive Haemophilus influenzae type b disease among children of Finland. J Pediatr 1989;115:694-701

M-10: Michaelsen KM, Johansen JS, Samuelson G, Price PA, Christiansen C, Skakkeba NE. Serum bone Gla protein (BGP, Osteocalcin) in infants: Values positively correlated with human milk intake. Mechanisms Regulating Lactation and Infant Nutrient Utilization. (Picciano MF, Lannerdal B, editors). Volume 15 of Contemporary Issues in Clinical Nutrition, pages 419-23.

M-11: Jones EG, Matheny RJ. Relationship between infant feeding and exclusion rate from child care because of illness. J Am Dietetic Assoc 1993;93:809-11

M-12: MacFarlane PI, Miller V. Human milk in the management of protracted diarrhœa of infancy. Arch Dis Child 1984;59, 260-65

M-13: Osborn GR. Stages in development of coronary disease observed from 1,500 young subjects. Relationship of hypotension and infant feeding to atiology. Watson Smith Lecture, delivered to the Royal College of Physicians of London, January 11, 1965.

M13a: Bergstra E, Hernell O, Persson La, Vessby B. Serum lipid values in adolescents are related to family history, infant feeding, and physical growth. Atherosclerosis 1995;117:1-13

M-14: Keating JP, Schears GJ, Dodge PR. Oral water intoxication in infants. Am J Dis Child 1991;145:985-90

M-14a: Bruce RC, Kiegman RM. Hyponatremic seizures secondary to oral water intoxication in infancy: association wiht commercial bottled drinking water. Pediatrics 1997;100; p e4

M-15: Finberg L. Water intoxication. (editorial). Am J Dis Child 1991;145:981-2

M-16: Shannon MW, Graef JW. Lead intoxication in infancy. Pediatrics 1992;89:87-90

M-17: Nako Y, Fukushima N, Tomomasa T, Nagashima K. Hypervitaminosis D after prolonged feeding with a premature formula. Pediatrics 1993;92:862-3

M-18: Uauy RD, Birch DG, Birch EE, Tyson JE, Hoffman DR. Effect of dietary omega-3 fatty acids on retinal function of very low birth weight neonates. Pediatr Res 1990;28:485-92

M-19: Hahn-Zoric M, Fulconis F, Minoli I, Moro G, Carlsson B, Battiger M, et al. Antibody responses to parenteral and oral vaccines are impaired by conventional and low protein formulas as compared to breastfeeding. Acta Pa diatr Scand 1990;79:1137-42

M-20: Arnon SS, Damus K, Thompson B, Midura TF, Chin J. Protective role of human milk against sudden death from infant botulism. J Pediatr 1982;100:568-73

M-21: Mason T, Rabinovich E, Fredrickson DD, Amoroso K, Reed AM, Stein LD, et al. Breastfeeding and the development of juvenile rheumatoid arthritis. J Rheumatol 1995;22:1166-70

M-22: Hasselbalch H, Jeppesen DL, Engelmann MDM, Fleischer-Michaelson K, Nielson MB. Decreased thymus size in formula-fed compared with breastfed infants. Acta P diatr 1996;85:1029-32

M-22a: Hasselbalch H, Engelmann MDM, Ersba¸ll AK, Jeppesen DL, Fleischer-Michaelson K. Breastfeeding Influences thymic size In late Infancy. Eur J Pediatr 1999;158:964-7

M-23: Daniels L, Gibson R, Simmer K. Selenium status of preterm infants: the effect of postnatal age and method of feeding. Acta P diatr 1997;86:281-8

M-24: Pettitt DJ, Forman MR, Hanson RL, Knowler WC, Bennett PH. Breastfeeding and incidence of non-insulin-dependent diabetes mellitus in Pima Indians. Lancet 1997;350:166-8

M-25: Routi T, Rannemaa T, Lapinleimu H, Salo P, Viikari J, Leino A, et al. Effect of weaning on serum lipoprotein (a) concentration: the STRIP baby study. Pediatric Research 1995;38:522-27

M-26: Bergstra E, Hernell O, Persson La, Vessby B. Serum lipid values in adolescents are related to family history, infant feeding and physical growth. Atherosclerosis 1995;117:1-13

M-27: Von Kries R, Sauerwald T, von Mutius E, Barnert D, Grunert V, von Voss H. Breastfeeding and obesity: cross sectional study. Br Med J 199;319:147-50

M-28: HÃ¥kansson A, Zhivotovsky B, Orrenius S, Sabharwal H. Apoptosis induced by a human milk protein. Proc Natl Acad Sci USA 1995;92:8064-68

M-29: Hakansson A, Andraasson J, Zhivotovsky B, Karpman D, Orrenius S, Svanborg C. Multimeric alpha lactalbumin from human milk induces apoptosis through a direct effect on cell nuclei. Exps Cell Research 1999;246:451-60

M-30: Fitzpatrick M, Mitchell K, et al. Soy formulas and the effects of Isoflavones on the thyroid NZ Med J 2000;113:?pages

M-31: Lambertina W, Freni-Titulaer MD, Cordero JF, Haddock L, Lebron G, Martinez R, Mills JL. Premature Thelarche In Puerto Rico. Am J Dis Child 1986;140:1263-7

M-32: Tulldahl J, Pettersson K, Andersson SW, Hultha. Mode of Infant feeding and achieved growth In adolescence: early feeding patterns In relation to growth and body composition In adolescence. Obesity Research 1999;7:431-7

M-33: Erickson PR, Mazhari E. Investigation of the role of human breastmilk in caries development. Pediatr Dent 1999;21:86-90

M-34: Setchell KDR, Zimmer-Nechmias L, Cai J, Heubi JE. Exposure of infants to phyto-oestrogens from soy-based infant formula. Lancet 1997;350:23-27


Breastmilk as "antimicrobial":

AM-1: Yoshioka H, Ken-ichi I, Fujita K. Development and differences of intestinal flora in the neonatal period in breastfed and bottle fed infants. Pediatrics 1983;72:317-21


AM-2: Hernell O, Ward H, Blackberg L, Pereira MEA. Killing of Giardia lamblia by human milk lipases: An effect mediated by lipolysis of milk lipids. J Infectious Diseases 1986;153:715-20

AM-3: Andersson B, Porras O, Hanson LA, Lagergard T, Svanborg-Edan C. Inhibition of attachment of Streptococcus pneumonia and Hamophilus influenza by human milk and receptor oligosaccharides. J Infectious Diseases 1986;153:232-7

AM-4: Bell LM, Clark HF, Offit PA, Slight PH, Arbeter AM, Plotkin SA. Rotavirus serotype-specific neutralizing activity in human milk. Am J Dis Child 1988;142:275-8

AM-5: Schroten H, Lethen A, Hanisch FG, Plogmann R, Hacker J, Nobis-Bosch R et al. Inhibition of adhesion of S-Fimbriated Escherichia coli to epithelial cells by meconium and feces of breastfed and formula fed newborns: mucins are the major inhibitory component. J Pediatr Gastroentero Nutr 1992;15:150-8

AM-6: Walterspiel JN, Morrow AL, Guerrero ML, Ruiz-Palacios GM, Pickering LK. Secretory anti-Giardia lamblia antibodies in human milk: protective effect against diarrhea. Pediatrics 1994;93:28-31

AM-7: Torres O, Cruz JR. Protection against Campylobacter diarrhea: role of milk IgA antibodies against bacterial surface antigens. Acta Pediatr Scand 1993;82:835-8

AM-8: Pickering LK, Morrow AL, Herrera I, O'Ryan M, Estes MK, Suilliams SE, et al. Effect of maternal rotavirus immunization on milk and serum antibody titers. J Inf Dis 1995;172:723-8

AM-9: Grover M, Giouzeppos O, Shnagl RD, May JT. Effect of human milk protaglandins and lactoferrin on respiratory syncytial virus and rotavirus. Acta P 1997;86:315-6

AM-10: Delneri MT, Carbonare SB, Silva MLM, Palmeira P, Carneiro-Sampaio MMS. Inhibition of enteropathogenic Escherichia coli adhesion to EHp-2 cells by colostrum and milk from mothers delivering low birth weight neonates. Eur J Pediatr 1997;156:493-8


Risks to the Mother

Ovarian Cancer:

MO-1: Hartge P, Schiffman MH, Hoover R, McGowan L, Lesher L, Norris HJ. A case control study of epithelial ovarian cancer. Am J Obstet Gynecol 1989;161:10-6


MO-2: Gwinn ML, Lee NC, Rhodes PH, Layde PM, Rubin GL. Pregnancy, breastfeeding and oral contraceptives and the risk of epithelial ovarian cancer. J Clin Epidemiol 1990;43:559-68

MO-3: Rosenblatt KA, Thomas DB, and the WHO collaborative study of neoplasia and steroid contraceptives. Lactation and the risk of epithelial ovarian cancer. International J Epidemiol 1993;22:192-7



MO-4: Aloia JF, Cohn SH, Vaswani A, Yeh JK, Yuen K, Ellis K. Risks factors for postmenopausal osteoporosis. Am J Med 1985;78:95-100


MO-5: Melton LJ, Bryant SC, Wahner HW, O'Fallon WM, Malkasian GD, Judd HL, Riggs BL. Influence of breastfeeding and other reproductive factors on bone mass later in life. Osteoporosis Int 1993;3:76-83

MO-6: Cumming RG, Klineberg RJ. Breastfeeding and other reproductive factors and the risk of hip fractures in elderly women. International J Epidemiol 1993;22:684-91

MO-6a: Blaauw R, Albertse EC, Beneke T, Lombard CJ, Laubscher R, Hough FS. Risk factors for the development of osteoporosis in a South African population. S Afr Med J 1994;84:328-32

MO-6b: Krieger N, Kelsey JL, Holford TR. O'Connor T. An epidemiologic study of hip fractures in potmenopausal women. Am J Epidemiol 1982;116:141-8


Endometrial Carcinoma:

MO-7: Petterson B, Hans-Olov A, Berstram R, Johansson EDB. Menstruation span-a time-limited risk factor for endometrial carcinoma. Acta Obstet Gynecol Scand 1986;65:247-55


MO-7a: Rosenblatt KA, Thomas DB, and the WHO collaborative study of neoplasia and steroid contraceptives. Prolonged Lactation and endometrial cancer. Int J Epidemiol 1995;24:499-503


Breast Cancer:

MO-8: Layde PM, Webster LA, Baughman AL, Wingo PA, Rubin GL, Ory HW and the cancer and steroid hormone study group. The independent associations of parity, age at first full term pregnancy, and duration of breastfeeding with the risk of breast cancer. J Clin Epidemiol 1989;42:963-73


MO-9: Ing R, Ho JHC, Petrakis NL. Unilateral breastfeeding and breast cancer. Lancet July 16, 19977;124-27

MO-10: McTiernan A, Thomas DB. Evidence for a protective effect of lactation on risk of breast cancer in young women. Am J Epidemiol 1986;124:353-74

MO-11: Yuan J-M, Yu MC, Ross RK, Gao Y-T, Henderson BE. Risk factors for breast cancer in Chinese women in Shanghai. Cancer Res 1988;58:99-104

MO-12: Yoo K-Y, Tajima K, Kuroishi T, Hirose K, Yoshida M, Miura S, Murai H. Independent protective effect of lactation against breast cancer: a case-control study in Japan. Am J Epidemiol 1992;135:726-33

MO-13: Reuter KL, Baker SP, Krolikowski FJ. Risk factors for breast cancer in women undergoing mammography. Am J Radiol 1992;158:273-8

MO-14: United Kingdom National Case-Control Study Group. Breastfeeding and risk of breast cancer in young women. Br Med J 1993;307:17-20

MO-15: Newcomb PA, Storer BE, Longnecker MP, Mittendorf R, Greenberg ER, Clapp RW, et al. Lactation and a reduced risk of premenopausal breast cancer. N Eng J Med 1994;330:81-7

MO-16: Tao S-C, Yu MC, Ross RK, Xiu K-W. Risk factors for breast cancer in Chinese women of Beijing. Int J Cancer 1988;42:495-98

MO-17: Siskind V, Schofield F, Rice D, Bain C. Breast cancer and breastfeeding: results from an Australian case-control study. Am J Epidemiol 1989;130:229-36

MO-18: Romieu I, Hernandez-Avila M, Lazcano E, Lopez L, Romero-Jaime R. Breast cancer and lactation history in Mexican women. Am J Epidemiol 1996;143:543-52

MO-18b: Furberg H, Newman B, Moorman P, Millikan R. Lactation and breast cancer risk. Int J Epidemiol 1999;28:396-402


Weight loss:

MO-19: Dewey KG, Heinig MJ, Nommsen LA. Maternal weight loss patterns during prolonged lactation. Am J Clin Nutr 1993;58:162-6 Risks to SocietyS-1: Thapa S, Short RV, Potts M. Breastfeeding, birth spacing, and their effects on child survival. Nature 1988;335:679-82


S-2: Short . Breastfeeding (contraceptive effect). Scientific American 1984;250:35-41

S-3: Bitoun P. The economic value of breastfeeding in France. Les Dossiers de l'Obstetrique. 1994;#216 (available on request)

S-4: Radford A. The ecological impact of bottle feeding. (available on request)

S-5: Gross BA. Is the lactational amenorrhea method a part of natural family planning? Biology and policy. Am J Obstet Gynecol 1991;165:2014-9

S-6: Kennedy KI, River R, McNeilly AS. Consensus statement on the use of breastfeeding as a family planning method. Contraception 1989;39:477-96

Compiled by Jack Newman, MD, FRCPC
May be copied and distributed without further permission

Sunday, 26 June 2005 16:41

Protocol for "Not Enough Milk"

Protocol for "Not Enough Milk"

Here is the way I proceed for "insufficient milk supply" (actually, most mothers have lots, but the problem is that the baby is not getting the milk which is available).


  1. Get the best latch possible. This needs to be shown by someone who knows what they are doing. Anyone can look at the baby at the breast and say the latch is good. The accompanying diagram, or the one available at the second website below shows how to get a good latch.



  • Know how to know the baby is getting milk (open-->pause-->close type of sucking). See handout: How to know my baby is getting enough milk at the website below.


  • Once the baby is no longer drinking, use compression to increase flow to the baby. See handout Breast Compression.


  • When the baby no longer drinks with compression, switch sides and repeat. Keep going back and forth until the baby does not drink even with compression.


  • Try fenugreek and blessed thistle. These two herbs seem to increase milk supply and increase rate of milk flow. There is more information on the handout Treatments for Problems.


  • In the evening when babies often want to be at the breast for long periods, get help to position the baby so that you can feed lying down. Let the baby nurse and maybe you will fall asleep. Or rent videos and let the baby nurse while you watch.


  • It is not always easy to decide if a baby needs supplementation. Sometimes more rapid growth is necessary. If possible get banked breastmilk to supplement if you can. If not available, formula may be necessary. However, sometimes slow but steady growth is acceptable. The main reason to worry about growth is that good growth is one sign of good health. A baby who grows well is usually in good health, but this is not necessarily so. Neither is a baby who grows slowly in poor health, but physicians worry about a baby who is growing more slowly than average.


  • If it is decided to supplement, the best way is at the breast with a lactation aid. Introduce the supplement with a nursing supplementer (lactation aid), not bottle, syringe, cup or finger feeding. See handout on Lactation Aid at the website below. Supplement only after steps 3 and 4 above and the baby has nursed on at least both sides.


  • If the baby is older than 3 or 4 months, formula is not necessary and extra calories can be given to the baby as solid foods. First solids may include: mashed banana, mashed avocado, mashed potato or sweet potato, infant cereals, as much as the baby will take, and after the baby has nursed, if he is hungry.


  • Domperidone is a possibility. It is not a panacea.

    Written by Jack Newman, MD, FRCPC
    May be copied and distributed without further permission

    Sunday, 26 June 2005 16:33

    Treatments for Problems (2)

    Treatments for Problems (2)

    Herbs for Increasing Milk Supply

    It is quite possible that herbal remedies help increase milk supply. There are several drugs which obviously do increase milk supply, and of course it is reasonable to assume that some plants and herbs might contain similar pharmacologic agents. Almost every culture has some sort of herb or plant or potion to increase milk supply. Some may work as placebos, which is fine; some may not work at all; some may have one or more active ingredients. Some will have active ingredients that will not increase the milk supply but have other effects, not necessarily desirable. Note that even herbs can have side effects, even serious ones. Natural source drugs are still drugs, and there is no such thing as a 100% safe drug. Luckily, as with most drugs, the baby will get only a tiny percentage of the mother’s dose. The baby is thus extremely unlikely to have any side effects at all from the herbs. Two herbal treatments that seem to increase the milk supply are fenugreek and blessed thistle, in the following dosages:

    fenugreek: 3 capsules 3 times a day
    blessed thistle: 3 capsules 3 times a day,
    or 20 drops of the tincture 3 or times a day

    The tincture container states that blessed thistle should not be taken by nursing mothers, presumably because of the tiny amount of alcohol the mother would get. Don’t worry about this. Teas also work, but to take enough to make a difference, you will be drinking tea all day and night.

    Other herbal treatments that have been used to increase milk supply are: raspberry leaf, fennel, brewer’s yeast. The effectiveness of none of these treatments, including blessed thistle and fenugreek, has been proved.

    Treatments for Raynaud’s Phenomenon (blanching of the nipple)

    Raynaud’s phenomenon is due to spasm of blood vessels preventing blood from getting to a particular area of the body. It occurs in response to a drop in temperature. Most commonly, Raynaud’s phenomenon will occur in the fingers, typically when someone goes outside from a warm house on a cool day. The fingers will turn white and the lack of blood getting to the tips of the fingers will cause pain. Raynaud’s phenomenon occurs more commonly in women than men, and is often associated with illnesses such as rheumatoid arthritis.

    Raynaud’s phenomenon can also occur in nipples. In fact, it is much more common than generally believed. It can occur along with any cause of sore nipples, but it may also, on occasion, occur without any other kind of nipple pain at all.

    Typically, Raynaud’s phenomenon occurs after the feeding is over, once the baby is already off the breast. Presumably, the outside air is cooler than the inside of the baby’s mouth. When the baby comes off the breast, the nipple is its usual colour, but soon, within minutes or even seconds, the nipple will start to turn white. Mothers generally describe a burning pain when the nipple turns white. After turning white for a while, the nipple may actually turn back to its normal colour (as blood starts to flow back to the nipple), and the mother will notice a throbbing pain. The nipple may go back and forth between colours (and types of pain) for several minutes or even an hour or two.

    The treatment for Raynaud’s phenomenon is to fix the original cause of the pain (poor latch, Candida etc). Almost always, as the nipple soreness from another cause is getting better, so will the pain from Raynaud’s phenomenon get better, but more slowly. Fixing the original cause of the pain (improving the latch, treating Candida etc) should be the focus of treatment. However, some mothers no longer have pain during the feeding, or never had it at all. Indeed, some start having Raynaud’s phenomenon during the pregnancy. If the pain is mild, there may be no reason to treat, and reassurance is all that is necessary. However, in some cases it is worth treating, especially if severe, and especially if the pain during the feeding does not improve, as severe restriction of blood supply to the nipple may delay healing.

    The first choice for treatment is:

    Vitamin B6. This has shown to work by trial and error, but it does seem to work. There is no scientific evidence that it works, but it does nevertheless. It is safe and will do no harm. The dose is 150 mg/day once a day for four days, followed by 25 mg/day once a day. The mother continues it until she is pain free for a few weeks. It can be restarted if necessary.

    If vitamin B6 does not work within a few days, it probably won’t. It is then useful to try:

    Nifedipine. This is a drug used for hypertension. One 30 mg tablet of the slow release formulation once a day often takes away the pain of Raynaud’s phenomenon. After two weeks, stop the medication. If pain returns (about 10% of mothers), start it again. After two weeks, stop the medication. If pain returns (a very small number of mothers), start it again. Very few mothers I am aware of took more than three courses. Side effects are uncommon, but headache does occur.

    Written by Jack Newman, MD, FRCPC
    May be copied and distributed without further permission

    Sunday, 26 June 2005 16:32

    Breastfeeding Your Adopted Baby

    Breastfeeding Your Adopted Baby

    You are about to adopt a baby and you want to breastfeed him? Wonderful! It is not only possible, it is fairly easy and the chances are you will produce a significant amount of milk. It is not complicated, but it is different than breastfeeding a baby with whom you have been pregnant for 9 months.

    Breastfeeding and Breastmilk

    There are really two objectives involved in nursing an adopted baby. One is getting your baby to breastfeed. The other is producing breastmilk. It is important to set your expectations at a reasonable level. Since there is more to breastfeeding than breastmilk, many mothers are happy to be able to breastfeed without expecting to produce all the milk the baby will need. It is the special relationship, the special closeness, the biological attachment of breastfeeding that many mothers are looking for. As one adopting mother said, "I want to breastfeed. If the baby also gets breastmilk, that’s great".

    Getting the baby to take the breast

    Although many people do not believe that the early introduction of bottles may interfere with breastfeeding, the early introduction of artificial nipples can indeed interfere. The sooner you can get the baby to the breast after he is born, the better. However, babies need flow from the breast in order to stay latched on and continue sucking, especially if they have gotten used to get flow from a bottle or another method of feeding (cup, finger feeding). So, what can you do?


    1. Speak with the staff at the hospital where the baby will be born and let the head nurse and lactation consultant know your plan to breastfeed the baby. They should be willing to accommodate your desire to have the baby fed by cup or finger feeding, if you cannot have the baby to feed immediately after his birth. In fact, more and more frequently, arrangements have been made where the adopting mother is present at the birth of the baby and takes the baby immediately to nurse. The earlier you start, the better.
    2. Some biological mothers are willing to nurse the baby for the first few days. There is some concern expressed amongst social workers and others that this will result in the biological mothers’ changing her mind. This is possible, and you may not wish to take that risk. However, this has been done, and it allows the baby to breastfeed, get colostrum, and not receive artificial feedings at first.
    3. Latching on well is even more important when the mother does not have a full milk supply, as when she does. A good latch means painless feedings. A good latch means the baby will get more of your milk, whether your milk supply is abundant or minimal. (Handout When Latching).
    4. If the baby does need to be supplemented, this should be done with a lactation aid with the supplement being given while the baby is breastfeeding (Handout #5 Using a Lactation Aid). Babies learn to breastfeed by breastfeeding, not cup feeding or finger feeding or bottle feeding. Of course, you can use your previously expressed milk to supplement. And if you can manage to get it, banked breastmilk is the second best supplement after your own milk.
    5. If you are having trouble getting the baby to take the breast, come to the clinic as soon as possible for help.


    Producing Breastmilk

    As soon as a baby is in sight, contact a specialized lactation clinic and start getting your milk supply ready. Please understand, you may never produce a full supply for your baby, though it may happen. You should not be discouraged by what you may be pumping before the baby is born, because a pump is never as good at extracting milk as a baby who is sucking well and well latched. The main purpose of pumping before the baby is born is to start the changes in your breast so that you will produce milk, not to build up a reserve of milk before the baby is born, though this is good if you can do it.

    If you know far enough in advance, say 6 or 7 months, treatment with a combination of oestrogen and progesterone (as in the birth control pill, but without a break) plus domperidone will simulate pregnancy somewhat, and may allow you to produce more milk. Get information about this protocol from the clinic.

    a. Pumping. If you can manage it, rent an electric pump with a double setup. Pumping both breasts at the same time takes half the time, obviously, but also results in better milk production. Start pumping as soon as the baby is in sight, even if this means you will be pumping for 4 months. You do not have to pump frequently on a schedule. Do what is possible. If twice a day is possible at first, do it twice a day. If once a day during the week, but 6 times during the weekend can be done, fine. Partners can help with nipple stimulation as well.

    b. Domperidone. (Handout #19 Domperidone). This drug can help you produce more milk. It is not necessary for you to use in order to breastfeed an adopted baby, but it will help you develop a more abundant milk supply faster. There is no such thing as a 100% safe drug. If you do decide to take it, the dose is 20 mg four times a day. Check the handout for more information. Ask at the clinic. Using pumping and domperidone, most adopting mothers have started to produce drops of milk after two to four weeks.

    But will I produce all the milk the baby needs?

    Maybe, but don’t count on it. But if you do not, breastfeed your baby anyhow, and allow yourself and him to enjoy the special relationship that it brings. In any case, some breastmilk is better than none.


    Written by Jack Newman, MD, FRCPC
    May be copied and distributed without further permission

    Sunday, 26 June 2005 00:00

    Candida Protocol

    Candida Protocol

    Start with local treatment consisting of:

    1. Gentian violet (look under that title at the websites below). Once a day for 4 to 7 days. If pain gone after 4 days, stop gentian violet. If better, but not gone after four days, continue for 7 days. Stop after 7 days no matter what. If not better at all at 4 days, stop the gentian violet, continue with the ointment as below and call.


    2. Nipple ointment as below:

    mupirocin 2% ointment (15 grams)
    nystatin 100,000 unit/ml ointment (15 grams)
    betamethasone 0.1% ointment (15 grams)

    The pharmacist mixes it all together and it is applied sparingly after each feeding (except the feeding when the mother uses gentian violet). Do not wash or wipe it off, even if the pharmacist asks you to. In Canada, Kenacomb (easier to find) or Viaderm KC (less expensive) ointment can be substituted for the above combination.

    This is used until pain free and then decrease frequency over a week or two until stopped. (See Treatments for Problems 1 under “all purpose nipple ointment”).

    3. If pain continues and it is sure the problem is Candida, or at least reasonably sure, add fluconazole 400 mg loading, then 100 mg twice daily for at least 2 weeks, until the mother is pain free for a week. The nipple ointment should be continued and the gentian violet can be repeated. If fluconazole too expensive, ketoconazole 400 mg loading, then 200 mg twice daily for same period of time (or grapefruit seed extract can be used). If Candida resistant, itraconazole, same dose and time period as fluconazole, though Candida actually is less sensitive to itraconazole, generally, than it is to fluconazole. (See handout Fluconazole). Fluconazole is apparently now available as a generic product (therefore less expensive). Fluconazole should not be used as a first line treatment or if nystatin alone does not work (which it usually doesn’t).

    4. Grapefruit seed extract, 250 mg three times a day orally (taken by the mother), seems to work well in many cases. It can be used instead of fluconazole or in addition to fluconazole in resistant cases.

    5. For deep breast pain, ibuprofen 400 mg every four hours may be used until definitive treatment is working (maximum daily dose is 2400 mg/day).

    Written by Jack Newman, MD, FRCPC
    May be copied and distributed without further permission

    How to be a Breastfeeding Supporting Health Care Professional

    Which health care professionals should be expected to be knowledgeable and well-informed about breastfeeding? Is breastfeeding management relevant to the practice of most doctors? What is the level of knowledge that should be expected of health care professionals?

    All health care professionals should have a basic knowledge of breastfeeding as the norm in infant nutrition. Those who do not work directly with mothers and babies should know that breastfeeding is the gold standard of nutrition for infants, and should know the accepted guidelines concerning breastfeeding, such as the guidelines of the American Academy of Pediatrics. (See box.) All practitioners with the exception perhaps of geriatricians may find themselves treating and prescribing for breastfeeding mothers. Thus, even the podiatrist may find himself doing so, and should know that most drugs are not contraindicated during breastfeeding, because the risks associated with not breastfeeding are almost always greater than the risk of a small amount of the drug in the milk.

    Radiologists should know that MRI scans are not contraindicated during breastfeeding. Cardiologists should know that most antihypertensive medications are not contraindicated, and they should know the pharmacology and comparative safety of drugs in lactating women.

    What a health care provider can do to be breastfeeding-friendly:

    Everyone who works with mothers and babies should work to optimize the birth experience. A birth with as few medications and interventions as possible is important in allowing breastfeeding to get off to a good start. Women who trust their bodies and birth successfully are more able to breastfeed successfully. Mothers and babies should not be separated after birth; procedures such as bathing, medical tests and treatments (eye drops, vitamin K, heel sticks) should be delayed until breastfeeding has been initiated. There should be no normal newborn nursery in hospitals, and babies should room-in with mothers. Couplet care at the bedside should be routine, even if brighter lights and portable equipment are needed.


    1. The primary care provider for the baby should know how to help with breastfeeding, what normal breastfeeding looks like, and how and where to get help if something is not working. Anyone that works with newborns should have a clear understanding of how to determine if supplementation is needed (see breastfeeding decision-making tree). This policy should be flexible, and those who determine a need for supplementation should be very knowledgeable about normal breastfeeding behavior. A lactation consultant should be available on all shifts during which babies may be born or mothers may need help; this means 24 hours a day. Care providers should refer to lactation consultants when specialized care is needed.



  • Anyone who is in a position to discuss infant nutrition with a mother needs to advocate the use of donor human milk when supplementation is needed. They need to know how to prescribe donor milk, how to obtain and use it, and should support its use rather than ABM. Midwives and doctors need to know that ABM is not equivalent to human milk, and be willing to prescribe donor milk. They need to understand the dangers of using ABM in place of human milk, and be able to educate mothers about any decisions they make about their choice in feeding.


  • Care providers should know that breastfeeding is not the same as bottle feeding. They should understand the fundamental physiologic differences, and know that artificial feeding methods are unproven and not at all similar to breastfeeding. For example, it should be understood that what is commonly called “non-nutritive sucking” is an important part of milk production and the breastfeeding relationship. No one should be telling a mother that any method of delivering milk to a baby’s mouth is even remotely similar to the human breast. This includes understanding that any artificial nipples can undermine breastfeeding, including pacifiers. Anyone that suggests or provides ABM or pacifiers to a mother and baby should have written consent from the parent before they are used.


  • HCPs should encourage parenting styles that support breastfeeding, and discourage mother-baby separation. Any questions about parenting practices should be answered in light of normal breastfed baby behavior. Your personal experience with breastfeeding and child rearing may not be typical. All babies are different. Use your own experience only to underscore suggestions based on normal infant behavior, not to promote artificial ideas about babies’ need or capabilities.


  • Everyone who works with mothers and children should support and expect breastfeeding to continue throughout the first year, with no outside limits beyond that time. They should know the recommendations about breastfeeding, such as the AAP statement and the WHO code. Parents should not be encouraged to start solids until the middle of the first year, based on signs of readiness from the baby. Early weaning of the baby should be avoided, and can usually be prevented with adequate support of breastfeeding and skillful resolution of breastfeeding problems.


  • HCPs should understand the continuing role of human milk in the child’s diet beyond infancy, and understand the role of breastfeeding in the child’s psychosocial development past infancy. Medical practitioners should know that human milk contributes to a child’s immune system competency for as long as breastfeeding continues, and that the nutritive value of human milk changes to suit the age of the child, but never becomes valueless. HCPs should support child-led weaning, and understand that breastfeeding beyond the first year strengthens a child’s emotional well-being, and does not lead to future psychological difficulties, or indicate an inappropriate relationship between mother and child.


  • HCPs and institutions should not undermine breastfeeding by using or distributing advertising materials for ABM companies. This includes using common tools or printed materials with the name of ABM companies on it, even if they purport to be “educational.” Giving out any material with a company name on it implies to parents that the HCP endorses that company’s products. No one who fully supports breastfeeding wants to be seen as doing advertising work for companies that produce ABM. If you, as the medical advisor to a mother and baby, would not recommend that the mother or baby smoke cigarettes, you would probably not give the mother free gifts or advertising materials provided by a tobacco company. It is clear that the distribution of materials for ABM companies is profitable to them, or why else would they be so eager to have it done?


  • Interrupting breastfeeding may have serious, long-term side effects for mother and baby. Breastfeeding should not be interrupted except for the most critical, emergent, medically valid reasons. Contrary to general opinion, very few medications, medical tests, or infant or maternal illnesses require interruption of breastfeeding. Any medications or treatments recommended to the mother or baby should allow for continued breastfeeding. Any time a treatment is necessary that requires an interruption of the breastfeeding relationship, all measures should be employed to ensure that the disruption is handled as smoothly as possible. Mothers should be helped to express and store milk in advance of such an event, and time should be allowed to help the baby get used to an alternative method of feeding. Whenever possible, alternative drugs, tests, or treatments should be chosen with the goal of continuing uninterrupted breastfeeding. Use of tetracycline, for example, while contraindicated for use in children and during pregnancy, is quite safe for the mother to use during breastfeeding. Hospitals should be able to care for a breastfeeding mother and baby together to minimize the impact that hospitalization will have on both of them.


  • Jaundice appears quite commonly in breastfed as well as bottlefed babies. This fact alone should imply that there is an as yet unknown physiologic reason for jaundice. Physicians must know the difference between breastmilk jaundice and “lack of breastmilk” jaundice, and how to manage both situations. Higher than average bilirubin levels in the first few days, if not caused by hemolysis or other pathology, is usually due to inadequate intake of breastmilk. Stopping breastfeeding is not only unnecessary (because the baby is already not breast “feeding” sufficiently), but positively harmful because the mother gets the message that her breastmilk is dangerous, and the interruption makes breastfeeding more difficult to establish. It is true that giving formula will result in a drop in bilirubin, but so will giving adequate amounts of breastmilk. When the problem is inadequate intake, the solution is to fix the breastfeeding so that the baby gets breastmilk.


  • HCPs should operate an evidence-based practice. They should not extrapolate from personal experience, especially when it is negative, and should not operate on the basis of unsubstantiated beliefs. They should use current information about breastfeeding that is accepted by practitioners in the field, and not use information provided by those with a vested interest in undermining breastfeeding. Critical analytical skills should be used in evaluating research or literature about infant nutrition.

    HCPs and institutions that work with mothers and babies need to move ahead to a new era of support for breastfeeding. They need to support the Baby Friendly Hospital Initiative and encourage their institutions to adopt these practices; they need to know how to use local resources, such as breastfeeding support groups and milk banks; and they need to continue to educate themselves about lactation. They should be able to provide parents with the information needed to make informed decisions about feeding. A mother should not be told she must discontinue breastfeeding; it is the mother’s choice to wean or breastfeed, and medical advice offered to parents should support this choice.

    Written by Jack Newman, MD, FRCPC
    May be copied and distributed without further permission

    Sunday, 26 June 2005 16:30

    Starting Solid Foods

    Starting Solid Foods

    Breastmilk is all your baby needs until at least four months of age. Most babies will do fine with exclusive breastfeeding until 6 months of age or longer.

    Why start solid foods?

    Because there comes a time when breastmilk no longer supplies all your baby’s nutritional needs. (This does not mean, as some uninformed people say, that there is no nutritional value in breastmilk after the baby is six months old.) A full term baby will start requiring iron from other sources by 6 to 9 months of age. The calories supplied by breastmilk may become inadequate by 8 to 9 months of age, although some babies can continue to grow well on breastmilk alone well past a year.

    Because some babies not started on solids by a certain age (9-12 months) may have great difficulty accepting solid foods.

    Because it is a developmental milestone that your child passes when he starts solid foods. He is growing up. Usually, he will want to eat solids. Why stop him?

    When to start solid foods

    The best time to start solids is when the baby is showing interest in starting. Some babies will become very interested in the food in their parents’ plates as early as 4 months of age. By 5 or 6 months of age, most babies will be reaching and trying to grab food that parents have on their plates. When the baby is starting to reach for food, this seems a reasonable time to start giving him some. There really is no reason to start on a specific date (4 months, or 6 months). Go by the baby’s cues.

    In some cases, it may be better to start food earlier. When a baby seems to be hungry, or when weight gain is not continuing at the desired rate, it may be reasonable to start solids as early as 3 months of age. However, it may be possible, with help, to continue breastfeeding alone and have the baby less hungry and/or growing more rapidly. But if the techniques used in the clinic do not deal with the problem, adding solids can help. There is no advantage to giving artificial baby milk (formula) and there may be some disadvantages. The baby who is not satisfied completely at the breast may start to take more and more from the bottle, and end up refusing to take the breast.

    The breastfed baby digests solid foods better and earlier than the artificially fed baby because breastmilk contains enzymes which help digest fats, proteins and starch. As well, breastfed babies have had a wide variety of tastes in their lives, since the flavours of many foods the mother eats will pass into her milk. Breastfed babies thus accept solids more readily than artificially fed babies. Breastmilk is amazing stuff, eh?

    How should solids be introduced?

    When the baby is starting to take solids at about 5 or 6 months of age, there is little difference what he starts with or in what order foods are introduced. It is prudent to avoid highly spiced or highly allergenic foods at first (e.g. egg white, strawberries), but if the baby reaches for the potato on your plate, make sure it is not too hot, and let him have the potato. There is no need to go in any specific order, and there is no need for the baby to eat only one food for a certain period of time. Some exclusively breastfed babies dislike infant cereal when it is introduced at 5 or 6 months of age. There is no need for concern and no need to persist if the baby doesn’t want the cereal. There is nothing magic or necessary about infant cereal. Offer the baby foods that he is interested in. Allow the baby to enjoy food and do not worry exactly how much he actually takes at first. Much of it may end up in his hair and on the floor anyhow. There is no need either that foods be pureed if the baby is 5 or 6 months of age or older. Simple mashing with a fork is all that is necessary at first. You also do not have to be exceedingly careful about how much the baby takes. Why limit the baby to one teaspoon if he wants more? You do not need to waste your money on commercial baby foods.

    Be relaxed, feed the baby at your mealtimes, and as he becomes a more accomplished eater of solid foods, offer a greater variety of foods at any one time.

    The best source of iron for the baby 5 or 6 months of age is meat. Infant cereal has iron, but it is poorly absorbed and may cause the baby to be constipated.

    There is no reason to introduce vegetables before fruit. Breastmilk is far sweeter than fruit, so there is no reason to believe that the baby will take vegetables better by delaying the introduction of fruit.

    Respect your baby’s likes and dislikes. There is no essential food (except breastmilk). If your baby does not like a certain food, do not push it on him. If you think it important for him, wait a few weeks and offer it again.

    At about 8 months of age, babies become somewhat assertive in displaying their individuality. Your baby may not want you to put a spoon into his mouth. He very likely will take it out of your hand and put it into his mouth himself, often upside down, so that the food falls on his lap. Respect his attempts at self sufficiency and encourage his learning.

    What if I am starting solids at 3 months?

    At this age, it may be prudent to go a little more slowly. Start with infant cereal or easily mashed foods such as banana. Sometimes a baby will eat better from your finger than off a spoon. Go a little more slowly with quantities as well. But as the baby tolerates solids, both quantity and variety of foods can be increased as the baby desires. Incidentally, why are you starting solids at 3 months?

    Solids or breast first?

    There seems to be considerable worry when a child is starting solids about whether to give the breast first or give solid food first. If breastfeeding and the introduction of solid foods both are going well, it probably does not matter much. Indeed, there is no reason that a baby needs both breast and solids every time he eats.

    Written by Jack Newman, MD, FRCPC
    May be copied and distributed without further permission

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