JBR Admin

JBR Admin

Sunday, 26 June 2005 16:22

Breastfeeding and Jaundice

Breastfeeding and Jaundice

Introduction

Jaundice is due to a buildup in the blood of bilirubin, a yellow pigment which comes from the breakdown of old red blood cells. It is normal for red blood cells to break down, but the bilirubin formed does not usually cause jaundice because the liver metabolizes it and gets rid of it into the gut. The newborn baby, however, often becomes jaundiced during the first few days because the liver enzyme which metabolizes bilirubin is relatively immature. Furthermore, newborn babies have more red blood cells than adults, and thus more are breaking down at any one time. If the baby is premature, or stressed from a difficult birth, or the infant of a diabetic mother, or more than the usual number of red blood cells are breaking down (as happens in blood incompatibility), the level of bilirubin in the blood may rise higher than what is usual.

Two Types of Jaundice

The liver changes bilirubin so that it can be eliminated from the body. If, however, the liver is functioning poorly, as occurs during some infections, or the tubes which transport the bilirubin to the gut are blocked, this changed bilirubin may accumulate in the blood and also cause jaundice. When this occurs, the changed bilirubin (called conjugated bilirubin), appears in the urine and turns the urine brown. This brown urine is an important clue that the jaundice is not "ordinary". Jaundice due to conjugated bilirubin is always abnormal, frequently serious and needs to be investigated thoroughly and immediately. Except in the case of a few extremely rare metabolic diseases, breastfeeding can and should continue.

Accumulation of bilirubin before it has been changed by the enzyme of the liver may be normal—"physiologic jaundice". Physiologic jaundice begins on the 2nd or 3rd day, peaks on the 3rd or 4th day and then begins to disappear. However, there may be other conditions which cause an exaggeration of this type of jaundice, such as a more rapid than normal breakdown of red blood cells. Because these conditions have no association with breastfeeding, breastfeeding should continue. If, for example, the baby has severe jaundice due to rapid breakdown of red blood cells, this is not a reason to take the baby off the breast. Breastfeeding should continue.

Breastmilk Jaundice

There is a condition commonly called breastmilk jaundice. No one knows what the cause of breastmilk jaundice is. In order to make this diagnosis, the baby should be at least a week old, though interestingly, many of the babies with breastmilk jaundice also have had physiologic jaundice, sometimes to levels higher than usual. The baby should be gaining well, with breastfeeding alone, having lots of bowel movements, passing plentiful, clear urine and be generally well (handout #4 Is my baby getting enough milk?). In such a setting, the baby has what some call breastmilk jaundice, though, on occasion, infections of the urine or an under functioning of the baby's thyroid gland may cause the same picture. Breastmilk jaundice peaks at 10-21 days, but may last for 2-3 months. Breastmilk jaundice is normal. Rarely, if ever, does breastfeeding need to be discontinued even for a short time. There is not one bit of evidence that this jaundice causes any problem at all for the baby. Breastfeeding should not be discontinued "in order to make a diagnosis". If, however, your doctor feels that discontinuing breastfeeding is appropriate, it would be worth trying a lactation aid with formula (handout #5 Using a Lactation Device) rather than taking the baby off the breast altogether, since this may result in difficulties with breastfeeding afterwards. If the baby is truly doing well on breast only, there is no reason, none, to stop breastfeeding or supplement with a lactation aid, for that matter. The notion that there is something wrong with the baby being jaundiced comes from the assumption that the formula feeding baby is the standard by which we should determine how the breastfed baby should be. This manner of thinking, almost universal amongst health professionals, truly turns logic upside down. Thus, the formula feeding baby is rarely jaundiced after the first week of life, and when he is, there is usually something wrong. Therefore, the baby with breastmilk jaundice is a concern and "something must be done". However, in our experience, most exclusively breastfed babies who are perfectly healthy and gaining weight well are still jaundiced at 5-6 weeks of life and even later. The question, in fact, should be whether it is normal not to be jaundiced and is this absence of jaundice something we should worry about? Do not stop breastfeeding for jaundice.

Not-enough-breastmilk Jaundice

Higher than usual levels of bilirubin or longer than usual jaundice may occur because the baby is not getting enough milk. This may be due to the fact that the mother's milk takes a longer than average time to "come in", or because hospital routines limit breastfeeding or because, most importantly, the baby is poorly latched on and thus not getting the milk which is available (handout #4 Is my baby getting enough milk?). When the baby is getting little milk, bowel movements tend to be scanty and infrequent so that the bilirubin that was in the baby's gut gets reabsorbed into the blood instead of leaving the body with the bowel movements. Obviously, the best way to avoid"not-enough-breastmilk jaundice" is to get breastfeeding started properly (handout #1 Breastfeeding—Starting Out Right). However, the answer to not-enough-breastmilk jaundice, is not to take the baby off the breast or to give bottles. If the baby is nursing well, more frequent feedings may be enough to bring the bilirubin down more quickly, though, in fact, nothing needs be done. If the baby is nursing poorly, helping the baby latch on better may allow him to nurse more effectively and thus receive more milk. Compressing the breast to get more milk into the baby may help (handout #15 Breast Compression). If latching and breast compression alone do not work, a lactation aid would be appropriate to supplement feedings (handout #5 Using a Lactation Aid).

Phototherapy (Bilirubin Lights)

Phototherapy increases the fluid requirements of the baby. If the baby is nursing well, more frequent feeding can usually make up this increased requirement. However, if it is felt that the baby needs more fluids, use a lactation aid to supplement, preferably expressed breastmilk, expressed milk with sugar water or sugar water alone rather than formula.

 

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

 

Sunday, 26 June 2005 16:22

Using a Lactation Aid

Using a Lactation Aid

Introduction

A lactation aid is a device which allows a breastfeeding mother to supplement her baby with expressed breastmilk, formula or glucose water with added colostrum (glucose water alone should only be used, in general, in the first day or two after birth) without using an artificial nipple. The early use of an artificial nipple may result in the baby becoming "bottle spoiled" or "nipple confused" because it interferes with the way a baby latches on to the breast. The better a baby latches on, the easier it is for him to get milk. If the baby does not get milk well from the breast, he may fall asleep or push away from the breast when the flow of milk slows down. Thus the baby may refuse the breast, be very fussy at the breast, gain weight poorly, lose weight or even become dehydrated. The mother may develop sore nipples. Though artificial nipples do not always cause problems, their use when things are already going badly will rarely make things better, and usually make things worse. The lactation aid is by far the best way to supplement, if the supplement is truly necessary. (However, proper latching on of the baby usually allows the baby to get more milk, and thus it is often possible to avoid the supplement). It is better than using a syringe, cup feeding, finger feeding or any other method, since the baby is at the breast and breastfeeding. Babies, like adults, learn by doing. Furthermore, the baby supplemented at the breast is also getting breastmilk from the breast.

A lactation aid consists of a container for the supplement—usually a feeding bottle with an enlarged nipple hole—and a long, thin tube leading from this container. Manufactured lactation aids are available and are easier to use in some situations, but not necessarily so. Manufactured lactation aids are particularly useful when the need for a lactation aid arises in an older baby, when a mother needs to supplement twins, when the need for a lactation aid will be long term, or whenever difficulty arises using the improvised lactation aid. Though the manufactured lactation aid is not inexpensive, the cost is about equal to 2 weeks of the usual milk based formula.

Please Note: Using a tube with a syringe, with or without a plunger, instead of the setup mentioned above, seems unnecessarily complicated and adds nothing to the effectiveness of the technique. On the contrary, it is more cumbersome.

Using the Lactation Aid (Improvised)

 

  1. The baby may be latched on to the breast first, and the tube slipped into the baby's mouth at the appropriate time. The better the latch, the better the baby will get your milk and the easier the aid will be to use, and the more quickly you will be able to get rid of the supplements. The breast should be gently eased out of the way so that the corner of the baby's mouth is seen, and the tube, held between the index finger and thumb, should be slipped into the corner of the baby's mouth so that it enters straight towards the back of the baby's mouth and at the same time, upwards towards the roof of the mouth. The tube is well placed when the supplemental fluid works its way down the tube at a rather rapid rate. There is usually no need to fill the tube with supplemental fluid before putting it into the baby's mouth.
  2. Or, the baby is latched on to the breast and the tube, which is run along the mother's breast and nipple, at the same time. The better the baby's latch, the easier the lactation aid is to use. Also, the better the latch, the more likely and the more rapidly the baby will be able to do without the lactation aid. Therefore, proper positioning and latching on of the baby are still very important.
  3. The tube may be taped to the breast if the mother desires, though this is not really necessary and not always helpful.
  4. The tube does not need to pass the end of the nipple and needs to be only just past the baby's gums to function properly. It does seem to function better if the tube is placed in the corner of the baby's mouth and enters straight into the baby's mouth over the tongue. (Point it to the roof of the baby's mouth). It is occasionally helpful for the mother to hold the tube in place with her finger, as some babies tend to push the tube out of position with their tongues.
  5. The bottle containing the supplement should not ordinarily be higher than the baby's head. If the lactation aid functions only when the bottle is held higher than the baby's head, something is wrong. Keep the bottle higher only if this is suggested by the doctor or lactation specialist.
  6. Unless otherwise instructed, it is best to use the tube with every feed, though some mothers find it easier not to use it during the night.
  7. Do not cut off the end of the tube. It works fine as it is.
  8. It should not take an hour for the baby to drink an ounce of milk from the lactation aid. If it is taking this long, the tube is probably not well positioned, or the baby is poorly latched on, or both. When the lactation aid is functioning well, it takes 15-20 minutes, usually less, for the baby to take an ounce of the supplement.

 

Cleaning the Device

 

  1. Do not boil the tube of the non-manufactured aid. It is not made to be boiled.
  2. After using the device, clean the bottle and nipple as usual. Do not boil the tube. The tube should be emptied after use and then rinsed through with hot water (suck up hot water into the tube from a cup) and then hung up to dry. Soap, though not necessary, may be used if desired, but rinse the tube well. Tubes may become stiff and unsuitable for use after about a week.

 

Weaning the Baby from the Lactation Device

 

  1. Maintain contact with the breastfeeding clinic for advice about weaning the baby from the lactation aid.
  2. Weaning the baby from the aid may take several weeks or only a short while. Do not be discouraged and do not try to force the weaning. Usually, the amount of milk required in the lactation aid increases over 1-2 weeks, then levels out for a variable period of time before decreasing. The whole process may take 2-8 weeks, although some mothers have used the device only a few days, whereas others have not been able to stop it at all. Rapid improvement sometimes occurs after a long period of little change.
  3. Observe the baby's nursing. If you do not know how to know if the baby is drinking, ask. Put the baby onto the breast, allow the baby to nurse as long as he is suckling and drinking, then use breast compression (handout #15 Breast Compression) to keep the baby drinking; then repeat the process on the second breast. You can return to the first breast and continue back and forth as long as the baby is drinking. After you have finished feeding on both breasts, insert the tube into the baby's mouth. Allow the baby to nurse until satisfied using the lactation aid.
  4. The bottle of the lactation aid can be lowered 6-12 inches below the baby's head, but do this only if the baby is drinking very quickly.

 

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

Sunday, 26 June 2005 16:21

Blocked Ducts and Mastitis

Blocked Ducts and Mastitis

Mastitis is a bacterial infection of the breast which usually occurs in breastfeeding mothers. However, it can occur even in women who are not breastfeeding or pregnant, and can even occur in small babies. Nobody knows exactly why some women get mastitis and others do not. Bacteria may gain access to the breast through a crack or sore in the nipple, but women without sore nipples also get mastitis.

Mastitis needs to be differentiated from a plugged or blocked duct, because the latter does not need to be treated with antibiotics, whereas mastitis often, but not always, does require treatment with antibiotics. A plugged duct presents as a painful, swollen, firm mass in the breast, often with overlying reddening of the skin, similar to mastitis, though not usually as intense. Mastitis, though, is usually associated with fever and more intense pain and redness of the breast. As you can imagine, it is not always easy to differentiate a mild mastitis from a severe blocked duct. A blocked duct can lead to mastitis.

In order to make a diagnosis of mastitis, there must be an area of hardness, pain, redness and swelling in the breast. The absence of such an area in the breast means that the mother does not have mastitis. Flu-like symptoms or fever alone are not enough to make the diagnosis of mastitis. Shooting pains in the breast without an area of hardness are not mastitis. These are more likely caused by a yeast infection and thus should not be treated with antibiotics.

As with almost all breastfeeding problems, a poor latch, and thus, poor draining of the breast sets up the situation where mastitis can occur.

Blocked Ducts

Blocked ducts will almost always resolve spontaneously within 24 to 48 hours after onset. During the time the block is present, the baby may be fussy when nursing on that side, as milk flow may be slower than usual. Blocked ducts can be made to resolve more quickly by:

 

  1. Continuing breastfeeding on the affected side.
  2. Draining the affected area better. One way of doing this is to position the baby so his chin "points" to the area of hardness. Thus, if the blocked duct is in the outside, lower area of your breast (about 4 o’clock), the football position would be best.
  3. Using breast compression while the baby is feeding (Handout #15 Breast Compression).
  4. Heat on the affected area (hot water bottle) also helps.
  5. The mother trying to rest. (Not always easy, but take the baby into bed with you).
  6. Sometimes a blocked duct is associated with a small blister on the end of the nipple. If you have this, you can open the blister with a sterile needle and squeezing out the toothpaste material in the duct (not always possible). This gives relief of nipple pain and may result in the blocked duct immediately resolving. Come to the clinic if you cannot open the blister yourself.

 

If a blocked duct has not settled within 48 hours (unusual), therapeutic ultrasound often works. This can be arranged at a neighbourhood physiotherapy office or sports medicine clinic. Many ultrasound therapists are not aware of this use of ultrasound. The dose of ultrasound is:

2 watts/cm 2 , continuous, for five minutes to the affected area, once daily for up to two doses.

If two treatments on two days do not work, there is no point in continuing with ultrasound. Get the blocked duct evaluated at the clinic or by your physician. Usually, however, if ultrasound is going to work, one treatment does the trick. Ultrasound also seems to prevent recurrent blocked duct which always occurs in the same place. Lecithin, one capsule (1200 mg) three or four times a day also seems to help prevent recurrent blocked ducts, at least for some mothers.

Mastitis: The following is my approach to dealing with mastitis.

If the mother has symptoms for more than 24 hours, she should start antibiotics. If the mother has symptoms for less than 24 hours, I will prescribe an antibiotic, but suggest the mother wait before starting the medicine. If, over the next 8-12 hours, her symptoms are worsening (more pain, spreading of the redness, enlargement of the hardened area), then the mother should start the antibiotics. If, 24 hours later, the mother has not worsened, but not improved, she should start the antibiotics. However, if symptoms are starting to decrease, there is no need to start the antibiotics. The symptoms usually continue to resolve and will have disappeared over the next 2 to 5 days. Fever will usually be gone within 24 hours, the pain within 24-48 hours, the breast hardness within the next couple of day. The redness may remain for a week or longer.

Once improvement begins, on or off antibiotics, it should continue. If you get worse, or symptoms do not continue to improve over 24 or 48 hours, call the clinic.

Remember:

 

  • Continue breastfeeding, unless it is just too painful to do so. If you cannot continue breastfeeding, express your milk as best you can in the meantime, and restart breastfeeding as soon as you can. Continuing breastfeeding helps mastitis to resolve more rapidly. There is no danger to the baby.
  • Heat (hot water bottle) applied to the affected area helps fight off the infection.
  • Rest helps fight off infection.
  • Fever helps fight off infection. Treat fever if you feel bad, not just because you have it.
  • Take acetaminophen, ibuprofen or other medication for pain as you need it. You will feel better and there is no danger to the baby, who gets only a tiny amount.

 

Note: Amoxycillin, plain penicillin and other antibiotics are often ineffective for mastitis. If you need an antibiotic, you need one which is effective against Staphylococcus aureus. Effective for this bug are: cephalexin, cefaclor, cloxacillin, flucloxacillin, amoxycillin-clavulinic acid, clindamycin and ciprofloxacin. The last two are effective for mothers allergic to penicillin. You can and should continue breastfeeding with all these medications.

Abscess: Abscess occasionally complicates mastitis. You do not have to stop breastfeeding, not even on the affected side. Usually, the abscess needs to be drained surgically, but you should continue breastfeeding. Contact the clinic.

 

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

 

How to Know a Health Professional is not Supportive of Breastfeeding

All health professionals say they are supportive of breastfeeding. But many are supportive only when breastfeeding is going well, and some, not even then. As soon as breastfeeding, or anything in the life of the new mother is not perfect, too many advise weaning or supplementation. The following is a list of clues which help you judge whether the health professional is supportive of breastfeeding, at least supportive enough so that if there is trouble, s/he will make efforts to help you continue breastfeeding.

How to know a health professional is not supportive:

 

  1. S/he gives you formula samples or formula company literature when you are pregnant, or after you have had the baby. These samples and literature are inducements to use the product, and their distribution is called marketing. There is no evidence that any particular formula is better or worse than any other for the normal baby. The literature or videos accompanying samples are a means of subtly and not so subtly undermining breastfeeding and glorifying formula. If you do not believe this, ask yourself why the formula companies are using cut-throat tactics to make sure that your doctor or hospital gives out their literature and samples and not other companies’? Should you not also wonder why the health professional is not marketing breastfeeding?

 

 

  • S/he tells you that breastfeeding and bottle feeding are essentially the same. Most bottle fed babies grow up healthy and secure and not all breastfed babies grow up healthy and secure. But this does not mean that breastfeeding and bottle feeding are essentially the same. Infant formula is a rough approximation of what we knew several years ago about breastmilk which is in itself a rough approximation of something we are only beginning to get an inkling of and are constantly being surprised by. The differences have important health consequences. Certain elements in breastmilk are not in artificial baby milk (formula) even though we have known of their importance to the baby for several years—for example, antibodies and cells for protection of the baby against infection, and long chain polyunsaturated fatty acids for optimal development of the baby’s vision and brain. And breastfeeding is not the same as bottle feeding, it is a whole different relationship. If you have been unable to breastfeed, that is unfortunate (though most times the problems could have been avoided), but to imply it is of no importance is patronizing and just plain wrong. A baby does not have to be breastfed to grow up happy, healthy and secure, but it is an advantage.
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  • S/he tells you that formula x is best. This usually means that s/he is listening too much to a particular formula representative. It may mean that her/his children tolerated this particular formula better than other formulas. It means that s/he has unsubstantiated prejudices.
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  • S/he tells you that it is not necessary to feed the baby immediately after the birth since you are (will be) tired and the baby is often not interested anyhow. It isn’t necessary, but it is very helpful. Babies can nurse while the mother is lying down or sleeping, though most mothers do not want to sleep at a moment such as this. Babies do not always show an interest in feeding immediately, but this is not a reason to prevent them from having the opportunity. Many babies latch on in the hour or two after delivery, and this is the time which is most conducive to getting started well, but they can’t do it if they are separated from their mothers. If you are getting the impression that the baby’s getting weighed, eye drops and vitamin K injection have priority over establishing breastfeeding, you might wonder about someone’s commitment to breastfeeding.
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  • S/he tells you that there is no such thing as nipple confusion and you should start giving bottles early to your baby to make sure that the baby accepts a bottle nipple. Why do you have to start giving bottles early if there is no such thing as nipple confusion? Arguing that there is no evidence for the existence of nipple confusion is putting the cart before the horse. It is the artificial nipple, which no mammal until man had ever used, and even man, not commonly before the end of the nineteenth century, which needs to be shown to be harmless. But the artificial nipple has not been proved harmless to breastfeeding. The health professional who assumes the artificial nipple is harmless is looking at the world as if bottle feeding, not breastfeeding, were the normal physiologic method of infant feeding. By the way, just because not all or perhaps even not most babies who get artificial nipples have trouble with breastfeeding, it does not follow that the early use of these things cannot cause problems for some babies. It is often a combination of factors, one of which could be the using of an artificial nipple, which add up to trouble.
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  • S/he tells you that you must stop breastfeeding because your are sick or your baby is sick, or because you will be taking medicine or you will have a medical test done. There are occasional, rare, situations when breastfeeding cannot continue, but often health professionals only assume that the mother cannot continue and often they are wrong. The health professional who is supportive of breastfeeding will make efforts to find out how to avoid interruption of breastfeeding (the information in white pages of the blue Compendium of Pharmaceutical Specialties is not a good reference—every drug is contraindicated according to it as the drug companies are more interested in their liability than in the interests of mothers and babies). When a mother must take medicine, the health professional will try to use medication which does not require the mother to stop breastfeeding. (In fact, very few medications require the mother to stop breastfeeding). It is extremely uncommon for there to be only one medication which can be used for a particular problem. If the first choice of the health professional is a medication which requires you to stop breastfeeding, you have a right to be concerned that s/he has not really thought about the importance of breastfeeding.
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  • S/he is surprised to learn that your 6 month old is still breastfeeding. Many health professionals believe that babies should be continued on artificial baby milk for at least nine months and even twelve months, but at the same time seem to believe that breastmilk and breastfeeding are unnecessary and even harmful if continued longer than six months. Why is the imitation better than the original? Shouldn’t you wonder what this line of reasoning implies? In most of the world, breastfeeding to 2 or 3 years of age is common and normal.
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  • S/he tells you that there is no value in breastmilk after the baby is 6 months or older. Even if it were true, there is still value in breastfeeding. Breastfeeding is a unique interaction between two people in love even without the milk. But it is not true. Breastmilk is still milk, with fat, protein, calories, vitamins and the rest, and the antibodies and other elements which protect the baby against infections are still there, some in greater quantities than when the baby was younger.
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  • S/he tells you that you must never allow your baby to fall asleep at the breast. Why not? It is fine if a baby can also fall asleep without nursing, but one of the advantages of breastfeeding is that you have a handy way of putting your tired baby to sleep. Mothers around the world since the beginning of mammalian time have done just that. One of the great pleasures of parenthood is having a child fall asleep in your arms, feeling the warmth he gives off as sleep overcomes him. It is one of the pleasures of breastfeeding, both for the mother and probably also for the baby, when the baby falls asleep at the breast.
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  • S/he tells you that you should not stay in hospital to nurse your sick child because it is important you rest at home. It is important you rest, and the hospital which is supportive of breastfeeding will arrange it so that you can rest while you stay in the hospital to nurse your baby. Sick babies do not need breastfeeding less than a healthy baby, they need it more.
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    Written by Jack Newman, MD, FRCPC
    May be copied and distributed without further permission

    Tuesday, 04 October 2005 11:38

    Finger Feeding

    Finger Feeding

    Introduction

    Finger feeding is a technique which allows you to feed the baby without giving the baby an artificial nipple. Finger feeding is also a method which helps train the baby to take the breast. If you want to breastfeed successfully, it is better to avoid the use of artificial nipples before your milk supply is well established. Finger feeding may be used if:

     

    1. The baby refuses the breast for whatever reason, or if the baby is too sleepy at the breast to nurse well. It is also a very good way to wake up a sleepy baby.
    2. The baby does not seem to be able to latch on to the breast properly, and thus does not get milk well. (If a lactation aid can be used at the breast, why use finger feeding?).
    3. The baby is separated from the mother, for whatever reason. However, in such a situation, a cup is probably a better method of feeding the baby.
    4. Breastfeeding is stopped temporarily (there are very few legitimate reasons to stop breastfeeding. See handout #9 You Can Still Breastfeed).
    5. Your nipples are so sore that you cannot put the baby to the breast. Finger feeding for several days may allow your nipples to heal without causing more problems by getting the baby used to an artificial nipple. Cup feeding is also more appropriate in this situation and takes less time. This is only a last resort. Proper positioning and a good latch help sore nipples far more frequently than finger feeding (Handout #3 Sore Nipples).

     

    Finger feeding is much more similar to breastfeeding than bottle feeding is. In order to finger feed, the baby must keep his tongue down and forward over the gums, the mouth wide open (the larger the finger used, the better), and the jaw forward. Furthermore, the motion of the tongue and jaw is similar to what the baby does while feeding at the breast. Finger feeding is best used to prepare the baby to take the breast. Cup feeding is usually easier and faster when the mother is not present to feed the baby.

    Please Note: If the baby is taking the breast, it is better by far to use the lactation at the breast, if supplementation is truly necessary (Handout #5 Using a Lactation Aid).

    Finger Feeding (best learned by watching and doing)

     

    1. Wash your hands. It is better if the finger nail on the finger you will use has been cut short, but this is not necessary.
    2. It is best to position yourself and the baby comfortably. The baby's head should be supported with one hand behind his shoulders and neck, the baby should be on your lap, half seated, and facing you. Any position which is comfortable, however, will do.
    3. You will need a lactation aid, made up of a feeding tube (#5F, 36" long), and a feeding bottle with expressed breast milk, sugar water, or, if necessary, formula, depending on the circumstances. The feeding tube is passed through the enlarged nipple hole into the fluid.
    4. Line up the tube so that it sits on the soft part of your index (or other) finger. The end of the tube should line up no further than the end of your finger. It is easiest to grip the tube, about where it makes a gentle curve, between your thumb and middle finger and then position your index finger under the tube. If this is done properly, there is no need to tape the tube to your finger.
    5. Using the finger with the tube, tickle the baby's lips lightly, until the baby opens up his mouth enough to allow your finger to enter. If the baby is very sleepy, but needs to be fed, the finger may be gently insinuated into his mouth. Generally, the baby will begin to suckle even if asleep, and receiving liquids will then awaken him.
    6. Insert your finger with the tube so that the soft part of your finger remains upwards. Keep your finger as flat as possible. Usually the baby will begin sucking on the finger, and allow the finger to enter quite far. The baby will not usually gag on your finger even if it is in his mouth quite far, unless the baby is full or used to bottles.
    7. Pull down the baby's chin, if his lower lip is sucked in.
    8. The technique is working if the baby is drinking. If feeding is very slow, you may raise the bottle above the baby's head. Try to keep your finger straight, flattening the baby's tongue. Try not to point your finger up, but keep it flat, thus keeping down the baby's tongue, and working the lower jaw forward.
    9. The use of finger feeding with a syringe to push milk into the baby's mouth, is, in my opinion, too difficult and definitely not more effective than simply using a bottle with the nipple hole enlarged and the tube coming from it.

     

    If you are having trouble getting the baby to latch on to or to suckle at the breast, remember that a ravenous baby can make the going very difficult. Take the edge of his hunger by using the finger feeding technique for a minute or so. Once the baby has settled a little, and sucks well on your finger (usually only a minute or so), try offering the breast again. If you still encounter difficulty, do not be discouraged. Go back to finger feeding and try again later in the feed or next feeding. This technique usually works. Sometimes several days, or on occasion a week or more, of finger feeding are necessary, however.

    If you are leaving the hospital finger feeding the baby, make an appointment with the clinic within a day or so of discharge. The earlier the better.

    Once the baby is taking the breast, he may still require the lactation aid to supplement for a period of time. Although the baby may take the breast, the latch can still be less than ideal, and the suckle may still not be efficient enough to ensure adequate intake.

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

    Sunday, 16 December 2012 21:03

    Fluconazole

    Fluconazole (Diflucan™) is a synthetic antifungal agent which can be used for the treatment of a variety of Candida albicans infections. For the breastfeeding mother in particular, it can be used to treat recurrent Candida infections of the nipples, and, if such an thing exists, Candida infections of the milk ducts.

    Candida (yeast) infections of the nipple and ducts

    Candida infections of the nipples may occur any time while the mother is breastfeeding. Candida albicans likes warm, moist, dark areas. It lives normally on us, and 90% of babies are colonised by it within a few hours of birth. It only becomes a problem under certain circumstances.

    Candida infections of the skin or mucous membranes are more likely to occur when there is a breakdown in the integrity of the skin or mucous membrane—another reason why a good latch is very important from the very first day. Many Candida infections would, perhaps, not have occurred, if the mother had not had sore nipples and a breakdown of the skin of the nipples and areola. The oozing of serum which occurs often in cracked nipples turns Candida albicans from its harmless form to a disease causing form.

    The widespread use of antibiotics also encourages the overgrowth of Candida albicans. Many pregnant women, women in labour, and new mothers, as well as their babies receive antibiotics, sometimes with very little justification.

    Diagnosis of Candida infections of the nipples and/or ducts

    There is no good test which helps makes the diagnosis. A positive culture from the nipple(s) proves little. Neither does a negative culture. The best way to make a diagnosis is by history.

    The presence or absence of a Candida infection in the baby is not helpful. A baby may have thrush all over his mouth, but the mother have no pain. A mother may have the classic symptoms of a Candida infection of the nipples, and the baby have no thrush or diaper rash.

     

    The typical symptoms of a Candida infection of the nipples are:

     

    • Nipple pain which begins after a period of pain free nursing. Though there are a few other causes of nipple pain which begin later, Candida infection is definitely the most common. The nipple pain of Candida may begin without an interval of pain free nursing, however.
    • Burning nipple pain which continues throughout the feeding, sometimes continuing after the feeding is over.
    • Pain in the breast which is "shooting" and which goes through to the mother’s back and shoulder. This pain is usually worse toward the end of the feeding, and worsens still more after the feeding is over. It also tends to be much worse at night. This pain may occur without any nipple pain.
    • Pain, as above, which is made much better with the use of gentian violet

    Treating Candida Infections

     

    Our first approach to treating these infections is gentian violet (handout #6 Using Gentian Violet). It is safe, works rapidly, and almost always, though there seems to have been a decrease in its effectiveness over the past few years. A good response to gentian violet confirms that the mother’s nipple pain is caused by Candida since little else will respond to gentian violet. It thus also justifies the use of fluconazole, if needed.

    Fluconazole

    Fluconazole is an antifungal agent which is taken systemically (taken by mouth or intravenously). It is fungistatic, which means that it stops fungi (such as Candida albicans) from multiplying, but does not actually kill them. This accounts for the fact that sometimes it takes several days to have an effect.

    Side Effects

    Fluconazole is generally well tolerated, but there is no such thing as a drug which never has side effects. Concern about liver injury is exaggerated, since this complication seems quite rare, and usually occurs in people who are taking other medications as well, and who have taken fluconazole for months or longer, and who have immune deficiencies. But it is a possibility that needs to be kept in mind.

    Vomiting, diarrhea, abdominal pain and skin rashes are the most common side effects. These are not usually severe, and only occasionally is it necessary to stop the medication because of these side effects. Allergic reactions are possible but uncommon. Call immediately if you have any concerns.

    Fluconazole in the milk

    Fluconazole does appear in the milk, and this is as it should be, since the idea is to treat infection in the ducts and nipples. It is thus superior to ketoconazole, which gets into the milk in only tiny amounts. The baby will obviously get some, but this drug is now being promoted for use in babies for the treatment of simple thrush. There have been no complications in the baby reported from exposure to fluconazole in the breastmilk. Continue breastfeeding while taking fluconazole, though you may be told you cannot.

    Dose of fluconazole

    Candida albicans is learning to become resistant to fluconazole, and the dose we use has increased over the past few years. Only a few years ago, 100 mg daily for 10 days cured 90% of women of their symptoms. We have now found this to be inadequate.

    Your prescription will be for fluconazole 200 mg as a first dose, followed by 100 mg twice daily for at least two weeks. We like the mother to be symptom free for at least a week before stopping the medication. This seems, on the basis of our experience, a fairly good guarantee against relapse. However, this means that although most mothers require only the usual two weeks, some need longer treatment. Occasionally it may take up to a week for the pain to even start going away. Call if there is no relief in seven days.

    It is sometimes useful to treat the baby as well. The dose for the baby would be 6 mg/kg as a first dose, followed by 3 mg/kg/day as one dose for the same period of time as the mother.

    Note: The mother’s 2 week prescription is likely to cost between $300 and $350.

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

    Sunday, 26 June 2005 16:18

    Using Gentian Violet

    Using Gentian Violet

    Gentian violet (1% solution in water) is an excellent treatment for Candida albicans. Candida albicans is a yeast which may cause an infection of skin and/or mucous membranes in both children and adults. In small children, this yeast may cause white patches in the mouth (thrush), or diaper rash. When the nursing mother has a yeast infection of the nipple, she may experience severe nipple pain, as well as deep breast pain.

    Nipple pain caused by Candida albicans

    The pain caused by a yeast infection is generally different from the pain caused by poor positioning and/or ineffective suckling. The pain caused by a yeast infection:

     

    1. is often burning in nature, rather than the sharp, stabbing or pinching pain associated with other causes. Burning pain may be due to other causes, however, and pain due to a yeast infection does not necessarily burn.
    2. frequently lasts throughout the feeding, and occasionally continues after the feeding has ended. This is in contrast to the pain due to other causes which usually hurts most as feeding begins, and gradually improves as the baby nurses.
    3. may radiate into the mother's armpit or into her back.
    4. may cause no change in appearance of the mother's nipples or areolas, though there may be redness, or some scaling, or the skin of the areola may be smooth and shiny.
    5. not uncommonly will begin after a period of pain free nursing. This characteristic alone is reason enough to try treatment for yeast. However, milk blisters on the nipple also may cause nipple pain after a period of pain free nursing.
    6. may be associated with recent use of antibiotics by the baby or mother, but not necessarily.
    7. may be quite severe, may or may not be itchy.
    8. may occur only in the breast. This pain is often described as "shooting", or "burning" in nature, and is often worse after the feeding is over. It is often said to be worse at night. At the same time, the breast appears or feels normal. This is not mastitis and there is no reason to treat with antibiotics. On the contrary, antibiotics may make the problem worse.

     

    Please Note:

     

    1. The baby does not have to have thrush in his mouth.
    2. A yeast infection of the nipple may be combined with other causes of soreness.

     

    Using Gentian Violet

    We believe that gentian violet is the best treatment of nipple soreness due to Candida albicans for the breastfeeding mother. This is because it works almost always, and relief is rapid. It is messy, and will stain clothing, but not skin. The baby’s lips will turn purple, but the purple will disappear after a few days. Gentian violet is available without prescription but is not available at all pharmacies. Call around before going out to get it.

     

    1. About 10 ml (two teaspoons) of gentian violet is more than enough for an entire treatment.
    2. Many mothers prefer doing the treatment just before bed so that they can keep their nipples exposed and not worry about staining their clothing. The baby should be undressed to his diaper, and the mother should be uncovered from the waist up. Gentian violet is messy.
    3. Dip an ear swab (Q-tip) into the gentian violet.
    4. Put the purple end of the ear swab into the baby's mouth and let him suck on the swab for a few seconds. The gentian violet usually spreads around the mouth quickly. If it does not, paint the inside of the mouth to cover as much of the inside of the cheeks and tongue as possible.
    5. Put the baby to the breast. In this way, both the baby's mouth and your nipple are treated.
    6. If, at the end of the feeding, you have a baby with a purple mouth, and two purple nipples, there is nothing more to do. If only one nipple is purple, paint the other one with the ear swab and the gentian violet. In this way, the treatment is finished in one go.
    7. Repeat the treatment each day for three or four days.
    8. There is often some relief within hours of the first treatment, and the pain is usually gone or virtually gone by the third day. If it is not, it is unlikely that Candida was the problem, though it seems Candida albicans is starting to show some resistance to gentian violet, as it is to other antifungal agents. Of course there may be more than one cause of nipple pain, but after three days the contribution to your pain caused by Candida albicans should be gone. Do not continue the gentian violet if no relief occurs after 3-4 days of treatment. Instead, get more information.
    9. All artificial nipples that the baby uses should be boiled daily during the treatment, or well covered with gentian violet. Consider stopping artificial nipples.
    10. There is no need to treat just because the baby has thrush in his mouth. The reason to treat is the mother's and/or the baby's discomfort. Babies, however, do not commonly seem to be bothered by thrush.
    11. Uncommonly, babies who are treated with gentian violet develop sores in the mouth which may cause them to reject the breast. If this occurs, or if the baby is irritable while nursing, stop the gentian violet immediately, and contact the clinic. The sores clear up within 24 hours and the baby returns to feeding.

     

    If the infection recurs, treatment can be repeated as above. But if the infection recurs a third time, a source of reinfection should be sought out. The source may be the mother who may be a carrier for the yeast (but may have no sign of infection elsewhere), or from artificial nipples the baby puts in his mouth. Treatment of the mother (usually with a medication other than gentian violet) at the same time as treatment is repeated for the nipples will usually eliminate reinfection. Contact the clinic.

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

    Sunday, 26 June 2005 16:17

    Breastfeeding and Guilt

    Breastfeeding and Guilt

    One of the most powerful arguments many health professionals, government agencies and formula company manufacturers make for not promoting and supporting breastfeeding is that we should "not make the mother feel guilty for not breastfeeding". Even some strong breastfeeding advocates are disarmed by this "not making mothers feel guilty" ploy.

    Because, indeed, it is nothing more than a ploy. It is an argument which deflects attention from the lack of knowledge and understanding of most health professionals about breastfeeding. This allows them not to feel guilty for their ignorance of how to help women overcome difficulties with breastfeeding, which could have been overcome and usually which could have been prevented in the first place if mothers were not so undermined in their attempts to breastfeed. This argument also seems to allow formula companies and health professionals to pass out formula company literature and free samples of formula to pregnant women and new mothers without pangs of guilt, though it has been well demonstrated that this literature and the free samples decrease the rate and duration of breastfeeding.

    Let's look at real life. If a pregnant woman went to her physician and admitted she smoked a pack of cigarettes, is there not a strong chance that she would leave the office feeling guilty for endangering her developing baby? If she admitted to drinking a couple of beers every so often, is there not a strong chance that she would leave the office feeling guilty? If a mother admitted to sleeping in the same bed with her baby, would most physicians not make her feel guilty for this even though it is the best thing for her and the baby? If she went to the office with her one week old baby and told the physician that she was feeding her baby homogenized milk, what would be the reaction of her physician? Most would practically collapse and have a fit. And they would have no problem at all making that mother feel guilty for feeding her baby cow's milk, and then pressuring her to feed the baby formula. (Not pressuring her to breastfeed, it should be noted, because "you wouldn't want to make a woman feel guilty for not breastfeeding".)

    Why such indulgence for formula? The reason of course, is that the formula companies have succeeded so brilliantly with their advertising to convince most of the world that formula feeding is just about as good as breastfeeding, and therefore there is no need to make such a big deal about women not breastfeeding. As a vice president of Nestle here in Toronto was quoted as saying "Obviously, advertising works". It is also a balm for the consciences of many health professionals who, themselves, did not breastfeed, or their wives did not breastfeed. "I will not make women feel guilty for not breastfeeding, because I don't want to feel guilty for my child not being breastfed".

    Let's look at this a little more closely. Formula is certainly theoretically more appropriate for babies than cow's milk. But, in fact, there are no clinical studies which show that there is any difference between babies fed cow's milk and those fed formula. Not one. Breastmilk, and breastfeeding, which is not the same as breastmilk feeding, has many more theoretical advantages over formula than formula has over cow's milk (or other animal milk). And we are just learning about many of these advantages. Almost every day there are more studies telling us about these theoretical advantages. But there is also a wealth of clinical data showing that, even in affluent societies, breastfed babies, and their mothers incidentally, are much better off than formula fed babies. They have fewer ear infections, fewer gut infections, a lesser chance of developing juvenile diabetes and many other illnesses. The mother has a lesser chance of developing breast and ovarian cancer, and is probably protected against osteoporosis. And these are just a few examples.

    So how should we approach support for breastfeeding? All pregnant women and their families need to know the risks of formula feeding. All should be encouraged to breastfeed, and all should get the best support available for starting breastfeeding once the baby is born. Because all the good intentions in the world will not help a mother who has developed terribly sore nipples because of the baby's poor latch at the breast. Or a mother who has been told, almost always inappropriately, that she must stop breastfeeding because of some medication or illness in her or her baby. Or a mother whose supply has not built up properly because she was given wrong information. Make no mistake about it—health professionals' advice is often the single most common reason for mothers' failing at breastfeeding!

    If mothers get the information about the risks of formula feeding and decide to formula feed, they will have made an informed decision. This information must not come from the formula companies themselves, as it often does. Their pamphlets give some advantages of breastfeeding and then go on to imply that their formula is almost, actually just as good. If mothers get the best help possible with breastfeeding, and find breastfeeding is not for them, they will get no grief from me. It is important to know that a woman can easily switch from breastfeeding to bottle feeding. In the first days or weeks—no big problem. But the same is not true for switching from bottle feeding to breastfeeding. It is often very difficult or impossible, though not always.

    Finally, who does feel guilty about breastfeeding? Not the women who make an informed choice to bottle feed. It is the woman who wanted to breastfeed, who tried, but was unable to breastfeed. In order to prevent women feeling guilty about not breastfeeding what is required is not avoiding promotion of breastfeeding, but promotion of breastfeeding coupled with good, knowledgeable and skillful support. This is not happening in most North American or European societies.

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

    Sunday, 26 June 2005 16:16

    Breast Compression

    Breast Compression

    The purpose of breast compression is to continue the flow of milk to the baby once the baby no longer drinks (open—pause—close type of suck) on his own. Breast compression simulates a letdown reflex and often stimulates a natural letdown reflex to occur. The technique may be useful for:

     

    1. Poor weight gain in the baby
    2. Colic in the breastfed baby
    3. Frequent feedings and/or long feedings
    4. Sore nipples in the mother
    5. Recurrent blocked ducts and/or mastitis
    6. Encouraging the baby who falls asleep quickly to continue drinking

     

    Breast compression is not necessary if everything is going well. When all is going well, the mother should allow the baby to "finish" feeding on the first side and, if the baby wants more, should offer the other side. How do you know the baby is finished? When he no longer drinks at the breast (open—pause—close type of suck).

    It may be useful to know that:

     

    1. A baby who is well latched on gets milk more easily than one who is not. A baby who is poorly latched on can get milk only when the flow of milk is rapid. Thus, many mothers and babies do well with breastfeeding in spite of a poor latch, because most mothers produce an abundance of milk.
    2. In the first 3-6 weeks of life, babies fall asleep at the breast when the flow of milk is slow, not necessarily when they have had enough to eat. After this age, they may start to pull away at the breast when the flow of milk slows down.
    3. Unfortunately many babies are latching on poorly. If the mother’s supply is abundant the baby often does well as far as weight gain is concerned, but the mother may pay a price—sore nipples, a "colicky" baby, a baby who is constantly on the breast (but feeding only a small part of the time).

     

    Breast compression continues the flow of milk once the baby starts falling asleep at the breast and results in the baby:

     

    1. Getting more milk.
    2. Getting more milk that is high in fat.

     

    Breast Compression—How to do it

     

    1. Hold the baby with one arm.
    2. Hold the breast with the other, thumb on one side of the breast, your other fingers on the other, fairly far back from the nipple.
    3. Watch for the baby’s drinking, though there is no need to be obsessive about catching every suck. The baby gets substantial amounts of milk when he is drinking with an open—pause—close type of suck. (open—pause—close is one suck, the pause is not a pause between sucks).
    4. When the baby is nibbling or no longer drinking with the open—pause—close type of suck, compress the breast. Not so hard that it hurts and try not to change the shape of the areola (the part of the breast near the baby’s mouth). With the compression, the baby should start drinking again with the open—pause—close type of suck.
    5. Keep the pressure up until the baby no longer drinks even with the compression, then release the pressure. Often the baby will stop sucking altogether when the pressure is released, but will start again shortly as milk starts to flow again. If the baby does not stop sucking with the release of pressure, wait a short time before compressing again.
    6. The reason to release the pressure is to allow your hand to rest, and to allow milk to start flowing to the baby again. The baby, if he stops sucking when you release the pressure, will start again when he starts to taste milk.
    7. When the baby starts sucking again, he may drink (open—pause—close). If not compress again as above.
    8. Continue on the first side until the baby does not drink even with the compression. You should allow the baby to stay on the side for a short time longer, as you may occasionally get another letdown reflex and the baby will start drinking again, on his own. If the baby no longer drinks, however, allow him to come off or take him off the breast.
    9. If the baby wants more, offer the other side and repeat the process.
    10. You may wish, unless you have sore nipples, to switch sides back and forth in this way several times.
    11. Work on improving the baby’s latch.

     

    The above works best, in our experience in the clinic, but if you find a way which works better at keeping the baby sucking with an open—pause—close type of suck, use whatever works best for you and your baby. As long as it does not hurt your breast to compress, and as long as the baby is "drinking" (open—pause—close type of suck), breast compression is working.

    You will not always need to do this. As breastfeeding improves, you will able to let things happen naturally.

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

     

     

    Sunday, 26 June 2005 16:15

    Breastfeeding: Starting Out Right

    Breastfeeding: Starting Out Right

    Breastfeeding is the natural, physiologic way of feeding infants and young children milk, and human milk is the milk made specifically for human infants. Formulas made from cow’s milk or soy beans (most of them) are only superficially similar, and advertising which states otherwise is misleading. Breastfeeding should be easy and trouble free for most mothers. A good start helps to assure breastfeeding is a happy experience for both mother and baby.

    The vast majority of mothers are perfectly capable of breastfeeding their babies exclusively for four to six months. In fact, most mothers produce more than enough milk. Unfortunately, outdated hospital routines based on bottle feeding still predominate in many health care institutions and make breastfeeding difficult, even impossible, for some mothers and babies. For breastfeeding to be well and properly established, a good early few days can be crucial. Admittedly, even with a terrible start, many mothers and babies manage.

    The trick to breastfeeding is getting the baby to latch on well. A baby who latches on well, gets milk well. A baby who latches on poorly has difficulty getting milk, especially if the supply is low. A poor latch is similar to giving a baby a bottle with a nipple hole which is too small—the bottle is full of milk, but the baby will not get much. When a baby is latching on poorly, he may also cause the mother nipple pain. And if he does not get milk well, he will usually stay on the breast for long periods, thus aggravating the pain. Here are a few ways breastfeeding can be made easy:

    1. The baby should be at the breast immediately after birth. The vast majority of newborns can be put to breast within minutes of birth. Indeed, research has shown that, given the chance, babies only minutes old will often crawl up to the breast from the mother’s abdomen, and start breastfeeding all by themselves. This process may take up to an hour or longer, but the mother and baby should be given this time together to start learning about each other. Babies who "self-attach" run into far fewer breastfeeding problems. This process does not take any effort on the mother’s part, and the excuse that it cannot be done because the mother is tired after labour is nonsense, pure and simple. Incidentally, studies have also shown that skin to skin contact between mothers and babies keeps the baby as warm as an incubator.

    2. The mother and baby should room in together. There is absolutely no medial reason for healthy mothers and babies to be separated from each other, even for short periods. Health facilities which have routine separations of mothers and babies after birth are years behind the times, and the reasons for the separation often have to do with letting parents know who is in control (the hospital) and who is not (the parents). Often bogus reasons are given for separations. One example is the baby passed meconium before birth. A baby who passes meconium and is fine a few minutes after birth will be fine and does not need to be in an incubator for several hours’ "observation".

    There is no evidence that mothers who are separated from their babies are better rested. On the contrary, they are more rested and less stressed when they are with their babies. Mothers and babies learn how to sleep in the same rhythm. Thus, when the baby starts waking for a feed, the mother is also starting to wake up naturally. This is not as tiring for the mother as being awakened from deep sleep, as she often is if the baby is elsewhere when he wakes up.

    The baby shows long before he starts crying that he is ready to feed. His breathing may change, for example. Or he may start to stretch. The mother, being in light sleep, will awaken, her milk will start to flow and the calm baby will be content to nurse. A baby who has been crying for some time before being tried on the breast may refuse to take the breast even if he is ravenous. Mothers and babies should be encouraged to sleep side by side in hospital. This is a great way for mothers to rest while the baby nurses. Breastfeeding should be relaxing, not tiring.

    3. Artificial nipples should not be given to the baby. There seems to be some controversy about whether "nipple confusion" exists. Babies will take whatever method gives them a rapid flow of fluid and may refuse others that do not. Thus, in the first few days, when the mother is producing only a little milk (as nature intended), and the baby gets a bottle (as nature intended?) from which he gets rapid flow, he will tend to prefer the rapid flow method. You don't have to be a rocket scientist to figure that one out, though many health professionals, who are supposed to be helping you, don’t seem to be able to manage it. Nipple confusion includes not just the baby refusing the breast, but also the baby not taking the breast as well as he could and thus not getting milk well and /or the mother getting sore nipples. Just because a baby will "take both" does not mean that the bottle is not having a negative effect. Since there are now alternatives available if the baby needs to be supplemented (see handout #5 Using a Lactation Aid, and handout #8 Finger Feeding) why use an artificial nipple?

    4. No restriction on length or frequency of breastfeedings. A baby who drinks well will not be on the breast for hours at a time. Thus, if he is, it is usually because he is not latching on well and not getting the milk which is available. Get help to fix the baby’s latch, and use compression to get the baby more milk (handout #15 Breast Compression). This, not a pacifier, not a bottle, not taking the baby to the nursery, will help.

    5. Supplements of water, sugar water, or formula are rarely needed. Most supplements could be avoided by getting the baby to take the breast properly and get the milk that is available. If you are being told you need to supplement without someone having observed you breastfeeding, ask for someone to help who knows what they are doing. There are rare indications for supplementation, but usually supplements are suggested for the convenience of the hospital staff. If supplements are required, they should be given by lactation aid (see handout #5), not cup, finger feeding, syringe or bottle. The best supplement is your own colostrum. It can be mixed with sugar water if you are not able to express much at first. Formula is hardly ever necessary in the first few days.

    6. A proper latch is crucial to success. This is the key to successful breastfeeding. Unfortunately, too many mothers are being "helped" by people who don’t know what a proper latch is. If you are being told your two day old’s latch is good despite your having very sore nipples, be skeptical, and ask for help from someone who knows.

    Before you leave the hospital, you should be shown that your baby is latched on properly, and that he is actually getting milk from the breast and that you know how to know he is getting milk from the breast (open—pause—close type of suck). If you and the baby are leaving hospital not knowing this, get help quickly.

    7. Free formula samples and formula company literature are not gifts. There is only one purpose for these "gifts" and that is to get you to use formula. It is very effective, and very unethical, marketing. If you get any from any health professional, you should be wondering about his/her knowledge of breastfeeding and his/her commitment to breastfeeding. "But I need formula because the baby is not getting enough!". Maybe, but, more likely, you weren’t given good help and the baby is simply not getting your milk well. Get good help. Formula samples are not help.

    Under some circumstances, it may be impossible to start breastfeeding early. However, most medical reasons (maternal medication, for example) are not true reasons for stopping or delaying breastfeeding, and you are getting misinformation. Get good help. Premature babies can start breastfeeding much, much earlier than they do in many health facilities. In fact, studies are now quite definite that it is easier for a premature baby to breastfeed than to bottle feed. Unfortunately, too many health professionals dealing with premature babies do not seem to be aware of this.

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

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