JBR Admin

JBR Admin

Sunday, 26 June 2005 16:14

Is My Baby Getting Enough Milk?

Is My Baby Getting Enough Milk?

Breastfeeding mothers frequently ask how to know their babies are getting enough milk. The breast is not the bottle, and it is not possible to hold the breast up to the light tosee how many ounces or millilitres of milk the baby drank. Our number obsessed society makes it difficult for some mothers to accept not seeing exactly how much milk the babyreceives. However, there are ways of knowing that the baby is getting enough. In the long run, weight gain is the best indication whether the baby is getting enough, but rulesabout weight gain appropriate for bottle fed babies may not be appropriate for breastfed babies.

Ways of Knowing

1. Baby's nursing is characteristic. A baby who is obtaining lots of milk at the breast sucks in a very characteristic way. The baby generally opens his mouth fairly wide as he sucks and the rhythm is slow and steady. His lips are turned out. At the maximum opening of his mouth, there is a perceptible pause which you can see if you watch his chin. Then, the baby closes his mouth again. This pause does not refer to the pause between suckles, but rather to the pause during one suckle as the baby opens his mouth to its maximum. Each one of these pauses corresponds to a mouthful of milk and the longer the pause, the more milk the baby got. At times, the baby can even be heard to be swallowing, and this is perhaps reassuring, but the baby can be getting lots of milk without making noise. Usually, the baby's suckle will change during the feeding, so that the above type of suck will alternate with sucks that could be described as "nibbling". This is normal. The baby who suckles as described above, with several minutes of pausing type sucks at each feeding, and then comes off the breast satisfied, is getting enough. The baby who nibbles only, or has the drinking type of suckle for a short period of time only, is probably not. This is the best way of knowing the baby is getting enough. This type of suckling can be seen on the very first day of life, though it is not as obvious as later when the mother has lots more milk.

2. Baby's bowel movements. For the first few days after delivery, the baby passes meconium, a dark green, almost black, substance. Meconium accumulates in the baby's gut during pregnancy. Meconium is passed during the first few days, and by the 3rd day, the bowel movements start becoming lighter, as more breastmilk is taken. Usually by the fifth day, the bowel movements have taken on the appearance of the normal breastmilk stool. The normal breastmilk stool is pasty to watery, mustard coloured, and usually has little odour. However, bowel movements may vary considerably from this description. They may be green or orange, may contain curds or mucus, or may resemble shaving lotion in consistency (from air bubbles). The variation in colour does not mean something is wrong. A baby who is breastfeeding only, and is starting to have bowel movements which are becoming lighter by day 3 of life, is doing well.

Without your becoming obsessive about it, monitoring the frequency and quantity of bowel motions is one of the best ways of knowing if the baby is getting enough milk. Afterthe first 3-4 days, the baby should have increasing bowel movements so that by the end of the first week he should be passing at least 2-3 substantial yellow stools eachday. In addition, many infants have a stained diaper with almost each feeding. A baby who is still passing meconium on the fifth day should be seen at the clinic the same day. A baby who is passing only brown bowel movements is probably not getting enough, but this is not yet definite.

Some breastfed babies, after the first 3-4 weeks of life, may suddenly change their stool pattern from many each day, to one every 3 days or even less. Some babies have gone as long as 15 days or more without a bowel movement. As long as the baby is otherwise well, and the stool is the usual pasty or soft, yellow movement, this is not constipation and is of no concern. No treatment is necessary or desirable, because no treatment is necessary or desirable for something that is normal.

Any baby between 5 and 21 days of age who does not pass at least one substantial bowel movement within a 24 hour period should be seen at the breastfeeding clinic the same day. Generally, small infrequent bowel movements during this time period means insufficient intake. There are definite exceptions and everything may be fine, but it is better to check.

3. Urination. With six soaking wet (not just wet) diapers in a 24 hours hour period, after about 4-5 days of life, you can be sure that the baby is getting a lot of milk. Unfortunately, the new super dry "disposable" diapers often do indeed feel dry even when full of urine, but when soaked with urine they are heavy. It should beobvious that this indication of milk intake does not apply if you are giving the baby extra water (which, in any case, is unnecessary for breastfed babies, and if given by bottle, may interfere with breastfeeding). The baby's urine should be clear as water after the first few days, though an occasional darker urine is not of concern.

During the first 2-3 days of life, some babies pass pink or red urine. This is not a reason to panic and does not mean the baby is dehydrated. No one knows what it means, or even if it is abnormal. It is undoubtedly associated with the lesser intake of the breastfed baby compared with the bottle fed baby during this time, but the bottle feeding baby is not the standard on which to measure breastfeeding. However, the appearance of this colour urine should result in attention to getting the baby well latched on and making sure the baby is drinking at the breast. During the first few days of life, only if the baby is well latched on can he get his mother's milk. Giving water by bottle or cup or finger feeding at this point does not fix the problem. It only gets the baby out of hospital with urine which is not red. If relatching and breast compression do not result in better intake, there are ways of giving extra fluid without giving a bottle directly (handout #5 Using a Lactation Aid). Limiting the duration or frequency of feedings can also contribute to decreased intake of milk.

The following are NOT good ways of judging

1. Your breasts do not feel full. After the first few days or weeks, it is usual for most mothers not to feel full. Your body adjusts to your baby's requirements. This change may occur quite suddenly. Some mothers breastfeeding perfectly well never feel engorged or full.

2. The baby sleeps through the night. Not necessarily. A baby who is sleeping through the night at 10 days of age, for example, may, in fact, not be getting enough milk. A baby who is too sleepy and has to be awakened for feeds or who is "too good" may not be getting enough milk. There are many exceptions, but get help quickly.

3. The baby cries after feeding. Although the baby may cry after feeding because of hunger, there are also many other reasons for crying. See also handout #2 Colic in the Breastfeeding Baby. Do not limit feeding times.

4. The baby feeds often and/or for a long time. For one mother every 3 hours or so feedings may be often; for another, 3 hours or so may be a long period between feeds. For one a feeding that lasts for 30 minutes is a long feeding; for another it is a short one. There are no rules how often or for how long a baby should nurse. It is not truethat the baby gets 90% of the feed in the first 10 minutes. Let the baby determine his own feeding schedule and things usually come right, if the baby is suckling and drinking at the breast and having at least 2-3 substantial yellow bowel movements each day. If that is the case, feeding on one breast each feeding (or at least finishing on one breast before switching over) will often lengthen the time between feedings. Remember, a baby may be on the breast for 2 hours, but if he is actually breastfeeding (open—pause—close type of sucking) for only 2 minutes, he will come off the breast hungry. If the baby falls asleep quickly at the breast, you can compress the breast to continue the flow of milk (handout #15 Breast Compression). Contact the breastfeeding clinic with any concerns, but wait to start supplementing. If supplementation is truly necessary, there are ways of supplementing which do not use an artificial nipple (handout #5 Using a Lactation Aid).

5. "I can express only half an ounce of milk". This means nothing and should not influence you. Therefore, you should not pump your breasts "just to know". Most mothers have plenty of milk. The problem usually is that the baby is not getting the milk that is there, either because he is latched on poorly, or the suckle is ineffective or both. These problems can often be fixed easily.

6. The baby will take a bottle after feeding. This does not necessarily mean that the baby is still hungry. This is not a good test, as bottles may interfere with breastfeeding.

7. The 5 week old is suddenly pulling away from the breast but still seems hungry. This does not mean your milk has "dried up" or decreased. During the first few weeks of life, babies often fall asleep at the breast when the flow of milk slows down even if they have not had their fill. When they are older (4-6 weeks of age), they no longer are content to fall asleep, but rather start to pull away or get upset. The milk supply has not changed; the baby has. Compress the breast (handout #15 Breast Compression) to increase flow.

Please Note: On occasion, it may be necessary to supplement a baby who is breastfeeding. If this is done by bottle, a bad situation may become worse. A lactation aid is a method of supplementing without giving a bottle and may allow you to supplement temporarily and get back to exclusive breastfeeding. It is generally easy to use. In an"emergency" situation, extra fluid can be given by spoon, cup or eyedropper until a lactation aid can be started.

Notes on scales and weights


1. Scales are all different. We have documented significant differences from one scale to another. Weights have often been written down wrong. A soaked cloth diaper may weigh several hundred grams (half a pound or more), so babies should be weighed naked.

 

2. Many rules about weight gain are taken from observations of growth of formula feeding babies. They do not necessarily apply to breastfeeding babies. A slow start maybe compensated for later, by fixing the breastfeeding. Growth charts are guidelines only.

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

Sunday, 26 June 2005 16:11

Domperidone

Introduction

Domperidone (Motilium™) is a drug which has, as a side effect, the increased production of the hormone prolactin. Prolactin is the hormone which stimulates the cells in the mother''s breast to produce milk. Domperidone increases prolactin secretion indirectly, by interfering with the action of dopamine. One of the actions of dopamine is that it decreases the secretion of prolactin by the pituitary gland. Domperidone is generally used for disorders of the gastrointestinal tract (gut) and has not been released in Canada for use as a stimulant for milk production. This does not mean that it cannot be prescribed for this reason, but rather that the manufacturer does not back its use for increasing milk production. It has been used, for several years, in small infants who spit up and lose weight, but it has recently been replaced for this reason by a newer drug called cisapride (Prepulsid™). Domperidone''s ability to increase milk production has been recognized since it first became available. Another, related, but older medication, metoclopramide (Maxeran™), is also known to increase milk production, but it has frequent side effects which have made its use for many nursing mothers unacceptable (fatigue, irritability, depression). Domperidone has many fewer side effects because it does not enter the brain tissue in significant amounts (does not pass the blood-brainbarrier).

When is it appropriate to use domperidone?
Domperidone must never be used as the first approach to correcting breastfeeding difficulties. Domperidone is not a cure for all things. It must not be used unless all other factors which may result in insufficient milk supply have been dealt with first. These include:

1. correcting the baby's latch so that the baby can obtain as efficiently as possible the milk which the mother has available. Correcting the latch may be all that is necessary to change a situation of "not enough milk" to one of "plenty of milk".

2. using breast compression to increase the intake of milk (handout #15 Breast Compression).

3. using milk expression after feedings to increase the supply.

4. correcting sucking problems, stopping the use of artificial nipples (handout #5, Using a Lactation Aid, and #8, Finger Feeding) and other stratagems.

Using domperidone for increasing milk production

Domperidone works particularly well to increase milk production under the following circumstances:

  • it has frequently been noted that a mother who is pumping milk for a sick or premature baby in hospital has a decrease in the amount she pumps around 4 or 5 weeks after the baby is born. The reasons for this are likely many, but domperidone generally brings the amount of milk pumped back
  • to where it was or even to higher levels.
  • when a mother has a decrease in milk supply, often associated with the use of birth control pills (avoid œstrogen containing birth control pills while breastfeeding), or on occasion for no obvious reason when the baby is 3 or 4 months old, domperidone will often bring the supply back to normal.

 

Domperidone still works, but often less dramatically when:

  • the mother is pumping for a sick or premature baby but has not managed to develop a full milk supply.
  • the mother is trying to develop a full milk supply while nursing an adopted baby.
  • the mother is trying to wean the baby from supplements.

 

Side effects of domperidone

As with all medications, side effects are possible, and many have been reported with domperidone (textbooks often list any side effect ever reported, but symptoms reported are not necessarily due to the drug a person is taking). There is no such thing as a 100% safe drug. However, our clinical experience has been that side effects in the mother areextremely uncommon, except for increasing milk supply. Some side effects which mothers we have treated have reported (very uncommonly, incidentally):

  • dry mouth
  • headache which disappeared when the dose was reduced
  • abdominal cramps

 

The amount that gets into the milk is so tiny that side effects in the baby should not be expected. Mothers have not reported any to us, in many years of use. Certainly theamount the baby gets through the milk is a tiny percentage of what babies would get if being treated for spitting up.

Are there long term concerns about the use of domperidone?


The manufacturer states in its literature that chronic treatment with domperidone in rodents has resulted in increased numbers of breast tumours in the rodents. The literature goes on to state that this has never been documented in humans. Note that toxicity studies of medication usually require treatment with huge doses over periods of time involving most or all of the animal''s lifetime. Note also that not breastfeeding increases the risk of breast cancer, and breast cancer risk decreases the longer you breastfeed.

 

Using Domperidone
Generally, we start domperidone at 20 milligrammes (two 10 mg tablets) four times a day. Printouts from the pharmacy often suggest taking domperidone 30 minutes beforeeating, but that is because of its use for digestive intolerance. You can take the domperidone about every 6 hours, when it is convenient (there is no need to wake up to keep to a 6 hour schedule—it does not make any difference). Most mothers take the domperidone for 3 to 8 weeks. Mothers who are nursing adopted babies may have to take thedrug much longer.

After starting domperidone, it may take three or four days before you notice any effect, though sometimes mothers notice an effect within 24 hours. It appears to take two to three weeks to get a maximum effect.

After you have used domperidone for two weeks, we ask you to call (416) 813-5757 (option 3) and ask for a return call. Based on your information, a decision will be made what to do next. If you have unexplained symptoms at any time call the same number immediately.

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

 

 

 

 

 

 

Friday, 15 February 2008 14:34

Colic in the Breastfed Baby

Colic is one of the mysteries of nature. Nobody knows what it really is, but everyone has an opinion. In the typical situation, the baby starts to have crying periods about two to three weeks after birth. These occur mainly in the evening, and finally stop when the baby is about 3 months of age (occasionally older). When the baby cries, he is often inconsolable, though if he is walked, rocked or taken for a drive, he may settle temporarily. For a baby to be called colicky, it is necessary that he be gaining weight well and be otherwise healthy.

The notion of colic has been extended to include almost any fussiness or crying in the baby, and this may be valid, since we do not really know what colic is. There is no treatment for colic, though many medications and behaviour strategies have been tried, without any proved benefit. It is admitted that everyone knows someone whose baby was cured of colic by a particular treatment. It is also admitted that almost every treatment seems to work - for a short time, anyhow.

The Breastfeeding Baby with Colic

Aside from the colic that any baby may have, there are three known situations in the breastfed baby which may result in fussiness or colic. Once again, it is assumed that the baby is gaining adequately and that the baby is healthy.

  1. Feeding Both Breasts at Each Feeding

Human milk changes during a feeding. One of the ways in which it changes is that the amount of fat increases as the baby nurses longer at the breast. If the mother automatically switches the baby from one breast to the other during the feed, before the baby has "finished" the first side, the baby may get a relatively low amount of fat during the feeding. This may result in the baby getting fewer calories, and thus feeding more frequently. If the baby takes in a lot of milk (to make up for the reduced concentration of calories), he may spit up. Because of the relatively low fat content of the milk, the stomach empties quickly, and a large load of milk sugar (lactose) arrives in the intestine all at once. The protein which digests the sugar (lactase) may not be able to handle so much milk sugar at one time and the baby will have the symptoms of lactose intolerance - crying, gas, and explosive, watery, greenish bowel movements. This may occur even during the feeding. These babies are not lactose intolerant. They have problems with lactose because of the sort of information women get about breastfeeding. This is not a reason to switch to lactose free formula.

  1. Do not time feedings. Mothers all over the world have breastfed babies successfully without being able to tell time. Breastfeeding problems are greatest in societies where everyone has a watch and least where no one has a watch.
  2. The mother should feed the baby on one breast, as long as the baby breastfeeds, until the baby comes off himself, or is asleep at the breast. If the baby feeds for only a short time only, the mother can compress the breast (handout #15 Breast Compression) to keep the baby nursing. Please note that a baby may be on the breast for two hours, but may actually feed for only a few minutes. In that case the milk taken by the baby may still be relatively low in fat. This is the rationale for compressing the breast. If, after "finishing" on the first side, the baby still wants to feed, offer the other side.
  3. The next feeding, the mother should start the baby on the other breast in the same way.
  4. The mother''s body will adjust quickly to the new method, and she will not become engorged or lop sided.
  5. Just as there should be no "rule" for feeding both breasts at each feeding, there should be no rule for one breast per feeding. Let the baby finish on one breast (compress milk into his mouth if necessary to keep him swallowing longer) but if he wants more, then offer the other side.
  6. In some cases, it may be helpful to feed the baby two or more feedings on one side before switching over to the other side for two or more feedings.
  7. This problem is made worse if the baby is not well latched on to the breast. A proper latch is the key to easy breastfeeding.
  1. Overactive Letdown Reflex

A baby who gets too much milk too quickly, may become very fussy, very irritable at the breast and may be considered "colicky". Typically, the baby is gaining very well. Typically, also, the baby starts nursing, and after a few seconds or minutes, starts to cough, choke or struggle at the breast. He may come off, and often, the mother''s milk will spray. After this, the baby frequently returns to the breast, but may be fussy and repeat the performance. He may be unhappy with the rapid flow, and impatient when the flow slows. This can be a very trying time for everyone. On rare occasions, a baby may even start refusing to take the breast after several weeks, typically around three months of age.

What can be done?

  1. If you have not already done so, try feeding the baby one breast/feed. In some situations, feeding even two or three feedings on one breast before changing to the other breast may be helpful. If you experience engorgement on the unused breast, express just enough to feel comfortable.
  2. Feed the baby before he is ravenous. Do not hold off the feeding by giving water (a breastfeeding baby does not need water even in very hot weather) or a pacifier. A ravenous baby will "attack" the breast and cause a very active letdown reflex. Feed the baby as soon as he shows any sign of hunger. If he is still half asleep, all the better.
  3. Feed the baby in a calm, relaxed atmosphere, if possible. Loud music, bright lights and lots of action are not conducive to a successful feeding.
  4. Lying down to nurse sometimes works very well. If lying sideways to feed does not help, try lying flat on your back with the baby lying on top of you to nurse. Gravity helps decrease the flow rate.
  5. If you have time, express some milk (an ounce or so) before you feed the baby.
  6. The baby may dislike the rapid flow, but also become fussy when the flow slows too much. If you think the baby is fussy because the flow is too slow, it will help to compress the breast to keep up the flow (handout #15 Breast Compression).
  7. This problem is made worse if the baby is not well latched on to the breast. A good latch is the key to easy breastfeeding.
  8. On occasion giving the baby commercial lactase (the enzyme that metabolizes lactose), 2-4 drops before each feeding, relieves the symptoms. It is available without prescription, but fairly expensive, and works only occasionally.
  9. A nipple shield may help, but use this only if nothing else has helped and only if you have gotten good help without any relief.
  10. As a last resort, rather than switching to formula, give the baby your expressed milk by bottle.
  1. Foreign Proteins in the mother''s milk

It has been shown that some proteins present in the mother''s diet may be excreted into her milk and may affect the baby. It would seem that the most common of these is cow''s milk protein. Other proteins have also been shown to be excreted into some mothers'' milk. The fact that these proteins and other substances appear in the mother''s milk is not necessarily a bad thing. Indeed, it should be considered a good thing. Ask about this if you have any questions.

Thus, in the treatment of the colicky breastfed baby, one step would be for the mother to stop taking dairy products. These includes milk, cheese, yoghurt, ice cream and anything else which may contain milk. When the milk protein has been changed (denatured), as in cooking for example, there should be no problem. Ask if you have any questions.

Please note: Intolerance to milk protein has nothing to do with lactose intolerance. A mother who is herself lactose intolerant should also still breastfeed her baby.

Suggested Method:

  1. The mother should eliminate all milk products for 7-10 days.
  2. If there has been no change, the mother can reintroduce milk products.
  3. If there has been a change for the better, the mother should then slowly reintroduce milk products into her diet, if these are normally part of her diet. (There is no need to drink milk in order to make milk). Some babies tolerate absolutely no milk products in the mother''s diet. Most tolerate some. The mother will learn what amount of dairy products she can take without the baby reacting.
  4. If there is concern about your calcium intake, calcium can be had without taking dairy products. Ask if you have any questions. One week off milk products will not cause any problems. Actually, evidence suggests that breastfeeding may protect the woman against the development of osteoporosis even if she does not take extra calcium. And the baby will get all he needs.
  5. The mother should be careful about eliminating too many things from her diet. Everyone will know someone whose baby got better when the mother stopped broccoli, beef, bananas, bread etc. The mother may find that she is eating white rice only. Our diets are too complex to be sure exactly what, if anything, is affecting the baby.

Be patient, the problem usually gets better no matter what. Formula is not the answer, though, because of the more regular flow, some babies do improve on it. But formula is not breastmilk. In fact, the baby would also improve on breastmilk from the bottle because of the regularity of the flow. Even if nothing works, time usually helps. The days and nights may seem eternal, but the weeks will fly by.

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

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