Sunday, 26 June 2005 17:02

Hey Guys! More than a Cracking Pair

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Hey Guys! More than a Cracking Pair

by Tee Ashford


They grow in all shapes and sizes. Creating quite a stir wherever they go. Small perky ones. Buoyant handfuls, more than just handfuls and some larger than life itself. Being a man makes you especially partial, to one or the other, or maybe all, if you're that way inclined. Some of you have a real problem, averting your eyes, which is very frustrating for the woman who would rather be recognized for her face than her so called "assets"....

We've all heard the derogatory jokes and pet names. Tits, boobs, melons, rosebuds, jugs (coming from the Latin word ampullae, the enlarged duct terminal at the base of the nipple). Calling them by their proper name is just tooooooo, embarrassing. We are more used to seeing these "assets" selling magazines, cars and beer. I thought it was time; we began to realize their real purpose and potential!

When you see the next women walking erotically along the shoreline with breasts jiggling and safely harnessed in a little Versace number, which in turn puts pressure on your lungs because you're hypo ventilating due to excitement. Remember that these precious soft mounds of flesh are capable, all on there own, along with the mother of course, of nourishing a child exclusively for the first six months of his/her life, sometimes even longer. Given the right circumstances and knowledgeable support before and after the baby is born from a Midwife or Lactation Consultant, these babies will double their weight on breast milk alone.

Those nipples and areolas (the area around the nipple) are a soft brown colour, becoming darker during pregnancy, not so you can pick them out at 50 metres in the dark. Instead if given the chance, immediately after birth, a baby can be laid on it's mothers tummy and crawl it's way to the breast and "self attach", taking their first comforting moments of oral satisfaction. The baby can locate the areola and nipple, more clearly, with their as yet immature unfocused eyes.

During pregnancy the breasts increase in size, WOW you say. This isn't for your "tit"illation. The blood supply increases, the network of veins become more apparent, all in preparation for the onslaught of mothers liquid gold.

All mammalian milk is species specific and we are after all, mammals. Even though some of us think we're God like. Human milk is a very precious commodity. No more precious than any other milk meant to feed it's infant, but over the years human breast-feeding has been left out in the cold and given bad press. Considering it is the best milk we can give to our babies only ....% feed past two weeks, .....% past six weeks and ....% to the recommended 6 months and beyond. We are the only species who routinely give their infants substitute milk, why??????

During the turn of the century the medical profession got all scientific and obsessed with numbers. Victorian breasts had to be hidden away. Breast-feeding became a rather vulgar occupation, especially in the upper classes. A breast-feeding child was marked by the devil, because you didn't do that sort of thing! Breasts belonged to men in the bedroom ensconced in a pretty decolletage and not for babies as nature intended. Women resorted to "closet" feeding and in affluent societies "wet nurses" took off, big time, (surrogate lactating mothers, prepared to feed another women's child). Less of this background information and back to the obsession with numbers.

Human beings are controlling creatures. The idea of not being able to see what a breast fed baby ingested in fl oz (milliliters), trusting nature to do it's job, was a temptation to huge to be ignored. The medics/pediatrics avidly watched and noted how much substitute milk disappeared from those forced bottle Glossary Link munching, babies. They clock watched too. They then applied the average time it took to drink a certain amount, how long it took the child to scream in hunger for more, to breast feeding infants, because it made them feel more secure in an area where little was known. BIG MISTAKE.

Just as we all have different fingerprints, so women have different breasts. The rules for scientific 3 - 4 hourly feeds (as it turned out) attributed to formulae fed babies (otherwise known as schedule feeding) may work for some breast feeding women, for most it will not! Human milk production and its very fine balance of supply and demand can be easily affected in the early weeks. Our desire to have "GOOD BABIES" leads many parents into believing that these strict regimens teach our babies to behave. Most people don't realize that formulae stays in the gut far longer than human milk. Ounce for ounce, quite frankly there is know comparison. Human milk is so pure and well absorbed it leaves the baby hungrier quicker, with less deposits (poops). It takes less breast milk to feed a child than it does formula. Breast fed babies, by design, need to be fed more frequently. In our society this is seen as a failure, infact the finger is pointed at the mother. Her "milk is thin", "quality substandard", "there's not enough" are sayings often heard. The "told you soÃ" comments come flying and the bottle of formula lands. Over this last century, in particular, a women's amazing ability to exclusively breast feed her child, as intended, has been manipulated, mistrusted and even seen as disgusting. Don't you find it a little strange, that thousands of years of evolution should be doubted and more trust put into the invention of the bottle? What would you prefer to rest your head on? I rest my case.... Formula (mostly made from cows milk) was meant for the sweet little mooing things in pastures green. It should be given to a baby as a last ditch resort. In well-supported environments this shouldn't arise. Unless the women have a physiological problem with the workings of her breasts the problem shouldn't arise, the health system will have failed the parents, not her breasts.

The manufacturers of formula have for years touted; their artificial feed is equal to human milk, in some cases better. This is about as far from the truth as saying men don't like breasts. In underdeveloped countries unsanitised water mixed with formula can kill the infants that drink it. Manufacturers advertise their formula product for one thing only "MONEY". The only financial gain in breast-feeding is the money the parents save buying formula. Get the picture? Breast milk is sterile and much more!

Human milk is a living substance, varying from mother to mother to fit her child. It contains every viral antibody the mother has ever been in contact with. Babe gets a shot of protection Everytime he/she feeds. Human milk contains all the vitamins, minerals, iron, fats, sugars, proteins, enzymes and water. Not one more drink has to pass babies lips, even on a scorching hot day. A breast fed child will be less likely to suffer from asthma, eczema and a whole host of other little goodies (saving yet more money, this time on medical bills). I'd better get off my soapbox.

Did you know that well-established breasts can produce a lot of milk...Inextricably women can produce more for one of her children than another? It's as if the mother and child intuitively know together what the baby needs. A mother can even feed triplets, in one breast-feeding-sitting. Kinda makes your teaspoon of bodily fluid look rather paltry doesn't it, just from a volume point of view!!!!!

As you can begin to see and appreciate, anything to do with the breasts shouldn't be rushed or underestimated. Just as you like to fondle, twiddle and linger, so does babe. Breast-feeding isn't just about milk. Offering the breast, anytime, anywhere should be normal. A babe sucking is an urge of great magnitude, rather like you. They need to suck. They expend energy; derive comfort, security, love and warmth. It's their first social exchange. It exercises their jaw and aids the growth of teeth. Demand feeding as we call it in the trade, is instinctive and shouldn't be messed with. We should promote this fact and be in tune with it. Sadly this is a lost art.

As you can see, breast-feeding is a 24 hr affair, for many reasons.

Breast-feeding helps women get back to their pre-pregnancy state. It contracts the uterus (the baby bag as we lovingly call it at home). Helps some women lose weight. The babes sucking, vital for the production of milk, (another reason why it shouldn't be scheduled) stimulates the release of milky hormones, prolactin and oxytocin. These hormones also help a women relax. It's been proven that the incidence of child abuse lessons in breast-feeding families.

Feeding in public. Ohhh, now this is a contentious issue. But why? If you lot like ogling, why stop just because a women feeds her child. I was once asked if I would go and feed my baby in the toilet, whilst nursing in a cafe. I said sure, if you'd like to bring your lunch and join us on the toilet seat. Thankfully the manager (a BLOKE....) asked HER to leave.......... If you round up this information and think logically (most men are good at lateral thinking), you'll understand what a "cracking pair" we women have. Nature at it's best and most beautiful. Breast-feeding for many women is a passionate affair. Tuck this somewhere safe in your mind and when the time comes to share your life with the woman you adore and you both decide to have children, give her all the encouragement you can. She'll love you even more for it. Passionately, together you can watch your child grow, oh and her breasts..........

Breasts are beautiful; they also produce milk, the best pre-packed convenience food out there, now that's an advertisement well worth remembering...

Tee Ashford (December 2000)

Sunday, 26 June 2005 16:57

Breastfeeding after Reduction

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Breastfeeding after Reduction

by Tee Ashford


I am exclusively feeding with occasional solids, our 11 month old child, after a breast reduction almost 4 years ago, which saw 2 1/2lbs of flesh disappear from my ample bosom. Our first two children were breastfed before my reduction. Not for as long, or as successfully. I can attribute this personal success to a number of things. Not necessarily in this order but:

  • A thank you to my surgeon, who performed a sympathetic reduction with fantastic results, even though he told me categorically I would not be able to breast-feed again and if I tried, it would be excruciatingly painful.
  • A big thank you goes to our third stillborn child who wasn't able to drink the milk that followed his birth, but who's pregnancy probably helped repair and prepare my breasts further.


Breast Feeding After Reduction, is a very viable possibility and one where success should not be measured in how much milk a mother can provide. Breast Feeding after a reduction does not need to be "all or nothing". Any breast milk is better than none at all.

However my story is different.

In fact my breastfeeding experience this time around, intriguingly has outstripped, by almost six months what I managed to achieve twice before with unreduced breasts.

Sadly until recently I had considered myself a failure to both Emily and Max in my attempts to give them mummies milk.

Emily and Max did not follow the formula fed growth charts to the letter and their own consistent growth was ignored. They were slower to pick up weight on reaching 3 months of age.

I was told on numerous occasions, "You're starving you're children".

The remaining two months of their time at the breast where spent in turmoil. My intuition told me one thing and the professionals who I was supposed to trust were telling me another.

I was told to supplement, told to wean, told to stop feeding during the night, and I did because they were right, weren't they? Nobody picked up on my children's biorhythms or individuality; they just blamed everything on my milk.

As I know now all this information put into practice added up to a dwindling milk supply and the end of my passionate affairs, leaving me totally bereft. I experienced a great loss, twice. Our potential, to bring to a natural close, what nature had intended us to do was prematurely severed. No one seemed to want to understand my emotions; they thought it was all easier with a bottle.

I actually thank myself. My bitterness gave me the foresight, to educate myself out of naivety. Today I know I did not fail my children, the UK childcare system failed me.

Facing up to my past breastfeeding experiences and educating myself, gave me strength and determination to have another go, to fulfill my dream of breastfeeding for as long as "WE CHOSE'. I knew after my third pregnancy I was in for a good chance, I leaked everywhere after Angus' birth. In fact I didn't think I would be unable to breastfeed. What I needed more than anything was constant reassurance. This came in the form of my Midwife Kate Christie and later to my Lactation Consultant Jean Ridler. A huge, huge thanks goes to them.

If it weren't for them, and their unending available support, all the other skeptics would have got under my skin. My mother breastfed me for two weeks after that I was fed condensed milk. She has at times found it difficult to support my actions, which is hardly surprising given the climate in the sixties surrounding bottles. However she has seen me continue even after I developed a breast abscess the size of a grapefruit, needing to be surgically drained, leaving me with a gaping whole to contend with and now looks at me with admiration.

I was unable to tell the pediatricain about my reduction. I knew straight away upon meeting him that he wasn't gemmed up on breastfeeding especially when he told me I needed to Glossary Link pop vitamin drops into my newborns mouth. So I knew I'd be taken to task if he found out that part of my plumbing was missing.

Even the baby clinic has fed me incorrect advice. When I told them of my reduction, instantly they said "oh we've had one of"those" before and we couldn't even squeeze out colostrum! On one occasion we decided to do a test weigh, because of my increasing nervous disposition. When it became apparent that he'd ingested 60 ml of milk (even though he'd fed an hour earlier), I was told "well that's not enough". It took them a while to remember what an SNS (supplemental Nursing System) was when they suggested I might need to top him up. I left that day convinced I was failing again.. thankfully I picked up the phone and spoke to Kate.
I'll stop rambling and get back to the beginning.......

Kate greeted me with a huge smile for the first time at home four days after Fergus's birth (10th January 2000). I told her about my breast reduction and she was unfazed. If she showed any signs of anxiety over me breastfeeding after a reduction, it was done behind closed doors. Kate heard sucking and swallowing, saw adequate wet and dirty nappies and told me it was perfectly normal for a baby to take two sometimes three weeks to regain his/her birth weight. During this time she encouraged me to "BELIEVE" in myself. Kate didn't text book assess our breastfeeding relationship. She saw a healthy happy baby. She didn't judge, she empathized and empowered me. She abstained from interfering with the delicate early weeks of supply and demand, while things looked good! We waited that time out. Since then his weight gain and growth have been consistently perfect for him.

Jean joined the team and continued in the same vein and together I feel we've beaten the system. We've squashed the myths and with few exceptions (there will always be some), proved that given the chance and correct environment breastfeeding works. The, knowledge, enthusiasm, support and patience Kate and Jean have imparted have been so valuable.

I've hit three major crisis points of "OH MY GOD NOT ENOUGH MILK", which should be called "OH MY GOD I'VE LOST THE PLOT", and, every time we've got through them, rationally, and not knee jerked into supplementation. In fact I don't think my anxiety will ever entirely leave me, until we've weaned, whenever that may be. Kate and Jean shared these breastfeeding anecdotes, which have become my mantra,

  • "Use it or lose it",
  • "There's always milk there",
  • "Believe in yourself",
  • "It's a confidence trick",
  • "Take each day as it comes",
  • And my own "I can provide the best pre packed convenience food there is".


I thank my husband for being in on the act, he continually tells me what a great job I'm doing, especially in the small hours of the night when it matters the most. And, obviously to my son Fergus whose milky smiles endear me to carry on and on, to the next stage, toddler nursing.

I have found and still do find breastfeeding a challenging full-time occupation. For me there is no need for substitutes. The only additive I've needed was a pair of listening ears. It shouldn't be luck, but I am lucky to have found a window of opportunity in Kate and Jean. I hope I have managed to imply what an important role a supportive environment plays in a breast-feeding woman's life. The breast-feeding chain has been broken by this bottle-feeding society. Mothers deserve up to date information from Doctors, Midwives, Health Visitors and Lactation Consultants, told with a sensitive, convincing, empowering approach.

I suppose you could call me a member of the breastfeeding militia. This is surprising if you were to view the anchor shaped scars on my breasts. Given hindsight, I would not have had this operation as lady luck might not have taken the ride with me and who knows how I would have felt if I were unable to exclusively feed, but that's another story. What I do know is, without my history I probably wouldn't have written about my experience, insisting it's every woman's right to be properly informed and encouraged to do what's NORMAL, breast feed her child.

Education, support, a large bucket of determination and faith are for me the way forward to breastfeeding success.

Tee Ashford (9th December 2000)

Friday, 15 February 2008 17:56

When the baby refuses to latch on

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When the baby refuses to latch on

Why would a baby refuse to take the breast?

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


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


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

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

But the baby is not latching on!

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


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


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

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


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


How to maintain and increase milk supply

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

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

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

Friday, 15 February 2008 17:49

Slow weight gain after the first few months

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Slow weight gain after the first few months


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

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

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

Why would your milk supply decrease?


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


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

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

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

How do you know the baby actually drinks at the breast

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

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

Sunday, 26 June 2005 16:43

How Breast Milk Protects Newborns

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How Breast Milk Protects Newborns

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

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

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

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

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

Breast Milk Antibodies

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

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

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

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

An Abundance of Helpful Molecules

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

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

Cellular Defenses

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

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

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

Added Benefits

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

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

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

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



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

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

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

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

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

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

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

Sunday, 26 June 2005 16:42

Risks of Artificial Feeding

Written by

Risks of Artificial Feeding

(Studies done mostly in affluent societies)

Risks to infant and child


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

Cognitive Development:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


Neurologic Outcome

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




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

Insulin Dependent Diabetes:

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


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

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

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

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

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

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

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

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

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


Cow milk Allergy and Intolerance:

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



Respiratory Illness:

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


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

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

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

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

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

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

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

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

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

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

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

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

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


Otitis Media:

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


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

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

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

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

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

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

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

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

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


Risks for the premature baby:

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


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

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

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

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

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

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

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

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


Childhood Cancer:

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


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

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

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


Gastrointestinal Disease and Infections:

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


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

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

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

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

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

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

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

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

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

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

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

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

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


Urinary Tract Infection:

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




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


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


Formula as a heavy metal cocktail:

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


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

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


Other Contamination due to bottle feeding:

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


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

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



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


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

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

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

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

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



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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


Breastmilk as "antimicrobial":

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


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

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

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

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

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

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

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

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

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


Risks to the Mother

Ovarian Cancer:

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


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

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



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


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

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

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

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


Endometrial Carcinoma:

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


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


Breast Cancer:

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


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

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

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

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

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

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

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

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

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

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

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


Weight loss:

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


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

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

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

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

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

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

Sunday, 26 June 2005 16:41

Protocol for "Not Enough Milk"

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Protocol for "Not Enough Milk"

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


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



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


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


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


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


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


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


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


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


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

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

    Sunday, 26 June 2005 16:33

    Treatments for Problems (2)

    Written by

    Treatments for Problems (2)

    Herbs for Increasing Milk Supply

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

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

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

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

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

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

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

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

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

    The first choice for treatment is:

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

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

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

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

    Sunday, 26 June 2005 16:32

    Breastfeeding Your Adopted Baby

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    Breastfeeding Your Adopted Baby

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

    Breastfeeding and Breastmilk

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

    Getting the baby to take the breast

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


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


    Producing Breastmilk

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

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

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

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

    But will I produce all the milk the baby needs?

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


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

    Sunday, 26 June 2005 00:00

    Candida Protocol

    Written by

    Candida Protocol

    Start with local treatment consisting of:

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


    2. Nipple ointment as below:

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

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

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

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

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

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

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

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