Sunday, 26 June 2005 16:28

Sore Nipples

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Sore Nipples

Introduction

The best treatment of sore nipples is prevention. The best prevention is latching the baby on properly from the first day.

Sore nipples are usually due to one or both of two causes. Either the baby is not positioned and latched properly, or the baby is not suckling properly, or both. Incidentally, babies learn to suck properly by getting milk from the breast when they are latched on well. (They learn by doing). Fungal infection (due to Candida albicans), may also cause sore nipples. The soreness caused by poor latching and ineffective suckle hurts most as you latch the baby on and usually improves as the baby nurses. The pain from the fungal infection goes on throughout the feed and may continue even after the feed is over. Women describe knife-like pain from the first two causes. The pain of the fungal infection is often described as burning, but may not have this character. Sudden, unexplained onset of nipple pain when feedings had previously been painless is a tipoff that the pain may be due to a yeast infection, but the pain may come on gradually or may be superimposed on pain due to other causes. Cracks may be due to a yeast infection.

Proper Positioning and Latching

It is not uncommon for women to experience difficulty positioning and latching the baby on. Proper positioning facilitates a good latch and good latching reduces the baby's chances of becoming "gassy", and also allows the baby to control the flow of milk. Thus, poor latching may also result in the baby not gaining adequately, or feeding frequently, or being colicky (handout #2 "Colic in the Breastfed Baby).

PositioningFor the purposes of explanation, let us assume that you are feeding on the left breast.

Good positioning facilitates a good latch. A lot of what follows under latching comes automatically if the baby is well positioned in the first place.

At first, it may be easiest to use the cross cradle hold to position your baby for latching on. Hold the baby in your right arm, the web between your thumb and index finger behind the nape of his neck (not behind his head) with your fingers (except for the thumb) supporting the baby's face from underneath, and your forearm supporting his back and buttocks. Hold the baby's buttocks between your chest and your forearm—this should give you good control. The baby should be almost horizontal across your body and should be turned so that his chest, belly and thighs are against you with a slight tilt so the baby can look at you. Hold the breast with your left hand, with the thumb on top and the other fingers underneath, fairly far back from the nipple and areola.

The baby should be approaching the breast with the head just slightly tilted backwards. The nipple then automatically points to the roof of the baby's mouth. (See handout on positioning and latching on)

Latching

 

  1. Now, get the baby to open up his mouth wide. The way to do this is to run your nipple, still pointing to the roof of the baby's mouth, along the baby's mouth, very lightly, from one corner of the mouth to the other. Or you can run the baby along your nipple, something some mothers find easier. Wait for the baby to open up as if yawning. WAIT FOR HIM. As you bring the baby toward the breast, his chin should touch your breast first.
  2. When the baby opens up his mouth, use the arm that is holding him to bring him onto the breast. Don't worry about the baby's breathing. If he is properly positioned and latched on, he will breathe without any problem. If he cannot breathe, he will pull away from the breast. Don't be afraid to be vigorous.
  3. If the nipple still hurts, use your index finger to pull down on the baby's chin in order to bring the lower lip out. You may have to do this for the duration of the feed, but this is usually not necessary.
  4. The same principles apply whether you are sitting or lying down with the baby or using the football hold. Get the baby to open wide, don't let the baby latch onto the nipple, but get as much of the areola (brown part of breast) into the mouth as possible (not necessarily the whole areola).
  5. There is no "normal" length of feeding time. If you have questions, call the clinic.
  6. A baby properly latched on will be covering more of the areola with his lower lip than with the upper lip.

 

Improving the baby's suckle

The baby learns to suckle properly by nursing and by getting milk into his mouth. The baby's suckle may be made ineffective or not appropriate for breastfeeding by the early use of artificial nipples or from poor latching on from the beginning. Some babies just seem to take their time developing an effective suckle. Suck training and/or finger feeding (handout #8 Finger Feeding) may help.

"My nipple turns white after the baby comes off the breast"

The pain associated with this blanching of the nipple is frequently described by mothers as "burning", but generally begins only after the feeding is over. It may last several minutes or more, after which the nipple returns to its normal colour, but then a new pain develops which is usually described by mothers as "throbbing". The throbbing part of the pain may last for seconds or minutes and may even blanch again. The cause would seem to be a spasm of the blood vessels in the nipple (when the nipple is white), followed by relaxation of these blood vessels (when the nipple returns to its normal colour). Sometimes this pain continues even after the nipple pain during the feeding no longer is a problem, so that the mother has pain only after the feeding, but not during it. What can be done?

 

  1. Pay careful attention to getting the baby to latch onto the breast properly. This type of pain is almost always associated with, and probably caused by whatever is causing your pain during the feeding. The best treatment is the treatment of the other causes of nipple pain.
  2. Heat (hot washcloth, hot water bottle, hair dryer) applied to the nipple immediately after nursing may prevent or decrease the reaction. Dry heat is usually better than wet heat, because wet heat may cause further damage to the nipples.
  3. On occasion, we have had to use a medicated paste (nitroglycerine) or an oral medication (nifedipine) to prevent this type of reaction.

 

General Measures

 

  1. l. Nipples can be warmed for short periods of time after each feeding, using a hair dryer on low setting.
  2. Nipples should be exposed to air as much as possible.
  3. When it is not possible to expose nipples to air, plastic dome-shaped breast shells (not nipple shields) can be worn to protect your nipples from rubbing by your clothing. Nursing pads keep moisture against the nipple and may cause damage that way. They also tend to stick to damaged nipples. If you leak a lot you can wear the pad over the breast shell.
  4. Ointments can sometimes be helpful. If you do use an ointment, use just a very small amount after nursing and do not wash it off.
  5. Do not wash your nipples frequently. Daily bathing is more than enough.
  6. If your baby is gaining weight well, there is no good reason the baby must be fed on both breasts at each feeding. It may save you pain, and speed healing if you feed your baby on only one breast each feed. It will help to compress the breast (handout #15 Breast Compression), once the baby is no longer swallowing on his own in order to continue his getting milk. You may be able to manage this some feedings, but not others. In very difficult situations, a lactation aid (handout #5 Using a Lactation Aid) can be used to supplement (preferably expressed milk), so that the baby will finish the feeding on the first side.

 

If you are unable to put the baby to the breast because of pain, in spite of trying all the above measures, it may still be possible to continue breastfeeding after a temporary (3-5 days) cessation to allow the nipples to heal. During this time, it would be better that the baby not be fed with a rubber nipple. Of course it is also best for you and the baby if the baby is fed your expressed milk. Use the technique called "finger feeding" (handout #8 Finger Feeding) or cup feeding.

Nipples shields are not recommended for sore nipples, because, although they may help temporarily, they usually do not. They may also cut down the milk supply dramatically, and the baby may become fussy and not gain weight well. Once the baby is used to them, it may be impossible to get the baby back onto the breast. In fact, many women who have tried nipple shields find that they do not help with soreness. Use as a last resort only, but get help first.

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

Sunday, 26 June 2005 16:27

You Can Still Breastfeed

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You Can Still Breastfeed

Introduction

Over the years, many, many, many women have been wrongly told to stop breastfeeding. The decision about continuing breastfeeding when the mother must take a drug, for example, involves more than consideration of whether the medication appears in the mother'¢s milk. It also involves taking into consideration the risks of formula feeding for the baby, which are substantial, the risks of not breastfeeding for the mother, which are substantial, and other issues as well. For example, feeding a breastfeeding baby by bottle for the time the mother is on medication (rarely less than 5 days), will very often result in the baby refusing the breast forever or at least becoming very difficult on the breast. On the other hand, it should be taken into consideration that some babies just will not take bottles, so the advice to stop is not only usually wrong, but impractical as well. Furthermore, it is easy to advise the mother to pump her milk when she is not feeding the baby, but adequate pumping is often very difficult to do for some mothers, with the result that the mothers may become very painfully engorged, which may further lead to serious complications.

Breastfeeding and Maternal Medication

Most drugs appear in the milk, but only in very tiny amounts. Although a very few drugs may still cause problems for infants even in tiny doses, this is not the case for the vast majority. Mothers who are told they must stop breastfeeding because of a certain drug should ask to be prescribed an alternative medication which is acceptable for breastfeeding mothers. In this day and age, it is rarely a problem to find such an alternative. If the prescribing physician does not know how to proceed, s/he should get more information. If the prescribing physician is not flexible, the mother should seek another opinion.

Most drugs may be considered safe for the mother to take and continue breastfeeding if:

 

  1. they are commonly prescribed for infants. Examples are amoxycillin, cloxacillin, most antibiotics.
  2. they are considered safe in pregnancy. Drugs enter directly into the baby's bloodstream when used during pregnancy. The baby generally gets much higher doses at a much more sensitive period during pregnancy, than during breastfeeding. This is not an absolute, however, as during pregnancy, the mother's liver and kidneys will get rid of the drug for the baby.
  3. they are not absorbed from the stomach or intestines. These include many drugs which are given by injection. Examples are gentamicin, heparin, lidocaine or other local anaesthetics used by dentists.

 

The following frequently used drugs are also generally safe during breastfeeding:

 

  • acetaminophen (Tylenol, Tempra), alcohol (in reasonable amounts), aspirin (in usual doses, for short periods), most antiepileptic medications, most antihypertensive medications, tetracycline, codeine, most nonsteroidal antiinflammatory medications, prednisone, thyroxine, propylthiouracil (PTU), warfarin, tricyclic antidepressant medications, sertraline (Zoloft), paroxetine (Paxil), other antidepressants, metronidazole (Flagyl), Nix, Kwellada.
  • Medications applied to the skin, inhaled or applied to the eyes or nose are almost always safe for breastfeeding.
  • You can still breastfeeding after general, regional or local anaesthesia. As soon as you are up to it. Medications you might take afterwards for pain are almost always permitted.
  • Immunizations given to the mother do not require her to stop breastfeeding (including with live viruses such as German measles, Hepatitis A and B).

Get reliable information before stopping breastfeeding. Once you have stopped it may be very difficult to restart, especially if the baby is very young.

 

Breastfeeding and Maternal Illness

Very few maternal illnesses require the mother to stop breastfeeding. This is particularly true of infections. Most infections are caused by viruses. Most infections caused by viruses are most infectious before the mother realizes she is sick. By the time the mother has fever (or cold, runny nose, diarrhea, vomiting, rash etc), she has already passed on the infection to the baby. However, breastfeeding protects the baby against infection, and the mother should thus continue breastfeeding, in order to protect the baby. If the baby does get sick, he usually is less sick than if breastfeeding had stopped. But often mothers are pleasantly surprised that their babies do not get sick at all. The baby was protected by his mother's continuing breastfeeding.

The only exception to the above is HIV infection in the mother. Until we have more information, it is considered safer for the baby that the mother who is HIV positive not breastfeed, at least where the risks of bottle feeding are acceptable. There are situations, however, even in Canada, where the risk of not breastfeeding is elevated enough that the mother who is HIV positive should nevertheless breastfeed her baby. The final word is not in, however.

Most other maternal illnesses raise questions because of the drugs the mother might have to take. These should rarely be a problem (see above).

X-rays and scans: Ordinary X-rays do not require a mother to stop breastfeeding even when used with contrast (e.g. IVP). A CT scan, MRI scan, even when used with contrast do not require a mother to stop. A radioactive scan (e.g. lung scan, bone scan) does not require a mother to stop. The only exception is a thyroid scan. However, most of the time the scan does not have to be done. See below.

A not uncommon problem in the early months after delivery is a condition called postpartum thyroiditis, a temporary derangement in the thyroid gland's function. A useful test to help understand the condition is a thyroid scan. However, the test requires that radioactive iodine be given to the mother and this material must not be given to nursing mothers. The radioactive iodine will be found in the milk for weeks, and concentrated in the baby's thyroid. There are ways of dealing with postpartum thyroiditis without doing this test. The drugs a mother might have to take to treat postpartum thyroiditis are compatible with continued breastfeeding (e.g. propranolol, propylthiouracil)

Breast Problems

Mastitis (breast infection) and breast abscess are not reasons to stop breastfeeding. Although surgery on a lactating breast is more difficult, the surgery does not necessarily become easier if the mother stops breastfeeding, as milk continues to be formed for weeks after stopping breastfeeding.

Mammograms are more difficult to read if the mother is breastfeeding, but can still be useful. Once again, how long must a mother wait for her breast no longer to be considered lactating? Evaluation of a lump can be done by other means besides mammography. Discuss options with your doctor. Let him/her know breastfeeding is important to you. A needle biopsy, for example, can be done of a lump which is of concern.

New Pregnancy

There is no reason that you cannot continue breastfeeding if you become pregnant. There is no evidence that this does any harm to you, to the baby in your womb or to the one who is nursing. If you wish to stop breastfeeding, take your time and wean slowly.

Infant Problems

Breastfeeding rarely needs to be discontinued for infant illness. Through breastfeeding, the mother is able to comfort the sick child, and, at the same time, the child is able to comfort the mother.

 

  1. Diarrhea and vomiting. Intestinal infections are rare in exclusively breastfed babies. (Though loose bowel movements are very common in exclusively breastfed babies). The best treatment for this condition if the baby gets it, is to continue breastfeeding. The baby will get better more quickly on breastmilk. The baby will do well with only breastmilk in the vast majority of situations, and will not require added fluids except in extraordinary cases.
  2. Respiratory illnesses. There is a medical myth that milk should not be given to children with respiratory infections. Whether this is true or not for milk, it is definitely not true for breastmilk (and breastfeeding).
  3. Jaundice. Exclusively breastfed babies are commonly jaundiced, even until the 3rd month, though generally the yellow colour of the skin is hardly noticeable. Rather than being a problem, this is normal. (There are causes of jaundice which are not normal, but these do not require stopping breastfeeding). If breastfeeding is going well, jaundice does not require the baby to stop breastfeeding. If breastfeeding is not going well, fixing the breastfeeding will improve the jaundice, whereas stopping breastfeeding even for a short time may completely destroy the breastfeeding. Stopping breastfeeding is not the answer. (See handout #7 Breastfeeding and Jaundice).

 

If the question you have is not discussed above, do not assume that you must stop breastfeeding. Do not stop, and get more information. Mothers have been told they must stop breastfeeding for reasons too inane to discuss.

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

Sunday, 26 June 2005 16:26

Breastfeed a Toddler: Why on Earth?

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Breastfeed a Toddler: Why on Earth?

Because more and more women are now breastfeeding their babies, more and more are also finding that they enjoy breastfeeding enough to want to continue longer than the usual few months they initially thought they would do it. UNICEF has long encouraged breastfeeding for two years and longer, and the American Academy of Pediatrics is now on record as encouraging mothers to nurse at least one year and as long after as both mother and baby desire. Breastfeeding to 3 and 4 years of age has been common in much of the world until recently, and breastfeeding toddlers is still common in many societies.

Why should breastfeeding continue past six months?

Because mothers and babies often enjoy breastfeeding a lot. Why stop an enjoyable relationship?

But it is said that breastmilk has no value after six months.

Perhaps this is said, but it is wrong. That anyone can say such a thing only shows how ignorant so many people in our society are about breastfeeding. Breastmilk is, after all, milk. Even after six months, it still contains protein, fat, and other nutritionally important and appropriate elements which babies and children need. Breastmilk still contains immunologic factors which help protect the baby. In fact, some immune factors in breastmilk which protect the baby against infection are present in greater amounts in the second year of life than in the first. This is, of course as it should be, since children older than a year are generally exposed to more infection. Breastmilk still contains factors which help the immune system to mature, and which help the brain, gut, and other organs to develop and mature.

It has been well shown that children in day-care who are still breastfeeding have far fewer and less severe infections than the children who are not breastfeeding. The mother thus loses less work time if she continues nursing her baby once she is back at her paid work.

It is interesting that formula company marketing pushes the use of formula (a rather imperfect copy of the real thing) for a year, yet implies that breastmilk (from which the imperfect copy is copied) is only worthwhile for 6 months. Too many health professionals have taken up the refrain.

I have heard that the immunologic factors prevent the baby from developing his own immunity if I breastfeed past six months.

This is untrue; in fact, this is absurd. It is unbelievable how so many people in our society twist around the advantages of breastfeeding and turn them into disadvantages. We give babies immunizations so that they are able to defend themselves against the real infection. Breastmilk also allows the baby to be fight off infections. When the baby fights off these infections, he becomes immune. Naturally.

But I want my baby to become independent.

And breastfeeding makes the toddler dependent? Don’t believe it. The child who breastfeeds until he weans himself (usually from 2 to 4 years), is generally more independent, and, perhaps more importantly, more secure in his independence. He has received comfort and security from the breast, until he is ready to make the step himself to stop. And when he makes that step himself, he knows he has achieved something, he knows he has moved ahead. It is a milestone in his life.

Often we push children to become "independent" too quickly. To sleep alone too soon, to wean from the breast too soon, to do without their parents too soon, to do everything too soon. Don’t push and the child will become independent soon enough. What’s the rush? Soon they will be leaving home. You want them to leave home at 14?

Of course, breastfeeding can, in some situations, be used to foster an overdependent relationship. But so can food and toilet training. The problem is not the breastfeeding. This is another issue.

What else?

Possibly the most important aspect of nursing a toddler is not the nutritional or immunologic benefits, important as they are. I believe the most important aspect of nursing a toddler is the special relationship between child and mother. Breastfeeding is a life affirming act of love. This continues when the baby becomes a toddler. Anyone without prejudices, who has ever observed an older baby or toddler nursing can testify that there is something almost magical, something special, something far beyond food going on. A nursing toddler will sometimes spontaneously break into laughter for no obvious reason. His delight in the breast goes far beyond a source of food. And if the mother allows herself, breastfeeding becomes a source of delight for her as well, far beyond the pleasure of providing food. Of course, it’s not always great, but what is? But when it is, it makes it all so worthwhile.

And if the child does become ill or does get hurt (and they do as they meet other children and become more daring), what easier way to comfort the child than breastfeeding? I remember nights in the emergency department when mothers would walk their ill, non nursing babies or toddlers up and down the halls trying, often unsuccessfully, to console them, while the nursing mothers were sitting quietly with their comforted, if not necessarily happy, babies at the breast. The mother comforts the sick child with breastfeeding, and the child comforts the mother by breastfeeding.

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

Sunday, 26 June 2005 16:25

Treatments for Problems

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Treatments for Problems

The following describes the use of some treatments for breastfeeding mothers who are having various problems.

Cabbage leaves for engorgement

Severe engorgement about the third or fourth day after the baby is born can usually be prevented by getting the baby latched on well and drinking well from the very beginning. If you do become engorged, please understand that engorgement diminishes within 1 or 2 days even without any treatment. Continue to breastfeed the baby, making sure he gets on well and nurses well. However, if you should get engorged to the point of severe discomfort, cabbage leaves seem to help decrease the engorgement more rapidly than ice packs or other treatments. If you are unable to get the baby latched on, start cabbage leaves, start expressing your milk and give the expressed milk to the baby by spoon, cup, finger feeding or eyedropper and get help quickly.

 

  1. Use green cabbage.
  2. Crush the cabbage leaves with a rolling pin if the leaves do not accommodate to the shape of your breast.
  3. Wrap the cabbage leaves around the breast and leave on for about 20 minutes. Twice daily is enough. It is usual to use the cabbage leaf treatment two or three times or less.
  4. Stop using as soon as engorgement is beginning to diminish and you are becoming more comfortable.
  5. You can use acetaminophen (Tylenol™, others) with or without codeine for pain relief. As with almost all medications, there is no reason to stop breastfeeding when taking analgesics.
  6. Ice packs also can be helpful.
  7. If you are one of the women who gets a large lump in the armpit about 3 or 4 days after the baby’s birth, you can use cabbage leaves in that area as well.

 

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 have an active ingredient. Some will have active ingredients which will not increase the milk supply but have other effects. 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 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 which have been used to increase milk supply are: raspberry leaf, fennel, brewer’s yeast. The effectiveness of none of these treatments has been proved.

All purpose nipple ointment

The best treatment of nipple soreness is prevention. The best prevention is an early start to breastfeeding and a good latch. More than minimal nipple pain in the first two or three days after your baby’s birth is due to a poor latch, no matter who tells you the latch is fine. Get help.

Sometimes nipple ointments such as Lansinoh™, Purlan™ and others can be very useful for mild to moderate pain, but fixing the latch is still the best treatment. Sometimes a "good-for-all-things-don’t-know-why-it-works" nipple ointment can also be very useful.

You may be prescribed such an ointment (which works better than a cream). It will contain:

 

  • One or more antibiotics. Almost all cracks and erosions have bacteria growing in the base. Whether they are actually causing infection, or whether they merely delay healing is not known. But it has been known for many years that antibiotic ointments help some mothers’ nipple pain get better.
  • An antifungal agent. Candida albicans can cause nipple soreness and cracking. Sometimes it is not easy to tell what contribution this fungus causes to breastfeeding mothers’ nipple soreness.
  • An antiinflammatory agent. Often it is the inflammation associated with infection or injury which causes the most pain. The antiinflammatory agent (a steroid) decreases the inflammatory response. In Canada, Kenacomb™ (more easily available) or Viaderm KC™ (less expensive) ointments contain the above ingredients. Ointments can also be made up from individual ingredients, our usual practice now. In the USA, mixing Mycolog™ ointment with 2% mupirocin ointment results in a similar concoction.

 

How to use? Apply the ointment sparingly after each feeding. Do not wash or wipe it off even if the baby goes back to the breast within minutes. Most of the ingredients are not absorbed from the baby’s gut and will do him no harm. Once you are feeling better (usually within 2-5 days), you can gradually decrease the use of the ointment until you are not using it at all. For some conditions, the mother may have to use the ointment daily or twice daily to keep pain free. This is not a problem and you may continue the use of the ointment for weeks or longer, if necessary.

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

What to Feed the Baby when the Mother is Working outside the Home

This is not an information sheet on all the ins and outs of working outside the home and breastfeeding. This sheet provides information on how your baby can be fed when you are not with him. It is addressed in particular to the mother who is returning to paid work when the baby is about 6 months of age. New mothers should stay home with their babies for as long as practical and take full advantage of the 26 weeks maternity leave to which mothers have a right in Canada. Your baby will never be this age again.

Some Myths:

1. Babies must learn to take a bottle so that they can be fed when the mother is not there.

Not true. Some exclusively breastfed babies will not take a bottle by 2 or 3 months of age. Most, who have not taken a bottle, and even some who did accept a bottle in the first weeks of life will not take one by the time they are 4 or 5 months of age. This is no tragedy, and there is no reason to give a bottle early so that the baby knows how. If your baby is refusing to take a bottle, do not try to force him; you and he may become very frustrated and there is just no need to go through all this. If the baby is 6 months of age when you start back at outside work, the baby quite simply does not need to take a bottle. He can be fed solids off a spoon just as any other 6 month old and by 6 months of age he can be taking enough so that he will not be hungry during the day. Furthermore, he can start learning to drink from a cup even by 5 or 6 months of age. The cup can be an open cup and does not need to have a spout. Start with water as your baby may spill a fair amount at first. If, however, he has not gotten the hang of the cup by the time you must leave him, do not worry, he can take fluids off a spoon, or the solid foods can be mixed with more liquid (expressed milk, juice). Obviously, if the baby is to be taking a fair amount of a variety of foods by 6 months of age, he may need to be started on solids by 5 months of age. However, some babies prefer to wait for the mother in order to drink something. This is fine; many babies sleep 12 hours at night without drinking or eating at all.

2. But getting the baby to take a bottle surely won’t hurt.

Not necessarily true. Some babies do fine with both. The occasional bottle, when breastfeeding is going well, will not hurt. But if the baby is getting several bottles a day on a regular basis, and, in addition, your milk supply decreases because the baby is nursing less, it is quite possible that the baby will start refusing the breast, even if he is older than 6 months of age.

3. Babies need to drink milk when the mother is not at home.

Not true. Three or four good nursings during a 24 hour period plus a variety of solid foods gives the baby all he needs, nutritionally, and thus he does not need any other type of milk when you are at your outside job. Of course, solid foods can be mixed with expressed milk or other milk, but this is not necessary.

4. If the baby is to get milk other than breastmilk, it needs to be artificial baby milk (infant formula) until the baby is at least 9 months of age.

Not true. If the baby is breastfeeding a few times a day and getting fair quantities of a variety of solid foods, infant formula is neither necessary nor desirable. Indeed, babies who have not had infant formula before 5 or 6 months of age often refuse to drink it because it tastes pretty bad. (If you want to convince yourself of how little we know about breastmilk, ask yourself why it is that though breastmilk and infant formulas have the same amount of sugar, breastmilk is so much sweeter). If you want to give the baby some other sort of milk, homogenized milk is acceptable at 6 months of age, as long as it is not the baby’s only food. In fact, if the baby is taking good quantities of a wide variety of foods, breastfeeding 3 or 4 times a day, and growing well, homogenized milk or 2% milk is good enough, but also not necessary.

5. Follow-up formulas (artificial milk for infants over 6 months of age) are specially adapted to the needs of infants 6 to 12 months of age.

Not true. They are completely unnecessary and are specially adapted to the needs of the formula companies’ profit margins. They also are part of a marketing strategy which tries to get around restrictions on the advertising of artificial baby milks directly to the public (widely disregarded in any case). In Europe now, there are special formulas available for the toddler (1-3 years of age). Some people will buy anything, it seems. But these toddler formulas will soon be here. You can bet on it. Bottom line uber alles.

6. The breastfed baby 4 months of age needs to be getting more iron than can be provided by breastmilk alone.

Not true. For the baby the baby born at term who is breastfeeding exclusively, all the iron required is provided by breastmilk. However, by 6 months of age, more or less, it is prudent for the baby to begin getting more iron than that provided by breastmilk alone.

7. The best way to assure the baby’s getting enough iron is to give him infant cereals.

Not true. Infant cereals do contain a lot of iron, but most of it is not absorbed, and this amount of iron seems to cause constipation in some babies. Furthermore, some breastfed babies who have had only breastmilk to 5 or 6 months of age do not like cereal. There is nothing wrong with infant cereal, but pushing this food on reluctant babies may result in later feeding problems. The best way to assure the baby is getting enough iron is to continue breastfeeding, and introduce solid foods in a relaxed, enjoyable way at the appropriate time (Handout #16 Starting Solid Foods). The appropriate time is when the baby is showing interest in eating by reaching out for and trying to eat food the parents or other members of the family are eating. This occurs usually about 4 1/2 to 5 1/2 months of age. A baby this age can eat what the parents eat, with few exceptions. There is no need to be obsessive about the order in which foods are introduced, or trying to keep the baby eating only one food/week. The best source of extra iron for the 6 to 12 month old baby is meat, the iron of which is very well absorbed. Start feeding the baby solids in a way that makes eating enjoyable, and the baby will eat iron containing foods just fine.

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

Sunday, 26 June 2005 16:24

More and More Breastfeeding Myths

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More and More Breastfeeding Myths

1. Nursing mothers cannot breastfeed if they have had X-rays.

Not true! Regular X-rays such as a chest X-ray or dental X-rays do not affect the milk or the baby and the mother may nurse without concern. Mammograms are harder to read when the mother is lactating, but can be done and the mother should not stop breastfeeding just to get this done. There are other ways of investigating a breast lump. Newer imaging methods such as CT scan and MRI scans are of no concern, even if contrast is used. And special X-rays using contrast media? As long as no radioactive isotope is used there is no concern and the mother should not stop even for one feed. Herein are included studies such as intravenous pyelogram, lymphangiogram, venogram, arteriogram, myelogram etc. What about studies using radioactive nucleotides (bone scans, lung scans, etc.)? The baby will get a little radioactive nucleotide. However, as we often do these very same tests on children, even small babies, and the potential loss of benefits if the mother stops breastfeeding are considerable, the mother should continue breastfeeding. The exception is the thyroid scan. This test must be avoided in breastfeeding mothers. There are many ways of evaluating the thyroid, and only very occasionally does a thyroid scan truly have to be done. Check first before taking the radioactive iodine—the test can wait until you know for sure. In many cases where the scan must be done, it can be put off for several months.

2. Breastfeeding mothers' milk can "dry up" just like that.

Not true! Or if this can occur, it must be a rare occurrence. Aside from day to day and morning to evening variations, milk production does not change suddenly. There are changes which occur which may make it seem as if milk production is suddenly much less:

 

  1. An increase in the needs of the baby, the so called growth spurt. If this is the reason for the seemingly insufficient milk, a few days of more frequent nursing will bring things back to normal. Try compressing the breast with your hand to help the baby get milk (Handout #15, Breast Compression).
  2. A change in the baby's behaviour. At about 5-6 weeks of age, more or less, babies who would fall asleep at the breast when the flow of milk slowed down, tend to start pulling at the breast or crying when the milk flow slows. The milk has not dried up, but the baby has changed. Try compressing the breast with your hand to help the baby get more milk.
  3. The mother's breasts do not seem full or are soft. It is normal after a few weeks for the mother no longer to have engorgement, or even fullness of the breasts. As long as the baby is drinking at the breast, do not be concerned (see handout 4 Is my baby getting enough milk).
  4. The baby breastfeeds less well. This is often due to the baby being given bottles or pacifiers and thus learning an inappropriate way of breastfeeding.

 

The birth control pill may decrease your milk supply. Think about stopping the pill or changing to a progesterone only pill. Or use other methods.

If the baby truly seems not to be getting enough, get help, but do not introduce a bottle which will only make things worse. If absolutely necessary, the baby can be supplemented, using a lactation aid which will not interfere with breastfeeding. However, lots can be done before giving supplements. Get help. Try compressing the breast with your hand to help the baby get milk (Handout #15, Breast Compression).

3. Physicians know a lot about breastfeeding.

Not true! Obviously, there are exceptions. However, very few physicians trained in North America or Western Europe learned anything at all about breastfeeding in medical school. Even fewer learned about the practical aspects of helping mothers start breastfeeding and helping them maintain breastfeeding. After medical school, most of the information physicians get regarding infant feeding comes from formula company representatives or advertisements.

4. Pediatricians, at least, know a lot about breastfeeding.

Not true! Obviously, there are exceptions. However, in their post medical school training (residency), most pediatricians learned nothing formally about breastfeeding, and what they picked up in passing was often wrong. To many trainees in pediatrics, breastfeeding is seen as an "obstacle to the good medical care" of hospitalized babies.

5. Formula company literature and free formula samples do not influence whether or how long a mother breastfeeds.

Really? So why do the formula companies work so hard to make sure that new mothers are given these samples, their company's samples? Are these samples and the literature given out to encourage breastfeeding? Is the cost of the samples and booklets taken on by formula companies so that mothers will be encouraged to breastfeed longer? The companies often argue that, if the mother does give formula, they want the mother to use their brand. In competing with each other, the formula companies also compete with breastfeeding. Did you believe that argument when the cigarette companies used it?

6. Breastmilk given with formula may cause problems for the baby.

Not true! Most breastfeeding mothers do not need to use formula and when problems arise that seem to require artificial milk, often the problems can be resolved without resorting to formula. However, when the baby may require formula, there is no reason that breastmilk and formula cannot be given together.

7. Babies who are breastfed on demand are likely to be "colicky".

Not true! "Colicky" breastfed babies often gain weight very quickly and sometimes are feeding frequently. However, many are colicky not because they are feeding frequently, but because they do not take the high fat milk as well as they should. Typically, the baby drinks very well for the first few minutes, then nibbles or sleeps. When the baby is offered the other side, he will drink well again for a short while and then nibble or sleep. The baby will fill up with relatively low fat milk and thus feed frequently. The taking in of mostly low fat milk may also result in gas, crying and explosive watery bowel movements. The mother can urge the baby to breastfeed longer on the first side, and thus get more higher fat milk, by compressing the breast once the baby no longer actually swallows at the breast. (Handouts #3 Colic in the breastfed babyand #15 Breast Compression).

8. Mothers who receive immunizations (tetanus, rubella, hepatitis B, hepatitis A, etc.) should stop breastfeeding for 24 hours (3 days, 2 weeks).

Not true! Why shouldn't they? There is no risk for the baby, and he may even benefit. The rare exception is the baby who has an immune deficiency. In that case the mother should not receive an immunization with a weakened live virus (e.g. oral, but not injectable polio, or measles, mumps, rubella) even if the baby is being fed artificially.

9. There is no such thing as nipple confusion.

Not true! A baby who is only bottle fed for the first two weeks of life, for example, will usually refuse to take the breast, even if the mother has an abundant supply. A baby who has had only the breast for 3 or 4 months is unlikely to take the bottle. Some babies prefer the right or left breast to the other. Bottle fed babies often prefer one artificial nipple to another. So there is such a thing as preferring one nipple to another. The only question is how quickly it can occur. Given the right set of circumstances, the preference can occur after one or two bottles. The baby having difficulties latching on may never have had an artificial nipple, but the introduction of an artificial nipple rarely improves the situation, and often makes it much worse. Note that many who say there is no such thing as nipple confusion also advise the mother to start a bottle early so that the baby will not refuse it.

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

Tuesday, 11 November 2008 07:23

More Breastfeeding Myths

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More Breastfeeding Myths

1. A breastfeeding mother has to be obsessive about what she eats.

Not true! A breastfeeding mother should try to eat a balanced diet, but neither needs to eat any special foods nor avoid certain foods. A breastfeeding mother does not need to drink milk in order to make milk. A breastfeeding mother does not need to avoid spicy foods, garlic, cabbage or alcohol. A breastfeeding mother should eat a normal healthful diet. Although there are situations when something the mother eats may affect the baby, this is unusual. Most commonly, "colic", "gassiness" and crying can be improved by changing breastfeeding techniques, rather than changing the mother's diet. (Handout #2 Colic in the breastfed baby).

2. A breastfeeding mother has to eat more in order to make enough milk.

Not true! Women on even very low calorie diets usually make enough milk, at least until the mother's calorie intake becomes critically low for a prolonged period of time. Generally, the baby will get what he needs. Some women worry that if they eat poorly for a few days this also will affect their milk. There is no need for concern. Such variations will not affect milk supply or quality. It is commonly said that women need to eat 500 extra calories a day in order to breastfeed. This is not true. Some women do eat more when they breastfeed, but others do not, and some even eat less, without any harm done to the mother or baby or the milk supply. The mother should eat a balanced diet dictated by her appetite. Rules about eating just make breastfeeding unnecessarily complicated.

3. A breastfeeding mother has to drink lots of fluids.

Not true! The mother should drink according to her thirst. Some mothers feel they are thirsty all the time, but many others do not drink more than usual. The mother's body knows if she needs more fluids, and tells her by making her feel thirsty. Do not believe that you have to drink at least a certain number of glasses a day. Rules about drinking just make breastfeeding unnecessarily complicated.

4. A mother who smokes is better not to breastfeed.

Not true! A mother who cannot stop smoking should breastfeed. Breastfeeding has been shown to decrease the negative effects of cigarette smoke on the baby's lungs, for example. Breastfeeding confers great health benefits on both mother and baby. It would be better if the mother not smoke, but if she cannot stop or cut down, then it is better she smoke and breastfeed than smoke and formula feed.

5. A mother should not drink alcohol while breastfeeding.

Not true! Reasonable alcohol intake should not be discouraged at all. As is the case with most drugs, very little alcohol comes out in the milk. The mother can take some alcohol and continue breastfeeding as she normally does. Prohibiting alcohol is another way we make life unnecessarily restrictive for nursing mothers.

6. A mother who bleeds from her nipples should not breastfeed.

Not true! Though blood makes the baby spit up more, and the blood may even show up in his bowel movements, this is not a reason to stop breastfeeding the baby. Nipples that are painful and bleeding are not worse than nipples that are painful and not bleeding. It is the pain the mother is having that is the problem. This nipple pain can often be helped considerably. Get help. (Handout #3 Sore Nipples). Sometimes mothers have bleeding from the nipples that is obviously coming from inside the breast and is not usually associated with pain. This often occurs in the first few days after birth and settles within a few days. The mother should breastfeed! If bleeding does not stop soon, the source of the problem needs to be investigated, but the mother should keep breastfeeding.

7. A woman who has had breast augmentation surgery cannot breastfeed.

Not true! Most do very well. There is no evidence that breastfeeding with silicone implants is harmful to the baby. Occasionally this operation is done through the areola. These women do have problems with milk supply, as does any woman who has an incision around the areolar line.

8. A woman who has had breast reduction surgery cannot breastfeed.

Not true! Breast reduction surgery does decrease the mother's capacity to produce milk, but since many mothers produce more than enough milk, mothers who have had breast reduction surgery sometimes manage very well to breastfeed exclusively. In such a situation, the establishment of breastfeeding should be done with special care to the principles mentioned in the handout #1 Breastfeeding—Starting Out Right. However, if the mother seems not to produce enough, she can still breastfeed, supplementing with a lactation aid (so that artificial nipples do not interfere with breastfeeding).

9. Premature babies need to learn to take bottles before they can start breastfeeding.

Not true! Premature babies are less stressed by breastfeeding than by bottle feeding. A baby as small as 1200 grams and even smaller can start at the breast as soon as he is stable, though he may not latch on for several weeks. Still, he is learning and he is being held which is important for his wellbeing and his mother's. Actually, weight orgestational age do not matter as much as the baby's readiness to suck, as determined by his making sucking movements. There is no more reason to give bottles to premature babies than to full term babies. When supplementation is truly required there are ways to supplement without using artificial nipples.

10. Babies with cleft lip and/or palate cannot breastfeed.

Not true! Some do very well. Babies with a cleft lip only usually manage fine. But many babies do indeed find it impossible to latch on. There is no doubt, however, that if breastfeeding is not tried, it will not work. The baby's ability to breastfeed does not always seem to depend on the severity of the cleft. Breastfeeding should be started, as much as possible, using the principles of proper establishment of breastfeeding. (Handout #1 Breastfeeding—Starting Out Right). If bottles are given, they will undermine the baby's ability to breastfeed. If the baby needs to be fed, but is not latching on, a cup can and should be used in preference to a bottle. Finger feeding occasionally is successful in babies with cleft lip/palate, but not usually.

11. Women with small breasts produce less milk than those with large breasts.

Nonsense!

12. Breastfeeding does not provide any protection against becoming pregnant.

Not true! It is not a foolproof method, but no method is. In fact breastfeeding is not a bad method of child spacing, and gives reliable protection especially during the first 6 months after birth. But it is reliable only when breastfeeding is exclusive, when feedings are fairly frequent (at least 6-8 times in 24 hours), there are no long periods during which the baby does not feed, and the mother has not yet had a normal menstrual period after giving birth. After the first six months, the protection is less, but still present, and on average women breastfeeding into the second year of life will have a baby every 2 to 3 years even without any artificial method of contraception.

13. Breastfeeding women cannot take the birth control pill.

Not true! The question is not exposure to female hormones, to which the baby is exposed anyway through breastfeeding. The baby gets only a tiny bit more from the pill. However, some women who take the pill, even the mini-pill, find that their milk supply decreases. Œstrogen in the pill decrease the milk supply. Because so many women produce more than enough, this often does not matter, but sometimes it does and the baby becomes fussy and is not satisfied by nursing. Babies respond to rate of flow of milk, not what's "in the breast", so that even a very good milk supply may seem to cause the baby who is used to faster flow to be fussy. Stopping the pill often brings things back to normal. If possible, women who are breastfeeding should avoid the pill until the baby is taking other foods (usually 4-6 months of age). Even if the baby is older, the milk supply may decrease significantly. If the pill must be used, it is preferable to use the progestin only pill (without œstrogen).

14. Breastfeeding babies need other types of milk after 6 months.

Not true! Breastmilk gives the baby everything there is in other milks and more. Babies older than 6 months should be started on solids mainly so that they learn how to eat and so that they begin to get another source of iron, which by 7-9 months, is not supplied in sufficient quantities from breastmilk alone. Thus cow's milk or formula will not be necessary as long as the baby is breastfeeding. However, if the mother wishes to give milk after 6 months, there is no reason that the baby cannot get cow's milk, as long as the baby is still breastfeeding a few times a day, and is also getting a wide variety of solid foods in more than minimal amounts. Most babies older than 6 months who have never had formula will not accept it, because of the taste.

 

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

 

Sunday, 26 June 2005 16:23

Some Breastfeeding Myths

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Some Breastfeeding Myths

1. Many women do not produce enough milk.

Not true! The vast majority of women produce more than enough milk. Indeed, an over abundance of milk is common. Most babies that gain too slowly, or lose weight, do so not because the mother does not have enough milk, but because the baby does not get the milk that the mother has. The usual reason that the baby does not get the milk that is available is that he is poorly latched onto the breast. This is why it is so important that the mother be shown, on the first day, how to latch a baby on properly, by someone who knows what they are doing.

2. It is normal for breastfeeding to hurt.

Not true! Though some tenderness during the first few days is relatively common, this should be a temporary situation which lasts only a few days and should never be so bad that the mother dreads nursing. Any pain that is more than mild is abnormal and is almost always due to the baby latching on poorly. Any nipple pain that is not getting better by day 3 or 4 or lasts beyond 5 or 6 days should not be ignored. A new onset of pain when things have been going well for a while may be due to a yeast infection of the nipples. Limiting feeding time does not prevent soreness. (See handout #3 Sore Nipples).

3. There is no (not enough) milk during the first 3 or 4 days after birth.

Not true! It often seems like that because the baby is not latched on properly and therefore is unable to get the milk. Once the mother's milk is abundant, a baby can latch on poorly and still may get plenty of milk. However, during the first few days, the baby who is latched on poorly cannot get milk. This accounts for "but he's been on the breast for 2 hours and is still hungry when I take him off". By not latching on well, the baby is unable to get the mother's first milk, called colostrum. Anyone who suggests you pump your milk to know how much colostrum there is, does not understand breastfeeding, and should be politely ignored.

4. A baby should be on the breast 20 (10, 15, 7.6) minutes on each side.

Not true! However, a distinction needs to be made between "being on the breast" and "breastfeeding". If a baby is actually drinkingfor most of 15-20 minutes on the first side, he may not want to take the second side at all. If he drinks only a minute on the first side, and then nibbles or sleeps, and does the same on the other, no amount of time will be enough. The baby will breastfeed better and longer if he is latched on properly. He can also be helped to breastfeed longer if the mother compresses the breast to keep the flow of milk going, once he no longer swallows on his own (Handout #15 Breast Compression). Thus it is obvious that therule of thumb that "the baby gets 90% of the milk in the breast in the first 10 minutes" is equally hopelessly wrong.

5. A breastfeeding baby needs extra water in hot weather.

Not true! Breastmilk contains all the water a baby needs.

6. Breastfeeding babies need extra vitamin D.

Not true! Except in extraordinary circumstances (for example, if the mother herself was vitamin D deficient during the pregnancy). The baby stores vitamin D during the pregnancy, and a little outside exposure, on a regular basis, gives the baby all the vitamin D he needs.

7. A mother should wash her nipples each time before feeding the baby.

Not true! Formula feeding requires careful attention to cleanliness because formula not only does not protect the baby against infection, but also is actually a good breeding ground for bacteria and can also be easily contaminated. On the other hand, breastmilk protects the baby against infection. Washing nipples before each feeding makes breastfeeding unnecessarily complicated and washes away protective oils from the nipple.

8. Pumping is a good way of knowing how much milk the mother has.

Not true! How much milk can be pumped depends on many factors, including the mother's stress level. The baby who nurses well can get much more milk than his mother can pump. Pumping only tells you have much you can pump.

9. Breastmilk does not contain enough iron for the baby's needs.

Not true! Breastmilk contains just enough iron for the baby's needs. If the baby is full term he will get enough iron from breastmilk to last him at least the first 6 months.Formulas contain too much iron, but this quantity may be necessary to ensure the baby absorbs enough to prevent iron deficiency. The iron in formula is poorly absorbed, and most of it, the baby poops out. Generally, there is no need to add other foods to breastmilk before about 6 months of age.

10. It is easier to bottle feed than to breastfeed.

Not true! Or, this should not be true. However, breastfeeding is made difficult because women often do not receive the help they should to get started properly.A poor start can indeed make breastfeeding difficult. But a poor start can also be overcome. Breastfeeding is often more difficult at first, due to a poor start, but usually becomes easier later.

11. Breastfeeding ties the mother down.

Not true! But it depends how you look at it. A baby can be nursed anywhere, any time, and thus breastfeeding is liberating for the mother. No need to drag around bottles or formula. No need to worry about where to warm up the milk. No need to worry about sterility. No need to worry about how your baby is, because he is with you.

12. There is no way to know how much breastmilk the baby is getting.

Not true! There is no easy way to measure how much the baby is getting, but this does not mean that you cannot know if the baby is getting enough. The best way to know is that the baby actually drinks at the breast for several minutes at each feeding(open—pause—close type of suck). Other ways also help show that the baby is getting plenty (Handout #4 Is my Baby getting enough milk?).

13. Modern formulas are almost the same as breastmilk.

Not true! The same claim was made in 1900 and before. Modern formulas are only superficially similar to breastmilk. Every correction of a deficiency in formulas is advertised as an advance. Fundamentally they are inexact copies based on outdated and incomplete knowledge of what breastmilk is. Formulas contain no antibodies, no living cells, no enzymes, no hormones. They contain much more aluminum, manganese, cadmium and iron than breastmilk. They contain significantly more protein than breastmilk. The proteins and fats are fundamentally different from those in breastmilk. Formulas do not vary from the beginning of the feed to the end of the feed, or from day 1 to day 7 to day 30, or from woman to woman, or from baby to baby... Your breastmilk is made as required to suit your baby. Formulas are made to suit every baby, and thus no baby. Formulas succeed only at making babies grow well, usually, but there is more to breastfeeding than getting the baby to grow quickly.

14. If the mother has an infection she should stop breastfeeding.

Not true! With very, very few exceptions, the baby will be protected by the mother's continuing to breastfeed. By the time the mother has fever (or cough, vomiting, diarrhea, rash, etc) she has already given the baby the infection, since she has been infectious for several days before she even knew she was sick. The baby's best protection against getting the infection is for the mother to continue breastfeeding. If the baby does get sick, he will be less sick if the mother continues breastfeeding. Besides, maybe it was the baby who gave the infection to the mother, but the baby did not show signs of illness because he was breastfeeding. Also, breast infections, including breast abscess, though painful, are not reasons to stop breastfeeding. Indeed, the infection is likely to settle more quickly if the mother continues breastfeeding on the affected side. (Handout #9 You can still breastfeed).

15. If the baby has diarrhea or vomiting, the mother should stop breastfeeding.

Not true! The best medicine for a baby's gut infection is breastfeeding. Stop other foods for a short time, but continue breastfeeding. Breastmilk is the only fluid your baby requires when he has diarrhea and/or vomiting, except under exceptional circumstances. The push to use "oral rehydrating solutions" is mainly a push by the formula (and oral rehydrating solutions)manufacturers to make even more money. The baby is comforted by the breastfeeding, and the mother is comforted by the baby's breastfeeding. (Handout #9 You can still breastfeed).

16. If the mother is taking medicine she should not breastfeed.

Not true! There are very very few medicines that a mother cannot take safely while breastfeeding. A very small amount of most medicines appears in the milk, but usually in such small quantities that there is no concern. If a medicine is truly of concern, there are usually equally effective, alternative medicines which are safe. The loss of benefit of breastfeeding for both the mother and the baby must be taken into account when weighing if breastfeeding should be continued (Handout #9 You can stillbreastfeed).

 

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

 

Sunday, 26 June 2005 16:22

Breastfeeding and Jaundice

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Breastfeeding and Jaundice

Introduction

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

Two Types of Jaundice

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

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

Breastmilk Jaundice

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

Not-enough-breastmilk Jaundice

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

Phototherapy (Bilirubin Lights)

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

 

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

 

Sunday, 26 June 2005 16:22

Using a Lactation Aid

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Using a Lactation Aid

Introduction

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

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

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

Using the Lactation Aid (Improvised)

 

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

 

Cleaning the Device

 

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

 

Weaning the Baby from the Lactation Device

 

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

 

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

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