|
|
Please
Note:
No
information given here can replace the advice of your or
your child's Health Care Provider, and these articles should
be used for informational purposes only. |
|
Articles:
Candida Protocol
The Importance of Skin to Skin Contact
Is My Baby Getting Enough Milk?
When Latching
When the Baby Refuses to Latch On
How to Bottle Feed Safely
What If I Want To Wean My Baby?
Breastfeeding: the normal way to feed your baby
By Anne
Stiller, RNC, IBCLC
Human milk is made for human
babies: Breastfeeding is the natural continuation of pregnancy.
Human babies are meant to receive their mothers' milk
immediately after they are born, and for about the first six
months of life, mothers' milk is all that babies need to promote
normal, healthy growth and development. Breastmilk contains
scores, even hundreds of factors that protect the newborn from
illness and provide exactly the balance of proteins, healthy
fats and sugars, and everything else the baby needs to continue
the growth that began in the womb and produced the amazing
little human being that he is at birth. A healthy newborn does
not need anything other than his mother's milk; in fact,
anything else given to the baby will change the perfect balance
in his gut (intestinal tract) and will interfere with nature's
provision of a perfect system to protect him from all of the
bacteria and viruses that are present around him once he leaves
the safety of the womb and comes into the world. Because of
this, no formula, water or anything else should be given to the
baby unless there is a medical reason for it. (See the AAP
Policy on Breastfeeding) Supplements of water or formula given
to the breastfeeding baby also "interfere with the mother to
infant biology of breastfeeding," (AAP booklet quote), and will
result in the mother having a lower milk supply and the baby
receiving less benefit from her milk.
Although formula companies want us to believe that their
products come close to breastmilk, and they spend millions of
dollars advertising the "new" components that they discover and
add to an increasing number of formulas available, the truth is
that breastmilk can never be duplicated. Breastmilk is a living,
changing fluid. Each mother's milk contains antibodies to
exactly the germs that she and her baby are exposed to in their
own environment. As the baby grows, there are also changes that
take place in the make-up of the milk that make it perfectly
suited to the changing needs of the newborn, infant and toddler.
Dr. Jack Newman, a leading researcher in the breastfeeding
field, states: " The differences between cow's milk and formula
are much smaller than the differences between formula and
breastmilk." (Newman, Jack, MD. The Ultimate Breastfeeding Book
of Answers, Prima Publishing Roseville, CA: 2000, p. 13.) He
goes on to say: "All pregnant women and their families need to
know the risks of formula feeding. It does matter. All should be
encouraged to breastfeed, and all should get the best support
available start breast- feeding once the baby arrives." (Ibid.)
Why, if it is the natural way to feed a baby, does it seem so
hard to breastfeed? Why do so many mothers try and fail? Why do
so many pediatricians advise moms to stop breastfeeding and
switch to formula at the first sign of trouble?
The American Academy of
Pediatrics strongly recommends breastfeeding without giving the
baby any other foods for the first six months, and that
breastfeeding continue with the gradual addition of other foods
in the second half of baby's first year. They recommend "that
breastfeeding continue for at least 12 months, and thereafter
for as ling as mutually desired." (American Academy of
Pediatrics Work Group on Breastfeeding, Breastfeeding and the
Use of Human Milk, Pediatrics Vol 100 No. 6, December, 1997,
p.1037)
In spite of this strong position
on the importance of breastfeeding, many nurses, doctors and
other health care providers do not have the specific training
needed to adequately help mothers and babies who are
experiencing breastfeeding difficulty. Often breastfeeding
failure happens because hospital procedures in the hours and
days after the babies birth prevent the normal progression of
lactogenesis (the process by which the mother's milk supply is
established) or a misunderstanding of the newborn's feeding
patterns leads to the early use of bottles and pacifiers in the
absence of a medical need for such intervention. This causes
subtle changes in the way the baby sucks, and makes some babies
begin to refuse the breast and to prefer the very rapid flow of
milk from the bottle. Even if a baby has had some bottles and
has begun to show a preference for the bottle rather than the
breast, it is not too late! Most young babies can learn to
breastfeed effectively, most mothers can establish a good milk
supply with the right kind of help and support.
Board Certified Lactation
Consultants have special training in helping overcome some of
these breastfeeding problems. The earlier a mother gets help,
the easier it should be to establish breastfeeding even if a mom
and baby have a rough start and encounter problems in the
beginning. Other good sources of help are La Leche League, a
volunteer organization with chapters in most places in the USA
and Canada, as well as in many other countries. In the USA, most
local WIC offices have resources to help mothers who want to
breastfeed their babies.(Go to
http://www.ilca.org/falc.html for
a list of Certified Lactation Consultants in your area).
While it is ideal for mother and baby to be together so that
baby can feed frequently during the day and night, many moms
today face the reality of returning to the workplace within
weeks of the baby's birth. It is entirely possible to provide
your milk to your baby even if you must be separated for many
hours of the day. Do not let the necessity of working outside
your home rob you and your baby of this priceless gift.
Look for the information about pumping if you must be away from
your baby and still want to provide him/her with your milk.
Back to Top
Breastfeeding - Starting out
Right
by
Jack Newman, MD, FRCPC
Breastfeeding is the natural, physiologic way of feeding
infants and young children, and human milk is the milk made
specifically for human infants. Formulas made from cow's milk or
soybeans (most formulas, even "designer formulas") are only
superficially similar, and advertising which states otherwise is
misleading. Breastfeeding should be easy and trouble free for
most mothers. A good start helps to ensure breastfeeding is a
happy experience for both mother and baby.
The vast majority of mothers are perfectly capable of
breastfeeding their babies exclusively for about six months. In
fact, most mothers produce more than enough milk. Unfortunately,
outdated hospital routines based on bottle feeding still
predominate in too many health care institutions and make
breastfeeding difficult, even impossible, for too many mothers
and babies. For breastfeeding to be well and properly
established, a good start in the early few days can be crucial.
Admittedly, even with a terrible start, many mothers and babies
manage.
The trick to breastfeeding is getting the baby to latch on
well. A baby who latches on well, gets milk well. A baby who
latches on poorly has more difficulty getting milk, especially
if the supply is low. A poor latch is similar to giving a baby a
bottle with a nipple hole that is too small-the bottle is full
of milk, but the baby will not get much. When a baby is latching
on poorly, he may also cause the mother nipple pain. And if he
does not get milk well, he will usually stay on the breast for
long periods, thus aggravating the pain. Unfortunately anyone
can say that the baby is latched on well, even if he isn't. Too
many people who should know better just don't know what a good
latch is. Here are a few ways breastfeeding can be made easy:
- A proper latch is crucial to success. This is the key to
successful breastfeeding. Unfortunately, too many mothers
are being "helped" by people who don't know what a proper
latch is. If you are being told your two day old's latch is
good despite your having very sore nipples, be sceptical,
and ask for help from someone else who knows. Before you
leave the hospital, you should be shown that your baby is
latched on properly, and that he is actually getting milk
from the breast and that you know how to know he is getting
milk from the breast (open mouth wide-pause-close mouth type
of suck). See also
videos on how to latch a baby on (as well as other
videos). If you and the baby are leaving hospital not
knowing this, get experienced help quickly (see handout When
Latching). Some staff in the hospital will tell mothers that
if the breastfeeding is painful, the latch is not good
(usually true), so that the mother should take the baby off
and latch him on again. This is not a good idea. The pain
usually settles, and the latch should be fixed on the other
side or at the next feeding. Taking the baby off the breast
and latching him on again and again only multiplies the pain
and the damage.
- The baby should be at the breast immediately after
birth. The vast majority of newborns can be at the breast
within minutes of birth. Indeed, research has shown that,
given the chance, many babies only minutes old will crawl up
to the breast from the mother's abdomen, latch on and start
breastfeeding all by themselves. This process may take up to
an hour or longer, but the mother and baby should be given
this time together to start learning about each other.
Babies who "self-attach" run into far fewer breastfeeding
problems. This process does not take any effort on the
mother's part, and the excuse that it cannot be done because
the mother is tired after labour is nonsense, pure and
simple.
Incidentally, studies have also shown that skin-to-skin
contact between mothers and babies keeps the baby as warm as
an incubator (see section on skin to skin contact).
Incidentally, many babies do not latch on and breastfeeding
during this time. Generally, this is not a problem, and
there is no harm in waiting for the baby to start
breastfeeding. The skin to skin contact is good for the baby
and the mother even if the baby does not latch on.
- The mother and baby should room in together. There is
absolutely no medical reason for healthy mothers and babies
to be separated from each other, even for short periods.
Health facilities that have routine separations of
mothers and babies after birth are years behind the times,
and the reasons for the separation often have to do with
letting parents know who is in control (the hospital) and
who is not (the parents). Often, bogus reasons are given for
separations. One example is that the baby passed meconium
before birth. A baby who passes meconium and is fine a few
minutes after birth will be fine and does not need to be in
an incubator for several hours' "observation".
There is no evidence that mothers who are separated from
their babies are better rested. On the contrary, they are
more rested and less stressed when they are with their
babies. Mothers and babies learn how to sleep in the same
rhythm. Thus, when the baby starts waking for a feed, the
mother is also starting to wake up naturally. This is not as
tiring for the mother as being awakened from deep sleep, as
she often is if the baby is elsewhere when he wakes up. If
the mother is shown how to feed the baby while both are
lying down side by side, the mother is better rested.
The baby shows long before he starts crying that he is
ready to feed. His breathing may change, for example. Or he
may start to stretch. The mother, being in light sleep, will
awaken, her milk will start to flow and the calm baby will
be content to nurse. A baby who has been crying for some
time before being tried on the breast may refuse to take the
breast even if he is ravenous. Mothers and babies should be
encouraged to sleep side by side in hospital. This is a
great way for mothers to rest while the baby nurses.
Breastfeeding should be relaxing, not tiring.
- Artificial nipples should not be given to the baby.
There seems to be some controversy about whether "nipple
confusion" exists. Babies will take whatever gives them a
rapid flow of fluid and may refuse others that do not. Thus,
in the first few days, when the mother is normally producing
only a little milk (as nature intended), and the baby gets a
bottle (as nature intended?) from which he gets rapid flow,
the baby will tend to prefer the rapid flow method. You
don't have to be a rocket scientist to figure that one out,
though many health professionals, who are supposed to be
helping you, don't seem to be able to manage it. Note, it is
not the baby who is confused. Nipple confusion includes a
range of problems, including the baby not taking the breast
as well as he could and thus not getting milk well and/or
the mother getting sore nipples. Just because a baby will
"take both" does not mean that the bottle is not having a
negative effect. Since there are now alternatives available
if the baby needs to be supplemented (see handout #5, Using
a Lactation Aid, and handout #8 Finger Feeding) why use an
artificial nipple?
- No restriction on length or frequency of breastfeedings.
A baby who drinks well will not be on the breast for hours
at a time. Thus, if he is, it is usually because he is not
latching on well and not getting the milk that is available.
Get help to fix the baby's latch, and use compression to get
the baby more milk (handout #15, Breast Compression).
Compression works very well in the first few days to get the
colostrum flowing well. This, not a pacifier, not a bottle,
not taking the baby to the nursery, will help.
- Supplements of water, sugar water, or formula are rarely
needed. Most supplements could be avoided by getting the
baby to take the breast properly and thus get the milk that
is available. If you are being told you need to supplement
without someone having observed you breastfeeding, ask for
someone to help who knows what they are doing. There are
rare indications for supplementation, but often supplements
are suggested for the convenience of the hospital staff. If
supplements are required, they should be given by lactation
aid at the breast (see handout #5), not cup, finger feeding,
syringe or bottle. The best supplement is your own colostrum.
It can be mixed with 5% sugar water if you are not able to
express much at first. Formula is hardly ever necessary in
the first few days.
- Free formula samples and formula company literature are
not gifts. There is only one purpose for these "gifts" and
that is to get you to use formula. It is very effective, and
it is unethical marketing. If you get any from any health
professional, you should be wondering about his/her
knowledge of breastfeeding and his/her commitment to
breastfeeding. "But I need formula because the baby is not
getting enough!" Maybe, but, more likely, you weren't given
good help and the baby is simply not getting the milk that
is available. Even if you need formula, nobody should be
suggesting a particular brand and giving you free samples.
Get good help. Formula samples are not help.
Under some circumstances, it may be impossible to start
breastfeeding early. However, most "medical reasons"
(maternal medication, for example) are not true reasons for
stopping or delaying breastfeeding, and you are getting
misinformation. Get good help. Premature babies can start
breastfeeding much, much earlier than they do in many health
facilities. In fact, studies are now quite definite that it
is less stressful for a premature baby to breastfeed than to
bottle feed. Unfortunately, too many health professionals
dealing with premature babies do not seem to be aware of
this.
Handout #1. Breastfeeding-Starting Out Right.
Revised January 2005
Written by Jack Newman, MD, FRCPC. Copyright 2005
This handout may be copied and distributed without
further permission, on the condition that it is not used in
any context in which the WHO code on the marketing of
breastmilk substitutes is violated
Back to Top
Just One Bottle Won't Hurt - Or Will
It?
By Marsha Walker, RN, IBCLC
Did you know
. . .
That just one bottle can
have serious consequences for both the mother and baby?
Unfortunately, it is very easy to give a breastfed baby "just
one bottle" and the reasons for giving a bottle often show
concern and compassion; e.g.,
-
Letting the mother have a well deserved rest after a
long delivery.
-
Settling a hungry baby who is difficult to feed.
-
Give the mother's sore nipples a rest.
But studies
show that "just one bottle" can be harmful to both the
mother and baby by
-
Increasing the likelihood of serious allergy to cows' milk
protein.
-
Increasing the chance of bowel infection and diarrhea by
changing the pH of the bowel. It may take up to a month to
return to normal, safer levels.
-
Causing
nipple confusion--having difficulty latching to the breast.
-
Affecting the delicate supply and demand balance.
-
Increasing engorgement by not emptying the breasts.
-
Decreasing the mother's confidence in her ability to feed
her baby.
-
Reducing the duration of breastfeeding.
Copyright
Marsha Walker. Used by
permission of the author.
References:
Vnuk, A. Breastfeed
Rev II (8): 358, 1993.
Bullen, C.L. et al.
The effects of humanized milks and supplemented breastfeeding on
the faecal flora of infants. J Med Microbiol 10: 403-413, 1977.
De Coopman, J.
Breastfeeding after pituitary resection: Support for a theory of
autocrine control of milk supply? J. Hum Lact 9: 35-40, 1993.
Gray-Donald, K. et
al. Effect of formula supplementation in the hospital on the
duration of breastfeeding: a controlled clinical trial.
Pediatrics 75: 514-518, 1985.
Host, A. et al. A
prospective study of cow's milk allergy in exclusively breastfed
infants. Acta Paediatr Scand. 77: 663-670, 1988.
Houston, M.J. et
al. The importance of support for the breastfeeding mother.
Health Visitor 54: 243, 1981.
Moon, J.L. et al.
Breast engorgement: contributable variables and variables
amenable to nursing interventions. JOGNN 18: 309-315, 1989.
Newman, J. Breastfeeding problems associated with the early
introduction of bottles and pacifiers. J Hum Lact. 6: 59-63,
1990.
Back to Top
Candida Protocol
by
Jack Newman, MD, FRCPC
It is important to get the best latch possible when you have
sore nipples. Even if the cause of sore nipples is Candida,
improving the latch can decrease the pain. Note that with the
"ideal" latch, the baby covers more of the areola (brown or
darker part of the breast) with his lower lip than the upper
lip. Note also that the baby's nose does not usually touch the
breast (except when the mother's breasts are very large, and
even then, most babies well latched on will not have their noses
touching the breast). It is not always easy, though, to change
the latch of the older baby. See
videos showing how to latch on a baby.
Start with local treatment (applied on the nipple) with:
- Gentian violet (look under that title at the website
below or see handout: #6 Using Gentian Violet). Use once a
day for four to seven days. If pain is gone after four days,
stop gentian violet. If better, but not gone after four
days, continue for seven days. Stop after 7 days no matter
what. If not better at all at four days, stop the gentian
violet, continue with the ointment as below and call or
email. Gentian violet comes as a 1% solution in water. It
also usually dissolved in 10% alcohol, as gentian violet is
not soluble in pure water. This amount of alcohol is
negligible, as the baby will only get a drop of gentian
violet. Apparently some pharmacists will dissolve it in
glycerine instead of alcohol, if you wish. 2% gentian violet
should not be used.
Plus:
- APNO (All Purpose Nipple Ointment) as below:
Mupirocin 2% ointment (15 grams)
Betamethasone 0.1% ointment (15 grams)
To which is added miconazole powder so that the final
concentration is 2% miconazole. This combination gives a
total volume of just more than 30 grams. Clotrimazole powder
to a final concentration of 2% may be substituted if
miconazole powder is unavailable, but both exist (the
pharmacist may have to order it in, but compounding
pharmacies almost always have it on hand). I believe
clotrimazole is not as good as miconazole. Using powder
gives a better concentration of antifungal agent (miconazole
or clotrimazole) and the concentrations of the mupirocin and
betamethasone remain higher. Sometimes we will add ibuprofen
powder to a final concentration of 2%.
The combination is applied sparingly after each feeding
(except the feeding when the mother uses gentian violet).
"Sparingly" means that the nipple and areola will shine but
you won't be able to see the ointment. Do not wash or wipe
it off, even if the pharmacist asks you to. I used to use
nystatin ointment or miconazole cream (15 grams) as part of
the mixture, and these work well enough, but I believe the
use of powdered miconazole (or even clotrimazole powder)
gives better results. These ointments can be used for any
cause of nipple soreness ("all purpose nipple ointments"),
not just for Candida (yeast). Use the ointment until you are
pain free and then decrease frequency over a week or two
until stopped. (See Handout #3b Treatments for Sore Nipples
and Sore Breasts under "all purpose nipple ointment"). If
you are not having less pain after 3 or 4 days of use, or if
you need to be using it for longer than two or three weeks
to keep pain free, get help or advice.
- Grapefruit seed extract (not grape seed extract, ACTIVE
INGREDIENT MUST BE "CITRICIDAL"), 250 mg (usually 2 tablets)
three or four times a day orally (taken by the mother),
seems to work well in many cases. If preferred the liquid
extract can be taken orally, 5 drops in water three times
per day (though this is not as effective). Oral GSE can be
used before trying fluconazole, instead of fluconazole or in
addition to fluconazole in resistant cases. See below for
information on grapefruit seed extract used directly on the
nipples.
- 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 two 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 is too expensive, ketoconazole 400 mg loading,
then 200 mg twice daily for same period of time (or
grapefruit seed) can be used instead. If Candida is
resistant, itraconazole, same dose and time period as
fluconazole, can be used and has worked, though Candida
actually is less sensitive to itraconazole, generally, than
it is to fluconazole. (See handout #20, 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). Before using fluconazole, nipple
pain should be treated aggressively with good latch, gentian
violet, all purpose nipple ointment and grapefruit seed
extract. If used, fluconazole should be added to treatment
of the nipples, not used alone. Fluconazole takes three or
four days to start working, though occasionally, in some
situations, it has taken 10 days to even start working. If
you have had no relief at all with 10 days of fluconazole,
it is very unlikely it will work, and you should stop taking
it.
- 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).
Grapefruit Seed Extract (GSE)
Grapefruit seed extract (ACTIVE INGREDIENT MUST BE "CITRICIDAL")
should be used in conjunction with the APNO (All Purpose Nipple
Ointment). Apply the diluted liquid grapefruit seed extract on
the nipples, and then follow with the ointment (always after the
feeding).
Apply solution directly on the nipples. It does not need to
be refrigerated. It may be covered and used until solution is
finished. Mix very well five to 10 drops in 30 ml (1 ounce) of
water (preferably, but not necessarily, distilled).
Use cotton swab or Q-tip to apply on both nipples and areolas
after the feeding.
Let dry a few seconds, then apply "all purpose nipple
ointment".
If using Gentian Violet, do not use GSE on that particular
feed but use after all other feeds.
Should be used in conjunction with oral GSE, either tablets,
capsules, or liquid extract (see above)
Use until pain is gone and then wean down slowly over the
period of at least a week.
If pain is not significantly improving after two to three
days, increase the dose by 5 drops per 30 ml (ounce) of water.
Can continue increasing until 25 drops per 30 ml of water.
If flaking, drying, or whiteness appears on the skin,
substitute vitamin E oil or pure olive oil for APNO 1-3x/day.
Laundry can be treated as well: add 15-20 drops in the rinse
cycle of all wash loads.
If not using Gentian Violet, it may be helpful to treat baby
with acidophilus by rolling a wet finger in acidophilus powder
(break open a capsule), and let baby suck on the finger right
before a feeding. Use 2x first day, 2x second day only. Mother
may want to ingest Acidophilus as well, 3x/day for 1-2 weeks.
Handout C: Candida Protocol Jack Newman, MD,
FRCPC. Copyright 2005 Revised: January 2005
This handout may be copied and distributed without further
permission, on the condition that it is not used in any context
in which the WHO code on the marketing of breastmilk substitutes
is violated
Back to Top
The Importance of Skin to Skin
Contact
by
Jack Newman, MD, FRCPC
There are now a multitude of studies that show that mothers
and babies should be together, skin to skin (baby naked, not
wrapped in a blanket) immediately after birth, as well as later.
The baby is happier, the baby's temperature is more stable and
more normal, the baby's heart and breathing rates are more
stable and more normal, and the baby's blood sugar is more
elevated. Not only that, skin to skin contact immediately after
birth allows the baby to be colonized by the same bacteria as
the mother. This, plus breastfeeding, are thought to be
important in the prevention of allergic diseases. When a baby is
put into an incubator, his skin and gut are often colonized by
bacteria different from his mother's.
We now know that this is true not only for the baby born at
term and in good health, but also even for the premature baby.
Skin to skin contact and Kangaroo Mother Care can contribute
much to the care of the premature baby. Even babies on oxygen
can be cared for skin to skin, and this helps reduce their needs
for oxygen, and keeps them more stable in other ways as well.
From the point of view of breastfeeding, babies who are kept
skin to skin with the mother immediately after birth for at
least an hour, are more likely to latch on without any help and
they are more likely to latch on well, especially if the mother
did not receive medication during the labour or birth. As
mentioned in the information sheet, Handout #1
Breastfeeding-Starting out Right, a baby who latches on
well gets milk more easily than a baby who latches on less well.
When a baby latches on well, the mother is less likely to be
sore. When a mother's milk is abundant, the baby can take the
breast poorly and still get lots of milk, though the feedings
may then be long or frequent or both, and the mother is more
prone to develop problems such as blocked ducts and mastitis. In
the first few days, however, the mother does not have a lot of
milk (but she has enough!), and a good latch is important to
help the baby get the milk that is available (yes, the milk is
there even if someone has proved to you with the big pump that
there isn't any). If the baby does not latch on well, the mother
may be sore, and if the baby does not get milk well, the baby
will want to be on the breast for long periods of time worsening
the soreness.
To recap, skin to skin contact immediately after birth, which
lasts for at least an hour has the following positive effects on
the baby:
- Are more likely to latch on
- Are more likely to latch on well
- Have more stable and normal skin temperatures
- Have more stable and normal heart rates and blood
pressures
- Have higher blood sugars
- Are less likely to cry
- Are more likely to breastfeed exclusively longer
There is no reason that the vast majority of babies cannot be
skin to skin with the mother immediately after birth for at
least an hour. Hospital routines, such as weighing the baby,
should not take precedence.
The baby should be dried off and put on the mother. Nobody
should be pushing the baby to do anything; nobody should be
trying to help the baby latch on during this time. The mother,
of course, may make some attempts to help the baby, and this
should not be discouraged. The mother and baby should just be
left in peace to enjoy each other's company. (The mother and
baby should not be left alone, however, especially if the mother
has received medication, and it is important that not only the
mother's partner, but also a nurse, midwife, doula or physician
stay with them-occasionally, some babies do need medical help
and someone qualified should be there "just in case"). The
eyedrops and the injection of vitamin K can wait a couple of
hours. By the way, immediate skin to skin contact can also be
done after cæsarean section, even while the mother is getting
stitched up, unless there are medical reasons which prevent it.
Studies have shown that even premature babies, as small as
1200 g (2 lb 10 oz) are more stable metabolically (including the
level of their blood sugars) and breathe better if they are skin
to skin immediately after birth. The need for an intravenous
infusion, oxygen therapy or a nasogastric tube, for example, or
all the preceding, does not preclude skin to skin contact. Skin
to skin contact is quite compatible with other measures taken to
keep the baby healthy. Of course, if the baby is quite sick, the
baby's health must not be compromised, but any premature baby
who is not suffering from respiratory distress syndrome can be
skin to skin with the mother immediately after birth. Indeed, in
the premature baby, as in the full term baby, skin to skin
contact may decrease rapid breathing into the normal range.
Even if the baby does not latch on during the first hour or
two, skin to skin contact is still good and important for the
baby and the mother for all the other reasons mentioned.
If the baby does not take the breast right away, do not
panic. There is almost never any rush, especially in the full
term healthy baby. One of the most harmful approaches to feeding
the newborn has been the bizarre notion that babies must feed
every three hours. Babies should feed when they show signs of
being ready, and keeping a baby next to his mother will make it
obvious to her when the baby is ready. There is actually not a
stitch of proof that babies must feed every three hours or by
any schedule, but based on such a notion, many babies are being
pushed into the breast because three hours have passed. The baby
not interested yet in feeding may object strenuously, and thus
is pushed even more, resulting, in many cases, in babies
refusing the breast because we want to make sure they take the
breast. And it gets worse. If the baby keeps objecting to being
pushed into the breast and gets more and more upset, then the
"obvious next step" is to give a supplement. And it is obvious
where we are headed (see handout #26 When a Baby Refuses
to Latch On).
Handout #1a. The importance of skin to skin contact.
Revised January 2005 Written by Jack Newman, MD, FRCPC. Copyright 2005
This handout may be copied and distributed without further
permission, on the condition that it is not used in any context
in which the WHO code on the marketing of breastmilk substitutes
is violated
Back to Top
Is My Baby Getting Enough Milk?
by
Jack Newman, MD, FRCPC
Breastfeeding mothers frequently ask how to know their babies
are getting enough milk. The breast is not the bottle, and it is
not possible to hold the breast up to the light to see how many
ounces or millilitres of milk the baby drank. Our number
obsessed society makes it difficult for some mothers to accept
not seeing exactly how much milk the baby receives. However,
there are ways of knowing that the baby is getting enough. In
the long run, weight gain is the best indication whether the
baby is getting enough, but rules about weight gain appropriate
for bottle fed babies may not be appropriate for breastfed
babies.
Ways of knowing
- Baby's nursing is characteristic. A
baby who is obtaining good amounts of milk at the breast
sucks in a very characteristic way. 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 same 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—like feed the
baby twenty minutes on each side. A baby who does this type
of sucking (with the pauses) 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. See our
videos that show this pause in the
baby's chin.
Baby's bowel movements. For the first
few days after delivery, the baby passes meconium, a dark
green, almost black, substance. Meconium accumulates in the
baby's gut during pregnancy. It is passed during the first
few days, and by the third day, the bowel movements start
becoming lighter, as more breastmilk is taken. Usually by
the fifth day, the bowel movements have taken on the
appearance of the normal breastmilk stool. The normal
breastmilk stool is pasty to watery, mustard coloured, and
usually has little odour. However, bowel movements may vary
considerably from this description. They may be green or
orange, may contain curds or mucus, or may resemble shaving
cream in consistency (from air bubbles). The variations in
colour do not mean something is wrong. A baby who is
breastfeeding only, and is starting to have bowel movements
that are becoming lighter by day 3 of life, is doing well.
Without becoming obsessive about it, monitoring the
frequency and quantity of bowel motions is one of the best
ways, next to observing the baby's drinking, (see above, and
videos)
of knowing if the baby is getting enough milk. After the
first three to four days, the baby should have increasing
bowel movements so that by the end of the first week he
should be passing at least two to three substantial yellow
stools each day. In addition, many infants have a stained
diaper with almost each feeding. A baby who is still passing
meconium on the fourth or fifth day of life, should be seen
at the clinic the same day. A baby who is passing only brown
bowel movements is probably not getting enough, but this is
not very reliable.
Some breastfed babies, after the first three to four
weeks of life, may suddenly change their stool pattern from
many each day, to one every three days or even less. Some
babies have gone as long as 15 days or more without a bowel
movement. As long as the baby is otherwise well, and the
stool is the usual pasty or soft, yellow movement, this is
not constipation and is of no concern. No treatment is
necessary or desirable, because no treatment is necessary or
desirable for something that is normal.
Any baby between five and 21 days of age who does not
pass at least one substantial bowel movement within a 24
hour period should be seen at the breastfeeding clinic the
same day. Generally, small, infrequent bowel movements
during this time period mean insufficient intake. There are
definitely some exceptions and everything may be fine, but
it is better to check.
Urination. With six soaking wet (not
just wet) diapers in a 24 hours hour period, after about 4-5
days of life, you can be reasonably sure that the baby is
getting a lot of milk (if he is breastfeeding only).
Unfortunately, the new super dry "disposable" diapers often
do indeed feel dry even when full of urine, but when soaked
with urine they are heavy. It should be obvious that this
indication of milk intake does not apply if you are giving
the baby extra water (which, in any case, is unnecessary for
breastfed babies, and if given by bottle, may interfere with
breastfeeding). The baby's urine should be almost colourless
after the first few days, though occasional darker urine is
not of concern.
During the first two to three days of life, some babies
pass pink or red urine. This is not a reason to panic and
does not mean the baby is dehydrated. No one knows what it
means, or even if it is abnormal. It is undoubtedly
associated with the lesser intake of the breastfed baby
compared with the bottle fed baby during this time, but the
bottle feeding baby is not the standard on which to judge
breastfeeding. However, the appearance of this colour urine
should result in attention to getting the baby well latched
on and making sure the baby is drinking at the breast.
During the first few days of life, only if the baby is well
latched on can he get his mother's milk. Giving water by
bottle or cup or finger feeding at this point does not fix
the problem. It only gets the baby out of hospital with
urine that is not red. Fixing the latch and using
compression will usually fix the problem (See Handout B:
Protocol to Increase Breastmilk Intake by the Baby). If
relatching and breast compression do not result in better
intake, there are ways of giving extra fluid without giving
a bottle directly (handout #5 Using a Lactation Aid).
Limiting the duration or frequency of feedings can also
contribute to decreased intake of milk.
The following are NOT good ways of judging
Your breasts do not feel full. After the first
few days or weeks, it is usual for most mothers not to feel
full. Your body adjusts to your baby's requirements. This change
may occur quite suddenly. Some mothers breastfeeding perfectly
well never feel engorged or full.
The baby sleeps through the night. Not
necessarily. A baby who is sleeping through the night at 10 days
of age, for example, may, in fact, not be getting enough milk. A
baby who is too sleepy and has to be awakened for feeds or who
is "too good" may not be getting enough milk. There are many
exceptions, but get help quickly.
The baby cries after feeding. Although the
baby may cry after feeding because of hunger, there are also
many other reasons for crying. See also handout #2 Colic in the
Breastfeeding Baby. Do not limit feeding times. "Finish" the
first side before offering the other.
The baby feeds often and/or for a long time.
For one mother feeding every three hours or so may be often; for
another, three hours or so may be a long period between feeds.
For one, a feeding that lasts for 30 minutes is a long feeding;
for another, it is a short one. There are no rules how often or
for how long a baby should nurse. It is not true that the baby
gets 90% of the feed in the first 10 minutes. Let the baby
determine his own feeding schedule and things usually come
right, if the baby is suckling and drinking at the breast and
having at least two to three substantial yellow bowel movements
each day. Remember, a baby may be on the breast for two hours,
but if he is actually feeding or drinking (open wide—pause—close
mouth type of sucking) for only two minutes, he will come off
the breast hungry. If the baby falls asleep quickly at the
breast, you can compress the breast to continue the flow of milk
(handout #15, Breast Compression). Contact the
breastfeeding clinic with any concerns, but wait to start
supplementing. If supplementation is truly necessary, there are
ways of supplementing which do not use an artificial nipple
(handout #5, Using a Lactation Aid).
"I can express only half an ounce of milk".
This means nothing and should not influence you. Therefore, you
should not pump your breasts "just to know". Most mothers have
plenty of milk. The problem usually is that the baby is not
getting the milk that is available, either because he is latched
on poorly, or the suckle is ineffective or both. These problems
can often be fixed easily. The baby will take a bottle after
feeding. This does not necessarily mean that the baby is still
hungry. This is not a good test, as bottles may interfere with
breastfeeding.
The five week old is suddenly pulling away from the breast
but still seems hungry. This does not mean your milk has "dried
up" or decreased. During the first few weeks of life, babies
often fall asleep at the breast when the flow of milk slows down
even if they have not had their fill. When they are older (four
to six weeks of age), they no longer are content to fall asleep,
but rather start to pull away or get upset. The milk supply has
not changed; the baby has. Compress the breast (handout #15,
Breast Compression) to increase flow.
If the baby doesn't latch on, don't try to force him to stay
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 may work (only
before attempting the baby at the breast is good enough if
finger feeding is too slow, and finishing the feeding with cup
or bottle).
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.
If you must use a nipple shield, do not use one at least
until the milk supply is well established (at least 2 weeks
after the baby is born). Get good hands on help first.
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.
Handout #26. When The Baby Refuses to Latch On.
January 2005 Written by Jack Newman, MD, FRCPC. Copyright 2005
This handout may be copied and distributed without further
permission, on the condition that it is not used in any context
in which the WHO code on the marketing of breastmilk substitutes
is violated
Back to Top
How to Bottle Feed Safely
By Anne
Stiller, RNC, IBCLC
If your baby is not breastfed, or if you must supplement
feedings with additional milk, there are important facts you
need to know to make bottle feeding safe for your baby.
Formulas:
According to the American Academy of Pediatrics, babies under 12
months of age should be fed either breastmilk or infant formula.
No other type of milk provides all of the nutrients in the right
amounts to support optimal growth. Formula companies use human
milk as a standard and produce a product, usually based on cows'
milk, which contains proteins, fats and carbohydrates in a
proportion that is close to human milk. Then they add vitamins,
minerals and other ingredients to bring the final product as
close to human milk as possible. As ongoing research reveals
factors in mothers' milk that were previously not known, the
drug companies that manufacture infant formula add them, and
advertise the product as being "new" or "improved." Some recent
additions are ARA and DHA. Read labels carefully to know what is
in the brand you purchase. When you choose a formula for your
baby, it is usually best to start with one that is milk-based,
since these are tolerated by most babies and are lower in cost
than the specialized formulas. If your baby does not tolerate
his formula, consult your pediatrician about which one to try
next. While soy based formulas contain all of the nutrients
needed to sustain growth, they also contain phytoestrogens that
may affect a baby's growth and development, and they hinder the
absorption of zinc and calcium. According to an FDA paper, the AAP states
"Healthy full-term infants should be given soy
formula only when medically necessary." (http://www.fda.gov/Fdac/features/596_baby.html)
Specialized formulas for allergic babies are more expensive, and
should be used on the recommendation of a pediatrician.
Bottles:
If your formula feed your baby, you will need bottles, nipples
(teats), and a bottle brush for effective cleaning. There are
many types and styles of bottles available, and what you choose
depends upon your preference.
Bottles with disposable liners are fairly easy to use and easy
to clean, but they are more expensive than other types because
the liners have to be purchased throughout the months that your
baby uses a bottle. Plastic bottles are lightweight, and most
are easy to clean with hot soapy water and a brush. In recent
months, news articles have warned about possible dangers from
the leaching of a chemical called bisphenol A or BPA into milk
from the plastic when bottles are heated, and also from the
linings of the can the formula comes in. Although the FDA states
that plastic bottles do not present a hazard to babies, you
might want to research the different brands to see which are
considered safer before purchasing bottles for your baby. A
google search turned up lists of brands which are BPA free.
Different babies do better with different types of nipples. You
should choose those with a slow flow at first, especially for a
very young baby. If the milk flows too fast the baby may choke,
or take in too much air. Be sure to replace nipples that become
worn so that they do not break during a feeding. At times a baby
who is teething may chew on the nipple and cause tiny pieces to
come off, so inspect them on a regular basis.
Formula Preparation:
Infant formula comes in three forms: ready to feed concentrate,
and powder. Ready to feed formula is the easiest to use. It can
be stored at room temperature until the can is opened, and is
fed to the baby directly as it comes from the can. It is,
however, expensive compared to the other types. Both other forms
of formula must be mixed with water before feeding. It is very
important to read the directions on the can to be sure that you
add exactly the right amount of water so that the milk the baby
receives is neither too dilute (which could lead to
malnutrition) nor too concentrated (which could be hard on the
baby's kidneys). Some pediatricians (and the World Health
Organization) recommend boiling all water prior to using it for
a baby. Other doctors feel that it is OK to use water directly
from the tap as long as it has been proven safe for drinking. If
you are not sure, ask your pediatrician. Powdered formula is not
sterile, and in recent months, reports have warned about the
potential contamination of some such formulas with Enterobacter
sakazakii, a bacteria that can cause infections in all ages, but
newborns (under 1 month of age) and premature babies are at
greatest risk. The World Health Organization recommends that
formula given to these infants be ready to feed, or concentrate.
If powdered formula must be used for a newborn, it should be
prepared with boiling water or heated almost to boiling, then
cooled before feeding to kill the bacteria if it is present.
Once it is prepared, the formula should be refrigerated or kept
cold with ice packs until the baby is fed. Discard any unused
milk left in the bottle after feeding, since bacteria multiply
quickly in warmed milk. Heating baby bottles in the microwave is
not recommended because "hot spots" that can scald a baby may
occur. If you do use a microwave, be sure to shake the bottle
thoroughly to mix the formula completely. (Never microwave
expressed breastmilk because that would kill some of the living
cells that protect the baby from illness.)
Feeding the Baby:
Feeding time is very important in terms of your baby's emotional
and social well-being. You should always hold your baby in your
arms when giving him a bottle, and cuddle him close. This is a
good time to talk to your baby, look into his eyes, and watch
him smile and interact with you. His head should be slightly
elevated because most bottle nipples flow fast enough to choke a
baby who is lying flat when he swallows. When feeding a newborn,
stop and try to burp the baby every ounce or so. As baby grows,
he can take in larger amounts without burping. Ask your
pediatrician how much formula to feed your baby. Don't force him
to take finish a bottle if he stops drinking and acts full. Most
babies know how much they need, and overfeeding can predispose
him to obesity later on.. Never prop a bottle because of the
danger of choking, and don't put your baby to bed with a bottle.
Milk that remains on his teeth during the night will promote
tooth decay.
However your baby is fed, feeding time should be very
comfortable and enjoyable for both of you.
Additional Resources:
For additional information including videos, please visit
Dr.
Jack Newman's The Visual Guide to Breastfeeding.
Back to Top
What If I Want To Wean My Baby?
By Diane Wiessinger, MS, IBCLC
Breastfeeding your baby for even a day is the best baby gift
you can give. Breastfeeding is almost always the best choice for
your baby. If it doesn't seem like the best choice for you right
now, these guidelines may help.
IF YOU BREASTFEED YOUR BABY FOR JUST A FEW DAYS, he will have
received your colostrum, or early milk. By providing antibodies
and the food his brand-new body expects, nursing gives your baby
his first - and easiest - "immunization" and helps get his
digestive system going smoothly. Breastfeeding is how your baby
expects to start, and helps your own body recover from the
birth. Given how little it takes to offer it, and how very much
your baby stands to gain, it just makes good sense to breastfeed
for at least a day or two, even if you plan to bottle-feed after
that.
IF YOU BREASTFEED YOUR BABY FOR FOUR TO SIX WEEKS, you will have
eased him through the most critical part of his infancy.
Newborns who are not breastfed are much more likely to get sick
or be hospitalized, and have many more digestive problems than
breastfed babies. After 4 to 6 weeks, you'll probably have
worked through any early nursing concerns, too. Make a serious
goal of nursing for a month, call La Leche League or a certified
lactation consultant (IBCLC) if you have any questions, and
you'll be in a better position to decide whether continued
breastfeeding is for you.
IF YOU START WEANING AT 3 OR 4 MONTHS, her digestive system will
have matured a great deal, and she will be much better able to
tolerate the foreign substances in commercial formulas. Giving
nothing but your milk for the first four months gives strong
protection against ear infections for a whole year. If there is
a family history of allergies, though, you will greatly reduce
her risk by waiting a few more months before adding anything at
all to her diet of breastmilk.
IF YOU BREASTFEED YOUR BABY FOR 6 MONTHS without adding any
other food or drink, she will be much less likely to suffer an
allergic reaction to formula or other foods. The American
Academy of Pediatrics and the World Health Organization
recommend waiting until about 6 months to start solids.
Breastfeeding for at least 6 months helps ensure better health
throughout your baby's first year of life, reduces your little
one's risk of ear infections and childhood cancers, and reduces
your own risk of breast cancer. And exclusive, frequent
breastfeeding during the first 6 months, if your periods have
not returned, provides 98% effective contraception.
IF YOU BREASTFEED YOUR BABY FOR 9 MONTHS, you will have seen him
through the fastest and most important brain and body
development of his life on the food that was designed for him -
your milk. Nursing for at least this long will help ensure
better performance all through his school years. Weaning may be
fairly easy at this age... but then, so is nursing! If you want
to avoid weaning this early, be sure that, from the start, you
breastfeed willingly to provide comfort, not just to provide
food.
(continued on other side)
IF YOU BEGIN WEANING YOUR BABY AT A YEAR, you can avoid the
expense and bother of formula. Her one-year-old body can
probably handle most of the table foods your family enjoys. Many
of the health benefits this year of nursing has given your child
will last her whole life. She will have a stronger immune
system, for instance, and will be much less likely to need
orthodontia or speech therapy. The American Academy of
Pediatrics recommends breastfeeding for at least a year, because
it helps ensure normal nutrition and health for your baby.
IF YOU BEGIN WEANING YOUR BABY AT 18 MONTHS, you will have
continued to provide the nutrition, comfort, and illness
protection your baby expects, at a time when illness is common
in formula-fed babies. Your baby is probably well started on
table foods, too. He has had time to form a solid bond with you
- a healthy starting point for his growing independence. And he
is old enough that you and he can work together on the weaning
process, at a pace that he can handle. A former U.S. Surgeon
General said, "it is the lucky baby... that nurses to age two."
IF YOUR CHILD WEANS WHEN SHE IS READY, you can feel confident
that you have met your baby's physical and emotional needs in a
very normal, healthy way. In cultures where there is no pressure
to wean, children tend to breastfeed for at least two years. The
World Health Organization and UNICEF strongly encourage
breastfeeding through toddlerhood: "Breastmilk is an important
source of energy and protein, and helps to protect against
disease during the child's second year of life." Our biology
seems geared to a weaning age of between 2 1/2 and 7 years, and
it just makes sense to build our children's bones from the milk
that was designed for them. Your milk provides antibodies and
other protective substances as long as you continue nursing, and
families of breastfeeding toddlers often find that their medical
bills are lower than their neighbors' for years to come.
Research indicates that the longer a child breastfeeds, the
higher his intelligence. Mothers who nurse longterm have a still
lower risk of developing breast cancer. Children who were nursed
longterm tend to be very secure, and are less likely to suck
their thumbs or carry a blanket. Breastfeeding eases both of you
through the tears, tantrums, and tumbles that come with early
childhood, and helps ensure that any illnesses are milder and
easier to deal with. It's an all-purpose mothering tool you
won't want to be without! Don't worry that your child will
breastfeed forever. All children stop on their own, no matter
what you do, and there are more nursing youngsters around than
you might guess.
WHETHER YOU NURSE FOR A DAY OR FOR SEVERAL YEARS, the decision
to breastfeed your child is one you will never regret. And
whenever weaning takes place, remember that it is a big step for
both of you. If you feel you must wean before your child is
ready, be sure to do it gradually, and with love.
©2006 Diane Wiessinger, MS, IBCLC
www.normalfed.com Used by permission of the author.
Back to Top
|
