- How to Choose Ante Natal Class ?
- Finding a Breastfeeding Support Person
- The artificial labor-inducing hormone Pitocin may have unexpected risks for newborn babies
- EPIDURALS- Real Risk for Mother and Babies
- Episiotomy: Advantages and Disadvantages
- Understanding Episiotomy
- What is an episiotomy?
- What are the advantages of episiotomy?
- What are the disadvantages of routine episiotomy?
- Why are Kegel exercises important during pregnancy?
- Can a first time mom realistically avoid an episiotomy?
- What is the Evidence for Pushing Positions?
- Breastfeeding- Start Out Right
- Is My Baby Getting Enough Milk?
- Blocked Ducts & Mastitis
- Breast Abscess
- Breastfeeding and Illness
- Breastfeeding and Medications
- Breastfeeding and Other Foods
- Colic in the Breastfed Baby
- Breastfeeding and Storage Guidelines
- Myths and Breastfeeding
- Nipple Shield
- Immunization Schedule
- Cup feeding Video
- Breastfeeding Apps
- Useful Links
How to Choose Ante Natal Class ?
Do a bit of research to learn about the different childbirth education classes where you live. Talk to your healthcare provider, visit your local library or search online for information about the philosophy behind various approaches.
. Decide the approach you prefer, then ask these questions:
- Are you a certified childbirth educator?
- How long have you been teaching?
- What other classes do you teach?
- Where do you teach classes?
- What is your childbirth philosophy?
- What will I learn in the class?
- What method of childbirth education is taught? Does the course advocate a specific childbirth approach?
- What topics does the curriculum cover?
- Are breathing and relaxation taught?
- Does the class help women and their partners create a birth plan?
- Is this course for new parents, or is it more of a refresher?
- Is my partner expected to play a role in the birth? Will the environment be welcoming and comfortable, regardless if my childbirth partner is my spouse, partner, relative or friend?
- How is each class broken down between lecture, discussion and practice?
- How much does the course costs?
- How often does the class meet?
- For how many weeks does the class meet?
- How many other couples are in the class?
- When do you recommend that pregnant women begin the class?
- How far in advance do you recommend that I register to reserve a place? Do the classes fill up quickly?
Finding a Breastfeeding Support Person
Lactation Consultants are International Board Certified Lactation Consultants this means they are registered Lactation Consultants, IBCLC, RLC who are required to keep current with breastfeeding information and must recertify every five years. We provide hands-on clinical support and are trained to work with all breastfeeding-related problems. In order to certify we must have many thousands of hours of practical hands-on training and must have completed many education credits to write the international exam in the first place.
Breastfeeding Promoting Network of India BPNI works towards training of health professionals and community workers to protect promote and support breastfeeding. BPNI coordinates and facilitates the education and training of grassroots personnel in health and nutrition sector, both public and private hospitals as well. BPNI works to enhance the quality of BFHI through improved training.
HOW TO CHOOSE A GOOD and HELPFUL BREASTFEEDING-SUPPORT PERSON
- When you seek help from a Lactation Consultant (LC), you should not feel that she is mainly trying to rent or sell you some product. The Lactation Consultant is there to help you with your breastfeeding problem, and very often help does not require any products. Even if you do need to rent a pump, for example, you should not feel that the lactation consultant is focussing on sales or rentals. Certainly, if she does sell you a pump or product, this sale time should not be included in her hourly fee.
- No matter what your problem, a good LC should not be telling you that you cannot breastfeed. We hear of some Lactation Consultants and doctors telling mothers they cannot breastfeed. Do not believe them. If you have nipples you can breastfeed. Women are often told they must stop or interrupt breastfeeding due to illness or a medication they are taking or a test they must undergo–this is only very rarely true. See handouts You Should Continue Breastfeeding 1 and 2.
- No LC or breastfeeding-support person should ever bring formula with her to your home. LCs are not allowed to distribute formula samples or recommend a formula by name. Ask her ahead of time if she intends to bring some formula samples with her. This may be an indication of her true support for breastfeeding.
- Nipple shields and bottles are being used much too often to try to fix breastfeeding problems, even though they can, very occasionally, be useful. Nipple shields should never be used for the baby who refuses to latch on before the mother’s milk ‘comes in’ on day three or four (or sometimes later). Once the milk ‘comes in’, many babies will latch on easily without a nipple shield. There are usually better ways of supplementing or feeding babies than using a bottle. Be sceptical if you LC is quick to use a nipple shield. Patience, perseverance, and good technique are almost always good enough to get any baby latched. See handout When Baby Refuses To Latch On.
- REMEMBER to Get the best Start: Try to ensure and aim for the most natural labour possible. A good Midwife or Doula may be an invaluable way to achieve that goal.
BE WARY IF:
You are told to feed x number of minutes per side
- Babies can feed well being on the breast short periods of time, and can feed poorly being on the breast all day
- Timing is meaningless and tells us nothing about what the baby is actually getting and whether or not it is enough
You are told to feed x number of times per day
- A baby who feeds well 6 times a day is better off than a baby who feeds poorly 12 times a day
- There are no studies to support the claim that a baby must feed 8-12 x/24 hour period. None whatsoever.
You are told to wake the baby every x number of hours
- A baby who feeds well will wake up when he’s ready; if a baby feeds so poorly that he won’t wake up on his own, there is no point in waking him up so he feeds poorly more times a day; the point is to get the baby feeding well.
Your breastfeeding-support person weighs the baby before and after each feeding
- What does this tell us? Even if the scales could be relied on as always accurate—so what? A 15 gm gain, for example, may mean baby consumed 15 mls of breastmilk—but what kind of breastmilk? 10 am breastmilk? 3pm breastmilk? Tuesday’s breastmilk? The beginning of the feeding breastmilk? The end? What? Ensure baby is actually drinking instead of just sucking, and follow our Protocol to Increase Intake of Breastmilk. Watch the video clips at www.drjacknewman.com. That’s how you will know baby has had enough.
- Test weighs have been known to show many false negatives. See Handout Is my Baby Getting Enough?
Your breastfeeding-support person tells you that sore nipples are normal and you need to endure it, or that your nipples need to “toughen” up or that your skin is overly sensitive, or, if you are a red-head, that you are supposed to have overly-sensitive nipples
- A good latch prevents and fixes sore nipples
- Pain that endures for many weeks may mean there is something else going on—please see a Lactation Consultant to get this checked out
- Nipple shields are not usually an appropriate remedy for sore nipples
- Skin colour is irrelevant
Your breastfeeding support person asks you to finger feed after you breastfeed your baby
- If a baby needs supplementation then that baby should be supplemented at the breast as long as the baby is latching. Finger feeding is not an appropriate method of feeding a latching baby.
The artificial labor-inducing hormone Pitocin may have unexpected risks for newborn babies
New preliminary research raises concerns that Pitocin, a synthetic branded version of the natural hormone oxytocin that is commonly used to induce pregnant woman into labor, may not be as safe for newborn babies as previously assumed.
The study finds a link between Pitocin-induced infant deliveries and adverse short-term health effects like lower Apgar scores, which test a newborn’s physical condition immediately after birth.
Researchers say that the study, presented by Dr. Michael S. Tsimis on May 7 at the 2013 conference of The American College of Obstetricians and Gynecologists in New Orleans, is the first to analyze data on Pitocin’s side effects on newborn babies.
“As a community of practitioners, we know the adverse effects of Pitocin from the maternal side,” said Tsimis in a news release, “but much less so from the neonatal side.”
Dr. Tsimis led researchers at Beth Israel Medical Center in New York City in a retrospective analysis of 3,000 full-term infant deliveries that were induced or augmented with Pitocin from 2009 to 2011.
They correlated the use of Pitocin with incidences of events on the Adverse Outcome Index, which measures unexpected outcomes around the childbirth period like maternal and neonatal death rates, birth trauma, blood transfusions, and neonatal ICU admissions.
Analysis indicated that inducing labor with Pitocin was linked to a higher likelihood of a newborn’s unexpected admission to the neonatal intensive care unit (NICU) for over 24 hours, and was also a significant risk factor for Apgar scores of less than 7 at five minutes.
Apgar scores evaluate babies’ health at one and five minutes after birth based on indicators like skin coloration, heart rate, grimace response, muscle tone, and breathing rate. While a score of 8 to 10 is a good sign, scores less than 7 indicate that the baby needs medical attention.
The Apgar is not predictive of future health problems, but newborns with lower Apgar scores may need immediate treatment like oxygen or physical stimulation to promote healthy heart rate.
“These results suggest that Pitocin use is associated with adverse effects on neonatal outcomes,” said Dr. Tsimis in the news release.
Oxytocin is a vital natural hormone, flooding an expectant mother’s body to promote uterine contractions during the process of childbirth.
Pitocin, a synthetic form of oxytocin that is intravenously delivered to pregnant women, is meant to induce labor when they are overdue. It can also augment difficult labor by strengthening and speeding up uterine contractions, and reduce excessive blood loss after vaginal birth.
Common side effects of Pitocin for mothers include irritation at the injection site, appetite loss, nausea, vomiting, and cramping.
While suggestive, Dr. Tsimis’s findings about Pitocin are inconclusive about what caused the babies’ higher risk of NICU admissions and lower Apgar scores.
Dr. Christopher Colby, chair of the division of neonatal medicine at the Mayo Clinic Children’s Center, told the Huffington Post that the study is not definitive enough to offer conclusions about Pitocin’s safety for newborns.
“These findings could be explained if oxytocin was being used more commonly to deliver babies at earlier gestational ages or if the unborn baby was experiencing distress in utero,” he explained.
A 2011 review of Pitocin deliveries found that the drug has no side effects for mothers or babies, and was generally effective in shortening labor.
At the New Orleans conference, Dr. Tsimis said that his findings are not strong enough to discourage Pitocin as a method of inducing labor.
Still, he suggests that more research is warranted to examine the risk of Pitocin’s side effects for newborn babies and define a much more systematic and informed process for determining when it is medically necessary to induce labor.
EPIDURALS- Real Risk for Mother and Babies
Epidural pain relief is an increasingly popular choice . Up to one-third of all birthing women have an epidural1, and it is especially common amongst women having their first babies2. For women giving birth by caesarean section, epidurals are certainly a great alternative to general anaesthetic, allowing women to see their baby being born, and to hold and breastfeed at an early stage: however their use as a part of a normal vaginal birth is more questionable3.
There are several types of epidural . In a conventional epidural, a dose of local anaesthetic is injected through the lower back into the epidural space, around the spinal cord. This numbs the nerves which bring sensation from the uterus and birth canal. Unfortunately, the local anaesthetic also numbs the nerves which control the pelvic muscles and legs, so with this type of epidural, a woman usually cannot move her legs and, unless the epidural has worn off, cannot push her baby out, in the second stage of labour.
More recent forms of epidurals use a lower dose of local anaesthetic, usually combined with an opiate, such as pethidine, morphine or fentanyl (sublimaze). With this low-dose or combination epidural, most women can move around with support; however the chance of a woman being able to give birth without forceps is still low4. Another form of epidural, popular in the US, is the CSE, or combined spinal-epidural, where a one-off dose of opiate, with or without local anaesthetic, is injected into the spinal space, very close to the end of the spinal cord. This gives pain relief for around 2 hours, and if further pain relief is needed, it is given as an epidural. These forms of “walking epidural” may seem advantageous, but being attached to a CTG machine to monitor the baby, and hooked up to a drip which is also a requirement when an epidural is in place, can make walking impossible.
Many women have a good experience with epidurals. Sometimes the relief from pain can allow a woman to rest and relax sufficiently to go on and have a good birth experience. However deciding to use an epidural for pain relief can also lead to a “cascade of intervention”, where an otherwise normal birth becomes highly medicalised, and a woman feels that she loses her control and autonomy. Often the decision to accept an epidural is made without an awareness of these, and other, significant risks to both mother and baby.
Although the drugs used in epidurals are injected around the spinal cord, substantial amounts enter the mother’s blood stream, and pass through the placenta into the baby’s circulation. Most of the side effects of epidurals are due to these “systemic”, or whole-body effects.
One of the most commonly recognised side effects is a drop in blood pressure. Up to one woman in 8 will have this side effect to some degree5, and for this reason, extra fluids are usually given through a drip to prevent problems. A drop in the mother’s blood pressure will affect how much of her blood is pumped to the placenta, and can lead to less oxygen being available to the baby.
An epidural will often slow a woman’s labour, and she is three times more likely to be given an oxytocin drip to speed things up6 7. The second stage of labour is particularly slowed, leading to a three times increased chance of forceps8. Women having their first baby are particularly affected; choosing an epidural can reduce their chance of a normal delivery to less than 50%9.
This slowing of labour is at least partly related to the effect of the epidural on a woman’s pelvic floor muscles. These muscles guide the baby’s head so that it enters the birth canal in the best position. When these muscles are not working, dystocia, or poor progress, may result, leading to the need for high forceps to turn the baby, or a caesarean section. Having an epidural doubles a woman’s chance of having a caesarean section for dystocia10.
When forceps are used, or if there is a concern that the second stage is too long, a woman may be given an episiotomy, where the perineum, or tissues between the vaginal entrance and anus, are cut to enlarge the outlet and hurry the birth. Stitches are needed and it may be painful to sit until the episiotomy has healed, in 2 to 4 weeks.
As well as numbing the uterus, an epidural will numb the bladder, and a woman may not be able to pass urine, in which case she will be catheterised. This involves a tube being passed up from the urethra to drain the bladder, which can feel uncomfortable or embarrassing.
Other side effects of epidurals vary a little depending on the particular drugs used. Pruritis, or generalized itching of the skin, is common when opiate drugs are given. It may be more or less intense and affects at least ¼ of women11 12: morphine or diamorphine are most likely to cause this. Morphine also causes oral herpes in 15% of women13 .
All opiate drugs can cause nausea and vomiting, although this is less likely with an epidural (around 30%14) than when these drugs are given into the muscle or bloodstream, where larger doses are needed. Up to 1/3 of women with an epidural will experience shivering15, which is related to effects on the bodies heat- regulating system.
When an epidural has been in place for more than 5 hours, a woman’s body temperature may begin to rise16. This will lead to an increase in both her own and her baby’s heart rate, which is detectable on the CTG monitor. Fetal tachycardia, or fast heart rate can be a sign of distress, and the elevated temperature can also be a sign of infection such as chorioamnionitis, which affects the uterus and baby. This can lead to such interventions as caesarean section for possible distress or infection, or, at the least, investigations of the baby after birth such as blood and spinal fluid samples, and several days of separation, observation, and possibly antibiotics, until the results are available17.
Less common side effects for a woman having an epidural are; accidental puncture of the dura, or spinal cord coverings, which can cause a prolonged and sometimes severe headache (1 in 100)18 ongoing numb patches, which usually clear after 3 months(1 in 550)19; and weakness and loss of sensation in the areas affected by the epidural, (4-18 in 10,000) also usually resolving by 3 months20.
More serious but rare side effects include permanent nerve damage; convulsions and heart and breathing difficulties (1 in 20,000)21 and death attributable to epidural. (1 in 200,000)22 When opiates are used, a woman may experience difficulty in breathing which comes on 6 to 12 hours later23.
There is a noticeable lack of research and information about the effects of epidurals on babies24. Drugs used in epidurals can reach levels at least as high as those in the mother25, and because of the baby’s immature liver, these drugs take a long time- sometimes days- to be cleared from the baby’s body26. Although findings are not consistent, possible problems, such as rapid breathing in the first few hours27 and vulnerability to low blood sugar28 suggest that these drugs have measurable effects on the newborn baby.
As well as these effects, babies can suffer from the interventions associated with epidural use; for example babies born by caesarean section have a higher risk of breathing difficulties29. When monitoring of the heart rate by CTG is difficult, babies may have a small electrode screwed into their scalp, which may not only be unpleasant, but occasionally can lead to infection.
There are also suggestions that babies born after epidurals may have difficulties with breastfeeding30 31 which may be a drug effect, or may relate to more subtle changes. Studies suggest that epidurals interfere with the release of oxytocin32 which, as well as causing the let-down effect in breastfeeding, encourages bonding between a mother and her young33.
Epidural research, much of it conducted by the anaesthetists who administer epidurals, has unfortunately focussed more on the pro’s and con’s of different drug combinations than on possible serious side-effects34. There have been, for example, no rigorous studies showing whether epidurals affect the successful establishment of breastfeeding35.
Several studies have found subtle but definite changes in the behaviour of newborn babies after epidural36 37 38 with one study showing that behavioural abnormalities persisted for at least six weeks39. Other studies have shown that, after an epidural, mothers spent less time with their newborn babies40, and described their babies at one month as more difficult to care for41.
While an epidural is certainly the most effective form of pain relief available, it is worth considering that ultimate satisfaction with the experience of giving birth may not be related to lack of pain. In fact, a UK survey which asked about satisfaction a year after the birth found that despite having the lowest self-rating for pain in labour (29 points out of 100), women who had given birth with an epidural were the most likely to be dissatisfied with their experience a year later42.
Some of this dissatisfaction was linked to long labours and forceps births, both of which may be a consequence of having an epidural. Women who had no pain relief reported the most pain (70 points out of 100) but had high rates of satisfaction.
Pain in childbirth is real, but epidural pain relief may not be the best solution. Talk about other options with your care-givers and friends. With good support, and the use of movement, breathing and sound, most women can give themselves, and their babies, the gift of a birth without drugs.
Episiotomy: Advantages and Disadvantages
Episiotomy can prevent significant childbirth injury and should be used for some women. However, making episiotomy a routine practice is unnecessarily traumatic. Childbirth without tearing (or the need for stitches) is possible in many women, including first time moms! The problem is that until the baby’s head crowns and progressive, gentle stretching of the perineum is performed, one cannot determine if the baby’s head will slowly slide out or if an episiotomy is indicated.
What is an episiotomy?
Episiotomy is a minor surgical procedure in which an incision is made to enlarge the vaginal opening just prior to the birth of the baby. Midline episiotomy is made from the vaginal opening down towards the rectum, whereas a mediolateral episiotomy angles off towards the side away from the rectum. Episiotomy was developed in Ireland in 1742 for difficult childbirth, but had not been in wide use until the early to mid 1900s. Today, it is estimated that episiotomy is utilized in 80-90% of first time births and 50% of subsequent births.
What are the advantages of episiotomy?
When used properly, episiotomy can prevent more extensive childbirth injury. A single cut edge is easier to surgically repair than an extensive jagged edge, or multiple jagged edges. Episiotomy can shorten pushing by 15-30 minutes, critical in the case of fetal distress and helpful with maternal exhaustion. The use of episiotomy in difficult births, such as shoulder dystocia (trapped shoulders), can prevent permanent and disfiguring injury to the baby. Proponents of routine episiotomy believe it can lessen stretching of vaginal muscles, which can result in long term laxity.
What are the disadvantages of routine episiotomy?
Episiotomy used routinely can result in unnecessary trauma. Specifically, the incision may be more extensive than a small tear and certainly more extensive than no tear. This results in more bleeding, especially with mediolateral episiotomy. Healing after episiotomy is painful and can result in painful intercourse. Opponents to routine episiotomy believe that the stretching of the vaginal muscles have already occurred prior to the time of potential episiotomy, and that the performance of an episiotomy is of no help to prevent vaginal muscle laxity. Kegel exercises before and after childbirth best protect vaginal muscle integrity.
Why are Kegel exercises important during pregnancy?
During pregnancy, Kegel exercises strengthen and tone the pelvic floor muscles, which eases childbirth. After birth, they restore vaginal integrity, and improve sexual performance and satisfaction. Arnold Kegel, an American obstetrician-gynecologist, developed “Kegel” exercises more than fifty years ago to strengthen the pubovisceral muscles of the pelvic floor. These muscles surround the vagina. The technique is simple: contract and relax the muscles in quick succession for 10 seconds, then rest for 10 seconds. Next contract and hold the pelvic floor muscles for 10 seconds then rest for 10 seconds. Repeat the routine as many times as you can until fatigue, because when you tire, you cease to perform the exercise correctly. A woman can be certain she is using the correct muscles by stopping urination mid-stream or by placing a finger in her vagina and squeezing it. Do at least 25 repetitions at various times throughout the day, gradually increasing the total number to 100-150.
Can a first time mom realistically avoid an episiotomy?
Absolutely! The vagina is remarkably elastic and can stretch to a surprising degree. The key to preventing episiotomy and perineal trauma is slow, controlled delivery of the baby’s head while gently stretching the vaginal opening. The delivering physician must be extremely patient to wait for this stretching to occur. In our experience using this technique, 75% of first time moms and 90% of those with subsequent births, have avoided episiotomy and have required only minimal stitches, if any. The decision of whether or not an episiotomy is indicated for you should not take place in the office but rather in the delivery room. Talk with your doctor.
What is the Evidence for Pushing Positions?
Researchers hypothesize that pushing in an upright position is beneficial for multiple reasons. In an upright position, gravity can assist in bringing the baby down and out. Also, when a woman is upright, there is less risk of compressing the mother’s aorta and thus a better oxygen supply to the baby. Upright positioning also helps the uterus contract more strongly and efficiently and helps the baby get in a better position to pass through the pelvis. Finally, X-ray evidence has shown that the actual dimensions of the pelvic outlet become wider in the squatting and kneeling/hands-knees positions (Gupta et al. 2012).
However, despite these proposed benefits of pushing in an upright position, most women in the U.S. give birth either lying on their backs (57%) or in a semi-sitting/lying position with the head of the bed raised up (35%). A small minority of women give birth in alternative positions such as side lying (4%), squatting or sitting (3%), or hands-knees position (1%) (Declercq, Sakala et al. 2007).
It is thought that most women are encouraged to push in a lying or semi-sitting positions because it is more convenient for the care provider. When women are lying or semi-lying in bed, it is easier to access the woman’s abdomen to monitor the fetal heart rate. Care providers are also more comfortable with the lying or semi-sitting position because this is how many of them are trained to attend births (Gupta et al. 2012). This caregiver preference for non-upright positions has persisted, despite the fact that current major obstetric textbooks state that it is beneficial for women to push in upright positions, especially for first-time moms (Kilpatrick and Garrison 2012)
For a woman who does not have an epidural, which pushing positions are best supported by evidence?
In a 2012 Cochrane review, Gupta et al. pooled the results of 22 randomized, controlled studies that included more than 7,200 women. In these studies, women were randomly assigned to either upright or non-upright positions during pushing. Researchers defined upright positions as sitting (on a birthing stool or cushion), kneeling, and squatting. They defined non-upright positions as side-lying, semi-sitting/lying (in bed with the head of the bed raised up) and lithotomy (back-lying with feet up in stirrups or feet supported by care providers’ hands).
The overall quality of these studies was mixed with some poor-quality studies included. The researchers state that this weakness makes their conclusions tentative. However, the researchers controlled for the quality of the study by running “sensitivity analyses,” which means that they re-ran the statistics using only good-quality studies. When they did so, the results stayed the same.
In comparison with non-upright positions, women who were randomly assigned to upright positions were:
- 23% less likely to have a forceps or vacuum-assisted delivery
- 21% less likely to have an episiotomy
- 35% more likely to have a second-degree tear*, except when a “birth cushion” is used, in which case there was no additional risk of tearing
- 54% less likely to have abnormal fetal heart rate patterns
- 65% more likely to have blood loss greater than 500 mL**
There were no differences between groups with duration of pushing, Cesarean section rates, third or fourth degree perineal tears, need for blood transfusion, admission to neonatal intensive care units, or perinatal deaths.
*The lower risk of episiotomies in women who give birth in upright positions was offset by a higher risk of second degree tear. However, since other researchers have found strong evidence that tears heal easier and are less traumatic to tissue than episiotomies (Carroli and Mignini 2009), a higher second degree tear rate in exchange for a lower episiotomy rate is a good trade-off. This may be particularly true with care providers who have high episiotomy rates. On the other hand, there are many care providers and settings with very low episiotomy rates, so this finding about the lower risk of episiotomy might not be applicable to women in those settings.
**Researchers found that women in the upright group were 65% more likely to have an estimated blood loss greater than 500 mL. The researchers questioned the accuracy of this finding because the blood loss was based on care provider estimates, which is not an accurate way of measuring blood loss. As mentioned earlier, there were no differences in the need for blood transfusion between groups.
Researchers were not able to compare the side-lying position by itself to other upright and non-upright positions. So we cannot assess the effects of the side-lying position from this Cochrane review.
In summary, researchers concluded that upright positions were more efficient than non-upright positions, as evidenced by the decreased risk of vacuum-assisted delivery, forceps use, and episiotomy. The bottom line was that women without an epidural should be encouraged to push in whatever position is most comfortable for them.
For a woman who has an epidural, which pushing positions are best supported by evidence?
Almost three-quarters of women in the U.S. (71%) receive an epidural during childbirth (Declercq et al. 2007). There have been only two randomized, controlled trials that compared upright versus non-upright pushing positions in women with epidurals. Results from both studies show that being upright during the second stage of labor shortens labor in women with epidurals.
Karraz et al. (2003) randomly assigned 221 women with walking epidurals into either an upright group (walking, sit in a chair, or semi-lying) or a non-upright group (not allowed to sit or get out of bed). The upright group was encouraged to mobilize throughout labor (not just during pushing), and had a significantly shorter overall time from epidural insertion to delivery (173 minutes versus 236 minutes). There were no other differences in outcomes between the two groups.
In a smaller study, Golara et al. (2002) randomized 66 first-time mothers with walking epidurals to be upright (walk or stand at least 30 minutes) or remain lying down during the second stage of labor. They found that women who were upright during pushing had a significantly shorter pushing time—51 minutes versus 73 minutes. There were no significant differences between groups with any other outcomes that were measured (Golara, Plaat et al. 2002).
Overall, evidence suggests that women with walking epidurals are capable of mobilizing during the second stage of labor, and that women who are upright are more likely to have a shorter labor and pushing phase. However, the research for pushing positions with epidurals is quite limited. The two studies that discussed above only focused on women with walking epidurals—these are women who are able to actually get up and move around with support. No studies have compared upright positions (such as a supported squat), side-lying positions, or back-lying and semi-lying positions in women with traditional epidurals.
However, as the video below shows, it is possible for women to push in many different positions with an epidural. Also, many hospital beds can form and shape to different positions, making it easier for a woman with an epidural to push in positions other than lying down. For example, one manufacturer makes a maternity bed that can be used for upright sitting, squatting, McRobert’s maneuver, lithotomy, side-lying, knee/chest, kneeling, and leaning forward positions.
Summary of the Evidence:
- For women without an epidural, pushing in an upright position is associated with a decrease in the risk of episiotomies, vacuum and forceps-assisted deliveries, and fetal heart rate abnormalities, an increase in the risk of second-degree tears, and a possible increase in the risk of having blood loss more than 500 mL
- Women with walking epidurals who push in upright positions may experience a shortened labor and pushing phase
- More evidence is needed to evaluate pushing positions in women with traditional (non-walking) epidurals
- The take home message is that women should push in any position they find comfortable– it is not necessary to be continuously upright or continuously lying down during the pushing phase
The following videos are presented only to demonstrate some of the different pushing positions that are possible– not to advocate for one type of position over the other (see final take home message above).
Here is a nice video with examples of how a woman with an epidural can be assisted into different pushing positions
This video by Lamaze International demonstrates how women without an epidural can push in upright positions
Breastfeeding- Start Out Right
Breastfeeding is the natural and normal way of feeding infants and young children, and human milk is the milk made specifically for human infants.
Starting out right helps to ensure breastfeeding is a pleasant experience for both you and your baby. Breastfeeding should be easy and trouble free for most mothers.
The vast majority of mothers are perfectly capable of breastfeeding their babies exclusively for about six months. In fact, most mothers should be able to produce more than enough milk. Unfortunately, outdated hospital policies and 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. Too frequently also, these mothers blame themselves. For breastfeeding to be well and properly established, getting off to the best start from the first days can make all the difference in the world. Of course, even with a terrible start, many mothers and babies manage. And yes, many mothers just put the baby to the breast and it works just fine.
The basis of 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 milk supply is not abundant. The milk supply is not abundant in the first days after birth; this is normal, as nature intended, but if the baby’s latch is not good, the baby has difficulty getting the milk. It is for this reason that so many mothers “don’t have enough colostrum”. The mothers almost always do have enough colostrum but the baby is not getting what is there. Babies don’t need much milk in the first few days, but they need some.
Even if the mother’s milk production is plentiful, trying to breastfeed a baby with 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 or will get it very slowly—so the baby sucking at the breast may spend long periods on the breast or return to the breast frequently or not be happy at the breast, all of which may convince the mother she doesn’t have enough milk, which is most often not true.
When a baby is latching on poorly, he may also cause the mother nipple pain. And if, at the same time, he does not get milk well, he will usually stay on the breast for long periods, thus aggravating the pain. Too often the mothers are told the baby’s latch is perfect, but it’s easy to say that the baby is latched on well even if he isn’t. Mothers are also getting confusing and contradictory messages about breastfeeding from books, magazines, the internet, family and health professionals. Many health professionals actually have had very little training on how to prevent breastfeeding problems or how to treat them should they arise. Here are a few ways breastfeeding can be made easier:
- The baby should be skin-to-skin with the mother and have access to the breast immediately after birth. The vast majority of newborns can be skin-to-skin with the mother and have access to 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 only a few minutes or take up to an hour or longer, but the mother and baby should be given this time (at least the first hour or two) 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.
- The baby should be kept skin to skin with mother as much as possible immediately after birth and for as much as possible in the first few weeks of life. Incidentally, studies have also shown that skin-to-skin contact between mothers and babies keeps the baby as warm as an incubator (see paragraph on skin-to-skin contact, below, and the information sheet The Importance of Skin-to-Skin Contact). It is true that many babies do not latch on and breastfeed during this time but 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 and very important for the baby and the mother even if the baby does not latch on.
- Skin-to-skin contact helps the baby adapt to his new environment: the baby’s breathing and heart rate are more normal, the oxygen in his blood is higher, his temperature is more stable and his blood sugar higher. Furthermore, there is some good evidence that the more babies are kept skin-to-skin in the first few days and weeks of life (not just during the feedings) the better their brain development will be. As well, it is now thought that the baby’s brain develops in certain ways only due to this skin-to-skin contact, and this important growth happens mostly in the first 3-8 weeks of life.
- 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 baby’s latch is good despite your having very sore nipples, be sceptical and ask for help from someone else. 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 the videos on how to latch a baby on. There are also video clips of babies younger than 48 hours who are breastfeeding not just sucking. If you and the baby are leaving hospital not knowing this, get experienced help quickly (see also the information sheet When Latching).
Note: Mothers are often told 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 and again and again… This is not a good idea. Instead of delatching and relatching, fix the latch that you have as best you can by pushing the baby’s bottom into your body with your forearm. The baby’s head is tipped back so the nose is in ‘sniffing position’. If necessary, you might try gently pulling down the baby’s chin so he has more of the breast in his mouth. If that doesn’t help, do not take the baby off the breast and relatch him several times, because usually, the pain diminishes anyway. The latch can 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 and the mother’s and baby’s frustration.
- 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, even after caesarean section. Health facilities that have routine separations of mothers and babies after birth are not doing right by the mothers and babies. Studies showing that rooming-in 24 hours a day results in better breastfeeding success, less frustrated babies and happier mothers date back to the 1930’s. Too often, irrelevant excuses are given why baby should be separated from the mother. 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”.
- Separation of mother and baby so the mother can rest. There is no evidence that mothers who are separated from their babies are better rested. On the contrary, the mothers are better 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’s feeding cues. 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, often being in light sleep in sync with her baby, will wake up, her milk will start to flow and the calm baby will usually go to the breast contentedly. 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 breastfeeds. Breastfeeding should be relaxing, not tiring.
- Bathing. There is no reason the baby needs to be bathed immediately after birth and bathing can be delayed for several hours. Immediately after birth, the baby can be dried off but it is not a good idea to wash or wipe off the creamy layer on the baby’s skin (vernix) that has been shown to protect his delicate skin. It is best to wait at least until the mother and baby have had a chance to get breastfeeding well started, with baby coming to the breast and latching easily. Furthermore, diapering a baby before a feed is not advised as it often causes the baby to become upset. Mothers are sometimes told diapering will help the baby to wake up. It is not necessary to wake the baby for feedings. If the baby is skin-to-skin with the mother, the baby will wake when ready and search for the breast. A baby who is feeding well will let the mother know when he is ready for the next feed. Feeding by the clock makes no sense.
- Artificial nipples should not be given to the baby. There seems to be some controversy about whether “nipple confusion” exists. 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. Babies like fast flow. You don’t have to be a rocket scientist to figure that one out and the baby will very quickly. By the way, 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 the information sheets Lactation Aid, and Finger and Cup Feeding) why use an artificial nipple? Using a lactation aid, finger feeding or cup feeding to supplement when the baby does not need a supplement is only marginally better than using a bottle to supplement.
- No restriction on length or frequency of breastfeedings. A baby who drinks well will not be on the breast for hours at a time (see the video clips of very young babies getting milk very well). Thus, if the baby is on the breast for very long periods of time, 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 (See the information sheet 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 or nurses’ station, will help. Babies often feed frequently in the first few days of life—this is normal and temporary. In fact, babies tend to feed frequently during the first few days especially in the evening or night-time. This is normal and helps to establish the milk supply and facilitate mother’s uterus returning to normal. Latching a baby well, using compressions, and maintaining skin to skin contact between mother and baby helps this transitional period to go smoothly.
- Supplements of 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 “convenience” or due to outdated hospital policies. If supplements are required, they should be given by lactation aid at the breast (see the information sheet Lactation Aid), not cup, finger feeding, syringe or bottle.
- 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.
Not latching/Not breastfeeding? If for some reason baby is not taking the breast, then start expressing your colostrum by hand (often much more effective than using even a hospital grade pump) should be started within 6 hours or so after birth, or as soon as it becomes apparent baby will not be feeding at the breast.
Is My Baby Getting Enough Milk?
Breastfeeding mothers frequently ask how to know their babies are getting enough milk.The breast is not the bottly , 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.And this is a good thing!!
We are not supposed to know how much the baby is getting but rather is baby getting enough. 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. In the short term, there are ways to know if baby is satisfied by looking at how well the baby feeds, and even just looking at the baby after a feeding – is the baby content, satisfied, is he rooting or sucking his hand?
Ways of Knowing
- Baby’s breastfeeding 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 type of sucking). 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 can recognize this pause you will realize that so much of what women are told about timing the baby on the breast is meaningless. For example, it is meaningless to suggest to mothers to feed the baby twenty minutes on each side. Twenty minutes of what? Sucking without drinking? Sucking and drinking (some pausing in the movement of the chin)? All long pause-types of sucks? 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. Our website nbci.ca shows video clips of drinking at the breast. If the baby comes off the breast while doing this kind of drinking with long pauses, then baby is probably saying, I have had enough. If baby is continually just sucking without drinking (therefore little or no pausing) baby will still be hungry. Play detective, what is baby’s chin doing as he seems to “finish”? If the milk is flowing well the baby can either choose to drink it or take a little break (in fact the baby does not need to suck continuously and most babies do not). If the milk is not flowing well, then baby will be ‘forced’ to just suck without drinking. If this is the case, use compression to help more milk to flow .
- Baby’s bowel movements (stools, poops). For the first few days after birth, the baby passes meconium, a dark green, almost black, substance which has collected in his intestines during pregnancy. It is passed during the first few days, and by the third day, the bowel movements start becoming lighter, as the baby drinks more milk. Usually by the fourth 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 (full of air bubbles). The variations in colour do not mean something is wrong. A baby who is getting only breastmilk, 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 movements is one of the best ways, next to observing the baby’s drinking (see above, and videos at nbci.ca to see 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 a very reliable sign.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 20 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 if possible, but certainly within a couple of days. If this same baby is soaking at least 6 heavy wet diapers (see #3, Urination), then baby is most likely fine and getting enough. Generally, and only as a general rule, 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 (pees). If, after about 4 or 5 days of age, the baby is soaking six diapers in a 24 hour period, (the diapers should be soaking, not just damp or just wet) 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. If fixing the latch and breast compression do not result in better intake, there are ways of giving extra fluid without giving a bottle directly. 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 who are 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 woken 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 babies sometimes cry after feedings because of hunger, there are also other reasons for crying. See also the information sheet Colic in the Breastfeeding Baby. Do not limit feeding times. “Finish” the first side before offering the other. Remember, play detective and watch baby’s chin—this will tell you if baby has been actually feeding or just going through the motions!
- 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 breastfeed. It is not true that the baby gets 90% of the feed in the first 10 minutes. Let the baby determine when he is ready for feeding and things usually come right, if the baby is sucking 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 likely 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. Contact the breastfeeding clinic with any concerns, but wait to start supplementing.
- “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, and this is usually because he is latched on poorly, and/or the milk is not flowing well. Breast Compressions might need to be used. 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, and using this ‘test’ is not a good idea, as bottles may interfere with breastfeeding. Babies will often take more liquid from a bottle even if they are already full.
- 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 may no longer fall asleep but rather start to pull away or get upset. The milk supply has not changed; the baby has changed. Get the best latch possible and use compression to help you increase flow to the baby Notes on scales and weights
- Scales are all different. We have documented significant differences from one scale to another. Weights have often been written down wrong. A soaked cloth diaper may weigh 250 grams (half a pound) or more, so babies should be weighed naked.
- Many rules about weight gain are taken from observations of growth of formula feeding babies. They do not necessarily apply to breastfeeding babies. A slow start may be compensated for later by fixing the breastfeeding. Growth charts are guidelines only.
Blocked Ducts & Mastitis
Mastitis is due to an infection (almost always due to bacteria rather than other types of germs) that usually occurs in breastfeeding mothers. However it can occur in any woman, even if she is not breastfeeding and can even occur in newborn babies of either sex.
Nobody knows exactly why some women get mastitis and others do not. Bacteria may enter the breast through a crack or sore in the nipple but women without sore nipples also get mastitis and most women with cracks or sores do not.
Mastitis is different from a blocked duct because a blocked duct is not thought to be an infection and thus does not need to be treated with antibiotics. With a blocked duct, a mother has a painful, swollen, firm mass in the breast. The skin overlying the blocked duct is often red, but less intensely red than the redness of mastitis. Unlike mastitis, a blocked duct is not usually associated with fever, though it can be. Mastitis is usually more painful than a blocked duct, but both can be quite painful. Thus seeing the difference between a “mild” mastitis and a “severe” blocked duct may not be easy. It is also possible that a blocked duct goes on to become mastitis, so things become even more complicated. However, without a lump in the breast, there is no mastitis or blocked duct for that matter. In France, physicians recognize something they call lymphangite when the mother has a painful, hot redness of the skin of the breast, associated with fever, but there is no painful lump in the breast. Apparently, most do not believe this lymphangite requires treatment with antibiotics. I have seen a few cases that fit this description and yes, in fact, the problem goes away without the mother taking antibiotics. But then, often a full-blown mastitis also goes away without the mother taking antibiotics.
As with almost all breastfeeding problems, a poor latch, and thus, poor emptying of the breast sets the mother up for blocked ducts and mastitis.
Blocked ducts will almost always resolve without special treatment within 24 to 48 hours after starting. During the time the block is present, the baby may be fussy when breastfeeding on that side because the milk flow will be slower than usual. This is probably due to pressure from the lump collapsing other ducts. A blocked duct can be made to resolve more quickly if you:
- Continue breastfeeding on that side and draining the breast better. This can be done by:
- Getting the best latch possible (see the information sheet When Latching as well as the video clips on how to latch a baby on at the website nbci.ca).
- Using compression to keep the milk flowing (see the information sheet Breast Compression as the video clips on how to latch a baby on at the website nbci.ca). Get your hand around the blocked duct and compress it as the baby is breastfeeding if it is not too painful to do so.
- Feeds the baby in such a position that the baby’s chin “points” to the blocked duct. Thus, if the blocked duct is in the bottom outside area of the breast (7 o’clock), then feeding the baby in the football position may be helpful.
- Apply heat to the affected area. You can do this with a heating pad or hot water bottle, but be careful not to burn your skin by using too much heat for too long a period of time.
- Try to rest. Of course, with a new baby it is not always easy to rest. Try going to bed. Take your baby with you into bed and breastfeed him there.
A bleb or blister
Sometimes, but not always by any means, a blocked duct is associated with a bleb or blister on the end of the nipple. A flat patch of white on the nipple is not a bleb or blister. If there is no painful lump in the breast, it is confusing to call a bleb or blister on the nipple a blocked duct. A bleb or blister is, usually, painful and is one cause of nipple pain that comes on later than the first few days. Some mothers get blisters in the first few days due to a poor latch. Nobody knows why a mother would suddenly get a bleb or blister out of the blue several weeks after the baby is born.
A blister is often present without the mother having a blocked duct.
If the blister is quite painful (it usually is), it is helpful to open it, as this should give you some relief from the pain. You can open it yourself, but do this one time only. However, if you need to repeat the process, or if you cannot bring yourself to do it yourself, it is best to go to see your doctor or come to our clinic.
- Flame a sewing needle or pin, let it cool off, and puncture the blister.
- Do not dig around; just pop the top or side of the blister.
- Try squeezing just behind the blister; you might be able to squeeze out some toothpaste-like material through the now opened blister. If you have a blocked duct at the same time as the blister, this might result in the duct unblocking. Putting the baby to the breast may also result in the baby unblocking the duct.
Ultrasound for blocked ducts
Most blocked ducts will be gone within about 48 hours. If your blocked duct has not gone by 48 hours or so, therapeutic ultrasound often works. Most local physiotherapy or sports medicine clinics can do this for you. However, very few are aware of this use of ultrasound to treat blocked ducts. An ultrasound therapist with experience in this technique has more successful results.
Some mothers have used the flat end of an electric toothbrush to give themselves “ultrasound” treatment. And apparently have had good results.
If two treatments on two consecutive days have not helped resolve the blocked duct, there is no point in getting more treatments. Your blocked duct should be re-evaluated by your doctor or at our clinic. Usually, however, one treatment is all that is necessary. Ultrasound may also prevent recurrent blocked ducts that occur always in the same part of the breast.
The dose of ultrasound is 2 watts/cm² continuous for five minutes to the affected area, once daily for up to two treatments.
Lecithin is a food supplement that seems to help some mothers prevent blocked ducts. It may do this by decreasing the viscosity (stickiness) of the milk by increasing the percentage of polyunsaturated fatty acids in the milk. It is safe to take, relatively inexpensive, and seems to work in at least some mothers. The dose is 1200 mg four times a day.
If you start getting symptoms of mastitis (painful lump in the breast, redness and pain of the breast, fever), try to get some rest. Go to bed and take the baby with you so you can continue breastfeeding while remaining in bed. Rest is good to help fight off infection.
Continue breastfeeding on the affected side. It should go without saying that you should continue on the other breast as well. Of course, if you are in so much pain that you cannot put the baby to the affected breast, continue on the other side and as soon as your breast is less painful put the baby to the breast with the mastitis. Sometimes expressing your milk may be less painful, but not always, so if you can, continue breastfeeding on the affected side. Mothers and babies share all their germs.
Heat helps fight off infection. It also may help with draining of the breast. Use a hot water bottle or heating pad but be careful not to burn the skin.
Fever helps fight off infection. Adults usually feel terrible when they have a fever and you may want to bring down the fever for this reason. But you don’t need to bring down the fever just because it’s there. Fever does not cause the milk to go bad!
Potatoes (adapted from Bridget Lynch, RM, Community Midwives of Toronto). Within the first 24 hours of your symptoms beginning, you may find that applying slices of raw potato to the breast will reduce the pain, swelling, and redness of mastitis.
- Cut 6 to 8 washed raw potatoes lengthwise into thin slices.
- Place in a large bowl of water at room temperature and leave for 15 to 20 minutes.
- Apply the wet potato slices to the affected area of the breast and leave for 15 to 20 minutes.
- Remove and discard after 15 to 20 minutes and apply new slices from the bowl.
- Repeat this process two more times so that you have applied potato slices 3 times in an hour.
- Take a break for 20 or 30 minutes and then repeat the procedure.
Mastitis and Antibiotics
Generally, it is better to avoid antibiotics if possible since mastitis may improve all on its own and antibiotics may result in your getting a Candida (yeast, thrush) infection of the nipples and/or breast. Our approach is as follows:
If you have had symptoms consistent with mastitis for less than 24 hours, we would give you a prescription for an antibiotic, but suggest you wait before starting to take the medication.
- • If, over the next 8 to 12 hours, your symptoms are worsening (more pain, more spreading of the redness or enlarging of the painful lump), start the antibiotics.
- • If over the next 24 hours, your symptoms are not worse but not better, start the antibiotics.
- • If over the next 24 hours, your symptoms are lessening, then they will almost always continue to lessen and disappear without your needing to take the antibiotics. In this case, the symptoms will continue to lessen and will have disappeared over the next 2 to 7 days. Fever is often gone by 24 hours, the pain within 24 to 72 hours and the breast lump disappears over the next 5 to 7 days. Occasionally the lump takes longer than 7 days to disappear completely, but as long as it’s getting small, this is a good thing.
If you have had symptoms consistent with mastitis for more 24 hours and the symptoms have not improved, you should start the antibiotics straight away.
If you are going to take an antibiotic, you need to take the right one. Amoxicillin, plain penicillin and some other antibiotics used frequently for mastitis do not kill the bacterium that almost always causes mastitis (Staphylococcus aureus). Some antibiotics which kill Staphylococcus aureus include: cephalexin (our usual choice), cloxacillin, dicloxacillin, flucloxacillin, amoxicillin combined with clavulinic acid, clindamycin and ciprofloxacin. Antibiotics that can be used for community acquired methicillin-resistant Staphylococcus aureus (CA-MRSA): cotrimoxazole and tetracycline.
All these antibiotics can be used when mothers are breastfeeding and do not require her to interrupt breastfeeding.
You should not interrupt breastfeeding if you are infected with MRSA! Indeed, breastfeeding decreases the risk of the baby getting infection.
Medication for pain/fever (ibuprofen, acetaminophen, and others) can be helpful to get you through this. The amount that gets into the milk, as with almost all medications, is tiny. Acetaminophen is probably less useful than those drugs (e.g. ibuprofen) that have an anti-inflammatory affect.
The treatment of choice now for breast abscess is no longer surgery.We have had much better results with ultrasound to locate the abscess and a catheter inserted into the abscess to drain it.
Mothers going through this procedure do not stop breastfeeding even on the affected side, and complete healing occurs often within a week. This procedure is done by an intervention radiologist, not a surgeon. Ask your doctor to check out this study: Dieter Ulitzsch, MD, Margareta K. G. Nyman,MD, Richard A. Carlson, MD. Breast Abscess in Lactating Women: US-guided Treatment. Radiology 2004; 232:904–909
For small abscesses, aspiration with a needle and syringe plus antibiotics often is all that is necessary, though it may be necessary to repeat the aspiration more than once.
A lump that isn’t going away.
If you have a lump that is not going away or not getting smaller over more than a couple of weeks, you should be seen by a breastfeeding-friendly physician or surgeon. You don’t have to interrupt or stop breastfeeding to get a breast lump investigated (ultrasound, mammogram and even biopsy do not require you to stop breastfeeding even on the affected side). A breastfeeding friendly surgeon will not tell you that you have to stop breastfeeding before s/he can do tests to investigate a breast lump.
Breastfeeding and Illness
Over the years, far too many women have been wrongly told they had to stop breastfeeding. The decision about continuing breastfeeding when the mother takes a drug, for example, is far more involved than whether the baby will get any in the milk.
It also involves taking into consideration the risks of not breastfeeding, for the mother, the baby and the family, as well as society. And there are plenty of risks in not breastfeeding, so the question essentially boils down to: Does the addition of a small amount of medication to the mother’s milk make breastfeeding more hazardous than formula feeding? The answer is almost never. Breastfeeding with a little drug in the milk is almost always safer. In other words, being careful means continuing breastfeeding, not stopping. The same consideration needs to be taken into account when the mother or the baby is sick.
Remember that stopping breastfeeding for a week or even days may result in permanent weaning as the baby may then not take the breast again. On the other hand, it should be taken into consideration that some babies may refuse to take the bottle completely, so that the advice to stop is not only wrong, but often impractical as well. On top of that it is easy to advise the mother to pump her milk while the baby is not breastfeeding, but this is not always easy in practice and the mother may end up painfully engorged.
Illness in the Mother
Very few maternal illnesses require the mother to stop breastfeeding. This is particularly true for infections the mother might have, and infections are the most common type of illness for which mothers are told they must stop. Viruses cause most infections, and most infections due to viruses are most infectious before the mother even has an idea she is sick. By the time the mother has fever (or runny nose, or diarrhoea, or cough, or rash, or vomiting etc), she has probably already passed on the infection to the baby. However, breastfeeding protects the baby against infection, and the mother should continue breastfeeding, in order to protect the baby. If the baby does get sick, which is possible, he is likely to get 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 the mother’s continuing breastfeeding. Bacterial infections (such as “strep throat”) are also not of concern for the very same reasons.
The only exception to the above is HIV infection in the mother. Until we have further information, it is generally felt that the mother who is HIV positive not breastfeed, at least in the situation where the risks of artificial feeding are considered acceptable. There are, however, situations, even in Canada, where the risks of not breastfeeding are elevated enough that breastfeeding should not be automatically ruled out. The final word is not yet in. Indeed, recently information came out that exclusive breastfeeding protected the baby from acquiring HIV better than formula feeding and that the highest risk is associated with mixed feeding (breastfeeding + artificial feeding). This work needs to be confirmed.
Antibodies in the Milk
Some mothers have what are called “autoimmune diseases”, such as idiopathic thrombocytopenic purpura, autoimmune thyroid disease, autoimmune hemolytic anemia and many others. These illnesses are characterized by antibodies being produced by the mother against her own tissues. Some mothers have been told that because antibodies get into the milk, the mother should not breastfeed, as she will cause illness in her baby. This is incredible nonsense. The mother should breastfeed.
The antibodies that make up the vast majority of the antibodies in the milk are of the type called secretory IgA. Autoimmune diseases are not caused by secretory IgA. Even if they were, the baby does not absorb secretory IgA. There is no issue. Continue breastfeeding.
- Mastitis (breast infection) is not a reason to stop breastfeeding. In fact, the breast is likely to heal more rapidly if the mother continues breastfeeding on the affected side. (See Information Sheet Blocked Ducts and Mastitis)
- Breast abscess is not a reason to stop breastfeeding, even on the affected side. Although surgery on a lactating breast is more difficult, the surgery and the postpartum course do not necessarily become easier if the mother stops breastfeeding, as milk continues to be formed for weeks after stopping breastfeeding. Indeed, engorgement after surgery only makes things worse. Make sure the surgeon does not do an incision that follows the line of the areola (the line between the dark part of the breast and the lighter part). Such an incision may decrease the milk supply considerably. An incision that resembles the spoke on a bicycle wheel (the nipple being the centre of the wheel) would be less damaging to milk-making tissue. These days breast abscess does not always require surgery. Repeated needle aspiration, or placement of a catheter to drain the abscess plus antibiotics often allows avoidance of surgery.
- Any surgery does not require stopping breastfeeding. Is the surgery truly necessary now, while you are breastfeeding? Are you sure that other treatment approaches are not possible? Does that lump have to be taken out now, not a year from now? Could a needle biopsy be enough? If you do need the surgery now, make sure again the incision is not made around the areola. You can continue breastfeeding after the surgery is over, immediately, as soon as you are awake and up to it. If, for some reason, you do have to stop on the affected side, do not stop on the other. Some surgeons do not know that you can dry up on one side only. You do not have to stop breastfeeding because you are having general anaesthesia. You can breastfeed as soon as you are awake and up to it.
- 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 that requires more than history and physical examination can be done by other means besides a mammogram (for example, ultrasound, needle biopsy). Discuss the options with your doctor. Let him/her know breastfeeding is important to you.
There is no reason that you cannot continue breastfeeding if you become pregnant. There is no evidence that breastfeeding while pregnant does any harm to you, or the baby in your womb or to the one who is nursing. If you wish to stop, do so slowly, though; because pregnancy is associated with a decreased milk supply and the baby may stop on his own.
Illness in the Baby
Breastfeeding rarely needs to be discontinued for infant illness. Through breastfeeding, the mother is able to comfort the sick child, and, by breastfeeding, the child is able to comfort the mother.
- Diarrhoea and vomiting. Intestinal infections are rare in exclusively breastfed babies. (Though loose bowel movements are very common and normal in exclusively breastfed babies.) The best treatment for this condition is to continue breastfeeding. The baby will get better more quickly while breastfeeding. The baby will do well with breastfeeding alone in the vast majority of situations and will not require additional fluids such as so called oral electrolyte solutions except in extraordinary cases.
- Respiratory illness. There is a medical myth that milk should not be given to children with respiratory infections. Whether or not this is true for milk, it is definitely not true for breastmilk.
- Jaundice. Exclusively breastfed babies are commonly jaundiced, even to 3 months of age, though usually, the yellow colour of the skin is barely noticeable. Rather than being a problem, this is normal. (There are causes of jaundice that are not normal, but these do not, except in very rare cases, require stopping breastfeeding.) If breastfeeding is going well, jaundice does not require the mother to stop breastfeeding. If the breastfeeding is not going well, fixing the breastfeeding will fix the problem, whereas stopping breastfeeding even for a short time may completely undo the breastfeeding. Stopping breastfeeding is not an answer, not a solution, not a good idea. (See Information Sheet Breastfeeding and Jaundice)
A sick baby does not need breastfeeding less, he needs it more!
Breastfeeding and Medications
Introduction Over the years, far too many women have been wrongly told they had to stop breastfeeding because they must take a particular drug. The decision about continuing breastfeeding when the mother takes a drug, for example,
is far more involved than whether the baby will get any of the drug in the milk. It also involves taking into consideration the risks of not breastfeeding, for the mother, the baby and the family, as well as society. And there are plenty of risks in not breastfeeding, so the question essentially boils down to: Does the addition of a small amount of medication to the mother’s milk make breastfeeding more hazardous than formula feeding? The answer is almost never. Breastfeeding with a little drug in the milk is almost always safer. In other words, being careful means continuing breastfeeding, not stopping.
Remember that stopping breastfeeding for a week may result in permanent weaning since the baby may then not take the breast again. On the other hand, it should be taken into consideration that some babies may refuse to take the bottle completely, so that the advice to stop is not only incorrect, but often impractical as well. On top of that it is easy to advise the mother to pump her milk while the baby is not breastfeeding, but this is not always easy in practice and the mother may end up painfully engorged.
Breastfeeding and Maternal Medications
Most drugs appear in the milk, but usually only in 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. Breastfeeding mothers who are told they must stop breastfeeding because of a certain drug should ask the physician to make sure of this by checking with reliable sources. Note that the CPS (in Canada) and the PDR (in the USA) are not reliable sources of information about drugs and breastfeeding. These “resources” are merely a compilation of the information provided by the drug manufacturers who are more interested in their medical legal liability than the interests of the mother and baby. Their policy is essentially “We can’t be held responsible if the mother interrupts breastfeeding”. Or the mother should ask the physician to prescribe an alternate medication that is acceptable during breastfeeding. In this day and age, it should not be a problem to find a safe alternative. If the prescribing physician is not flexible, the mother should seek another opinion, but not stop breastfeeding.
Why do most drugs appear in the milk in only small amounts? Because what gets into the milk depends on the concentration in the mother’s blood, and the concentration in the mother’s blood is often measured in micro- or even nano-grams per millilitre (millionths or billionths of a gram), whereas the mother takes the drug in milligrams (thousandths of grams) or even grams. Furthermore, not all the drug in the mother’s blood can get into the milk. Only the drug that is not attached to protein in the mother’s blood can get into the milk. Many drugs are almost completely attached to protein in the mother’s blood. Thus, the baby is not getting amounts of drug similar to the mother’s intake, but almost always, much less on a weight basis. For example, in one study with the antidepressant paroxetine (Paxil), the mother got over 300 micrograms per kg per day, whereas the baby got about 1 microgram per kg per day).
Most Drugs Are Safe If:
They are commonly prescribed for infants. The amount the baby would get through the milk is much less than he would get if given directly.
They are considered safe in pregnancy. This is not always true, since during the pregnancy, the mother’s body is helping the baby’s get rid of drug. Thus it is theoretically possible that worrisome accumulation of the drug might occur during breastfeeding when it wouldn’t during pregnancy (though this is probably rare). However, if the concern is for the baby’s getting exposed to a drug, say an antidepressant, then the baby is getting exposed to much more drug at a much more sensitive time during pregnancy than during breastfeeding. Recent studies about withdrawal symptoms in newborn babies exposed to SSRI type antidepressants (Paxil, for example) during the pregnancy somehow managed to implicate breastfeeding as if this type of problem requires a mother not to breastfeed. (Good example of how breastfeeding is blamed for everything.) In fact, you cannot prevent these withdrawal symptoms in the baby by breastfeeding, because the baby gets so little in the milk.
They are not absorbed from the stomach or intestines. These include many, but not all, drugs given by injection. Examples are gentamicin (and other drugs in this family of antibiotics), heparin, interferon, local anaesthetics, omeprazole. Omeprazole (Losec, Prilosec) is interesting because it is destroyed very quickly in the stomach. During the manufacture of the drug, a protective layer is added to the drug to prevent its destruction and the drug is thus absorbed into the mother’s body. Thus, the drug is covered by a protective layer that prevents its destruction in the stomach. However, when the baby gets the drug (in tiny amounts incidentally) there is no protective layer on the drug, so it is immediately destroyed in the baby’s stomach.
They are not excreted into the milk. Some drugs are just too big to get into the milk. Examples are heparin, interferon, insulin, infliximab (Remicade), etanercept (Enbrel).
The Following Are A Few Commonly Used Drugs Considered 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, nonsteroidal antiinflammatory medications (such as ibuprofen), prednisone, thyroxin, propylthiourocil (PTU), warfarin, tricyclic antidepressants, sertraline (Zoloft), paroxetine (Paxil), other antidepressants, metronidazole (Flagyl), omperazole (Losec), Nix, Kwellada.
Note: Though generally safe, fluoxetine (Prozac) has a very long half life (stays in the body for a long time). Thus, a baby born to a mother on this drug during the pregnancy, will have large amounts in his body, and even the small amount added during breastfeeding may result in significant accumulation and side effects. These are rare, but have happened. There are two options that you might consider:
- Stop the fluoxetine (Prozac) for the last 4 to 8 weeks of your pregnancy. In this way, you will eliminate the drug from your body and so will the baby. Once the baby is born, he will be free of drug and the small amounts in the milk will not usually cause problems and you can restart the fluoxetine (Prozac).
- If it is not possible to stop fluoxetine (Prozac) during your pregnancy, consider changing to another drug that does not get into the milk in significant amounts once the baby is born. Two good choices are sertraline (Zoloft) and paroxetine (Paxil).
Medications applied to the skin, inhaled (for example, drugs for asthma) or applied to the eyes or nose, are almost always safe for breastfeeding.
Drugs for local or regional anaesthesia are not absorbed from the baby’s stomach and are safe. Drugs for general anaesthesia will get into the milk in only tiny amounts (like all drugs) and are extremely unlikely to cause any effects on your baby. They usually have very short half lives and are eliminated extremely rapidly from your body. You can breastfeed as soon as you are awake and up to it.
Immunizations given to the mother do not require her to stop breastfeeding. On the contrary, the immunization will help the baby develop immunity to that immunization, if anything gets into the milk. In fact, most of the time nothing does get into the milk, except, possibly some of the live virus immunizations, such as German Measles. And that’s good, not bad.
X-rays and scans. Ordinary X-rays do not require a mother to interrupt breastfeeding even when used with contrast material (example, intravenous pyelogram). The reason is that the material does not get into the milk, and even if it did it would not be absorbed by the baby. The same is true for CT scans and MRI scans. You do not have to stop for even a second.
What About Radioactive Scans?
We do not want babies to get radioactivity, but we rarely hesitate to do radioactive scans on them. When a mother gets a lung scan, or lymphangiogram with radioactive material, or a bone scan, it is usually done with technetium (though other materials are possible). Technetium has a half life (the length of time it takes for ½ of all the drug to leave the body) of 6 hours, which means that after 5 half lives it will be gone from the mother’s body. Thus, 30 hours after injection all of it will be gone (well 98% will be gone) and the mother can breastfeed her baby without concern about his getting radiation. But does all the radioactivity need be gone? After 12 hours, 75% of the technetium is gone, and the concentration in the milk very low. I think that waiting 2 half lives is enough, for a material such as technetium. But: Not all technetium scans require stopping breastfeeding at all (HIDA scan, for example). It depends on which molecule the technetium is attached to. In the first few days, there is very little milk (though there is enough). In this situation it would be unnecessary for the mother to stop breastfeeding after a lung scan, for example. However, one of the most common reasons to do a lung scan is to diagnose a clot in the lung. This can now be done better and faster with CT scan, which does not require interrupting breastfeeding for even 1 second.
If you decide that interruption of breastfeeding is the best course to follow, then express milk for several days in advance (if you have advance warning about the test) and this can be fed via cup for a few days. Then while not breastfeeding, express your milk but don’t throw away the milk. The radioactive tracer that is present in the milk decays and the radiation is gone in 5 half-lives. So, even for I¹³¹ used in thyroid scans (see below), the radioactivity of the iodine will be gone in 5 half-lives, so the milk can be used in 6 to 8 weeks (the half-life of I¹³¹ is about 8 days). Only occasionally is a radioactive scan so urgent that it cannot be delayed for a few days.
Thyroid scans are different. Radioactive iodine (I¹³¹) is concentrated in milk and will be ingested by the baby and it will go to his thyroid where it will stay for a long time. This is definitely of concern. So, the mother will have to stop breastfeeding? No, because often the test does not need to be done at all. Differentiating postpartum thyroiditis from Graves’ Disease (the most common reason for doing the scan in breastfeeding mothers) does not require a thyroid scan. Get more information from the clinic. If a scan needs to be done, it is possible to do a thyroid scan I¹²³ which requires stopping for only 12 to 24 hours, depending on the dose given or technetium (see above). Don’t forget to express milk in advance so the baby can get it instead of formula.
Breastfeeding and Other Foods
Introduction Breastmilk is the only food your baby needs until about 6 months of age. There is no advantage to adding other sorts of foods or milks to breastmilk before about 6 months, except under unusual circumstances.
Many of the situations in which breastmilk seems to require addition of other foods arise from misunderstandings about how breastfeeding works and/or originate from a poor start at establishing breastfeeding. In other words, if your baby is breastfeeding well and gaining weight well, then add solids only when the baby shows signs of being ready to eat solids.
Supplementing during the first few days
It is thought by many that there is “no milk” during the first few days after the baby is born, and that until the milk “comes in” some sort of supplementation is necessary. This idea seems to be born out by the fact that babies, during the first few days, will often seem to feed for long periods and yet, not be satisfied. However, the key phrase is that “babies seem to feed” for hours when in fact, they are not really feeding much at all . A baby cannot get milk efficiently when he is not latched on properly to the breast, particularly when the supply is not yet abundant. Note, it is not supposed to be abundant in these early days. But during the first few days, if the baby is not latched on properly, he cannot get milk easily and thus may “seem to feed” for very long periods. There is a difference between being “on the breast” and drinking milk at the breast. The baby must latch on well so he can get the mother’s milk that is available in sufficient quantity for his needs, as nature intended. In the first few days, the mother does have the appropriate amount of milk that baby requires. She is not supposed to have a large amount and nobody has proved that the large amount of formula a baby will take in the first few days is good for him or safe! Yes, the milk is there even if someone has proved to you with the big pump that there isn’t any. How much does or does not come out in the pump proves nothing—it is irrelevant. Also note, no one who squeezes a mother’s breast can tell whether there is enough milk in there or not.
A good latch is important to help the baby get that milk that is available. If the baby does not latch on well, the mother may be sore, and if the baby does not get milk well, the baby may want to be on the breast for long periods of time worsening the soreness. Or the baby may fall asleep at the breast and seem to have fed well; but babies tend to fall asleep at the breast when the flow of milk is slow.
- A baby who drinks well and falls asleep at the breast > that’s the way it should be.
- A baby who drinks poorly and then falls asleep at the breast > that’s not the way it should be. The mother and baby need help with the breastfeeding.
When the mother’s milk becomes more plentiful, after 3-4 days, the baby may do well even if he is not well latched on (the mother may be sore, but even this is not necessarily so—many mothers just put the baby to the breast any old way and both she and the baby do fine). If a better latch, and compressiondo not get the baby breastfeeding, then supplementation, if medically needed, can be given by lactation aid. The lactation aid is a far better way to supplement than finger feeding or cup feeding, if the baby is taking the breast. And it is much, much better than using a bottle. But remember, getting the baby well latched on first and using compressions will work most of the time and no supplements will be needed. Using a lactation aid before helping the mother and baby with the breastfeeding is not appropriate just because a bottle is not being used to supplement.
Breastmilk is over 90% water. Babies breastfeeding well do not require extra water, even in summer, even in the hottest weather. If they are not breastfeeding well, they also do not need extra water, but rather, the mother and baby need help so that breastfeeding works better.
It seems that breastmilk does not contain much vitamin D, but it does have a little. We must assume this is as nature intended not a mistake of evolution. In fact, breastmilk is one of the few natural foods that does contain some vitamin D. We were obviously meant to get our vitamin D from being exposed to sunlight. The baby stores up vitamin D during the pregnancy and he will remain healthy without vitamin D supplementation for at least a couple of months, unless the mother herself is vitamin D deficient during the pregnancy. Vitamin D deficiency in pregnant women in Canada and the USA is uncommon, but it does exist. Outside exposure also gives your baby vitamin D even in winter, even when the sky is cloudy. A few minutes of exposure very late on a summer’s day is ample. Thirty minutes during a summer week, and an hour or so in winter, gives your baby more than enough vitamin D even if only his face is exposed.
Under unusual circumstances, it may be prudent to give the baby vitamin D. For example, in situations where exposure of the baby to ultraviolet rays of the sun is not possible (Northern Canada in winter or if the baby is never taken outside), giving the baby vitamin D drops would be advised. If you have had very little outside exposure yourself (women who are veiled are particularly at risk, especially if they are dark skinned), make sure your intake of vitamin D during the pregnancy is higher than usually recommended. Your baby may need vitamin D supplementation as well. Recent studies suggest that high intake of vitamin D while breastfeeding (4000 IU a day—10 times the usual recommended dose) does in fact increase the amount of vitamin D in the milk to levels that will protect the baby from rickets.
Breastmilk contains much less iron than formulas, especially the iron-enriched formulas, and this is as it should be. Actually, the low levels of iron in breastmilk are thought to give the baby extra protection against infection, as many bacteria require iron in order to multiply. The iron in breastmilk is very well utilized by the baby (about 50% is absorbed), while being unavailable to bacteria and the breastfed full term baby does not need any additional iron before about 6 months of age. However, introduction of iron containing foods should not be delayed much beyond 6 months of age.
Colic in the Breastfed Baby
Colic is one of the mysteries of nature. Nobody knows what it really is, but everyone has an opinion. In the typical situation, the baby starts to have crying spells about two to three weeks after birth.
These occur mainly in the evening, and finally stop when the baby is about three months old (occasionally older). When the baby cries, he is often inconsolable, though if he is walked, rocked or taken for a walk, he may settle temporarily. For a baby to be called colicky, it is necessary that he be gaining weight well and be otherwise healthy. However, even if the baby is gaining weight well, sometimes the baby is crying because he is still hungry. See below.
The notion of colic has been extended to include almost any fussiness or crying in the baby, and this is not surprising since we do not really know what colic is. There is no treatment for colic, though many medications and behaviour strategies have been tried, without any proven benefit. Of course, everyone knows someone whose baby was “cured” of colic by a particular treatment. Also, almost every treatment seems to work, at least for a short time, anyhow.
The Breastfeeding Baby with Colic
Aside from the colic that any baby may have, there are three known situations in the breastfed baby that may result in fussiness or colic. Once again, it is assumed that the baby is gaining adequately and that the baby is healthy.
Feeding both breasts at each feeding or feeding only one breast at each feeding
Human milk changes during a feeding. One of the ways in which it changes is that, in general, the amount of fat increases as the baby drains more milk from the breast. If the mother automatically switches the baby from one breast to the other during the feed, before the baby has “finished” the first side, the baby may get a relatively low amount of fat during the feeding. This may result in the baby getting fewer calories, and thus feeding more frequently. If the baby takes in a lot of milk (to make up for the reduced concentration of calories), he may spit up. Because of the relatively low fat content of the milk, the stomach empties quickly, and a large amount of milk sugar (lactose) arrives in the intestine all at once. The enzyme which digests the sugar (lactase) may not be able to handle so much milk sugar at one time and the baby will have the symptoms of lactose intolerance—crying, gas, explosive, watery, green bowel movements. This may occur even during the feeding. These babies are not lactose intolerant. They have problems with lactose because of the sort of information women get about breastfeeding. This is not a reason to switch to lactose-free formula.
It is also very important that you realize that a baby is not drinking milk from the breast just because the baby is making sucking movements on the breast. He may be “nibbling” not drinking and therefore the baby is not getting higher fat milk just because he is on the breast and sucking.
- Do not time feedings. Mothers all over the world have successfully breastfed babies without being able to tell time. Breastfeeding problems are greatest in societies where everyone has a watch and least where no one has a watch.
- The mother should feed the baby on one breast, as long as the baby actually gets milk from the breast, until the baby comes off himself, or is asleep at the breast from being full or is nibbling even with compression. Use breast compressio to keep baby drinking and not just sucking. Please note that a baby may be on the breast for two hours, but may actually be drinking milk for only a few minutes. In that case the milk taken by the baby may still be relatively low in fat. This is the rationale for using compression. If, after “finishing” the first side, the baby still wants to feed, offer the other side. Do not prevent the baby from taking the other side if he is still hungry.
- This is not a suggestion to feed only one breast at a feeding. You might be able to do it, and that’s fine, but not all mothers can manage it. You might find it possible in the morning when you have more milk (as most mothers do) but not in the evening when you have less milk (as most mothers do). If you insist on feeding on just one side, you may find your baby is “colicky” in the evening when he is, in fact, hungry.
- At the next feeding, start the baby on the other breast and proceed in the same way.
- Your body will adjust quickly to the new method and you will not become engorged or lop sided after a short while. But remember this: feeding on one side at a feeding, if you can manage it, will reduce the milk supply so that what may work now (breastfeeding on one breast at a feeding) may not work as the milk supply decreases. Therefore do not keep the baby to one breast, but “finish” one side and if the baby wants more, offer the other side.
- It is not a good idea to feed the baby on just one side, to follow a rule. Yes, making sure the baby “finishes” the first side before offering the second can help treat poor weight gain or colic in the baby, but rules and breastfeeding do not go together well. If the baby is not drinking, actually getting milk, there is no point in just keeping the baby sucking without getting any milk for long periods of time. You should “finish” one side and if the baby wants more, offer the other.How do you know the baby is “finished” the first side? The baby is no longer drinking, even with compression. This does not mean you must take the baby off the breast as soon as the baby doesn’t drink at all for a minute or two (you may get another milk ejection reflex or letdown reflex, so give it a little time), but if it is obvious the baby is not drinking, take the baby off the breast and if the baby wants more, offer the other side. How do you know the baby is drinking or not?If the baby lets go of the breast on his own, does it mean that the baby has “finished” that side? Not necessarily. Babies often let go of the breast when the flow of milk slows, or sometimes when the mother gets a milk ejection reflex and the baby, surprised by the sudden rapid flow, pulls off. Try him again on that side if he wants more, but if the baby is obviously not drinking even with compression, switch sides.
- In some cases, it may be helpful to feed the baby two or more feedings on one side before switching over to the other side for two or more feedings, as long as baby has come of the breast from drinking. Putting a baby back on a breast that was just “emptied” may cause baby to fuss or pull at the breast or fall asleep but not be full.
- This problem is made worse if the baby is not well latched on to the breast. A good latch is the key to easy breastfeeding.
Overactive Letdown Reflex
A baby who gets too much milk very quickly, may become very fussy and irritable at the breast and may be considered “colicky”. Typically, the baby is gaining very well. Typically, also, the baby starts breastfeeding, and after a few seconds or minutes, starts to cough, choke or struggle at the breast. He may come off, and often, the mother’s milk will spray. After this, the baby frequently returns to the breast, but may be fussy and repeat the performance. He may be unhappy with the rapid flow and impatient when the flow slows. This can be a very trying time for everyone. On rare occasions, a baby may even start refusing to take the breast after several weeks, typically around three months of age. What can you do?
- Get the best latch possible. This problem is made worse if the baby is not well latched on to the breast. A good latch is the key to easy breastfeeding. No matter what you are told about how good the latch looks, try to improve on it. Think of it this way: if your chin is tucked into your chest while you are trying to drink you would become overwhelmed by the fast flow very easily. If you want to drink quickly you will throw your head back, chin in the air, and be able to handle the fast flow. This is the kind of position baby’s head should be in while breastfeeding—his chin deep into your breast, his head in a slightly tipped-back position, his nose away from your breast, and his chin far from his own chest. This position will help him to handle the faster flow of the let down.
- If you have not already done so, try feeding the baby one breast per feed. In some situations, feeding even two or three feedings on one breast before changing to the other breast may be helpful. If you experience engorgement on the unused breast, express just enough to feel comfortable. Remember, if the baby wants the second breast, the mother should offer it.
- Feed the baby before he is ravenous. Do not hold off the feeding by giving water (a breastfed baby does not need water even in very hot weather) or a pacifier. A ravenous baby will “attack” the breast and may cause a very active letdown reflex. Feed the baby as soon as he shows any sign of hunger. If he is still half asleep when you put him to the breast, all the better.
- Feed the baby in a calm, relaxed atmosphere, if possible. Loud music, bright lights are not conducive to a good feeding. Older babies tend to become very distracted as the flow slows down. Using compressions gently at first, and then more firmly as necessary to keep the speed of flow consistent, will often keep baby interested in staying on the breast longer, because he is drinking better.
- Lying down to breastfeed sometimes works very well. If lying sideways to feed does not help, try lying flat, or almost flat, on your back with the baby lying on top of you to breastfeed, or try leaning back in a chair. Gravity helps decrease the flow rate. Remember, the baby may be frustrated at the inconsistent flow, so it may be necessary to lie down at the beginning when the flow is fast, and sit back up as the milk slows. Babies like the lying down position; they tend not to fuss with slower flow but tend to sleep.
- The baby may dislike the rapid flow, but also become fussy when the flow slows too much. If you think the baby is fussy because the flow is too slow, it will help to compress the breast to keep up the flow,If all else has not made things better:
- As a last resort, rather than switching to formula, give the baby your expressed milk by cup or by bottle if baby won’t take a cup.
Foreign Proteins in the Mother’s Milk
Sometimes, proteins present in the mother’s diet may appear in her milk and may affect the baby. The most common of these is cow’s milk protein. Other proteins have also been shown to be excreted into some mothers’ milk. The fact that these proteins and other substances appear in the mother’s milk is not usually a bad thing. Indeed, it is usually good, helping to desensitize your baby to these proteins. Ask about this if you have any questions.
Thus, in the treatment of the colicky breastfed baby, one step would be for the mother to stop taking dairy products or other foods, but only one type of food at a time. Dairy products include milk, cheese, yoghurt, ice cream and anything else that may contain milk, such as salad dressings with whey protein or casein. Check labels on prepared foods to see if they include milk or milk solids. When the milk protein has been changed (denatured), as in cooking for example, there should be no problem. Ask if you have any questions.
If eliminating certain foods from the mother’s diet does not work, the mother can take pancreatic enzymes (Cotazyme, Pancrease 4, for example), starting with 1 capsule at each meal, to break down proteins in her intestines so that they are less likely to be absorbed into her body as whole protein and appear in the milk. Of course, your chances of not being able to produce enough of your own enzymes from your pancreas are very low (unless you have cystic fibrosis, for example), but it has been shown that whole protein does get absorbed into the breastfeeding mother’s body and into her milk and adding the enzymes may decrease the amounts of whole protein entering your body and getting into the milk.
Please note: Intolerance to milk protein has nothing to do with lactose intolerance, a completely different issue. Also, a mother who is lactose intolerant herself should still breastfeed her baby.
- Eliminate all milk products for 7-10 days.
- If there has been no change for the better in the baby, the mother can reintroduce milk products.
- If there has been a change for the better, you can then slowly reintroduce milk products into her diet, if these are normally part of your diet. (There is no need to drink milk in order to make milk, for example, so if you don’t drink milk normally, don’t while you are breastfeeding). Some babies will tolerate absolutely no milk products in the mother’s diet. Most tolerate some. You will learn what amount of dairy products you can take without the baby reacting.
- If you are concerned about your calcium intake, calcium can be obtained without taking dairy products. Speak with your doctor or a dietician. But, 7-10 days off milk products will not cause you any nutritional problems. Actually, evidence suggests that breastfeeding may protect the woman against the development of osteoporosis even if she does not take extra calcium. The baby will get all he needs.
- Be careful about eliminating too many things from your diet all at once. Everyone will know someone whose baby got better when the mother stopped broccoli, beef, bananas, bread, etc. You may find that you are eating white rice only. Our diets are too complex to be sure exactly what, if anything, is affecting the baby.
One more piece of information. Some babies are hungry even if they are gaining weight really well. This may occur for several reasons, some mentioned earlier in this information sheet. One more way a baby can be hungry and nevertheless gain weight well is that you are limiting the feedings; for example, you feed the baby 10 or 20 minutes a side. If you have a lot of milk, the baby may gain weight well and still be hungry. So don’t limit feedings.
Be patient, the problem usually gets better no matter what. Formula is not the answer, but, because of the more regular flow, some babies do improve on it. But formula is not breastmilk and breastfeeding is much more than breastmilk. In fact, the baby would also improve on breastmilk from the bottle because of the regularity of the flow. Even if nothing works, time usually helps. The days and nights may seem eternal, but the weeks will fly by.
More than mild engorgement in the breasts is usually a sign that the breastfeeding is not going very well. It is due to the combination of milk stasis (the milk is not coming out) and oedema (swelling due to water retention in the area).
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 goes away within 1 or 2 days even without any treatment, but can be uncomfortable during that time. Massaging the breasts in a downward motion is not recommended as a treatment for engorgement. Continue to breastfeed the baby, making sure he gets on well and nurses well and the engorgement will resolve. However, if you should get engorged to the point where the baby is not able to take the breast, or if there is more than minimal discomfort in the breast and/or areola (the coloured part surrounding the nipple), then there is a simple way to temporarily move swelling away from the areola:
How to do REVERSE PRESSURE SOFTENING
Developed by K. Jean Cotterman RNC-E, IBCLC
Try this if pain, swelling, or fullness creates problems during the early days of learning to breastfeed. The key is making the areola very soft right around the base of the nipple, for better latching.
- A softer areola protects the nipple deep in baby’s mouth helping his tongue remove milk better. Mothers say curved fingers work best. (Fig. 1 or 2)
- Press inward toward the chest wall and count slowly to 50.
- Pressure should be steady and firm, and gentle enough to avoid pain.
- If mom wishes, someone else may help, using thumbs (Fig. 5).
- (For long fingernails, try another way shown below.)
- If breasts are quite large or very swollen, count very slowly, with mom lying down on her back. This delays return of swelling to the areola, giving more time to latch.
- Soften the areola right before each feeding (or pumping) till swelling goes away. For some mothers, this takes 2-4 days.
- Make any pumping sessions short, with pauses to re-soften the areola if needed.
- Use medium or low vacuum, to reduce the return of swelling into the areola.
Cabbage Leaves and Compresses
Cabbage leaves may also be used to help decrease the engorgement, as can ice packs and cold compresses. Some studies suggest cabbage may accomplish this more quickly. 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. See also the information sheet When the Baby Does Not Yet Latch at the websites nbci.ca.
- Use green cabbage
- Crush the cabbage leaves with a rolling pin if the leaves do not take the shape of your breast.
- 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 less than two or three times. Some will say to use the cabbage leaves after each feeding and leave them on until they wilt. Some are concerned that using them too often will decrease the milk supply
- Stop using as soon as engorgement is beginning to go away and you are becoming more comfortable.
- You can use acetaminophen (Tylenol™, others) with or without codeine, ibuprofen, or other medication for pain relief. As with almost all medications, there is no reason to stop breastfeeding when taking analgesics
- Ice packs also can be helpful
- Some women get a large lump in the armpit about 3 or 4 days after the baby’s birth. Cabbage leaves may be used in that area as well to help the lump go away.
Breastfeeding and Storage Guidelines
All milk should be dated before storing. Storing milk in 2-4 ounce (60 to 120 ml) amounts may reduce waste. Refrigerated milk has more anti-infective properties than frozen milk. Cool fresh milk in the refrigerator before adding it to previously frozen milk.
Preferably, human milk should be refrigerated or chilled right after it is expressed. Acceptable guidelines for storing human milk are as follows.
|Milk Storage Guidelines|
|At room temperature (fresh milk)||66° to 78° F (19° to 26° C)||4 hours (ideal) up to 6 hours (acceptable)*||Contents should be covered and kept as cool as possible; covering the container with a damp towel may keep milk cooler.|
|Insulated cooler bag||5° -39° F (-15° -4° C)||24 hours||Keep ice packs in constant contact with milk containers; limit opening cooler bag.|
|In a refrigerator||<39° F (<4° C)||72 hours (ideal) up to 8 days (acceptable)**||Collect in a very clean way to minimize spoilage. Store milk in the back of the main body of the refrigerator.|
|Freezer (compartment of refrigerator)||5° F (-15° C)||2 weeks||Store milk away from sides and toward the back of the freezer where temperature is most constant. Milk stored longer than these ranges is usually safe, but some of the fats break down over time.|
|Freezer (compartment of refrigerator with separate doors)||0° F (-18° C)||3 – 6 months|
|Deep Freezer||-4° F (-20° C)||6 – 12 months|
* The preference is to refrigerate or chill milk right after it is expressed.
** Eight days acceptable if collected in a very clean, careful way.
What Type of Container to Use
The best options for storing human milk:
- glass or hard-sided plastic containers with well-fitting tops
- containers not made with the controversial chemical bisphenol A (BPA), identified with a number 3 or 7 in the recycling symbol. A safe alternative is polypropylene, which is soft, semi-cloudy, and has the number 5 recycling symbol and/or the letters PP. You can avoid the dangers completely by using glass bottle.
- containers which have been washed in hot, soapy, water, rinsed well, and allowed to air-dry before use
- containers may also be washed and dried in a dishwasher
- containers should not be filled to the top – leave an inch of space to allow the milk to expand as it freezes
Important: Plastic bottles and component parts become brittle when frozen and may break when dropped. Also, bottles and component parts may become damaged if mishandled, e.g. dropped, over-tightened, or knocked over. Take appropriate care in handling bottles and components. Do not use the breastmilk if bottles or components become damaged.
- freezer milk bags that are designed for storing human milk
- put only 60 to 120 ml (two to four ounces) of milk in the container (the amount your baby is likely to eat in a single feeding) to avoid waste
- Squeeze out the air at the top before sealing, and allow about an inch for the milk to expand when frozen.
- Stand the bags in another container at the back of the refrigerator shelf or in the back of freezer where the temperature will remain the most consistently cold.
Disposable bottle liners or plastic bags are not recommended. With these, the risk of contamination is greater. Bags are less durable and tend to leak, and some types of plastic may destroy nutrients in milk. Mark the date on the storage container. Include your baby’s name on the label if your baby is in a day care setting.
How to Warm the Milk
Frozen milk: thaw in the refrigerator overnight or under cool running water. Gradually increase the temperature of the water to heat the milk to feeding temperature.
Refrigerated milk: Warm the milk under warm running water for several minutes. Or immerse the container in a pan of water that has been heated on the stove. Do not heat the milk directly on the stove. Some babies accept milk right from the refrigerator.
Do not bring temperature of milk to boiling point.
Human milk may separate into a milk layer and a cream layer when it is stored. This is normal. Swirl it gently to redistribute the cream before giving it to baby.
Do not use a microwave oven to heat human milk. It may cause the loss of some of the beneficial properties of the milk. Microwaves do not heat liquids evenly and may leave hot spots in the container of milk. This could be dangerous for infants.
Sometimes thawed milk may smell or taste soapy. This is due to the breakdown of milk fats. The milk is safe and most babies will still drink it. If there is a rancid smell from high lipase (enzyme that breaks down milk fats) activity when the milk has been chilled or frozen, the milk can be heated to scalding (bubbles around the edges, not boiling) after expression, then quickly cooled and frozen. This deactivates the lipase enzyme. Scalded milk is still a healthier choice than commercial infant formula.
If you or your baby has a thrush or yeast/fungus infection, continue to breastfeed during the outbreak and treatment. While being treated, you can continue to express your milk and give it to your baby. Be aware that refrigerating or freezing milk does not kill yeast. After treatment is finished, any leftover milk that was expressed during the infection should be discarded.
Previously frozen milk that has been thawed can be kept in the refrigerator for up to 24 hours. While there is limited evidence to date that milk thawed for a few hours may be refrozen, this results in further breakdown of milk components and loss of antimicrobial activity. At this time, the accepted practice is not to refreeze thawed milk. While some mothers and caregivers reheat expressed milk that was leftover and refrigerated after a previous feeding, there is no research on the safety of this practice. There is also no research about whether freshly expressed milk left unfinished at room temperature should be discarded, or can be saved for a short time (perhaps up to one hour as reported by some mothers and caregivers) to finish the feeding if the baby wakens from having fallen asleep or still appears hungry.
Myths and Breastfeeding
Many women do not produce enough milk. Not true! The vast majority of women produce more than enough milk. Indeed, an overabundance 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 that lasts only a few days and should never be so bad that the mother dreads breastfeeding. 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 three or four or lasts beyond five or six 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. Taking the baby off the breast for the nipples to heal should be a last resort only.
3. There is no (not enough) milk during the first three or four 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 that is available. When there is not a lot of milk (as there is not, normally, in the first few days), the baby must be well latched on in order to get the 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. Once the mother’s milk is abundant, a baby can latch on poorly and still may get plenty of milk, though good latching from the beginning, even in if the milk is abundant, prevents problems later on.
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 drinking for 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 better and longer if the mother compresses the breast to keep the flow of milk going, once he no longer drinks on his own Thus it is obvious that the rule of thumb that “the baby gets 90% of the milk in the breast in the first 10 minutes” is equally hopelessly wrong. To see how to know a baby is getting milk see the videos at nbci.ca.
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! Everyone needs vitamin D. Formula has it added at the factory. But the baby is born with a liver full of vitamin D, and breastmilk does have some vitamin D. Outside exposure allows the baby to get the rest of his vitamin D requirements from ultraviolet light even in winter. The baby does not need a lot of outside exposure and does not need outside exposure every day. Vitamin D is a fat soluble vitamin and is stored in the body. In some circumstances (for example, if the mother herself was vitamin D deficient during the pregnancy) it may be prudent to supplement the baby with vitamin D. Exposing the baby to sunlight through a closed window does not work to get the baby more vitamin D.
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 breastfeeds 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 six 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 the baby poops out most of it. 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 breastfed anywhere, anytime, 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 mouth wide—pause—close mouth type of suck). Other ways also help show that the baby is getting plenty (Information Sheet Is my Baby Getting Enough Milk?). Also see the videos at nbci.ca.
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, formulas 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, lead 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 nutrients.
14. If the mother has an infection she should stop breastfeeding. Not true! With very, very few exceptions, the mother’s continuing to breastfeed will actually protect the baby. 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.
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 manufacturers (who also make oral rehydrating solutions) to make even more money. The baby is comforted by the breastfeeding, and the mother is comforted by the baby’s breastfeeding.
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 that are safe. The risks of artificial feeding for both the mother and the baby must be taken into account when weighing if breastfeeding should be continued
It is surprising that the nipple shield, the use of which we had seen decline rapidly from the 1970’s and before, would once again be thought in the 2000’s as an appropriate treatment to cure many breastfeeding problems?
It was generally thought to be a mistake to use nipple shields as their use resulted in babies seeming to be stuck on these gadgets. With time, the mother’s milk production would usually decrease if a mother used a nipple shield. Some studies will suggest that there is not a decrease; if one compares milk extraction on a nipple shield to a poorly latched baby, sure, there may be no decrease. The point is to get a baby well latched. We believe a nipple shield does not allow for this. Unfortunately, it is still true in our opinion that it is often not best practise to use a nipple shield and it is the considered opinion of our clinic and institute that nipple shields need hardly ever, if ever, be used.
What are nipple shields?
A nipple shield is different from a breast shield or shell. The breast shell is not used while feeding the baby, but rather in between feedings, and its purpose is to make the nipple more prominent, so that the baby will take the breast better, or, to protect the nipple from contact with the mother’s bra, particularly when the nipple has trauma. Whether the shell actually succeeds in this purpose is debatable, but a breast shell is probably harmless; a nipple shield is not harmless.
Nipple shields are flexible artificial nipples put over the mothers nipple and areola. They are made of silicone nowadays and come in various diameters and sizes. They are used generally for the following reasons:
- The baby will not take the breast.
- The mother has sore nipples.
- The baby is born prematurely.
- The baby needs to “learn how to suck”.
Nipple shields are not, in fact, the answer to these problems. They give the illusion that the problems have been dealt with, but in fact, the problems have not been dealt with at all. The illusion that things are now going well leads to mothers not getting help early and making fixing the problems more difficult as time goes by. Let’s look at these questions more closely.
1. The baby will not take the breast.
A nipple shield is not usually the answer. In fact, a baby who sucks at the breast through a nipple shield is not latched on to the breast; he is latched on to the nipple shield. Does this matter? Yes, because a poor latch is still a poor latch and baby on a nipple shield has, at best, a poor latch. This means the baby will depend on the mother’s having milk ejection reflexes (letdown reflexes) in order to get milk. If the mother’s milk production is abundant, then the baby actually may gain weight well. Even then, however, we believe that it is problematic to use the nipple shield (see below).
Many mothers have a good milk supply but not what one would call an abundant milk supply. In that case it is very possible that the baby will not gain weight adequately with a nipple shield. Furthermore, as mentioned above, when a baby feeds through a nipple shield, the milk supply can even decrease. Even worse, if the milk supply decreases, it becomes more difficult to get the baby to take the breast without using a nipple shield.
Even if some justification can be found for using a nipple shield, starting one before the “milk comes” in is, in our opinion, not best practise. So many babies who do not latch on in the first few days, will latch on without trouble, even easily, when the mother’s milk “comes in”, especially if the mother gets good help. If the mother believes that the nipple shield has dealt with her problem, she may not get help until it is too late. Here is just one email (identifying information deleted) of hundreds we could have included:
“My baby was born on xxx weighing 2.5 kg (5lb 8oz). I started using a breast shield when the baby was a few days old because my baby would not latch on; everything seemed to go okay, but somewhere around 3 weeks I began to notice she didn’t seem to be sucking properly and by her one month check up she’d only gained an ounce.”
So what now? After a month feeding on the nipple shield, it may be extremely difficult to get the baby to take the breast directly especially if the slow weight gain was due to the milk supply decreasing rather than the baby not getting milk well because of the nipple shield (both are, in fact, possible). The mother may have been asked to supplement. The mother needed a lot of support.
We believe it is better that a mother express her milk and give it to the baby by cup (or, if absolutely necessary, by bottle) rather than use a nipple shield. At least expressing milk will usually maintain the milk supply.
2. The mother has sore nipples
Using a nipple shield for sore nipples has the same problems as using it for a baby who will not latch on. Milk supply may decrease and the baby may not want to take the breast directly again. Furthermore, a nipple shield is not a good way to treat sore nipples, oftentimes it will make the problem worse and cause more trauma. True, I have heard from some mothers that using the nipple shield helped them get past the pain and they were able to get the baby to take the breast again without pain; this is not always the case and there are better ways of dealing with sore nipples (prevention being the best of all
3. The baby is born prematurely.
If the baby is not restricted to starting breastfeeding at 34 weeks gestation (as in most of special care units or neonatal intensive care units in North America and Western Europe), if the mother is helped get the best latch possible and shown how to know a baby is getting milk, then nipple shields will hardly ever be necessary for the premature baby.
4. The baby needs to learn how to suck
A baby learns to suck and suck well by breastfeeding. If a baby “sucks better” on a nipple shield it’s only because the baby is not latching on to the breast. A baby who latches on and gets milk will suck just fine. The problem is that the baby is not latching on well and using a nipple shield does not teach a baby now to do that.
Desperate for sleep? Tired of getting up? Your baby can’t sleep alone? If you can check off each item under the “Safe Sleep Seven” below, then you can make your bed as SIDS-safe as a crib and greatly reduce other risks in just afew steps.
Follow these steps for “emergency bedsharing” and sleep better
tonight (unless you want to do it again tomorrow).
The Safe Sleep Seven
You need to be
1. A nonsmoker
2. Sober (no drugs, alcohol, or medications that make you
Your baby needs to be
4. Full-term and healthy
5. Kept on his back when he’s not nursing
6. Unswaddled, in a onesie or light jammies And you both need to be On a safe surface
Here’s how to make your bed a safe surface:
1. Have your partner, other children, and pets sleep somewhere else. Or you and the baby do.Just for tonight
2. Strip the bed. Take everything off but a thin mattress pad (if you use one) and bottom sheet. Everything.
3. Put back your own pillow(s), top sheet, and lightweight blanket or duvet. No super- heavy covers or quilts.
4. Put your baby on his back in the middle of the bed. Lie down next to him, on your side and facing him, with his face at about the level of your breast. If your bed is near a wall, put yourself
between him and the wall.
5. Nurse your baby and get some sleep.
The Safe Surface Checklist
Avoid these possible smothering risks:
Sofas and recliners
Softness or sagging that keeps a baby from lifting his head free
Spaces between mattress and headboard, side rails, and wall where a baby could get stuck
A bed partner who thrashes or sleeps exceptionally soundly
Pets that could interfere
Clear your bed of:
Heavy covers and comforters
Anything nearby that dangles or tangles (such as cords, strings,
scarves, ribbons, elastics)
Check your bed for possible hazards:
Distance to floor
Sharp, poking, or pinching places
Cup feeding Video
Breastfeeding Promotion Network of India
Academy of Breastfeeding Medicine
American Academy of Pediatrics
American Academy of Pediatrics Bright Futures
American College of Nurse-Midwives
American College of Obstetricians and Gynecologists
American Dietetic Association
Attachment Parenting International
Australian Breastfeeding Association
Baby Friendly USA
Baby Milk Action
Breastfeeding and Maternal and Child Health (MCH) Division at the Institute for Reproductive Health (IRH)
Center for Infant and Young Child Care
Coalition for Improving Maternity Services
Human Milk Banking Association of North America
International Board of Lactation Consultant Examiners
International Baby Food Action Network
International Lactation Consultant Association
Indian Academy of Pediatrics
La Leche League
National Alliance for Breastfeeding Action
National Perinatal Association
The Natural Child Project
United States Breastfeeding Committee
World Alliance for Breastfeeding Action
World Health Organization