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------------------------- ------------------------- CLICK HERE IF YOU ARE A CONSULTANT Welcome to BreastFeeding Inc.I'M LOOKING FOR...
Information Sheets | Resource Videos | Shop | Parenting 101 Course | A Certified Lactation Consultant | BreastFeeding Advice NEWS & ANNOUNCEMENTS ------------------------- Domperidone Update: Important Statement Regarding Health CanadaWarning
BREASTFEEDINGINC.CA
------------------------- At BreastFeeding Inc. our aim is to empower parents by providing the most up-to-date information to assist them with breastfeeding their baby. We provide this information through breastfeeding resources which include, but are not limited to, free information sheets, video clips, and articles. Some resources, such as books, protocols and videos can also be purchased through the products page . We created this site and our products after listening to parents and health-care professionals about what breastfeeding help is truly needed in today’s world of information overload. Our resources help to diagnose breastfeeding concerns, treat pain, milk supply issues, concerns around babies’ health as related to feeding, and help to prevent future proble LEARN MOREINFORMATION SHEETS
-------------------------LACTATION AID
27 Jun, 2019 •
Introduction
A lactation aid is a device that allows a breastfeeding mother to supplement her baby with expressed breastmilk, formula, glucose water with added colostrum or plain glucose water without using a bottle. The early use of artificial nipples may result in the baby becoming “bottle spoiled” or “nipple confused” especially when the mother’s breastfeeding is not yet well established or flow from the breast is slow because of milk supply issues. In fact, the baby is not confused. The baby knows exactly what the score is. If he goes to the breast and gets little milk or the flow is slow and then gets a bottle with rapid or steady flow, especially in the first few days, most can figure that one out fairly quickly. Bonding is very important, buthunger comes first.
The better a baby latches on, the easier it is for him to get milk, particularly if the mother’s supply is low. In the first few days, it may seem as though the mother may not have much milk; however, the mother does have the appropriate amount of milk that baby requires (see the video clip 2 day old baby at the website nbci.ca and watch this baby drink great guns—compare to the other video clips that show older babies drinking). 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—pumps don’t work that well either when the milk is there in the small, but normal, quantities of the first days, as nature intended, incidentally. Also note, no one who squeezes a mother’s breast can tell whether there is enough milk in there or not. And 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 get sore nipples, and if the baby does not get milk well, the baby will want to be on the breast for long periods of time, worsening the soreness. What we have here is a perfect “vicious circle”, which can be avoided,actually.
Though artificial nipples do not always cause problems, their use when things are already going badly will rarely make things better and usually make things worse. And “newer bottle nipples” are no better than the old ones; that’s just good marketing. The lactation aid is by far the best way to supplement, if the supplement is truly necessary. (However, proper latching on of the baby usually allows the baby to get more milk, and thus it is often possible to avoid the supplement). The lactation aid is better than using a syringe, cup feeding, finger feeding or any other method, since the baby is on the breast and breastfeeding. Babies, like adults, learn by doing. Furthermore, the baby supplemented while latched on to the breast is also getting breastmilk from the breast. And there is much more to breastfeeding than breastmilk. Why Is The Lactation Aid Better? Babies learn to breastfeed by breastfeeding Mothers learn to breastfeed by breastfeeding The baby continues to get the mother’s milk even while beingsupplemented
The baby will not reject the breast, which is very possible if supplementing off the breast There is more to breastfeeding than the breastmilk What Is A Lactation Aid? A lactation aid consists of a container for the supplement—usually a feeding bottle with an enlarged nipple hole—and a long, thin tube leading from this container. Manufactured lactation aids are available and are easier to use in some situations, but not necessarily. Manufactured lactation aids are particularly useful when the need for a lactation aid arises in an older baby, when a mother needs to supplement twins, when the need for a lactation aid will be long term, or whenever difficulty arises using the improvised lactation aid. Though the manufactured lactation aid is not inexpensive, the cost is about equal to two weeks of the usual milk-based formula. Please Note: Using a tube with a syringe, with or without a plunger, instead of the setup mentioned above, seems unnecessarily complicated and adds nothing to the effectiveness of the technique. On the contrary, it is more cumbersome and pushing the milk into the baby’s mouth with the syringe does not teach the baby how to breastfeed because he gets milk even if he sucks poorly. Using The Lactation Aid (Improvised). (Use should be shown by a person experienced in helping mothers with breastfeeding). See the videoclips at nbci.ca.
The baby may be latched on to the breast first, and the tube slipped into the baby’s mouth at the appropriate time (after the baby has breastfed on at least both sides first). The better the latch, the better the baby will get your milk and the easier the aid will be to use, and the more quickly you will be able to get rid of it and the supplements. The breast should be gently eased out of the way so that the corner of the baby’s mouth is seen, and the tube, held between the index finger and thumb, should be slipped into the corner of the baby’s mouth so that it enters straight towards the back of the baby’s mouth and at the same time, slightly upwards towards the roof of the mouth (see the video clip called Inserting Lactation Aid). The tube is well placed when the supplemental fluid works its way down the tube at a rather rapid rate. There is usually no need to fill the tube with supplemental fluid before putting it into the baby’s mouth. Or, the baby is latched on to the breast and the tube, which is run along the mother’s breast and nipple, at the same time. The better the baby’s latch, the easier the lactation aid is to use. Also, the better the latch, the more likely and the sooner the baby will be able to do without supplements. Therefore, proper positioning and latching on of the baby are still very important. The tube may be taped to the breast if the mother desires, though this is not really necessary and not always helpful. The tube does not need to pass the end of the nipple and needs to be only just past the baby’s gums to function properly. It does seem to function better if the tube is placed in the corner of the baby’s mouth and enters straight into the baby’s mouth over the tongue. (Point it slightly to the roof of the baby’s mouth). It is occasionally helpful for the mother to hold the tube in place with her finger, as some babies tend to push the tube out of position withtheir tongues.
The bottle containing the supplement should not be higher than the baby’s head. If the lactation aid functions only when the bottle is held higher than the baby’s head, something is wrong. Keep the bottle higher only if the doctor or lactation specialist suggests this (as in the care of breast refusal for example). It is best to use the tube as necessary to keep the baby drinking at the breast. Follow the Protocol to Increase Breastmilk Intake. Feed baby from both breasts before adding the supplement. Some mothers find it easier not to use it during the night. Better eight supplements a day of 30 ml (1 ounce) per feeding than 2 large supplements a day of 120 ml (4 ounces) each. Do not cut off the end of the tube as cutting it makes the end sharp–it works fine as it is. It should not take an hour for the baby to drink an ounce of milk from the lactation aid. If it is taking this long, the tube is probably not well positioned, or the baby is poorly latched on, or both. When the lactation aid is functioning well, it takes 15-20 minutes, usually less, for the baby to take 30 ml (1 ounce) of the supplement. A trick for easier use: Wear a shirt with pockets, and put the bottle in the pocket or stick it in your bra strap.Cleaning the Device
Do not boil the tube of the non-manufactured aid. It is not made to beboiled.
After using the device, clean the bottle and nipple as usual. Do not boil the tube. The tube should be emptied after use and then rinsed through with hot water (suck up hot water into the tube from a cup) and then hung up to dry. Soap, though not necessary, may be used if desired, but rinse the tube well. Tubes may become stiff and unsuitable for use after a few days to a week. Weaning the Baby from the Lactation Device Maintain contact with the breastfeeding clinic for advice about weaning the baby from the lactation aid. See the information sheet Protocol to Manage Breastmilk Intake. Weaning the baby from the aid may take several weeks or only a short while. Do not be discouraged and do not try to force the weaning. Usually, the amount of milk required in the lactation aid increases over one or two weeks, and then levels out for a variable period of time before decreasing. The whole process may take two to eight weeks or longer, although some mothers have used the device only a few days, whereas others have not been able to stop using it at all until the baby was well established on solids. Rapid improvement sometimes occurs after a long period of little change. Observe the baby’s breastfeeding. If you do not know how to know if the baby is drinking, see the video clips at nbci.ca. Put the baby onto the breast, allow the baby to breastfeed as long as he is suckling and drinking, then use breast compression (see the information sheet Breast Compression) to keep the baby drinking; then repeat the process on the second breast. You can return to the first breast and continue back and forth as long as the baby is drinking. After you have finished feeding on both breasts, insert the tube into the baby’s mouth. Allow the baby to breastfeed until satisfied usingthe lactation aid.
Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond. To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002. Lactation Aid, 2009© Written and revised (under other names) by Jack Newman, MD, FRCPC,1995-2005©
Revised Jack Newman MD, FRCPC, IBCLC and Edith Kernerman, IBCLC, 2008,2009©
All of our information sheets may be copied and distributed without further permission on the condition that it is not used in ANY contextthat violates the
WHO International Code on the Marketing of Breastmilk Substitutes(1981)
and subsequent World Health Assembly resolutions.WHEN LATCHING
27 Jun, 2019 •
Cross Cradle Position for Left Breast: Align baby’s nose so that it does not go past your nipple, or go to the left of your nipple, in other words, your nipple should not be aligned with his chin Place your right hand under baby’s face so your four fingers make a pillow for baby’s cheek (keep your four fingers tightly together as if the were stuck together with glue) You are now supporting the weight of baby’s head with your hand You may want to sit baby’s bottom on you arm as though it were a shelf (this will work in the beginning with a newborn) Or you may want to let baby’s bottom fall diagonally a bit and squeeze it against your rib cage with your elbow Baby’s body and legs should be wrapped around mother. Pull baby’s bottom into your body with the inside/underside of your forearm as if serving baby to you on a platter This will bring him toward your breast with the nipple pointing to theroof of his mouth
Head supported but NOT pushed in against your breast. In fact, try to think of it not as bringing baby’s head into or near your breast at all—instead, bring baby’s body into your body and the head will follow, as if serving baby to you on a platter. Head should be tilted back slightly so the nose is up and the baby’s chin is coming into the breast while the nose never touches thebreast.
Use your whole arm to bring the baby onto the breast, when baby’smouth is wide.
Baby’s chin should be far away from Baby’s chest. WATCH LOWER LIP, aim it as far from base of nipple as possible, so tongue draws lots of breast into mouth. Move baby’s body and head together – keep baby uncurled. If you keep your wrist straight, with baby’s cheek resting on your fingers, then baby’s chin will not bend down toward his chest Once latched, baby’s top lip will be close to nipple, areola shows above lip. Keep baby’s chin close against your breast. Need mouth wide before baby moved onto breast. Teach baby to openwide/gape:
Avoid placing baby down in a feeding position until you are completely ready to latch baby. The longer baby waits while you get ready (undoing your breast, etc) the more frustrated baby gets and the less open baby’s mouth will go. move baby toward breast, touch top lip against nipple move mouth away SLIGHTLY touch top lip against nipple again, move away again repeat until baby opens wide and has tongue forward Or, better yet, run nipple along the baby’s upper lip, from one corner to the other, lightly, until baby opens wideMother’s Posture
Sit with straight, well-supported back Trunk facing forwards, lap flat Baby’s Position Before Feed Begins Nipple points to the baby’s upper lip or nostrilBaby’s Body
Placed not quite tummy to tummy, but so that baby comes up to breast from below and baby’s eyes make contact with mother’s SupportBreast
Firm inner breast tissue by raising breast slightly with fingers placed flat on chest wall and thumb pointing up (if helpful, also use sling or tensor bandage around breast) Move Baby Quickly On To Breast Head tilted back slightly, pushing in across shoulders so chin and lower jaw make contact (not nose) while mouth still wide open, keep baby uncurled (means tongue nearer breast) lower lip is aimed as far from nipple as possible so baby’s tongue draws in maximum amount ofbreast tissue
Cautions
Mother needs to AVOID pushing her breast across her body chasing the baby with her breast flapping the breast up and down holding breast with scissor grip not supporting breast twisting her body towards the baby instead of slightly away aiming nipple to centre of baby’s mouth pulling baby’s chin down to open mouth flexing baby’s head when bringing to breast moving breast into baby’s mouth instead of bringing baby to breast moving baby onto breast without a proper gape not moving baby onto breast quickly enough at height of gape having baby’s nose touch breast and not the chin holding breast away from baby’s nose (not necessary if the baby is well latched on, as the nose will be away from the breast anyway) Also see videos of latching and latching in other positions Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond. To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002. When Latching, 2009© Written and revised (under other names) by Jack Newman, MD, FRCPC,1995-2005©
Revised by Jack Newman MD, FRCPC, IBCLC and Edith Kernerman, IBCLC,2008, 2009©
All of our information sheets may be copied and distributed without further permission on the condition that it is not used in ANY contextthat violates the
WHO International Code on the Marketing of Breastmilk Substitutes(1981)
and subsequent World Health Assembly resolutions. If you don’t know what this means, please email us to ask! WHEN BABY DOES NOT YET LATCH27 Jun, 2019 •
There are many reasons a baby might refuse to take the breast. Often there is a combination of reasons. For example, a baby might latch on even with a tight frenulum if no other factors come into play, but if, for example, he is also given bottles early on, or if the mother’s nipples and areolas are swollen from fluid from the fluids she received during the labour and birth, this may very well change the situation from “good enough”, to “not working at all”. Some babies are unwilling to nurse, or suck poorly as a result of medication they received during the labour. Narcotics are responsible for many such situations, and meperidine (Demerol) is particularly bad as it stays in the baby’s blood for a long time and affects the way he sucks for several days. Even morphine given in an epidural (Epimorph) may cause the baby to be unwilling to nurse or latch on, since medication from an epidural definitely does get into the mother’s blood, and thus into the baby before he is born. Other interventions during labour and birth (e.g. intravenous fluids in large amounts, vigorous suctioning of the baby at birth which is simply not necessary for a healthy full term baby) can also cause difficulties with the baby latching on. For more information see the book The Latch and other keys to successful breastfeeding, chapter 4, Causes of Latch Problems, and/or see theL-Eat Latch ad Transfer Tool,Step #8, N-eat.
Abnormalities of the baby’s mouth may result in the baby’s not latching on. Cleft palate, but not usually cleft lip alone, causes severe difficulties in latching on. Sometimes the cleft palate is not obvious, affecting only the soft palate, the part inside the baby’smouth.
A baby learns to breastfeed by breastfeeding. Artificial nipples interfere with how the baby takes the breast. Babies are not stupid. If they get slow flow from the breast (as is expected in the first few days of life) and rapid flow from the bottle, they will not be confused—many will figure it out quite quickly, and prefer thefaster flow.
If the mother’s nipples are particularly large, or inverted, or flat, these nipple variations may make latching on more difficult, not usually impossible. However most women said to have flat or inverted nipples actually do not. In fact, nipples that look flat are almost always normal, but we live in a society where bottle feeding is still the norm, so if a mother doesn’t have nipples that look like the end of a feeding bottle may be told that their nipples are flat. A tight frenulum (the whitish tissue under the tongue) may result in a baby having difficulty latching on. This is not, strictly speaking, considered an abnormality, and thus, many practitioners do not believe that it can interfere with breastfeeding; many studies indicate that it can indeed interfere. However, one of the most common causes of babies’ refusing to latch on arises from the misguided belief that babies in the first few days must breastfeed every 2 hours, or 3, or on some other aberrant sort of schedule. Babies were not meant to feed by the clock even during the first days. Belief in the schedule and trying to stick to a schedule results in anxiety on the part of the staff when a baby has not fed, for example, for three hours after birth, which then results, frequently, in babies being forced to the breast when they are not yet ready to feed. When the baby is forced into the breast, and kept there by force, especially when the baby is not interested or ready, we should not be surprised that some babies develop an aversion to the breast. If this misguided approach then results in panic, and “the baby must be fed”, alternative feeding methods (the worst of which is the bottle) are then used, resulting in worsening of the situation and the beginning of a vicious circle. There is no evidence that a healthy full term newborn must feed every three hours (or two hours, or whatever) during the first few days. There is no evidence that they will develop low blood sugars if they don’t feed every three hours (the whole issue of low blood sugars has become a mass hysteria in many postpartum areas which, like all hysterias, results from a grain of truth, perhaps, but actually causes more problems than it prevents, including the problem of many babies getting formula when they don’t need it, being separated from their mothers when they don’t need to be, and not latching on). Babies should be together, skin to skin with their mothers, most of the day (See the information sheet Skin to Skin Contact). When they are ready, most will start looking for the breast. Having the baby with the mother skin to skin immediately after birth and allowing the baby and the mother the time to “find” each other will prevent most situations of the baby not latching on. Mother and baby skin to skin will also keep the baby as warm as being under a heating lamp, and, more importantly, not too warm but just right. Having the baby and mother together for 5 minutes though, is not the answer. The mother and baby should be together until the baby latches on, without pressure, without time limits (“we’ve got to weigh the baby”, “we’ve got to give the baby vitamin K,” etc—these procedures can wait!). This might take 1-2 hours or more. But The Baby Is Not Latching On! Okay, so how long can we wait? There is no obvious answer to that. Certainly, if the baby has shown no interest in nursing or feeding by 12 to 24 hours after birth, it may be worthwhile to do something, mostly because hospital policies usually require the mother to be discharged by 24 to 48 hours. What can be done? The mother should start expressing her milk, and that milk (colostrum), either alone, or mixed with sugar water, should be fed to the baby, preferably by finger feeding (see below and the information sheet on Finger and Cup Feeding). The mother should start expressing her milk as soon as it has been decided to feed the baby off the breast or supplements are necessary. See information sheet, Expressing Milk. If it is difficult to get colostrum (often hand expression works better than a pump in the first few days), then sugar water alone is fine for the first few days. With finger feeding, most babies will start sucking, and many will wake up enough to attempt going to the breast. As soon as the baby is sucking well, finger feeding should be stopped and the baby tried at the breast (Often a minute or two of finger feeding will do the trick). See the video clip “Finger feeding to Latch” at the website nbci.ca). Finger feeding is essentially a procedure to prepare the baby to take the breast, not primarily a method of avoiding the bottle, Though finger feeding can be used for avoiding a bottle as well, a cup is probably a better option than finger feeding. Therefore finger feeding is done before attempting the baby at the breast, to prepare him to take the breast. Before discharge, early, competent help needs to be arranged so that the mother and baby are getting help by day four or five at the latest. Many babies not able to latch on in the first few days will latch on beautifully once the mother’s milk supply has increased substantially as it usually does around day 3 or 4. Getting help at this time avoids the negative associations with the breast that many babies develop as time goes on. A nipple shield started before the mother’s milk becomes abundant (day 4 to 5) is bad practice; in fact, I believe it should never be done. Starting a nipple shield before the mother’s milk “comes in” is not giving time a chance to work. Furthermore, used improperly (as we see it often being used), a nipple shield may result in severe depletion of the milk supply, and the baby refusing to ever latch on to the breast without it. See below on the importance of maintaining a good milk supply. We’re Home From Hospital, The Baby Won’t Latch On. Now What Do IDo?
The single most important factor influencing whether or not the baby eventually latches on is the mother’s developing a good milk supply. If the mother’s supply is abundant, the baby will latch on by 4 to 8 weeks of life no matter what in almost all cases. What we try to do at the clinic is get the baby latching on earlier, so that you won’t have to wait that long. So, it is more important you keep up your supply, than avoid a bottle. The bottle interferes, and it is better you use other methods (such as a cup) if you can, but if you feel you have no choice, you should do what you need to do. Learn how to get the best position and latch from an experienced lactation specialist (see also information sheet When Latching and see the videos at nbci.ca). As the baby comes onto the breast, compress the breast so that the baby gets a gush of milk. Try the baby on the breast he seems to prefer, or the breast that has more milk, or the side you feel most comfortable with if neither of the previous apply, but do not start on the breast he resists more. If the baby latches on, he will start sucking and start drinking (get information on how to know a baby is actually getting milk at the breast—see information sheet Enough and see the videos at nbci.ca). If the baby doesn’t latch on, don’t try to force him to stay on the breast; it won’t work. He will either get hysterical or “go limp”. Move him away from the breast and start again. It is better to go on-off, on-off several times than to push him into the breast when he hasn’t latched on. Pushing the baby into the breast won’t work and may cause baby to refuse even more. If the baby goes to the breast and sucks once or twice, he hasn’t latched on a little; he hasn’t latched on at all. If the baby refuses the breast, don’t keep at it until he’s angry. Try finger feeding a few seconds to a minute or two, and try again, perhaps on the other side. Finger feeding is primarily used to prepare the baby to take the breast, not primarily to avoid a bottle. If the baby doesn’t latch on, finish the feeding with whatever method you find easiest. Cup feeding works well and is better than abottle.
Using a lactation aid at the breast may be helpful, but often requires an extra hand. The baby is more likely to latch on if the flow is rapid, and the lactation aid increases the milk flow to the baby. At about two weeks after birth, a change in what you have been doing often seems to send a message to the baby that “there’s more than one way to do this”. If you have been finger feeding only, a change to a cup or bottle will sometimes work. If you have been bottle feeding only, switching to finger feeding may work (only before attempting the baby at the breast is good enough if finger feeding is too slow, and finishing the feeding with cup or bottle). How to Maintain and Increase Milk Supply Express your milk as often as is practical, at least 8 times a day, using a reliable pump that expresses both breasts at the same time. The best time to express your milk is right after baby has a feeding. See the information sheet Expressing Breast Milk. Some mothers actually find expressing by hand easiest and just as productive as using a pump. Using compression while pumping increases the efficiency of pumping and increases the milk supply (another hand is helpful, but mothers have rigged up the pump so that they don’t have to hold onto the tubing or flanges while pumping and thus can compress withouthelp).
If the baby hasn’t latched on by day 4 or 5, start fenugreek and blessed thistle to increase milk flow. See the information sheet Herbal Remedies for Increasing Milk Supply. Domperidone may also be useful. See the information sheets Domperidone, Starting and Domperidone, Stopping. If you must use a nipple shield, (and we are not advising that you do), do not use one at least until the milk supply is well established (at least 2 weeks after the baby is born). But get good hands on help first—a nipple shield is really a last resort. Do not get discouraged. Even if your milk supply is not up to the needs of your baby, your baby is still likely to latch on. Get good hands-onhelp. Do not try to do this on your own. Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond. To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002. The Baby Who Does Not Yet Latch On, 2009© Written and revised (under other names) by Jack Newman, MD, FRCPC,1995-2005©
Revised by Jack Newman MD, FRCPC, IBCLC and Edith Kernerman, IBCLC,2008, 2009©
All of our information sheets may be copied and distributed without further permission on the condition that it is not used in ANY contextthat violates the
WHO International Code on the Marketing of Breastmilk Substitutes(1981)
and subsequent World Health Assembly resolutions. WHAT TO FEED THE BABY WHEN THE MOTHER IS WORKING OUTSIDE THE HOME27 Jun, 2019 •
This is not an information sheet on all the ins and outs of working outside the home and breastfeeding. This sheet provides information on how your baby can be fed when you are not with him. It is addressed in particular to the mother who is returning to paid work when the baby is about 6 months of age or older. Mothers in Canada have the right to 52 weeks maternity leave. You should take full advantage of this time if it is at all possible. Remember that there are costs to returning to outside work (transportation, clothes, daycare) that may cancel any benefit of increased income. If you cannot take a full year, take at least 6 months, better 7 months (from the point of view of ease of continuing breastfeeding while away from your baby). Your baby will never be this age again.Some Myths:
Babies must learn to take a bottle so that they can be fed when the mother is not there. Not true. Why not an open cup? It is true that some exclusively breastfed babies will not take a bottle by 2 or 3 months of age. Most, who have not taken a bottle, and even some who once did accept a bottle will not take one by the time they are 4 or 5 months of age. This is no tragedy, and there is no reason to give a bottle early so that the baby knows how. If your baby is refusing to take a bottle, do not try to force him; you and he may become very frustrated and there is just no need to go through all this. If the baby is at least 6 months of age when you start back at outside work, the baby quite simply does not need to take a bottle. If he is even 3 or 4 months, he does not need to take a bottle. He can be fed liquids or solids off a spoon and by 6 months of age he can be taking enough so that he will not be hungry during the day. Furthermore, he can start learning to drink from a cup even by 1 day of age. The cup can be an open cup and is best not to have a spout (a “sippy” cup is, essentially, a bottle). If, however, he has not got the hang of the cup by the time you must leave him, do not worry, he can take fluids off a spoon, or his solid foods can be mixed with more liquid (expressed milk, water). Obviously, if the baby is to be taking a fair amount of a variety of foods by 6 months of age, he may need to be started on solids by 5 months of age. However, some babies prefer to wait for their mother in order to drink something. This is fine; many babies sleep 12 hours at night without drinking or eating at all. But getting the baby to take a bottle surely won’t hurt. Not necessarily true. Some babies do fine with both. The occasional bottle, when breastfeeding is going well, may not hurt. But if the baby is getting several bottles a day on a regular basis, and, in addition, your milk supply decreases because the baby is breastfeeding less, it is quite possible that the baby will start refusing the breast, even if he is older than 6 months of age. Babies need to drink milk when the mother is not at home. Not true. Three or four good breastfeedings during a 24-hour period plus a variety of solid foods in goodly amounts gives the baby all he needs nutritionally, and thus he does not need any other type of milk when you are at your outside job. Of course, solid foods can be mixed with expressed milk or other milk, but this is not necessary. If the baby is to get milk other than breastmilk, it needs to be artificial baby milk (infant formula) until the baby is at least 9 months of age. Not true. If the baby is breastfeeding a few times a day and getting fair quantities of a variety of solid foods, infant formula is neither necessary nor desirable. Indeed, babies who have not had infant formula before 5 or 6 months of age often refuse to drink it because it tastes pretty bad. (If you want to convince yourself of how little we know about breastmilk, ask yourself why it is that, although breastmilk and infant formulas have the same amount of sugar, breastmilk is so much sweeter). If you want to give the baby some other sort of milk, homogenized milk is acceptable at 6 months of age, as long as it is not the baby’s only food. In fact, if the baby is taking good quantities of a wide variety of foods, breastfeeding 3 or 4 times a day, and growing well, homogenized milk or 2% milk is good enough, but also not necessary. The “need” for formula to 9 months to 12 months of age is basically formula company marketing and very successful at that. Statements by the Canadian Paediatric Society and the American Academy of Pediatrics urging formula to a year surely did not take into consideration the baby who is continuing to breastfeed after 6 months. Babies need to drink milk to get calcium. Not true. If you are worried about the baby’s intake of calcium, he can eat cheese or yogurt. There is no need to drink the calcium. Besides, if the baby is also breastfeeding, breastmilk still contains calcium. Follow-up formulas (artificial milk for infants over 6 months of age) are specially adapted to the needs of infants 6 to 12 months of age. Not true. They are completely unnecessary and are specially adapted to the needs of the formula companies’ profit margins. They also are part of a marketing strategy that tries to get around restrictions on the advertising of artificial baby milks directly to the public (widely disregarded in any case). In Europe now, there are special formulas available for the toddler (1-3 years of age). In Singapore, they have formulas for children up to 7 years of age. Some people will buy anything, it seems. But these toddler formulas will soon be here in North America and soon nobody will consider it unusual to feed formula to a 3 year old. In fact, just as some paediatricians in France now push formula to 3 years, some paediatricians in North America will too. You can bet on it. Bottom line über alles. We will all soon be on formula from birth to death. The breastfed baby 4 months of age needs to be getting more iron than can be provided by breastmilk alone. Not true. For the baby born at term who is breastfeeding exclusively, all the iron required is provided by breastmilk. However, by 6 months of age, more or less, it is prudent for the baby to begin getting more iron than that provided by breastmilk alone. The best way for your baby to get iron is through his food, and the best source of iron is meat, not formula, and notinfant cereals.
The best way to assure the baby’s getting enough iron is to give him infant cereals. Not true. Infant cereals do contain a lot of iron, but most of it is not absorbed, and this amount of iron seems to cause constipation in some babies. Furthermore, some breastfed babies who have had only breastmilk to 5 or 6 months of age do not like cereal. There is nothing wrong with infant cereal, but pushing this food on reluctant babies may result in later feeding problems. The best way to ensure the baby is getting enough iron is to continue breastfeeding, and introduce solid foods in a relaxed, enjoyable way at the appropriate time (See the information sheet Starting Solid Foods). The appropriate time is when the baby is showing interest in eating by reaching out for and trying to eat food the parents or other members of the family are eating. This occurs usually about 4 ½ to 5 ½ months of age. A baby this age can eat what the parents eat, with few exceptions. There is no need to be obsessive about the order in which foods are introduced, or trying to keep the baby eating only one food/week. The easiest way to give extra iron for the 6 to 12 month old baby is meat, the iron of which is very well absorbed. Start feeding the baby solids in a way that makes eating enjoyable and the baby will eat iron-containing foods just fine. Do not get discouraged. Even if your milk supply is not up to the needs of your baby, your baby is still likely to latch on. Get good hands-onhelp. Do not try to do this on your own. Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond. To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002. What to Feed the Baby when the Mother is Working Outside the Home,February 2009©
Written and revised (under other names) by Jack Newman, MD, FRCPC,1995-2005©
Revised by Jack Newman MD, FRCPC, IBCLC and Edith Kernerman, IBCLC,2008, 2009©
All of our information sheets may be copied and distributed without further permission on the condition that it is not used in ANY contextthat violates the
WHO International Code on the Marketing of Breastmilk Substitutes(1981)
and subsequent World Health Assembly resolutions. VASOSPASM AND RAYNAUD’S PHENOMENON27 Jun, 2019 •
These conditions are due to a spasm of blood vessels preventing blood from getting to a particular area of the body, typically the end of an extremity, though not necessarily. They often occur in response to a drop in temperature. Raynaud’s phenomenon will occur in the fingers, for example, when someone goes outside from a warm house on a cool day. The fingers will turn white and the lack of blood getting to the tips of the fingers will cause pain. Raynaud’s phenomenon occurs more commonly in women than men, and can be often associated with “auto-immune” illnesses such as rheumatoid arthritis. Here, we will refer to both conditions as vasospasm. Vasospasm can also occur in nipples. In fact, it is much more common than generally believed. It can occur along with any cause of sore nipples, and is, in fact, probably a result of damage, but it may also, on occasion, occur without any other kind of nipple pain at all. Typically, vasospasm occurs after the feeding is over, once the baby is already off the breast. Presumably, the outside air is cooler than the inside of the baby’s mouth. When the baby comes off the breast, the nipple is its usual colour, but soon, within minutes or even seconds, the nipple will start to turn white. This is likely also due to drying of the nipple. Mothers generally describe a burning pain when the nipple turns white. After turning white for a while, the nipple may actually turn back to its normal colour (as blood starts to flow back to the nipple), and the mother will notice a throbbing pain. See the video clip of a mother’s nipple going from white to pink. The nipple may go back and forth between colours (and types of pain) for several minutes or even an hour or two. Sometimes, the mother does not even notice her nipple turning white and instead sees it change form pink to red to purple and back to pink again. That the nipple changes colour is not the concern; that the mother is in pain is a concern. Interestingly some mothers do not have pain with thevasospasm.
The treatment for vasospasm is to fix the original cause of the pain (poor latch, Candida). See the information sheets When Latching, Candida Protocol and Sore Nipples as well as the video clips. Almost always, as the nipple soreness from another cause is getting better, so will the pain from the vasospasm, but more slowly. Fixing the original cause of the pain (improving the latch, treating Candida etc) should be the focus of treatment. However, some mothers no longer have pain during the feeding, or never had it at all. Indeed, some start having vasospasm during the pregnancy. If the pain is mild, there may be no reason to treat, and reassurance is all that is necessary. However, it is worth treating when the pain is distressing to the mother, and especially if the pain during the feeding does not improve, as severe restriction of blood supply to the nipple may delayhealing.
Treatments for Raynaud’s phenomenon (blanching of the nipple) Identify and Fix the original cause of the pain: i.e. Poor Latchingand/or Candida.
Stop Air Drying of the nipples. When baby comes off the breast, immediately cover the nipple with your warm hand while you get your bra done up. After talking a shower, avoid going out of the shower enclosure until the breasts are completely covered and kept warmed so the cold air cannot reach the nipples. The All Purpose Nipple Ointment may also help for the soreness during the feeding, especially when ibuprofen powder has been mixed in. See the information sheets Candida Protocol and All Purpose NippleOintment.
Olive Oil Warming olive oil in mother’s fingers and then gently massaging the oil into the nipples during the burning may be very soothing. We have heard from many mothers that this gave them instant relief and seemed to decrease the occurrence of the vasospasm overall. It’s important that the oil be really massaged into the nipples andnot just dabbed on
Vitamin B6 Multi Complex. There have not yet been studies done to show that vitamin B6 works, but enough anecdotal evidence has come forward to support that it does work at least some of the time. It is safe and will do no harm. It is best that B6 not be taken on its own but instead as part of a B complex of vitamins that includes niacin. Depending on the overall dose of the B complex, the amount of B6 itself should be approximately 100 mg 2x/day for at least a couple of weeks. So, for example, if the overall capsule is 125 mg of B complex and there is only 50 mg of B6 in that capsule, then mother would need to take 2 capsules at a time to equal one dose and that dose would need to be taken 2x/day. The mother continues it until she is pain free for a few weeks. It can be restarted if necessary. If you have been pain free for a week or two, try going off the vitamin B6. If vitamin B6 does not work within a week, it probably won’t. Warm dry compresses can be very effective at stopping the vasospasm as it is occurring and for treating the pain. Lying down after a feeding and applying a heating pad to the breasts for a few minutes or more may help considerably. Certainly, it will allow mother to rest and this may help to deal with the pain, as well. Magnesium supplements with added Calcium taken as 2 teaspoons (300mg Magnesium/200 mg Calcium (gluconate), or taken separately: 2x daily or 300mg Magnesium 2x daily & 200mg of Calcium.) After working on the latch, possibly as effective as all of the above is the massaging of the chest muscles which are below the collar bone and above the breasts after the feedings or at onset of nipple or breast pain. The massage should be very vigorous and firm and is done on the chest, not necessarily the breasts. The mother could also massage under the pectoral muscles, in her armpits, but this massage should be done gently. When this is not enough: Nifedipine. This is a drug used for hypertension. One 30 mg tablet of the slow release formulation once a day often takes away the pain of vasospasm. After two weeks, stop the medication. If pain returns (about 10% of mothers), start it again. After two weeks, stop the medication. If pain returns (a very small number of mothers), start it again. No mothers I am aware of took more than three, two week courses. Side effects are uncommon, but headache may occur. It is a prescription drug. The dose can be increased if 1 tablet is insufficient. The nifedipine treatment may be used in conjunction with all of the other treatments listed above. Note: We no longer recommend nitroglycerin paste, as severe headache associated with its use is fairly common. It also does not work more than about 50% of the time. Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond. To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002.Vasospasm, 2009©
Written by Edith Kernerman, IBCLC, 2008© Revised by Jack Newman MD, FRCPC and Edith Kernerman, IBCLC, 2008,2009©
All of our information sheets may be copied and distributed without further permission on the condition that it is not used in ANY contextthat violates the
WHO International Code on the Marketing of Breastmilk Substitutes(1981)
and subsequent World Health Assembly resolutions. USING GENTIAN VIOLET27 Jun, 2019 •
Gentian violet (1% solution in water) is still an excellent treatment for Candida Albicans, though we don’t suggest mothers use it alone for Candida Albicans (thrush, yeast) because it tends to dry out the nipple and areola. Furthermore, it does not seem to work as well as it used to. Candida albicans is a fungus that may cause an infection of skin and/or mucous membranes (inside of mouth, for example) in both children and adults. In small children, this yeast is a frequent cause of white patches in the mouth (thrush), or diaper rash. When the nursing mother has a Candidal infection of the nipple, she may experience severe nipple pain, as well as deep breast pain. Please note: Gentian violet 1% in water also contains alcohol (10% by volume), but the amount of alcohol in the tiny amount of gentian violet you use is of no concern. Apparently some pharmacists are now dissolving it in glycerin, thus avoiding the use of alcohol, but if gentian violet is used as directed baby will get vanishingly smallamounts.
Nipple pain caused by Candida albicans The pain caused by a Candida infection is generally different from the pain caused by poor positioning and/or ineffective suckling. The pain caused by a Candida infection: Is often burning in nature, rather than the sharp, stabbing or pinching pain associated with other causes (such as a poor latch). Burning pain may be due to other causes, however, and pain due to a Candida infection does not necessarily burn. Frequently lasts throughout the feeding, and occasionally continues after the feeding has ended. This is in contrast to the pain due to other causes that usually hurts most when the baby latches on, and gradually improves as the baby sucks (unless nipple damage is very severe, in which case the pain may continue throughout the feeding). May radiate into the mother’s armpit or into her back. This does not mean that the Candida actually is inside the breast or in the ducts. Pain that is felt in a place where there is no cause of the pain, but due to pain elsewhere in the body is called ‘referred pain’. An example is pain in the neck which is actually due to heartburn which may also be felt at the lower end of the breast bone. May cause no change in appearance of the mother’s nipples or areolas, though there may be redness, or some scaling, or the skin of the areola may be smooth and shiny and the nipple may crack. Not uncommonly will begin after a period of pain free nursing. This characteristic alone is reason enough to try treatment for Candida. However, milk blisters on the nipple also may cause nipple pain after a period of pain free nursing as may eczema or other skin condition. Also, if the mother’s milk supply diminishes, the mother may start having pain later on since babies tend to slip down on the breast when the flow is slow. Another possibility is a new pregnancy, which in itself can cause sore nipples and since the milk production decreases during pregnancy may cause soreness also for that reason. May be associated with recent use of antibiotics by the baby or mother, but not necessarily. May be quite severe, may or may not be itchy. May occur in one breast or nipple only. May occur only in the breast. This pain is often described as “shooting”, or “burning” in nature, and is often worse after the feeding is over. It is often said to be worse at night. At the same time, the breast appears or feels normal. This is not mastitis since mastitis is associated with a large painful lump in the breast; therefore, there is no reason to treat with antibiotics. On the contrary, antibiotics may make the problem worse.Please Note:
a) The baby does not have to have thrush in his mouth. b) A Candida infection of the nipple may be combined with other causesof soreness.
Using Gentian Violet We believe that gentian violet (combined with “all purpose nipple ointment”, see the information sheet Candida Protocol) is a good treatment of nipple soreness due to Candida albicans for the breastfeeding mother. This is because it often works even when used alone (though we don’t recommend this, see first paragraph), and relief is rapid. It is messy, and will stain clothing (actually, it will usually wash out eventually or may be removed from clothing with rubbing alcohol), but not skin. The baby’s lips will turn purple, but the purple will disappear after a few days. Gentian violet is available without prescription but is not available at all pharmacies. Call around before going out to get it. If you are in the US: gentian violet seems to be sold commonly as a 2% solution rather than a 1% solution. This is too strong a concentration and probably accounts for the mouth ulcers that some babies get after being treated with it. The pharmacist should dilute it for you. It’s easy to do on your own: just add an equal amount of water to the gentian violet 2% and you have gentian violet 1%. About 10 ml (two teaspoons) of gentian violet is more than enough for an entire treatment. Many mothers prefer doing the treatment just before bed so that they can keep their nipples exposed and not worry about staining their clothing. The baby should be undressed to his diaper, and the mother should be uncovered from the waist up. Gentian violet is messy. Your baby will be less purple if, before you apply gentian violet, you rub some olive oil into the baby’s cheeks and around his mouth. Dip a clean ear swab (Q-tip) into the gentian violet. Paint one of your nipples and the areola and let dry for a fewseconds.
Put the baby to the breast. In this way, both the baby’s mouth and your nipple are treated. When baby is finished on that side, touch up the gentian violet on the nipple if necessary, place a breast pad over top, and cover up thatside.
Repeat for the other side If, at the end of the feeding, you have a baby with a purple mouth, and two purple nipples, there is nothing more to do. If only one nipple is purple, paint the other one with the ear swab and the gentian violet. In this way, the treatment is finished in one go. A cotton pad can then be used to wipe the excess gentian violet frombaby’s face
11. Repeat the treatment each day for at least three or four days t see if it is working and then continue for the rest of the week if it is seen to be working (see the Candida Protocol information sheet for how long to use gentian violet). There is often some relief within hours of the first treatment, and the pain is usually gone or virtually gone by the third day. If it is not, it is unlikely that Candida was the problem, though it seems Candida albicans is starting to show some resistance to gentian violet, as it already has to other antifungal agents. Of course, there may be more than one cause of nipple pain, but after three days the contribution to your pain caused by Candida albicans should be gone. However, if your pain is virtually gone after three or four days, but not completely, you can use gentian violet a few more days ifnecessary.
All artificial nipples that the baby uses should be boiled daily during the treatment, or well covered with gentian violet, or rinsed in a solution with grapefruit seed extract. Consider stopping artificial nipples. Artificial nipples can interfere with the way the baby latches on and may contribute to your pain. There is no need to treat just because the baby has thrush in his mouth. The reason to treat is the mother’s and/or the baby’s discomfort. Babies, however, only very occasionally seem to bebothered by thrush.
Uncommonly, babies who are treated with gentian violet develop sores in the mouth that may cause them to reject the breast. If this occurs, or if the baby is irritable while nursing, stop the gentian violet immediately, and contact the clinic. The sores clear up within 24 hours and the baby returns to feeding. It is advisable that a mother with a recurring infection take probiotics orally for a few weeks and or grapefruit seed extract orally for at least 2 weeks. In this case, the baby should probably be treated with probiotics as well (see the Candida Protocol informationsheet).
If the infection recurs, treatment can be repeated as above. But if the infection recurs a third time, a source of re-infection should be sought out. The source may be the mother who may be a carrier for the yeast (but may have no sign of infection elsewhere), or from artificial nipples the baby puts in his mouth. See the Candida Protocol information sheet. Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond. To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002. Gentian Violet, Revised 2009 Written and Revised by Jack Newman, MD, FRCPC 1995-2005 Revised by Edith Kernerman, IBCLC, and Jack Newman, MD, FRCPC © 2009 All of our information sheets may be copied and distributed without further permission on the condition that it is not used in ANY contextthat violates the
WHO International Code on the Marketing of Breastmilk Substitutes(1981)
and subsequent World Health Assembly resolutions. TOXINS AND INFANT FEEDING27 Jun, 2019 •
The question of toxins in breastmilk is being addressed in a patient information sheet because the issue comes up every few months in the media, as regular as clockwork. It frightens many pregnant women out of breastfeeding their babies and many women who are already breastfeeding into stopping. Journalists do not seem to know how to handle this question very well. Some may have an ulterior motive (“my baby wasn’t breastfed and he’s okay”) thus finding a way of getting back at breastfeeding advocates and justifying their “choice of infant feeding”. It is, of course, unprofessional to do this, but that doesn’t stop them. Others are merely trying to get out the news but often without understanding what they are doing. They don’t understand, for example, that by talking about toxins in breastmilk and considering formula as an almost as good alternative, they are striking a blow against breastfeeding. Why are there all these studies that look at toxins in breastmilk? One gets the impression that there is panic about the state of breastmilk in the modern world, that it is so polluted that everyone is trying to study it. But the reason that breastmilk is being studied so often is that it is easily available, and gives us an easily obtained sample of human fluid. That’s the reason, not because scientists are worried about breastmilk in particular. We need to be worried about all our bodily fluids given the levels of pollution we have created in theworld.
Is Formula Almost The Same As Breastmilk? This question needs to be considered in trying to understand the issue of toxins in breastmilk and the answer is no, formula is not almost like breastmilk, not by a long shot. Just because every few years the formula manufacturers add something to their formulas that we knew was in breastmilk for years but the manufacturers denied were of any importance, doesn’t mean that the “new and improved” formula is just like breastmilk. In some cases, the formula is improved, but remember, they were telling us that the formula before the “new and improved” version was also “almost like breastmilk”. This is true, for example, of the long chained polyunsaturated fatty acids (DHA and AA) that are supposed to make your baby smarter (one company even calls their formula A+, but it deserves a C- at best). We’ve known how important these fats are for many years, but for many years (before they were added to formula, of course), the manufacturers, echoed by many health professionals, just kept saying that it didn’t matter, and that there was no proof that these fats were of any importance at all (this is still in the Canadian Paediatric Society’s 1995 statement on the nutrient needs of premature babies). This cycle of “our milk is just like breastmilk” followed by “we have now added x to our milk so that it is even more like breastmilk” has been going on since the 19th century. The truth of the matter is this: Just adding something to formula, even if it is in the same amounts as in breastmilk, does not mean that the baby will get the amount he needs or the best sort of this something that he needs. The example of iron helps us understand this. Breastmilk contains enough iron (with the stores the baby has during pregnancy), to keep the baby iron sufficient for at least 6 months. To maintain iron sufficiency in formula fed babies, formula needs to contain at least 6 times more iron than breastmilk, just because iron does not get absorbed from the baby’s gut as well from formula as it does from breastmilk. There are still hundreds of components of breastmilk that are still not added to formulas. Breastmilk varies in what it contains, from morning to evening, from day to day, from beginning of the feeding to the end, from day 1 to day 4 to day 10 to day 100, so there is no way we can know what breastmilk really contains. This means that there is no way to duplicate breastmilk because there is no such thing as a standard breastmilk. In fact, since every woman produces somewhat different breastmilk, the notion of a standard breastmilk becomes an absurdity. Breastmilk is a living, dynamic fluid. Formula is a chemical soup. So What Does This Mean? This means that we should consider formula a drug, which, if one thinks about it, is exactly what it is. It replaces a normal fluid (breastmilk). It is only very superficially like that fluid it replaces. There are known side effects of formula, in the short term, medium term and long term, some quite serious and irreversible. Formula may occasionally be necessary, but so are drugs. In rare cases, formula can be lifesaving, but so can some other drugs. A drug is, as my pharmacology professor said to us in medical school, a poison or toxin with beneficial side effects. There is much wisdom in that statement. So when a mother decides to feed her baby artificial milk instead of breastfeeding, she is not avoiding the problem of giving toxins to her baby. In fact, it is amazing how indulgent we are towards formulas. In none of the articles or television programmes that bring us the news of toxins in breastmilk, do they ever, in any I have read or heard, talk about toxins in formula. There are toxins in formula. Why would everything on earth be polluted, even the far reaches of the Arctic, but not formula? Formula is full of heavy metals, including lead, for example, in quantities much higher than breastmilk. And why would pesticides not be present in formula? After all, the cows do eat the grass in the countryside where the fields are sprayed. And soybeans grow there too. Interesting you never read about this in thenewspapers.
But Toxins Are Not Good Are They? No they are not and breastfeeding helps to diminish their bad effects. Here are some facts: Toxins increase the risk of developing some cancers. True, and the evidence shows that breastfeeding babies have a lower risk of some cancers than artificially fed babies. Toxins may interfere with neurological function and learning abilities. True, and the evidence shows that children who were breastfed do better on neurological and intelligence tests than artificially fed children, and the longer they are breastfed, thebetter they do.
Toxins may interfere with immunity. True, and the evidence shows that infants who are breastfed have better and more mature immunity than artificially fed infants, and that this better immunity carries on much longer than the length of time the infant or child is breastfed.What Should You Do?
If you breastfeed your baby, you are doing the best for your baby, and for the world, for that matter. Breastfeeding is very environmentally friendly. Formula feeding pollutes the environment. The fact that there are pollutants in breastmilk can be likened to the situation of the canary in the coal mine. We should be worried about what we are doing to our planet, but this should not lead us to encourage mothers to feed their babies artificially. See the video clips and other information at nbci.ca. Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond. To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002. Toxins and Infant Feeding, 2009© Written and revised (under other names) by Jack Newman, MD, FRCPC,1995-2005©
Revised Jack Newman MD, FRCPC, IBCLC and Edith Kernerman, IBCLC, 2008,2009©
All of our information sheets may be copied and distributed without further permission on the condition that it is not used in ANY contextthat violates the
WHO International Code on the Marketing of Breastmilk Substitutes(1981)
and subsequent World Health Assembly resolutions. MYTHS OF BREASTFEEDING27 Jun, 2019 •
1. 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. (See Information Sheet SoreNipples).
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 problemslater 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 (Information Sheet Breast Compression). 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 havemuch 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 thannutrients.
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. (Information Sheets Breastfeeding and Medication and Breastfeeding andIllness).
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. (Information Sheets Breastfeeding and Medication and Breastfeeding and Illness). 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 (Information Sheets Breastfeeding and Medication and Breastfeeding andIllness).
All of our information sheets may be copied and distributed without further permission on the condition that it is not used in ANY contextthat violates the
WHO International Code on the Marketing of Breastmilk Substitutes(1981)
and subsequent World Health Assembly resolutions. If you don’t know what this means, please email us to ask!NIPPLE SHIELDS
27 Jun, 2019 •
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 isnot 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 followingreasons:
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 (see the information sheet Slow Weight Gain after Early Good Weight Gain). 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. See the information sheets When the Baby Does Not Yet Latch, Finger & Cup Feeding and Expressing Milk. 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). See the information sheets When Latching, Sore Nipples, The All Purpose Nipple Ointment, Candida Protocol as well as the video clips. 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. See the information sheet 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. Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond. To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002. Nipple Shields April 2009© Written by Jack Newman MD, FRPC, and Edith Kernerman IBCLC, 2009© All of our information sheets may be copied and distributed without further permission on the condition that it is not used in ANY contextthat violates the
WHO International Code on the Marketing of Breastmilk Substitutes(1981)
and subsequent World Health Assembly resolutions. ON THE FDA AND DOMPERIDONE27 Jun, 2019 •
As a paediatrician who deals now only with mothers and babies who are having difficulty with breastfeeding, I am very concerned about the warning about domperidone which was issued by the Federal Drug Administration in the US on June 7, 2004. It warns breastfeeding mothers about getting domperidone to enhance milk supply because it conceivably can cause cardiac arrhythmias. The FDA has basically come up with a political statement. They seem really bothered because people were going around using a drug which they have not approved. The deaths (and I believe there were two) occurred with intravenous domperidone, which is never used any more and has never been used for enhancing milk supply. Domperidone was given intravenously in huge doses to patients who were sick with other problems as well, notably cancer for which they were getting chemotherapy. Domperidone was being used to decrease nausea and vomiting. Some patients were getting 1000 mg of domperidone every 4 hours intravenously, compared to our usual dose of 30 mg 3 times a day, taken by mouth. It is also likely that some of the chemotherapy drugs the patients would have received have cardiac side effects (for example, doxorubicin) and it was the combination of the huge doses of domperidone intravenously plus other drugs that caused the problem. Furthermore, unlike what the FDA has led people to believe, perhaps unintentionally, these are not new cases, but 2 decades old. Why didn’t they mention metoclopramide in their warning, which is far more dangerous (it can cause severe depression in oral doses, which domperidone does not) and is also being used off label to increase milk supply in the US, but which, on the other hand, is available and approved for gastric motility problems in the US? Can it be that they are not concerned about the danger but rather the threat to their authority? Here is part of a letter I received about metoclopramide and domperidone as a result of this to do about domperidone. “…my mother…is on domperidone for gastroparesis. She’s 5 feet tall, and lost over 20 lbs…down to 82 lbs. And why is she on domperidone? Because she had depression and SEVERE panic attacks with the Reglan (metoclopramide). She was in and out of the senior psych ward all last spring. So my folks get domperidone fromoutside the US.”
Why didn’t they mention the danger to diabetics, if they are so concerned, for whom some endocrinologists in the US are prescribing domperidone for gastric paresis? Why specifically for breastfeeding women? Why not specifically for diabetics who are at much greater risk of cardiac arrhythmias than women of reproductive age? Why did this warning come out exactly on the day that the National Breastfeeding Campaign was to begin in the US? I have used domperidone, in infants (for spitting up) but mostly to increase milk supply in women, in thousands of women, without any more than the occasional mother getting mild headaches or occasional menstrual irregularities or mild abdominal cramping as side effects. I cannot say the same for metoclopramide which I saw causing severe CNS side effects, aside from depression. I have personally seen two children die of Stevens-Johnson Syndrome after taking Septra. If I have seen two, how many have actually occurred in the US and Canada? Why no such warnings on Septra? I have, as a medical resident, seen at least one person die and several get severely ill after taking ASA, from gastric bleeding. In overdose, many children have died and many have become seriously ill over the years because of ASA. Why no such warning on aspirin? Many women have died and many more severely injured from taking the birth control pill. Why is it not banned? The issue comes up about providing a drug for women in good health and that we should not be treating healthy women with a drug. I disagree. With all the talk about preventive medicine, when it actually comes down to trying to prevent illness, it is all lip service. The data are clear. Breastfeeding decreases the risk of breast cancer and type 2 diabetes in the mother. In the baby it decreases the risk of diabetes (type 1 and 2), obesity, hypertension, high LDL/HDL levels, otitis media, asthma, and allergies, gastroenteritis, and and in premature babies, necrotizing enterocolitis. The first 4 of these are all risk factors for atherosclerosis, the most significant degenerative disease in affluent societies and the biggest killer. The data are clear that breastfeeding results in better cognitive development in children. The data are less clear, but suggestive, that breastfeeding decreases the risk of certain cancers in children (Hodgkin’s and non Hodgkin’s lymphoma, breast cancer in later life), multiple sclerosis and inflammatory bowel disease. Thus, we should do all that is reasonable to maintain and increase the success of woman who are breastfeeding. If this means that, in some cases, we use a drug that, in my experience of using it with thousands of women, is safe, with only minor side effects, we should have that option. Of course, there is no such thing as a drug which never causes side effects, and there are probably very few approved drugs (yes, even approved drugs) out there that haven’t killed someone, but if one weighs the risk against the benefits, domperidone can do much good. I will continue to prescribe domperidone to women when I feel it will be useful. It’s a shame, though, for women in the US to be deprived of this drug. The FDA says that it will monitor the border to make sure none gets through. Good for them. With heroine and cocaine getting through their borders as through a sieve, it’s great that the US can now be sure that their borders are safe against an influx of the dreaded domperidone. What a waste of manpower! What a waste! Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond. To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002. First written in June 2004 by Jack Newman, MD, FRCPC Revised February 2009 All of our information sheets may be copied and distributed without further permission on the condition that it is not used in ANY contextthat violates the
WHO International Code on the Marketing of Breastmilk Substitutes(1981)
and subsequent World Health Assembly resolutions.* Previous
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VIDEOS
------------------------- TONGUE–TIE RELEASE27 Jun, 2019 •
A simple and quick procedure that can make a significant difference in breastfeeding success. The research supporting tongue-tie release iscompelling.
JIGGLING AND PULLING27 Jun, 2019 •
A good alternative to the bottle. ParticulThis is an older baby, about 3 or 4 months of age, whose mother’s production has decreased. See the information sheet Slow Weight Gain Following Early Good Weight Gain for some reasons this decrease in milk production might occur. Some of the reasons that may result in a decreased milk production include the mother’s using a hormonal birth control method (including hormone releasing intrauterine devices or intravaginal hormone releasing rings), the mother’s feeding one breast at a feeding “as a rule” instead of “finishing” one side and then offering the other. But the most common reason is the one discussed in the paragraph “This reason (number 11) requires more explanation”. The baby is jiggling and unsettled at the breast because the flow of milk is slow. Note that he hardly drinks at the breast (very few pauses, see the videos Really Good Drinking, and Good Drinking), though his chin is a little bit difficult to see. This sort of behaviour is often said to be due to an over rapid milk flow but by watching the chin one can see that this behaviour in this case is due to too slow milk flow. However, babies pull at the breast more frequently because the flow of milk is slow rather than because the flow of milk is “too rapid”. Note that giving such babies bottles, may quickly result in their refusing to latch on.arly useful for the baby who is refusing thebreast.
Note that the baby laps the milk up with his tongue. One does not pour the milk down his throat. VASOSPASM TURNS PINK27 Jun, 2019 •
This mother’s nipples turn white after baby has finished feeding. They turn white for some time and then eventually turn pink again. This change in colour is sometimes accompanied by throbbing and burning in the nipples. This is often due to poor latching and/or ayeast infection.
CUP FEEDING
27 Jun, 2019 •
A good alternative to the bottle. Particularly useful for the baby who is refusing the breast. Note that the baby laps the milk up with his tongue. One does not pour the milk down his throat. NOT YET LATCHING, FINGER FEED TO LATCH27 Jun, 2019 •
Finger feeding is to be used primarily to prepare a baby who does not latch on to take the breast. Note that finger feeding is done only long enough to calm the baby and to get the baby sucking well. This rarely takes more than 60 seconds. It should not be used as a method of supplementation when the baby does take the breast. In such a case supplementation, if necessary, should be given at the breast with a lactation aid. We filmed this baby because he had already latched on after beingfinger fed.
Why did he not latch on to the right side in this video? Because he already had fed on the right side, the flow of milk from the breast was slower: babies like fast flow and even if the lactation aid would provide him with more flow, it wasn’t enough Why did he latch on to the left side? Because he hadn’t yet fed on the left side, the breast was “fuller” and the flow was rapid: babies like fast flow Note that we do not try to force a baby to stay at the breast. If the baby struggles, allows the breast into his mouth but doesn’t suck, or cries, then we let him come away from the breast and try again. If the baby latches on, there is no need to try to force him to stay,he’s latched on
If the baby does not latch on, trying to force him to stay at the breast is futile and likely to make him angrier or “go limp” INSERTING A LACTATION AID27 Jun, 2019 •
This baby needs to receive supplementation. It is best that the baby receive this via lactation aid because: The baby is still on the breast and breastfeeding. Babies learn to breastfeed by breastfeeding. Mothers learn to breastfeed by breastfeeding. The baby is still getting milk from the breast thus helping increase the mother’s milk production. The baby is not likely to reject the breast as he would if he were supplemented by bottle or by any method not on the breast. There is more to breastfeeding than breastmilk; the baby and mother are in close physical contact. One way to introduce the tube is to insert it while the baby is at the breast as in this video clip. The other is to line up the tube with the nipple and latch the baby on the breast and lactation aid tube atthe same time.
Note the position of the baby: The baby’s chin touches the breast but nose does not touch. The baby covers more of the areola with his lower lip than his upperlip.
The baby is slightly tilted up towards the mother. The baby has now fed from both breasts and is not getting much milk flow (mostly nibbling at the breast—see video clips of babies drinking or not drinking). It is time to supplement.Note the following:
The breast tissue is eased out of the way so that the corner of the baby’s mouth is visible. The fact that the baby is tilted slightly upwards makes it easier to find the corner of the baby’s mouth and insert the tube. The tube is inserted in the corner of the baby’s mouth. The tube is pushed almost straight back towards the back of the baby’s throat but also slightly upward toward the roof of thebaby’s mouth.
The milk moves down the tube to the baby’s mouth, but the baby does not drink (see video clips of babies drinking or not drinking). Something is not working. The mother is attempting compression, but compression should be done when the baby is sucking and not drinking, not when the baby is not sucking at all. Moreover, compression while the baby is being supplemented at the breast with a lactation aid is not necessary. At 21 seconds into the video, I fiddle with the tube placement, and now it starts working. The baby is drinking. Notice the baby pops his eyes open when he starts getting milk again. Babies are not “lazy”; they respond to milk flow. Young babies such as this one tend to fall asleep when the flow of milk is slow, not necessarily if they have had enough. More fiddling with the tube at about 35 seconds. If the baby is well latched on and tube is well placed, supplementing using the lactation aid takes no more time than giving the baby the bottle or finger feeding. Using finger feeding to supplement when the baby takes the breast is not the best approach either. At about 1 minute into the video, I pull the baby’s chin down a bit. Remember, good latch and good placement of the tube make this system work best. Pulling down the chin gets more of the breast into thebaby’s mouth.
At about 1 minute and 18 seconds, we bring the baby around even more asymmetrically by having the mother push the baby’s bottom in withher forearm.
At about 1 minute and 55 seconds, milk comes out of the baby’s mouth means something is not right. Baby has slipped off the breast or the tube has moved. Fiddling with the tube again makes it work properlyagain.
SQUEEZING NIPPLE DEMONSTRATING DIFFERENCE BETWEEN POOR LATCH27 Jun, 2019 •
When the baby latches on to the nipple only, he gets very little milk. When the baby latches on where he should, the milk flows rapidly. 4 DAY OLD AFTER TONGUE-TIE RELEASE WITH COMPRESSIONS27 Jun, 2019 •
The baby just had a tongue tie release. The mother is doing compressions appropriately. She waits to see if the baby is drinking or not (pause in the chin). If the baby is not drinking, she compresses, holds the compression until the baby stops sucking or stops drinking and then releases. She waits for the baby to start sucking and if the baby starts sucking but does not drink, she repeats the process. BABY LED MOTHER GUIDED STARTED UPRIGHT LEFT BREAST, LATCHES27 Jun, 2019 •
When the baby does not yet take the breast or refuses it completely, this technique can help to put the baby in a state where he can accept the breast. The baby is skin to skin with the mother and indicates when he is ready to search for the breast. When he starts searching, the mother helps him, guiding him toward the breast, supporting his back and neck. The mother is careful not to hold his head. Babies need to have their necks supported but not their heads. See the informationsheets.
The Importance of Skin to Skin Contact and When the Baby Does Not YetLatch.
BABY 28 HOURS OLD ASSISTED LATCHING27 Jun, 2019 •
Shows latching on. Not perfect, but good enough. The mother had no pain. It did take two tries to get the baby to latch on, but that’s okay; there’s no point in trying to force a baby who does not take the breast to stay on the breast. It won’t work. Note the baby has an “asymmetric” latch, with the chin touching the breast, the nose not touching the breast, and he covers more of the areola with his lower lip than the upper. Compressions help the baby get more milk.* Previous
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LATEST VIDEOS & POSTS -------------------------LACTATION AID
27 Jun, 2019 •
Introduction
A lactation aid is a device that allows a breastfeeding mother to supplement her baby with expressed breastmilk, formula, glucose water with added colostrum or plain glucose water without using a bottle. The early use of artificial nipples may result in the baby becoming “bottle spoiled” or “nipple confused” especially when the mother’s breastfeeding is not yet well established or flow from the breast is slow because of milk supply issues. In fact, the baby is not confused. The baby knows exactly what the score is. If he goes to the breast and gets little milk or the flow is slow and then gets a bottle with rapid or steady flow, especially in the first few days, most can figure that one out fairly quickly. Bonding is very important, buthunger comes first.
The better a baby latches on, the easier it is for him to get milk, particularly if the mother’s supply is low. In the first few days, it may seem as though the mother may not have much milk; however, the mother does have the appropriate amount of milk that baby requires (see the video clip 2 day old baby at the website nbci.ca and watch this baby drink great guns—compare to the other video clips that show older babies drinking). 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—pumps don’t work that well either when the milk is there in the small, but normal, quantities of the first days, as nature intended, incidentally. Also note, no one who squeezes a mother’s breast can tell whether there is enough milk in there or not. And 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 get sore nipples, and if the baby does not get milk well, the baby will want to be on the breast for long periods of time, worsening the soreness. What we have here is a perfect “vicious circle”, which can be avoided,actually.
Though artificial nipples do not always cause problems, their use when things are already going badly will rarely make things better and usually make things worse. And “newer bottle nipples” are no better than the old ones; that’s just good marketing. The lactation aid is by far the best way to supplement, if the supplement is truly necessary. (However, proper latching on of the baby usually allows the baby to get more milk, and thus it is often possible to avoid the supplement). The lactation aid is better than using a syringe, cup feeding, finger feeding or any other method, since the baby is on the breast and breastfeeding. Babies, like adults, learn by doing. Furthermore, the baby supplemented while latched on to the breast is also getting breastmilk from the breast. And there is much more to breastfeeding than breastmilk. Why Is The Lactation Aid Better? Babies learn to breastfeed by breastfeeding Mothers learn to breastfeed by breastfeeding The baby continues to get the mother’s milk even while beingsupplemented
The baby will not reject the breast, which is very possible if supplementing off the breast There is more to breastfeeding than the breastmilk What Is A Lactation Aid? A lactation aid consists of a container for the supplement—usually a feeding bottle with an enlarged nipple hole—and a long, thin tube leading from this container. Manufactured lactation aids are available and are easier to use in some situations, but not necessarily. Manufactured lactation aids are particularly useful when the need for a lactation aid arises in an older baby, when a mother needs to supplement twins, when the need for a lactation aid will be long term, or whenever difficulty arises using the improvised lactation aid. Though the manufactured lactation aid is not inexpensive, the cost is about equal to two weeks of the usual milk-based formula. Please Note: Using a tube with a syringe, with or without a plunger, instead of the setup mentioned above, seems unnecessarily complicated and adds nothing to the effectiveness of the technique. On the contrary, it is more cumbersome and pushing the milk into the baby’s mouth with the syringe does not teach the baby how to breastfeed because he gets milk even if he sucks poorly. Using The Lactation Aid (Improvised). (Use should be shown by a person experienced in helping mothers with breastfeeding). See the videoclips at nbci.ca.
The baby may be latched on to the breast first, and the tube slipped into the baby’s mouth at the appropriate time (after the baby has breastfed on at least both sides first). The better the latch, the better the baby will get your milk and the easier the aid will be to use, and the more quickly you will be able to get rid of it and the supplements. The breast should be gently eased out of the way so that the corner of the baby’s mouth is seen, and the tube, held between the index finger and thumb, should be slipped into the corner of the baby’s mouth so that it enters straight towards the back of the baby’s mouth and at the same time, slightly upwards towards the roof of the mouth (see the video clip called Inserting Lactation Aid). The tube is well placed when the supplemental fluid works its way down the tube at a rather rapid rate. There is usually no need to fill the tube with supplemental fluid before putting it into the baby’s mouth. Or, the baby is latched on to the breast and the tube, which is run along the mother’s breast and nipple, at the same time. The better the baby’s latch, the easier the lactation aid is to use. Also, the better the latch, the more likely and the sooner the baby will be able to do without supplements. Therefore, proper positioning and latching on of the baby are still very important. The tube may be taped to the breast if the mother desires, though this is not really necessary and not always helpful. The tube does not need to pass the end of the nipple and needs to be only just past the baby’s gums to function properly. It does seem to function better if the tube is placed in the corner of the baby’s mouth and enters straight into the baby’s mouth over the tongue. (Point it slightly to the roof of the baby’s mouth). It is occasionally helpful for the mother to hold the tube in place with her finger, as some babies tend to push the tube out of position withtheir tongues.
The bottle containing the supplement should not be higher than the baby’s head. If the lactation aid functions only when the bottle is held higher than the baby’s head, something is wrong. Keep the bottle higher only if the doctor or lactation specialist suggests this (as in the care of breast refusal for example). It is best to use the tube as necessary to keep the baby drinking at the breast. Follow the Protocol to Increase Breastmilk Intake. Feed baby from both breasts before adding the supplement. Some mothers find it easier not to use it during the night. Better eight supplements a day of 30 ml (1 ounce) per feeding than 2 large supplements a day of 120 ml (4 ounces) each. Do not cut off the end of the tube as cutting it makes the end sharp–it works fine as it is. It should not take an hour for the baby to drink an ounce of milk from the lactation aid. If it is taking this long, the tube is probably not well positioned, or the baby is poorly latched on, or both. When the lactation aid is functioning well, it takes 15-20 minutes, usually less, for the baby to take 30 ml (1 ounce) of the supplement. A trick for easier use: Wear a shirt with pockets, and put the bottle in the pocket or stick it in your bra strap.Cleaning the Device
Do not boil the tube of the non-manufactured aid. It is not made to beboiled.
After using the device, clean the bottle and nipple as usual. Do not boil the tube. The tube should be emptied after use and then rinsed through with hot water (suck up hot water into the tube from a cup) and then hung up to dry. Soap, though not necessary, may be used if desired, but rinse the tube well. Tubes may become stiff and unsuitable for use after a few days to a week. Weaning the Baby from the Lactation Device Maintain contact with the breastfeeding clinic for advice about weaning the baby from the lactation aid. See the information sheet Protocol to Manage Breastmilk Intake. Weaning the baby from the aid may take several weeks or only a short while. Do not be discouraged and do not try to force the weaning. Usually, the amount of milk required in the lactation aid increases over one or two weeks, and then levels out for a variable period of time before decreasing. The whole process may take two to eight weeks or longer, although some mothers have used the device only a few days, whereas others have not been able to stop using it at all until the baby was well established on solids. Rapid improvement sometimes occurs after a long period of little change. Observe the baby’s breastfeeding. If you do not know how to know if the baby is drinking, see the video clips at nbci.ca. Put the baby onto the breast, allow the baby to breastfeed as long as he is suckling and drinking, then use breast compression (see the information sheet Breast Compression) to keep the baby drinking; then repeat the process on the second breast. You can return to the first breast and continue back and forth as long as the baby is drinking. After you have finished feeding on both breasts, insert the tube into the baby’s mouth. Allow the baby to breastfeed until satisfied usingthe lactation aid.
Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond. To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002. Lactation Aid, 2009© Written and revised (under other names) by Jack Newman, MD, FRCPC,1995-2005©
Revised Jack Newman MD, FRCPC, IBCLC and Edith Kernerman, IBCLC, 2008,2009©
All of our information sheets may be copied and distributed without further permission on the condition that it is not used in ANY contextthat violates the
WHO International Code on the Marketing of Breastmilk Substitutes(1981)
and subsequent World Health Assembly resolutions.WHEN LATCHING
27 Jun, 2019 •
Cross Cradle Position for Left Breast: Align baby’s nose so that it does not go past your nipple, or go to the left of your nipple, in other words, your nipple should not be aligned with his chin Place your right hand under baby’s face so your four fingers make a pillow for baby’s cheek (keep your four fingers tightly together as if the were stuck together with glue) You are now supporting the weight of baby’s head with your hand You may want to sit baby’s bottom on you arm as though it were a shelf (this will work in the beginning with a newborn) Or you may want to let baby’s bottom fall diagonally a bit and squeeze it against your rib cage with your elbow Baby’s body and legs should be wrapped around mother. Pull baby’s bottom into your body with the inside/underside of your forearm as if serving baby to you on a platter This will bring him toward your breast with the nipple pointing to theroof of his mouth
Head supported but NOT pushed in against your breast. In fact, try to think of it not as bringing baby’s head into or near your breast at all—instead, bring baby’s body into your body and the head will follow, as if serving baby to you on a platter. Head should be tilted back slightly so the nose is up and the baby’s chin is coming into the breast while the nose never touches thebreast.
Use your whole arm to bring the baby onto the breast, when baby’smouth is wide.
Baby’s chin should be far away from Baby’s chest. WATCH LOWER LIP, aim it as far from base of nipple as possible, so tongue draws lots of breast into mouth. Move baby’s body and head together – keep baby uncurled. If you keep your wrist straight, with baby’s cheek resting on your fingers, then baby’s chin will not bend down toward his chest Once latched, baby’s top lip will be close to nipple, areola shows above lip. Keep baby’s chin close against your breast. Need mouth wide before baby moved onto breast. Teach baby to openwide/gape:
Avoid placing baby down in a feeding position until you are completely ready to latch baby. The longer baby waits while you get ready (undoing your breast, etc) the more frustrated baby gets and the less open baby’s mouth will go. move baby toward breast, touch top lip against nipple move mouth away SLIGHTLY touch top lip against nipple again, move away again repeat until baby opens wide and has tongue forward Or, better yet, run nipple along the baby’s upper lip, from one corner to the other, lightly, until baby opens wideMother’s Posture
Sit with straight, well-supported back Trunk facing forwards, lap flat Baby’s Position Before Feed Begins Nipple points to the baby’s upper lip or nostrilBaby’s Body
Placed not quite tummy to tummy, but so that baby comes up to breast from below and baby’s eyes make contact with mother’s SupportBreast
Firm inner breast tissue by raising breast slightly with fingers placed flat on chest wall and thumb pointing up (if helpful, also use sling or tensor bandage around breast) Move Baby Quickly On To Breast Head tilted back slightly, pushing in across shoulders so chin and lower jaw make contact (not nose) while mouth still wide open, keep baby uncurled (means tongue nearer breast) lower lip is aimed as far from nipple as possible so baby’s tongue draws in maximum amount ofbreast tissue
Cautions
Mother needs to AVOID pushing her breast across her body chasing the baby with her breast flapping the breast up and down holding breast with scissor grip not supporting breast twisting her body towards the baby instead of slightly away aiming nipple to centre of baby’s mouth pulling baby’s chin down to open mouth flexing baby’s head when bringing to breast moving breast into baby’s mouth instead of bringing baby to breast moving baby onto breast without a proper gape not moving baby onto breast quickly enough at height of gape having baby’s nose touch breast and not the chin holding breast away from baby’s nose (not necessary if the baby is well latched on, as the nose will be away from the breast anyway) Also see videos of latching and latching in other positions Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond. To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002. When Latching, 2009© Written and revised (under other names) by Jack Newman, MD, FRCPC,1995-2005©
Revised by Jack Newman MD, FRCPC, IBCLC and Edith Kernerman, IBCLC,2008, 2009©
All of our information sheets may be copied and distributed without further permission on the condition that it is not used in ANY contextthat violates the
WHO International Code on the Marketing of Breastmilk Substitutes(1981)
and subsequent World Health Assembly resolutions. If you don’t know what this means, please email us to ask! Show MoreShare by:
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