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| Introduction PEACE AT THE TABLE: THE WHYS AND HOWS OF NURTURANCE | 1 | (4) | |||
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| Appendices | 207 | (16) | |||
| I WHAT CAREGIVERS NEED TO KNOW: A CHECKLIST | 207 | (2) | |||
| II FOOD-MEDICATION INTERACTIONS | 209 | (3) | |||
| III STANDARD GROWTH CHARTS | 212 | (4) | |||
| IV BODY MASS INDEX CHARTS | 216 | (2) | |||
| V FOOD SUBSTITUTIONS | 218 | (1) | |||
| VI HEALTH AND NUTRITIONAL RESOURCES | 219 | (2) | |||
| RESOURCES FROM THE AMERICAN ACADEMY OF PEDIATRICS | 221 | (2) | |||
| Index | 223 |
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Chapter One
What's Best for My Newborn?
Like many new parents, you're probably eager to do what's "right." We want to stress at the outset that you're embarking on one of life's greatest and most rewarding adventures--namely, parenthood. Usually, there is no right or wrong way; instead, it's a matter of deciding what works best for you and your baby. So relax. Enjoy getting to know your new baby and trust your own sense of what's right for you .
When Laura and Jim Hawkins brought baby Emily home from the hospital, they were both overjoyed and overwhelmed. "We were absolutely delighted to finally have a baby," Laura recalls, "but neither of us knew anything about infant care. Since I planned to breastfeed, I figured I'd instinctively know what to do. It didn't take long for reality to set in!" Nurses at the hospital helped Laura start breastfeeding, and showed her such babycare basics as diapering and bathing. But in just two days, the Hawkinses were on their own at home. "For weeks we called our pediatrician almost daily with questions," Laura recounts.
Not surprisingly, many of these questions dealt with Emily's diet. "How often should I feed her?" "How can I tell whether she's getting enough milk?" "Should I give her supplemental formula `just in case'?" "Does she need extra iron and vitamins?" "What about water?" "Her stools are runny and yellowish. Does she have diarrhea?" "I have a bad cold. Is it safe for me to breastfeed?" "What should I do if I'm unable to nurse for a few days?"
Common Concerns
Many if not most new parents have similar concerns. In fact, parents ask pediatricians more questions about how and what to feed their babies than about any other aspect of early childcare. Although this book is intended to answer the most frequently asked of these questions, it's important to remember that no two babies are exactly alike: What's good for your baby isn't necessarily good for your sister's or your neighbor's. Your pediatrician is your best source of advice about what's best for your baby, and you should not hesitate to discuss any concerns with him or her.
Decisions, Decisions
Even before your baby's birth, you need to decide how you want to feed her: Will you feed your baby breastmilk or formula? The American Academy of Pediatrics, the American Dietetic Association, and other organizations concerned with health and nutrition advocate breastfeeding for most women, and a growing number of American women plan to nurse.
The American Academy of Pediatrics has always advocated breastfeeding as the best way to nourish babies. Breastfeeding is best for the health of babies and mothers alike. It is economical and convenient.
In new and even stronger guidelines, the Academy encourages mothers to breastfeed exclusively for the first 6 months (about the time your baby's diet begins to include solid foods), and to continue breastfeeding for at least 12 months or as long as baby and mother want to continue.
HOW MANY WOMEN BREASTFEED?
A survey found that 80 to 90 percent of pregnant women wanted to breastfeed, but in actual practice, only about 60 percent of American mothers start nursing. Although this figure is lower than we'd like it to be, it's a marked improvement over the all-time low of 26.5 percent in 1970.
The guidelines recommend that health insurers cover necessary services and supplies. They emphasize the importance of providing workplace facilities where working mothers can pump milk to save for their babies.
Breastfeeding has many advantages (see The Special Health Benefits of Breastfeeding, p. 9), but there are instances in which it is not possible: for example, when a baby has a condition such as classic galactosemia, also known as GALT deficiency, which is a rare, inborn inability to digest the sugar in milk. A mother may also be advised not to breastfeed when she is HIV-positive or has a serious disorder, such as hepatitis B, that could be passed in the breastmilk, or takes medication that might harm her baby (see Why Some Women Should Not Breastfeed, p. 14). Personal factors may make nursing impossible, and some women and/or their partners simply are not comfortable with the idea or they harbor mistaken notions about what it entails (see Common Myths About Breastfeeding, p. 19). At any rate, you should talk over the pros and cons of breastfeeding with your obstetrician and pediatrician well before your due date. Learn as much as possible about breastfeeding, and make the best decision for your baby and yourself.
Even though breastfeeding is a natural function, most women need help in getting started. Prenatal classes often include breastfeeding instructions. Some doctors and maternity centers have lactation consultants--specially trained nurses or other health professionals--who teach the basics of breastfeeding. Maternity nurses also help teach new mothers. Unfortunately, the trend toward 24- to 48-hour hospital stays following delivery often doesn't allow enough time to ensure that all is going smoothly before going home. If problems do arise after you leave the hospital, your pediatrician can help you or may recommend a lactation consultant. Many lactation consultants make home visits. There are also support groups for nursing mothers (see Health and Nutrition Resources, Appendix VI).
NURSING CRAMPS
For days or weeks after delivery, many women have cramping pain in the abdomen at the start of each feeding. This is because nursing stimulates the release of hormones that help shrink the uterus back to its normal size.
Getting Started
The offspring of any mammal instinctively seeks out a nipple and begins suckling within minutes of being born. Similarly, most human babies are alert and eager to suckle shortly after birth, provided there are no problems. Mothers who nurse while still in the delivery room typically describe a deep sense of pleasure and satisfaction. The earlier breastfeeding starts, the easier it is for mother and baby. However, if the first attempt is delayed, breastfeeding can still be initiated successfully later. Olfactory bonding--through which a baby learns to recognize his own mother's scent--develops while the mother holds her baby, even if he is not suckling.
Regardless of when the first feeding takes place, you may need help positioning your baby comfortably and getting him to "latch on" properly. To do this, with your baby lying on his side, bring his head up to your breast until his nose is level with your nipple (Figure 1). Hold your baby with one arm and use the other hand to support the breast. Gently stroke his lips with your nipple or finger to stimulate his rooting reflex and interest in nursing (Figure 2). You also may try squeezing out a few drops of milk, then lightly brushing the nipple against your baby's lower lip; this will further stimulate his desire to nurse and prompt him to open his mouth wide. When his mouth is fully open, quickly bring your baby to the breast with his lips around the areola and the nipple deep in his mouth (Figure 3). This allows your baby to latch on and begin suckling. Make sure your baby's face is not at an angle to your nipple, but facing straight on to your breast. Your baby's chest and abdomen also should be facing directly toward your chest and abdomen. His neck should be straight and not turned.
It's important to position the nipple far back in your baby's mouth so that it touches the roof of her mouth and she is able to compress the areola, which contains the milk sinuses, as she suckles (Figure 4). If she latches on to only the nipple, milk can dribble out the side of her mouth. In addition, sucking on the nipple alone can make it sore and cracked. You'll soon be able to feel whether your baby is suckling properly; in the beginning, check that the nipple and most of the areola are inside your baby's mouth, with her nose and chin just touching the breast and the lips relaxed. Her jaws should move up and down, her ears should wiggle as she suckles, and she should swallow after every few sucks. If you have continuing pain, take your baby off the breast and reposition her. If your breasts are large and your baby's nose is buried, draw her bottom and legs closer to your midsection and lift your breast up a bit from underneath to let your baby breathe from the sides of her nose as she nurses.
When your baby stops nursing, gently break the suction by inserting a finger in the corner of her mouth, letting in some air and encouraging your baby to let go. To prevent injury to the nipple, do not pull your baby off the breast while she is still suckling and tightly attached.
FINDING THE RIGHT POSITION
Almost all nursing mothers describe breastfeeding as a highly pleasurable experience, but to make it so, you need to find a position that is comfortable for both you and your baby. Experiment with the following positions until you find what works best for you at various times.
Lying down. Both you and your baby lie on your sides facing each other. Rest your baby's head in the crook of your arm with a pillow at his back for support. Place a pillow under your head and another behind your back so you can be at the correct angle for your baby to latch on. A pillow between your knees is also comfortable. Women recovering from a cesarean delivery often find this the most comfortable position; it's also good for night feedings. After the feedings, put your baby back in his crib. It's the safest place for him to sleep.
Cradle hold. Sit in a comfortable chair or in bed with pillows tucked behind your back, under your arm on the nursing side, and on your lap to support your baby. Position your baby on his side with his tummy close to yours, his head cradled in the crook of your arm with his face next to your breast, his back resting along your forearm, and his bottom supported by your hand. In this and other positions, he should be able to latch on without turning his head. If your baby is very small or has a weak sucking reflex, try supporting the back of his head with your other hand rather than placing it in the crook of your elbow. (This is sometimes called the modified cradle or transitional hold.)
Clutch, side, or football hold. Sit in a comfortable chair (a roomy rocker is ideal) with a pillow on your lap to bring your baby up level with your breast. Position him with his legs under your arm and his head resting on your hand. If your arm gets tired, support it on a pillow or your thigh (bend your knee and place your foot on a stool or low table). The side position works especially well if you have large breasts or flat nipples, or after a cesarean section.
Breastfeeding and Intelligence
Several studies of children's development reveal some intriguing findings about the relationship between breastfeeding and intelligence. Children who had been nourished on breastmilk did slightly but consistently better on standard tests in school than those who were fed formula. The longer they were breastfed, the better they did. What's more, the advantages persisted well beyond early childhood. The breastfed children were more likely to complete high school, irrespective of their family income, education, and standard of living, among other factors. Thus, breastfed babies appear not only to be healthier but also to do better in school.
Nutritional factors in breastmilk, a lower rate of illnesses, and psychological effects may also help explain the better performance seen in breastfed children.
THE SPECIAL HEALTH BENEFITS OF BREASTFEEDING
Pediatricians and nutrition experts agree that breastmilk is the ideal food for newborns and young babies. It's also inexpensive, and breastfeeding has emotional and physical benefits for the mother. Here are some of the reasons:
* Breastmilk is uniquely tailored to meet all your baby's nutritional needs for about the first 6 months of life. Its composition changes as your baby's needs change. For example, during the first few days the breasts secrete colostrum, which is especially rich in antibodies to protect against infections. It also contains substances that get your baby's digestive system working.
* Babies can digest breastmilk more easily than formula.
* According to several researchers, breastfed babies have fewer allergies, intestinal upsets, ear infections, and other common childhood problems than their formula-fed counterparts. If there is a family history of asthma, eczema, hayfever, or other allergies, breastfeeding is especially important in reducing allergy symptoms. The longer you nurse, the better.
* The benefits of breastfeeding appear to extend beyond infancy. Studies show that children who were breastfed have lower rates of diabetes, asthma, and certain other chronic illnesses-- benefits that tend to persist into adulthood.
* Breastfeeding is cheaper and more convenient than formula.
* Breastfed babies adapt more readily to new foods when solids are introduced.
* A baby's suckling prompts the release of oxytocin, a pituitary hormone that, in addition to triggering the flow of breastmilk, causes the uterus to contract and regain its pre-pregnancy size more quickly.
* Women who breastfeed have lower rates of certain types of breast and ovarian cancers and fewer hip fractures later in life.
Vitamins for Breastfed Babies
Breastmilk provides sufficient amounts of vitamins except, possibly, for vitamin D in some specific cases. Vitamin D promotes the absorption of calcium and is needed to build healthy bones and teeth. Babies who are not regularly exposed to sunlight, who have dark skin, and who are dressed heavily when outside may not get enough of this vitamin. Your pediatrician may prescribe a vitamin D supplement for your breastfed infant. Commercial formulas are usually fortified with vitamin D and other vitamins to ensure that babies get enough of these essential nutrients.
A mother who follows a vegan diet, which excludes all foods of animal origin, should talk to her pediatrician about her baby's vitamin needs. A vegan diet lacks both vitamin D and vitamin B12. A deficiency of vitamin B12 in an infant's diet can lead to anemia and abnormalities of the nervous system.
INFANT FORMULAS COME IN THREE FORMS
* The ready-to-use types are the most convenient--all you need to do is pour them into a clean bottle--but they are also the most expensive.
* Concentrated liquid formulas are mixed with an equal amount of water; these are not as costly as the ready-to-use type, but you must make sure that the water is clean.
* Powdered formulas are the least expensive; they also require the most preparation.
Bottle Feeding
Although no infant formula exactly duplicates breastmilk--and experts agree that mother's milk is best--the reality is that 85 percent of babies in the United States, including many who are breastfed, are given formula for at least some feedings. In some instances, mothers use formula became they choose not to or cannot breastfeed. Formula is also used to give Mom an occasional break or, less commonly, to supplement inadequate production of breastmilk. There are also medical conditions that prevent breastfeeding (see Why Some Women Should Not Breastfeed, p. 14).
A baby may have a problem that requires a special formula, either as the primary food or as a supplement to breastmilk. For example, premature or low-birth-weight babies may need special formulas to supply the extra energy and nutrients they need for growth. In these small babies, too, the sucking reflex may not be fully developed, in which case they will be fed with a special tube or by bottle. Still, a premature infant can benefit from the antibodies and other unique components of breastmilk. Mothers of premature and other high-risk infants are usually encouraged to express their breastmilk, which may be fortified with the additional nutrients needed and fed to her baby. Then when the baby is ready to breastfeed directly from mother, the switch can be made.
Infants from highly allergic families may react to certain foods the mother eats that then pass into the breastmilk, such as the protein from cow's milk or cheese, or from eggs, seafood, and nuts. Breastfeeding mothers can help prevent allergies in their infants by avoiding such foods while nursing. In rare cases, such as certain metabolic diseases, a baby may not be able to tolerate breastmilk, in which case a special formula will be needed. A physical abnormality that makes it difficult for a baby to suckle normally, such as a cleft palate, may make breastfeeding impossible (see p. 18).
There are many kinds of infant formulas; most are based on cow's milk, but there are also several formulas available for babies who cannot tolerate cow's milk. Regular cow's and goat's milk, as well as canned condensed or evaporated milk, should not be given during the first year of life. Young babies cannot digest the protein in cow's milk. Regular cow's milk also doesn't have enough iron and other vitamins or the right amounts of the minerals that are essential for proper growth and development. A child may also lose blood through the stools, because cow's milk can damage the intestine.
PRACTICAL BOTTLE-FEEDING TIPS
* Bottle feeding can be a warm, loving experience: Cuddle your baby closely, gaze into her eyes, and coo and talk to her. Never prop the bottle and let your baby feed alone; not only will you miss the opportunity to bond with her while she feeds, but there's also a danger she'll choke or the bottle will slip out of position. This practice also increases the risk of ear infections. We do not recommend devices to hold a bottle in a baby's mouth--they could be dangerous.
* Although some babies will drink a bottle straight from the refrigerator, most prefer milk warmed to room temperature. You can warm a bottle by holding it under a running hot-water faucet or placing it in a bowl of hot water for a few minutes. Sprinkle a few drops on your wrist; it should feel lukewarm. If it's too warm, wait for it to cool a bit and test again.
Note: NEVER warm a bottle of formula or breastmilk in the microwave. The bottle itself may feel cool, while the liquid inside can be too hot. Microwaving also heats unevenly. Even though a few drops sprinkled on your wrist may feel okay, some of the formula or breastmilk may be scalding. Also, the composition of breastmilk may change.
* Make sure the nipple hole is the right size. If your baby seems to be gagging or gulping too fast, the nipple hole may be too large. Similarly, if your baby is sucking hard and seems frustrated, the hole may be too small.
* Try different nipple shapes to see which your baby prefers. There is no "correct" shape.
* Angle the bottle so your baby isn't sucking in air. Burp your baby a couple of times during the course of a feeding.
* Encourage your partner to give your baby a bottle now and then, perhaps one of the late-night feedings. This not only allows you some extra rest, but it also fosters father-infant bonding.
* Don't let your baby fall asleep sucking on a bottle of milk, especially if she is beginning to cut teeth. Milk pooled in your baby's mouth can cause serious tooth decay, known as nursing-bottle caries. After feeding and before putting your baby to sleep, gently wipe any milk residues from her gums. If she needs to suck herself to sleep, give her a pacifier instead of a bottle.
* Repeated sterilization may distort nipple openings. Test to make sure milk flow through the nipple is adequate.
What's in It for My Baby?
Although no formulas on the market even come close to matching the hundreds of known ingredients in breastmilk, most provide a comparable balance of fat, protein, and sugar. Formulas are also supplemented with various vitamins and minerals, especially calcium, iron, and vitamins C, D, and K. Should you choose not to breastfeed, your pediatrician can advise which formula is most suitable for your baby. Sometimes you may need to switch formulas if your baby is ill.
Regardless of which formula you use, it's critical that you prepare it according to instructions. It is especially important not to add more or less water than recommended. Families who are short of money may be tempted to add extra water to make the formula go farther. Formulas are designed to provide the energy (about 20 calories per ounce) and nutrients that a baby needs for proper growth. If the formula is too weak, your baby will be underfed and may have stunted growth and nutritional deficiencies. Formula that's too strong can also be dangerous. Not adding enough water can result in dehydration, kidney problems, and other potentially serious disorders.
Sterilizing and Warming Bottles
Parents and pediatricians today are not as concerned with sterilizing bottles and water as they were a generation ago. But many are having second thoughts in light of recent reports of contaminated city water supplies and increased concern over food safety. For starters, always wash your hands before handling baby bottles or feeding your baby. If you use disposable plastic bottle liners and ready-to-use formula, you still need to make sure the nipples are clean. Scrub them in hot, soapy water, then rinse to get rid of all traces of soap; some experts recommend boiling them for 5 to 10 minutes. Always wash and thoroughly rinse and dry the top of the formula can before you open it; also make sure the can opener, mixing cups, jars, spoons, and other equipment are clean.
If you use regular glass bottles and concentrated or powdered formula, you must make sure that the bottles and water added to the formula are germ-free. If you don't want to boil the bottles, you can put them, along with mixing cups and other equipment used to prepare the formula, in a dishwasher that uses heated water and has a hot drying cycle. Or you can wash the bottles in hot, soapy water and rinse thoroughly. This alone should kill most germs; any that do survive the washing can be killed by putting the empty bottles in an oven set at 250 [degrees] F for 20 minutes or in a microwave oven set on medium for 4 minutes.
In general, tap water that comes from a municipal system is safe for older babies and children. But for the first month or two, it's a good idea to boil water for at least 5 minutes. Or you can use sterile bottled water. There is no need to sterilize bottles after your baby is about 3 months old.
If you elect to boil your bottles and don't want to invest in a sterilizer, use a large covered pot. There are two general methods:
* Place the empty bottles, along with the measuring cup and other equipment used to make the formula, in a large pot, fill with water to completely cover all items, and boil for 20 minutes. When the bottles are cool enough, either cover them and put them away, or fill with breastmilk or formula, refrigerate, and use within 48 hours. (Breastmilk in bottles can be refrigerated for at least 12 hours.)
* Fill the bottles with breastmilk or formula, loosely screw on the caps, and place the bottles in a pot large enough so that they can stand upright. Add a few inches of water, cover the pot, and boil for 25 minutes. Tighten caps, refrigerate, and use within 48 hours.
Supplemental Bottles
Many breastfeeding mothers use an occasional bottle of expressed, frozen breastmilk or formula because they need to be away from the baby. In unusual cases, a pediatrician may recommend a combination of breastfeeding and formula if the mother is returning to work, or if she is ill or exhausted. It is commonly--though often wrongly--thought that supplemental bottles are given because the mother does not have enough milk. As stressed earlier, the vast majority of mothers produce more than enough milk to meet their babies' needs, even for twins. When there appears to be a problem of supply-and-demand, your pediatrician may encourage you to see a lactation consultant.
If supplemental bottles are given for the sake of convenience, experts advise waiting until your baby is 3 or 4 weeks old. This allows time for your milk supply to become well established, and for you and your baby to get used to breastfeeding. Don't be surprised if your baby doesn't immediately take to a bottle. To obtain the benefits of human milk, it is best if you express your breastmilk and store it for bottle feeding as needed. Expressing breastmilk also helps maintain your milk supply. Formula can also be fed while you continue breastfeeding as often as possible. Use the formula your pediatrician recommends.
DISCARD ANY LEFTOVERS
A note of caution: If your baby does not drink the entire bottle, discard what's left over. Germs and enzymes from your baby's mouth can enter the bottle and spoil the milk.
Breastfeeding Problem Solving
Many women breastfeed with nary a problem, but others may encounter difficulties. Fortunately, most problems are easily solved. If the measures outlined below don't work, talk to your doctor or a lactation consultant.
INVERTED OR FLAT NIPPLES. Inverted or flat nipples do not preclude nursing and, in many cases, can be corrected. Your obstetrician may recommend breast shells worn during the last trimester, with the time gradually increasing to 4 to 6 hours a day. After your baby is born, the nipples will respond to suckling. Other devices are sometimes recommended, but they often don't work and can make the breasts sore and promote infection. Nipple shields are not recommended.
ENGORGEMENT (OVERFILLED BREASTS). This usually occurs in the first few days of breastfeeding or when you cut back on nursing, resulting in overfilled breasts. Engorgement usually can be prevented by frequent nursing and draining the breasts. Make sure your baby is suckling properly. If your breasts are producing more milk than your baby can consume, you may need to express the excess before he latches on. If pain is hindering your milk flow (letdown), taking a warm shower or applying a warm compress before nursing may help. Some women find cold compresses or ice packs provide more relief. Occasional use of a breastpump may also help. Experiment to find what works best for you, but above all, don't cut back on your breastfeeding; this will worsen the problem. Regular, frequent breastfeeding is the best way to prevent and relieve engorgement.
CRACKED OR SORE NIPPLES. First, try to find out the cause. Most often, it turns out that the nipple is incorrectly placed in the baby's mouth. If the soreness develops in the first few weeks of breastfeeding, check to make sure your baby is latching on properly, with most of the areola in his mouth. He may possibly be chewing or gumming on the nipple, or perhaps his lower lip is turned inward, which can lead to soreness and even cracking.
To heal the nipples, try expressing a few drops of colostrum or mature milk and rubbing it gently into the sore area. Allow the milk to dry on the nipples. Wash them with plain water and avoid using soap, which promotes cracking by removing protective skin oils. Don't use ointments or creams unless specifically recommended by your doctor. Ultrapurified anhydrous lanolin may promote healing and does not need to be removed from the nipples before nursing.
POOR MILK LETDOWN. Letdown is the automatic release of milk stored in breast tissue into the milk ducts, allowing it to flow more easily into your baby's mouth. Suckling stimulates the letdown reflex; infrequent nursing or a poor latchon to the breast can hinder it. Stress, pain, fatigue, anxiety, nicotine, alcohol, and certain medications are among the many factors that can inhibit letdown. In most instances, you can solve letdown problems with frequent nursing and proper positioning of your baby on the breast. You should also try to reduce stress and avoid alcohol and caffeine. Before breastfeeding, try massaging your breasts, gently rubbing your nipples, applying warm compresses, or taking a warm shower. When using a breastpump, mental images can also trigger release of the hormone (oxytocin) that prompts letdown; picture your baby nursing. In some women, just hearing a baby cry triggers letdown. If none of these tactics works, ask your doctor or consultant for advice.
LEAKY BREASTS. Leaking is most common in the early weeks of breastfeeding, but it's not unusual for it to continue for weeks or even months. Sometimes leaking occurs when you're not breastfeeding. Also, some women leak without a letdown, just from continuing overproduction, which can be alleviated by expressing some milk. Many women leak milk when their breasts are stimulated during sexual activity. Wearing breast shells too long can also promote leaking. Cotton nursing pads tucked into your bra help minimize staining. Change pads frequently and avoid using plastic coverings, which can promote bacterial growth and skin problems. You can also stop the milk flow by pressing gently on your nipples.
PLUGGED OR CAKED MILK DUCT. A sore breast lump and decreased milk flow without a fever or other symptoms of mastitis (see below) may indicate an obstructed or plugged duct. Possible causes include infrequent nursing, incomplete softening or draining of the breast, and engorgement. To dislodge the plug, try applying a warm compress and then massaging the breast to stimulate milk flow just before breastfeeding. Breastfeed frequently on that side to clear the plugged area. If symptoms continue, see your physician.
MASTITIS. Mastitis is caused by a bacterial infection in the breast. It typically develops in only one breast and starts with fatigue, achy muscles, fever, and other flulike symptoms, followed by breast inflammation and pain. Mild cases may require only rest, frequent nursing (or pumping) to drain the breast, and warm compresses to relieve pain. More severe cases can be cleared up with antibiotics. Breastfeeding can and should continue in nearly all cases. If an abscess forms, it may have to be drained. See your doctor promptly if you develop symptoms or signs of mastitis.
WHY SOME WOMEN SHOULD NOT BREASTFEED
Doctors advise women not to breastfeed under the following conditions:
* If they have certain infectious diseases, a positive HIV test or AIDS, human T-cell leukemia virus (HTLV) infection, or untreated tuberculosis, that could be passed on to their babies.
* If they must take medications--such as cyclosporine, antithyroid medications, or drugs that suppress the immune system--that pass into the breastmilk and are harmful to babies. Most medicines prescribed by your physician are likely to be safe for breastfed babies, but it's best to ask him or her to check them. If you're breastfeeding, always check with your pediatrician before taking any nonprescription, herbal, or folk or natural remedies.
* If they use marijuana, cocaine, heroin, amphetamines, or other illicit/recreational drugs.
* If their breasts lack enough glandular tissue to make milk. This is very rare, and is unrelated to breast size--women with small breasts can produce as much milk as large-breasted women.
* Women who have chronic or debilitating medical conditions may be advised not to breastfeed. Some doctors think that women with silicone breast implants should not breastfeed, but there is no evidence that children are harmed by implants.
Baby Problem Solving
Like most new mothers, Jasmine felt a bit overwhelmed by the responsibility of caring for a brand-new baby, even though her husband was supportive and both of them had prepared thoroughly at parenting classes. Four days after they brought their baby home, Jasmine was worried that she wasn't producing enough milk. Responding to her pediatrician's questions at an office visit, Jasmine told him that the baby nursed vigorously every 2 to 3 hours and slept after each feeding. Her breasts felt full before feedings and softened after the baby nursed. The baby had passed two loose stools each day since they came home, and Jasmine was changing wet diapers about six times a day.
"There's nothing to worry about," the pediatrician told Jasmine. "You're doing a great job and your baby is beautiful. Call me if you have any questions."
Wet diapers are an important guide to whether babies are feeding well. However, the absorbent qualities of some of the newest, stay-dry disposable diapers can make it hard to tell if a baby has urinated. It may be best to avoid super-absorbent diapers for the first few weeks, until you and your baby have settled into a routine.
SPITTING UP. Most babies spit up varying amounts of milk or formula, often for no apparent reason and with no health consequences. Spitting up, or reflux of stomach contents back into the esophagus, should not be confused with vomiting--the forceful expulsion of stomach contents. Reflux becomes a problem if the baby develops esophagitis, which causes pain. (In adults, this pain is called heartburn.) A baby with esophagitis becomes irritable shortly after feedings begin. The infant may appear hungry and start to feed eagerly, but then begin to cry or fuss as if in pain. If your baby has these symptoms or becomes fussy during feedings, consult your pediatrician. You probably don't need to worry about spitting up so long as your baby is growing normally, wetting at least six to eight diapers a day, and having normal bowel movements. To reduce spitting up, hold your baby quietly upright for a few minutes after each feeding. In bottle-fed infants, an intolerance to in ingredient in the formula or a response to supplements may trigger vomiting, but not spitting up. If you suspect a problem, consult your pediatrician. (Also see Chapter 7.)
GAS. When 2-week-old Alex cried hard after feedings, drew his knees up, and passed gas repeatedly, his mother called her pediatrician. "Is it colic? My mother warned me about it."
After a few questions, the pediatrician was able to reassure this anxious mother that her baby wasn't colicky. Alex was calmer after passing gas, he spat up very little, and he was sleeping well between feedings.
"Alex's digestive tract is getting used to food. It's developing a balance of the normal bacteria we need for digestion. The gas is a normal part of this process; it shows that your baby is adapting well to life on the outside."
COLIC. Dr. Stern's rule for recognizing colic: "You know your baby has colic when you have an irresistible urge to get him his own apartment." Colic is marked by periods of prolonged, inconsolable crying that seems to come from abdominal cramping and discomfort. The spells, which have no apparent cause, typically occur at about the same time every afternoon or evening. Colic usually develops between 2 and 6 weeks of age and disappears in 3 or 4 months. In contrast to simple gas, the crying does not stop after the baby passes gas. While colic lasts, both parents and baby go through acute suffering. No one knows what causes colic. It occurs more often in bottlefed babies but can also appear in breastfed infants; it is also more common in first babies. Sometimes, but not very often, changing the mother's diet helps (see Chapter 15). You might try eliminating cow's milk from your diet as well as other sensitizing foods, such as wheat, peanuts, eggs, and seafood. You're more likely to be successful in calming your baby if you experiment with soothing tactics such as rocking, walking with him, playing music, or going for a car ride. You also should consult your pediatrician to make sure the crying is not due to a medical problem.
CONSTIPATION. Some breastfed babies go for several days without having a bowel movement. So long as the stool is soft and easily passed and your baby is growing normally, there's no need for concern. But you should consult your pediatrician if the stools are hard or your baby's tummy is hard and distended.
DIARRHEA. Loose stools do not necessarily indicate diarrhea. If your baby has no other symptoms and is gaining normally, her runny stools may be what's normal for her. But if she has large, frequent, watery stools, a fever, or other symptoms, call your pediatrician. If your baby is dehydrated, a rehydrating solution may be needed. In most cases, breast- or bottle-feeding can continue until the problem clears up, but follow your pediatrician's instructions.
SLEEPY BABY. Most babies are born alert and are eager to feed in the first hour or so of life. Experts recommend feeding a newborn for about 30 minutes and to change breasts while she's still alert and interested. Typically, a baby will then fall asleep and wake up every 2 or 3 hours to nurse. But some babies are sleepy in the first day or two--they often need to be awakened to feed, and even then, they may fall asleep after only a few minutes of nursing. Often, cooling your baby down by removing some clothing or a blanket will help wake her up. Or try talking or singing to her, stroking her head, rubbing her buttocks or back, or wiping her face with a damp cloth. It's important that you get her to nurse for long enough to get the milk she needs for proper growth and also to drain your breasts to ensure steady milk production. If you have problems keeping her awake to feed, consult your pediatrician.
FUSSY EATER. Babies, like everyone else, have taste preferences. If your baby has been feeding normally and suddenly seems unhappy with your milk, suspect something you've eaten. The tastes of onions, garlic, cabbage, and other strong-flavored foods can pass into your milk, and the first time may surprise your baby. Most babies get to like new tastes; babies may even like the taste of garlic. If your baby stays fussy, try eliminating possibly offending foods, one at a time, for a week. Then try the eliminated food again. If it again provokes a reaction, eliminate the food until you stop nursing.
BREASTMILK JAUNDICE. The most common form of jaundice, called "physiologic jaundice of the newborn," affects two thirds of all babies and develops in the first few days after birth. Late onset jaundice appears a little later or may be a continuation of the early jaundice. Your baby's skin may remain yellow for 6 to 12 weeks. The yellowing is caused by excess blood levels of bilirubin, a pigment normally eliminated by the liver. For unknown reasons, something in breastmilk triggers jaundice in susceptible babies. In nearly all cases, breastfeeding should continue, but your pediatrician will monitor your baby's bilirubin level. If the level is very high, you may be advised to stop breastfeeding for a day or so to lower the bilirubin level. During this time, you can keep up the milk flow with a breast pump until your baby is ready to breastfeed again.
WEAK SUCK. Most babies are born with a strong rooting reflex and have no trouble suckling, even when they are only minutes old. Occasionally, however, a baby has difficulty sucking. Telltale signs include losing hold of the breast, possible choking or gagging, and milk leaking from your baby's mouth. Sometimes a weak suck in a newborn is due to medications given to the mother during birth; if so, it should disappear as the medicines clear from your baby's system. Changing position to give your baby a better latch-on may help. But if the problem persists, your pediatrician should evaluate your baby for a possible physical problem or illness. GROWTH. At about 6 months of age, babies who are exclusively breastfed may have a. drop-off of weight in relation to length, which continues to increase normally. In fact, the baby's rate of growth may cross growth-chart percentiles. However, this is normal and no cause for concern so long as the length increases are steady. TONGUE ABNORMALITIES. Rarely, a baby is born with a tongue abnormality that prevents proper latching on or suckling. Your pediatrician can advise you how to handle the problem.
CLEFT LIP. Babies born with a cleft lip can usually suckle normally, although the split in the lip will allow some milk to leak from your baby's mouth. You may have to experiment with positions to help your baby latch on; a nurse or lactation consultant can help you get started.
CLEFT PALATE. A cleft palate prevents a baby from effective suckling, but there are techniques to help babies feed. Also, a baby may be fitted with an appliance to temporarily seal the hole in the palate and make suckling easier. Breastmilk is particularly beneficial for infants with cleft palate because it reduces the risk of ear and lung infections, to which they are more susceptible.
WARNING ON WATER
Healthy infants do not need extra water. Breastmilk or formula provides all the fluids they need. A small amount of water may be needed in very hot weather, but check with your pediatrician on how much is safe. The American Academy of Pediatrics warns that during the exclusive nursing period (up to 6 months of age), giving a lot of water carries a risk of water intoxication and may interfere with breastmilk intake. With the introduction of solid foods, water can be added to your baby's diet.
Is Milk Really Enough?
Yes, for about 4 to 6 months of life. Pediatricians now agree that other foods should not be given until babies are about 6 months old. Still, many well-meaning grandparents, aunts, and others who reared their children in the 1960s and '70s advise earlier feeding of different foods.
When Gladys Evans became a mother in 1970, her obstetrician discouraged her from breastfeeding and her pediatrician respected her decision to use formula. Her baby, Sally, was healthy and active and, at her 8-week checkup, she had gained 3 pounds since birth. At that point, her pediatrician recommended starting Sally on rice cereal thinned with formula and progressing to puréed and strained fruit a week or so later, followed by strained vegetables a couple of weeks after that.
"At first, Sally simply spit out most of the cereal," Gladys recalls, "but then I tried putting the food way back on her tongue so she had to swallow it. After that, I didn't have any problems getting her to eat."
Now that Gladys is a grandmother, it's understandable that she is worried about the way Sally is feeding her own baby. "He's almost 5 months old and he's still on nothing but breastmilk," Gladys explains. "Is this really enough?"
Changing Views
As this typical case illustrates, views on infant feeding have changed over the last few decades. Pediatricians and nutrition experts now know that giving foods other than breastmilk or formula in the first few months of life is detrimental for several reasons:
* Until babies are at least 4 months old, their digestive systems have trouble breaking down the starches and components of other foods.
* An immature digestive system may allow whole proteins to be absorbed, thus setting the stage for an allergic reaction, especially if there is a family history of allergies. By 4 months, the digestive system can break down proteins into their amino acid building blocks, which are less likely to provoke allergies.
* When a spoon touches a young baby's tongue, it triggers an automatic extrusion reflex, in which the tongue thrusts forward and prevents swallowing. This reflex disappears at about 3 to 4 months of age.
Breastmilk provides all the nutrients that a healthy baby needs for about the first 6 months of life. Breastfeeding also benefits the mother (see The Special Health Benefits of Breastfeeding, p. 9).
Eating for Two
During pregnancy and while breastfeeding, you are eating for both yourself and your baby. Indeed, your health and nutrition during pregnancy are big factors in determining your baby's nutritional needs. Ideally, sound infant nutrition begins even before conception. It's a good idea to have a thorough pre-pregnancy checkup to make sure you're not anemic or don't have hidden nutritional, metabolic, or other problems. Your doctor will advise you about what supplements you need during pregnancy and how much weight you should gain, as well as foods and substances you should avoid. Be sure to tell your doctor if you follow a vegetarian diet or one that excludes certain foods. It may be advisable for you to take a vitamin supplement during pregnancy and while breastfeeding.
As part of your plan to breastfeed, you should continue eating a healthful diet that provides the extra energy and nutrients you need to make milk. In the past, breastfeeding mothers were advised to consume an extra 400 or 500 calories a day and to drink at least eight glasses of water and other fluids. Doctors now recognize that there are no set rules--some women may need an extra 500 calories, while others will gain unwanted pounds by eating this much. The best rule is to eat and drink enough to satisfy your hunger and thirst. Follow the Food Guide Pyramid (see p. 90), with ample fresh or lightly processed fruits and vegetables to provide essential vitamins and minerals. Nursing mothers eating a balanced diet do not require any added calcium. If there is a family history of allergies, they may prefer to minimize cow's milk consumption while nursing so that their babies are not exposed to excess cow's milk protein.
Certain strongly flavored foods and spices can affect the taste and composition of breastmilk and may cause digestive problems in babies. A common culprit is cabbage. Most babies develop a liking for garlic and onions after the initial surprise. Garlic and spices need not be avoided unless your baby continues to react negatively to them. Excessive caffeine (more than five cups a day of coffee or other caffeinated beverages, such as tea and sodas) may make your baby jittery and fussy. In addition, both caffeine and nicotine decrease milk flow. If something in your diet seems to upset your baby's appetite or disposition, eliminate it for the time being. You may, however, need to keep a food diary to identify the offending food.
Important No-Nos
Because much of what you eat and drink can enter your breastmilk, it's important that you avoid any substance that can harm your baby. Here are a few commonsense rules to follow:
Always check with your pediatrician before taking any medication , both prescription and over- the-counter products, as well as herbal or natural remedies. Prescription drugs that are contraindicated during breastfeeding include some bloodpressure-lowering medications, certain antibiotics, antithyroid medications, and cancer chemotherapy drugs. Many people mistakenly assume that over-the-counter drugs and herbal remedies have no adverse effects; this is not true. Even aspirin in breastmilk can cause problems in a baby. Herbal remedies can be toxic, especially to babies. However, most over-the-counter products sold to relieve common symptoms such as headache and indigestion are acceptable, though you should check with your doctor before taking them.
IF YOU SMOKE, NOW IS THE TIME TO STOP. Not only does nicotine enter your breastmilk, but it also lowers the amount of milk you produce. If you can't quit, at least cut down as much as you can and never smoke in the hour or so before nursing. Remember, too, that secondhand smoke is especially dangerous for your baby. Don't allow smoking in your house or car and certainly not in the presence of your baby.
AVOID ALCOHOL WHILE YOU ARE BREASTFEEDING. Doctors agree that substance abusers (those who use drugs such as marijuana, cocaine, heroin, and amphetamines) should not nurse at all. Alcohol and these other substances pass into breastmilk and are harmful to your baby.
AVOID ENVIRONMENTAL TOXINS AS MUCH AS POSSIBLE. In some areas, breastfeeding mothers are advised not to eat freshwater fish because they may contain PCBs, potent cancer-causing chemicals. Pesticides can also enter breastmilk; always wash fresh fruits and vegetables before eating them.
COMMON MYTHS ABOUT BREASTFEEDING
Myth / Facts
You can't get pregnant while breastfeeding.
While it's true that breastfeeding prevents ovulation in some women, it is not a reliable form of birth control. Talk to your doctor about an acceptable form of contraception. Avoid estrogen-containing birth-control pills.
You need to "toughen" your nipples before your baby is born.
Normal nipples need no advance preparation or "toughening." Flat or inverted nipples, however, may be helped by certain exercises (see Inverted or Flat Nipples, p. 13).
Small breasts don't produce as much milk as large ones
Breast size has nothing to do with the amount of milk they produce.
Breastfeeding will ruin the shape of your breasts
Most women find that their breasts go back to their prepregnancy size and shape after they stop nursing. Age and weight gain have more effect on breast size than nursing.
Sexual arousal while breastfeeding is abnormal.
Many women experience sexual arousal while nursing. Breast stimulation is an important aspect of sexual activity, so it stands to reason that nursing can also arouse sexual feelings. In addition, oxytocin--the hormone released during breastfeeding--is also released during orgasm, another reason why nursing can be sexually stimulating.
All babies should be weaned before their first birthday.
When to stop breastfeeding is a highly personal decision and varies considerably according to custom and individual preferences. Some women stop breastfeeding after a few months; others are still nursing when their children are age 3 or even older. It's all a matter of what's right for you and your child.
ISSUES PARENTS OFTEN RAISE ABOUT BREASTFEEDING
I'm afraid of what's going to happen once I take my baby home from the hospital. What if I'm having problems breastfeeding and my baby isn't getting enough to eat?
If you have concerns after you leave the hospital, call your physician or your baby's pediatrician. He or she will be able to answer your questions and may suggest the help of a lactation consultant. Many of these counselors make home visits. Your doctor may also refer you to a support group for nursing mothers. (See p. 6 for more about breastfeeding instruction.)
How will I know when my baby is ready to start breastfeeding?
Like all other baby mammals, newborn humans are almost always alert and eager to suckle shortly after their birth. Provided there are no problems, your baby may be put to the breast immediately after birth. You'll soon learn the cry that tells you she's hungry! (Read about getting started with breastfeeding on p. 6.)
Does breastfeeding make a difference to children's health in the long term?
Breastfed babies have fewer allergies, intestinal upsets, ear infections, and other common childhood illnesses than formula-fed infants. Not only that, but children who were breastfed as babies have lower rates of diabetes, asthma, and other chronic disorders long after infancy. (For more about the health benefits of breastfeeding, see p. 9.)
I hoped to breastfeed my baby but my doctor says I shouldn't because I have to take medication for a chronic condition. Does this mean it'll be harder for me to bond with my child?
Your doctor is advising you to do what's best for both you and your baby. Like millions of other parents you'll find bottle-feeding a warm, loving, and fulfilling experience. Cuddle your baby, gaze into her eyes, and coo and talk to her as you feed her. This is all part of bonding. (Read more about bottle-feeding techniques on p. 10.)
If my baby doesn't finish a bottle of formula, how long is it safe to keep the leftovers?
Never keep leftover formula or breastmilk. Germs and enzymes from your baby's mouth normally enter the bottle and can spoil the formula. Use a fresh bottle for every feeding. (Read about how to sterilize and clean bottles and nipples on p. 12.)
Copyright © 1999 American Academy of Pediatrics. All rights reserved.
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