Adoptive Breastfeeding

You can get

domperidone (see attached protocols), without a prescription, COD

from Mexico at the following number.

011 526 654-1834

fax number 011 526 654-5522

Oscar and Gabriel speak English. They send it C.O.D. As far as I know they

have been very reliable.

Or, http://www.1drugstore-online.com/

You can get domperidone without a prescription. Look for the generic brand

by Jassen-Cilag which is domperidone maleate (Motilium) They sell 100 tabs

(10 mg) for $25. The minimum order is US$50 but shipping is free worldwide

and takes 10-15 days. If you need the medication fast, they'll ship it

express for US$30. They will accept orders from everywhere EXCEPT Canada.

Or, any Canadian Pharmacy can send you domperidone if you get a prescription

from your doctor. Following is one pharmacy which has experience with this.

Phone for more information:

murray shore pharmacy

For the U.S. and Canada

1-800-201-8590

1-800-201-8591 (fax)

http://www.mshorepharmacy.com/index.shtml

www.canadameds.com Domperidone is available there with a prescription for

$82.29 (about $54 US, depending on exchange rate) for a bottle of 500, 10 mg

tablets.

For Canadians who can't find a doctor to prescibe domperidone,

http://www.pharmagroup.com/

They can get domperidone without a prescription. Look for Motilium 10 mg 30

tabs for US$12. This comes out to US$120 for 300 tabs. They will ship

worldwide including Canada and the US under regular shipping for 6% of their

order or a minumum of US$16. If they want the order within 3 business days

they'll have to pay 10% of their order or a minumum of US$40.

Attached are:

1. a diagram showing the "ideal" latch. Note that the baby covers more of

the areola with his lower lip than upper lip. Note also that the baby's

nose is *not* in the breast.

2. a protocol for "not enough milk".

3. a first draft chapter on not enough milk, from my book, The Ultimate

Breastfeeding Book of Answers (published in the USA by Prima

Publishing,August 2000) or Dr. Jack Newman's Guide to Breastfeeding

(published in Canada by HarperCollins Publishing, February 2000).

The book is available at www.amazon.com or www.chapters.ca or www.indigo.ca

4. a photo showing a lactation aid in use.

5. a protocol for adoption by one of my former patients.

http://users.erols.com/cindyrn/newman.htm

Jack Newman, MD, FRCPC

When latching

Anne J Barnes – May 1995

Have nipple and baby’s nostrils in line before latching.

Mother’s hand under the baby’s face.

Head supported but NOT pushed in against breast.

Head tilted back slightly.

Baby’s body and legs wrapped in around mother.

Push with base of hand on baby’s back and shoulders when MOUTH WIDE OPEN to move baby quickly onto breast, so chin and lower jaw touch breast first.

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.

Once latched, top lip will be close to nipple, areola shows above lip. Keep chin close against breast.

WIDE MOUTH / GAPE

Need MOUTH WIDE BEFORE baby moved onto breast.

Teach baby to open wide/gape :

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

MOTHER’S VIEW WHILE LATCHING BABY

Move baby not breast

MOTHER’S VIEW OF NURSING BABY

RECOMMENDATIONS FOR THE MOTHER

Mother’s posture

sit with straight, well-supported back

trunk facing forwards, lap flat

Baby’s position before feed begins

on pillow, nostril (not mouth) in line with nipple

Baby’s body

placed not quite tummy to tummy, but so that baby comes up to breast from below and baby’s upper eye makes eye contact with mother’s

Support breast

and firm inner breast tissue by raising breast slightly with fingers placed flat on chest wall and thumb pointing up (if helpful, also use sling of tensor bandage around breast)

Entice baby to gape

baby’s head and shoulders supported so head extends slightly as baby moved to breast

touch baby’s top lip to nipple and move baby away slightly and repeat until baby opens wide with tongue `````forward

Move baby quickly on to breast

head tilted back slightly, pushing in across shoulders so chin and lower jaw make first 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 of breast 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 first and not the chin

holding breast away from baby’s nose

Anne J. Barnes May 1995

Not Enough Milk

Myth: Many women are not capable of producing enough milk to feed their babies.

Fact: The vast majority of women produce more than enough milk, most enough for twins and some enough even for triplets. True, a small number of women truly do not produce enough milk but the vast majority are perfectly capable of producing all the milk their babies need for at least four to six months, and can continue producing plenty of milk for months and years as their babies eat other foods as well. In fact, some women have the problem of an overabundance of milk. When babies do not do well on breastfeeding alone, the problem is usually not an insufficiency of milk, but rather the baby’s not getting the milk which is available.

Why then do so many women living in affluent societies believe they were not able to produce enough milk for their babies or worry they will not make enough milk. How is it that women all over the world, women living in poor countries, in difficult conditions, women suffering from chronic illnesses, including nutritional deficiencies usually manage to breastfeed quite adequately and produce enough milk, while well nourished, generally healthy women in affluent societies have so much trouble?

Is there really a Problem?

The Baby’s Behaviour

Sometimes mothers think they don’t have enough milk because of the way their babies behave. If the baby feeds frequently, or stays on the breast for long periods of time and does not seem content when not on the breast, many mothers, and their families will conclude that the mother does not have enough milk, or that her milk is “weak”. Interestingly, one of the problems of an “oversupply” of milk is that the baby feeds frequently, stays on the breast for long periods of time, and is often unhappy and fussy. Yet frequently, these babies not only gain weight well, they gain weight at a faster than average rate. For more on this, go to the section on the fussy baby.

On the other hand, a baby who sleeps a lot, especially in the first week, may not be doing well at all. More on this later.

Although we are seeing less of the scheduled feeding than we used to, there is an unfortunate comeback to scheduled feedings. Trying to stick to a schedule can make many mothers worry that they don’t have enough milk. If the baby wants to eat sooner than whatever the schedule says they should, and cries, as he will, usually, then the may assume that the baby did not get enough at the previous feeding. The problem is not the supply, though, it is the schedule. Breastfeeding works best when babies are fed when they want to be fed, so that the mother’s supply adjusts to the baby’s needs. And, incidentally, the baby will also adjust. But it is better not to force the adjustment.

A few words about weight gain and growth charts

Mothers also become concerned about their milk supplies after they have had the baby’s weight checked and charted at the baby’s doctor.

There is an awful lot of concern about weight gain amongst physicians, especially paediatricians, as well as public health nurses and, of course, new mothers and their families.

The first question we should be asking is “Why are we concerned about weight gain”? More particularly, why is it necessary for babies to gain a certain amount of weight each day or each week or each month?

Most physicians would say that it is normal for a baby to lose weight during the first few days, and then regain that weight by 10 days of age. (Actually, in my experience in Africa, where babies were with the mothers, in their beds during the entire hospital stay of a couple of days, many babies did not seem to lose weight at all. Midwives also report that babies born at home and breastfed without restrictions, will often be back over their birthweights by 4 or 5 days of age). After that, the baby gains about 30 grams (one ounce equals 28.8 grams, so about 1 ounce each day) each day for the first 2 months or so, and then 15 grams (about 1/2 ounce) a day until about 6 months of age. Thus a baby who is born at 3.3 kg (about 7 pounds 4 ounces) will lose some weight during the first days, and then, by 10 days of age will be back at 3.3 kg. By 30 days of age, he should weigh 3.9 kg (8 lb 9 oz). By 60 days of age, he should weigh another 900 grams or 4.8 kg (10 lb 9 oz). But now his rate of weight gain often will slow down. By 90 days of age (about 3 months), he will weigh about 5.25 kg (11 lb 9 oz). And by 180 days (about 6 months) the baby will weigh 6.57 kg (14 lb 7oz). Some physicians mistakenly expect the baby to continue gaining at the same rate in the 3rd to 6th month as he would normally gain in the first 2 months, in which case the baby would weigh an incredible 8.85 kg (19 lb 8 oz) at 6 months of age.

But all growth rates are guidelines. What does it mean if a baby gains a little less or a little more quickly? What does it mean if the baby gains a lot less or a lot more quickly?

The fact is that many health professionals seem to have forgotten what growth standards and growth charts are really for. When a baby or a child who gains weight and grows in length (or height) at a rate which can be considered “normal” or “average”, then this is a sign of good health and development. Just as a baby smiling by a certain age is a sign of good health and development, just as social interaction with other people is, and just as an absence of a heart murmur is. None of these, and the myriad other signs which we use, alone is a guarantee that a child actually is in good health. Thus a child who smiles socially at 4 weeks of age is on track for development, but could easily have a heart problem. A baby could gain weight just fine, yet have a kidney problem.

Growth charts developed because they were an easy way of keeping track of large numbers of babies, particularly in poor areas, where medical care was not as available as in more affluent areas of the world. Weighing babies, measuring their lengths and head circumferences, is an easy way of screening large numbers of infants to see which of them needs extra care. The weight, which is the first of the three measures to go off when something is wrong, allowed health workers to separate those babies who needed interventions from those who did not. The intervention may just have required information about feeding the baby more frequently on the breast if that is what seemed to be the problem, or may have required more serious intervention, for a baby with heart disease, for example.

Growth charts are designed so that the baby’s weight is charted against his age in months, and the lines which are on the chart are called percentile lines. The baby’s line, drawn over weeks or months is the baby’s percentile line. Many parents, and some physicians, seem to believe that only babies at the 50th percentile and above are normal. This is not true. Growth charts are made from data on normal babies (though the majority of them were formula fed or not breastfed more than a few weeks, and they often had solids introduced fairly early). Thus if a baby is on the fiftieth percentile for his age, it means that 50 percent of all normal babies his age weigh more than he, and 50 percent weigh less. It does not mean this baby is normal just because he is on the 50th percentile. If a baby is on the third percentile, it means that 97% of normal babies his age weigh more than he does. But it does not mean he is unhealthy, and it does not mean he should weigh more. Somebody has got to be there on the third percentile. If all babies weighed 50% more, and so did the baby on the 3rd percentile, the baby would still be on the third percentile.

Furthermore, a single weight does not tell anyone anything. A baby who was on the 50th percentile at 6 months of age, and is on the 10th percentile at 12 months, is a baby to be concerned about. A baby who was on the 10th percentile at 2, 4, 6, 8 and 12 months of age is probably fine. And he is doing just what we expect him to do.

In other words, growth charts have to be interpreted. The person that is reading the information has to take into account that the data might not be appropriate to the child being weighed and put on that chart. Growth charts available in North America were developed using data from mostly Caucasian babies and children, fed formula from early on in their lives and who got solids relatively early on as well. Thus, these growth charts may not represent normal growth curves for Chinese babies, or Inuit babies, regardless of how they were fed. (In fact they do not. Recently growth charts were developed in Hong Kong for babies of Chinese origin. Their curves, in a population where malnutrition in babies is almost unknown, are quite different from those developed in North America or Britain). And they may not represent normal growth curves for exclusively breastfed babies. As with all tools, mistakes can be made as well. A child who is 4 months old, whose weight is at the 50th percentile at 4 months, will look as if he is not doing well, if his weight is plotted on the line for a 6 month old. This is an easy mistake to make, by the way.

Incidentally, the birth weight is not the standard which determines where the baby should be. Some babies are born big and then settle into “their” percentile which might, in fact make them seem to be growing too slowly. Trying to keep them on their birth weight percentile is not only futile, but, may lead to early introduction of supplements which will undermine the breastfeeding, to no avail.

But does a baby really have to follow along “his line”? Remember our earlier discussion of weight gain being only one sign amongst many that gives us information about how the baby is doing. Is it okay for a baby to gain no weight for a prolonged period of time (which would result in his dropping down percentiles)? No, but as discussed below, there are ways of helping with the breastfeeding so that this problem is overcome. Is it okay for a baby to gain slowly, say 15 grams a day even during the first two months of age? Maybe. A baby who gains 15 grams a day will fall down percentiles. But does this mean something terrible will happen? No. A baby who gains 15 grams a day will be thin, but will also be fine. My approach would be to make sure the baby does not have any physical reasons for slower than average growth, to help the baby get more (see below), but if the baby is content, developing normally, and growing slowly but steadily, I would keep an eye on him, but not really be too concerned. On the other hand, if the baby is a very fussy baby, I believe it would be more important to improve the intake of milk (see below).

First of all, and it may surprise many people, breastfed babies who are doing well, actually gain weight faster than formula fed babies, at least for the first few months. Not all do, and some gain at about the same rate and some even more slowly. Between 4 and 6 months of age they actually gain more slowly than formula fed babies. As mentioned above, on the growth chart made for artificially fed babies, they may show weights that are passing from one percentile, say 50th, down through, say 25th. If the growth chart were made from breastfed babies, it might show the baby staying on the 50th percentile.

The importance of a good latch

If most women can produce enough or even more than enough milk, why is it that so many babies gain slowly or even not at all when “breastfeeding”? The answer is that in order to get milk well from the breast, the baby must latch on to the breast well. The word latch is used to describe the way a baby takes the breast into his mouth. The greater the mother’s milk supply, the less well the baby needs to latch on well, but the mother may pay a price. For example, sore nipples are almost always due to a poor latch. Even in the presence of an abundant milk supply, the baby who latches on poorly may be on the breast for long periods of time or frequently or both, leading some mothers to believe their milk supply is inadequate!

It may be helpful to use a bottle feeding comparison, as, in our bottle feeding culture, we understand bottle feeding much better than breastfeeding. When a baby latches on poorly, it is similar to his being fed a bottle with a nipple hole which is too small. The bottle is full of milk, but the baby will have difficulties getting that milk. The baby may suck for a long time, he may fall asleep while sucking, only to wake up soon after the bottle has been withdrawn from his mouth. Why does he wake up? Because he hasn’t taken much. The smaller the nipple hole, the less milk he will get, and the longer it will take for him to get that milk. At the extreme (no nipple hole at all), the baby will get no milk, and eventually become sleepier and sleepier, as he becomes more and more dehydrated, despite the fact that there was plenty of milk available, at least in theory.

It could be argued that women all over the world, since the beginning of human time on earth, have breastfed their babies, usually quite successfully, without paying much attention to how exactly the baby was latched on. This is undoubtedly true, but does not mean the latch is not important. Because most women have more than enough milk, babies almost always grew reasonably well, despite less than ideal latches, even before breastfeeding clinics and lactation specialists existed. In traditional cultures, however, the fact that the baby was on the breast many hours of the day, sometimes constantly, did not cause a great commotion. Babies were expected to be on the breast much of the time and nobody gave the mothers a hard time about their milk being too weak, or inadequate in quantity, or accused the mothers of spoiling the baby by having him on the breast too much or carrying him too much or sleeping with him at the breast. With a generous milk supply available to them, with free access to the breast, most babies gained weight just fine.

In addition, in more traditional cultures, mothers have, from the time they were toddlers, watched babies being breastfed. The notion of breastfeeding is as normal in their minds as breathing. They have a subconscious image of the way breastfeeding works, how babies are to be held and how they take the breast.

In modern, affluent societies (as well as the affluent parts of modern, not so affluent societies), however, an obsession with numbers and the clock, with scientific medicine’s increasingly greater involvement with infant feeding, this more relaxed and usually successful approach was largely discarded. Furthermore, our society’s mental image of infant feeding is not breastfeeding but bottle feeding. In our society, the bottle is the cliche image of babyhood. Using the bottle fed baby as our model of infant feeding has led to great problems of understanding of how breastfeeding works, for mothers, fathers, families of the new mother, and health professionals.

By the early years of the twentieth century, “scientific infant feeding” was starting to take over. Paediatricians were advising mothers to feed by the clock, so many minutes on each side every so many hours (each paediatrician had a different number of minutes which represented the ideal feeding time and so many hours the ideal feeding interval, though usually 3 or 4 hours). “Scientific” infant feeding, the basis from which the speciality of modern paediatrics grew, incidentally, often enough did not work, so that more and more, supplemental milk was “required”. Surprisingly, though, given the obstacles the scheduled feedings put in the way of successful breastfeeding, breastfeeding sometimes did work nevertheless. When the mother’s supply is abundant, sometimes even the most bizarre of rules will not derail the process. Of course, some mothers simply ignored the advice they got because the clock was not working, or because they couldn’t be bothered to try to feed a baby by the clock, which, in a way, takes more work and energy. This is lucky, since, otherwise, the art of breastfeeding might have been lost completely in the industrialized world.

We now know that there are more efficient and less efficient ways of having a baby take the breast. Observations by experienced mothers and interested health professionals have shown us that babies can do better or less well at the breast depending on how the babies are latched on to the breast. When the amount of time the baby spends at the breast or the frequency with which the baby takes the breast are not considerations, how well the baby takes the breast may not be that important. But when society, and the mother herself, and the “experts” expect the baby to feed 20 minutes on each side every three hours, a poor latch can result in the baby’s finding it very difficult to get enough milk within the given time limits. Furthermore, the less milk a mother has, even if the amount is sufficient to nourish her baby quite adequately, the better the latch of the baby must be in order for the baby to get enough milk.

1) good latch + abundant milk supply = good weight gain, pain free nursing, “short” feedings, feedings which are not frequent

2) adequate latch + abundant milk supply = good weight gain, pain free nursing, more frequent and longer feedings

3) poor latch + abundant milk supply = slower weight gain ± sore nipples. As the latch becomes poorer, there may be no weight gain, weight loss, or, on occasion even severe weight loss and dehydration even in the presence of an abundant milk supply.

4) good latch + average milk supply = good weight gain, pain free nursing, “short” feedings, feedings which are not usually frequent.

5) poor latch + average milk supply = slow weight gain, even weight loss ± sore nipples.

Another reason many women worry about not having enough milk is that there has been much media coverage recently of cases where babies who were breastfeeding became dehydrated. Actually, the babies who became dehydrated were not breastfeeding. If they were breastfeeding, they would not have become dehydrated. They had the breast in their mouths, but they were not getting milk. Note that dehydration may occur even in babies whose mothers have an abundant milk supply. In my experience, most of the mothers whose babies have become dehydrated have more than adequate milk supplies, and if they persist with breastfeeding usually are able to go on to breastfeed exclusively.

The principle always holds. The better the latch, the more easily the baby gets the mother’s milk. Even in the unusual instances when a mother is truly incapable of producing enough milk, the baby will still get more of her milk when he is well latched on than when he is poorly latched on.

If you are a nursing mother, you can try this test yourself. Pretend your thumb and index finger are your baby’s gums. Put your thumb over the top of one of your nipples and your index finger under the nipple. Now squeeze. You may feel pain, and notice how much milk comes out. Now move your fingers back 2 or 3 centimetres and squeeze. You likely feel no pain, and quite possibly your milk will spray out. What a big difference such a short distance can make. It is exaggerating only a little put it this way, but that’s all there is to breastfeeding—getting the baby to latch on properly.

What is a good latch? (PHOTOS OR DRAWINGS HERE)

The answer to this question has changed over the years, as more and more observations of breastfeeding babies were made by knowledgeable observers. It was often written that a baby was well latched on if he had most or all of the areola in his mouth. The areola is the pigmented area surrounding the nipple. As a general rule, it is probably good if the baby has most of the areola covered by his mouth, but this does not guarantee that he has a good latch. A baby may cover most of a small areola and still not be well latched on; a baby may cover nowhere near most of a large areola and still be well latched on. (Some women have areolas that cover well over a third of their entire breasts). Later it was said that the baby should have both his nose and his chin just touching the breast, and if his lips were flanged back, the baby was well latched on. This refinement has led to more babies and their mothers having an easier time of it. But more mothers and babies still will have an easier time of it if the baby comes to the breast and latches on asymmetrically, covering more of the areola with his lower lip than the upper lip. If a baby latches on this way, he can get his lower gums under the milk sinuses and extract milk from the breast in a more efficient manner.

In order to achieve this latch more easily, I encourage the mother to hold her baby in the “cross cradle” hold. Most mothers find this the easiest way of achieving the best latch. But it is not the only way. The best latch can also be achieved using the cradle hold (Madonna hold), or the “football” hold or while lying down with the baby side by side.

If the mother is putting the baby to the left breast using the “cross cradle” hold, she would hold the baby with her right arm. Her forearm holds the baby’s bottom firmly against her body and supports the baby’s weight. The baby’s legs would be under her right arm. The baby is “wrapped around” the mother’s body. The mother supports the baby’s head with her right hand, with her fingers on his face, and the web between her thumb and index finger at the nape of the baby’s neck. In this way, the mother’s forearm, not fingers, support the baby’s weight. The baby’s body will now be in a straight line (even though he’s “wrapped around the mother”), with the head slightly titled backwards. The baby will come toward the breast at an angle, so that the mother’s nipple points to the roof of his mouth. The mother should then lightly brush the baby’s upper lip with her nipple, from one corner of the baby’s mouth to the other, wait for the baby to open his mouth widely, like a yawn, and when he does, use her arm, not just her hand or wrist, to bring the baby onto the breast. If the baby gets on well:

1. he will cover more of the areola with his lower lip than his upper lip

2. his lips will be turned outwards

3. the baby’s chin, but not his nose, will be touching the mother’s breast

The fact that the baby’s nose is away from the breast is one sign that he is latched on well. The baby will usually be able to breathe just fine even if his nose is buried in the mother’s breast. It is not for the baby’s breathing that the baby is held in this way, but so that the baby can latch on well and get milk well, without causing the mother pain.

The whole point of using what many women would consider an unnatural way of putting the baby to the breast, is to get the baby onto the breast asymmetrically. So, do not bring the baby around, or lift the baby’s body so that the nipple is centred on the baby’s mouth just before you latch him on. That is what you are trying to avoid. While this position may seem awkward at first, it will more likely make breastfeeding easier for the mother, and the mother will naturally, over the next days or weeks revert to the more usual cradle hold.

The mother can achieve the above latch with any position of the baby; lying in bed side by side with the baby, or using the “football” hold, or the regular “cradle” hold. It is just easier to manage with the “cross cradle” hold. But it is best to do what works best for you.

The Best Way to Assure a Good Milk Supply: A good Beginning

How did we get the poor beginning?

From early in the twentieth century, hospital routines have made breastfeeding difficult to get going properly. Yes, some mothers managed regardless, but this should not be seen as an endorsement of these routines, which were based on bottle feeding babies and how they were supposed to be fed. Bottle fed babies could be given certain measured amounts of milk and the doctors and nurses could be relatively certain that the babies would sleep or be satisfied for a certain period of time. Hospital staff began to feel that since it was possible to make a baby drink 60 ml (about 2 ounces) of milk in 10 or 15 minutes, for example, and as a result have the baby sleep for 3 or 4 hours, this was a good thing. In fact, if the bottle fed baby would take that amount of milk (obviously much more than a breastfed baby was getting), and sleep 3 or 4 hours, this was not only a good thing, but probably the normal thing for babies to do. From there, it was only a short step to deciding that if the breastfeeding baby was at the breast for longer than 10 or 15 minutes, and wanted to return to the breast before 3 or 4 hours had elapsed, this was a bad thing.

Routines which seemed to work for the bottle fed babies were imposed on the breastfeeding babies, as most health professionals were becoming convinced that breastfeeding, though better, was essentially not different from bottle feeding. Artificial feeding was the same not only in the food the baby was getting (not true even today despite the many refinements which have improved infant formulas), but also in the “mechanics” of the feeding. Actually, by the 1920’s many health professionals were beginning to believe that bottle feeding was better, because it was more “scientific”. It was possible to say how much the baby was getting, in ounces and even quarter ounces. It was possible to make “special milks” for babies which would contain “exactly the ingredients” babies needed to grow properly. It was possible to keep a baby to a schedule. The fact that what you put into a formula does not necessarily mean that that is what the baby will absorb—the fact that knowledge of exactly what the baby needed to grow was extremely limited—the fact that we didn’t even know what was in breastmilk (and we are still quite ignorant of breastmilk’s ingredients, though we have learned a lot)—none of this mattered or was even considered. Because the babies thrived. Well, not always.

“In the late 19th century, as the chemical composition of milks was determined, animal milk was modified to approach human milk more closely in gross composition. Milk first was diluted with water, so that protein and electrolyte concentrations were reduced. Babies fed this diluted formula failed to grow. Experiments revealed that the caloric density of human and cow's milk were similar. Subsequently, sugar was added to the mixture. Some infants fed these formulas lived. Manipulating the composition of formulas heralded the advent of Pediatrics as a specialty.” Lewis Barness. Remarks to American Academy of Pediatrics, March 19, 1991 San Diego, California. In Pediatrics 1991;88:1055

And then there was money. Money? What has money got to do with it? Well, a lot. With increasing artificial feeding, physicians got a whole new business. With breastfeeding, in the days of yore before the art of it was lost, women would get help and information from their mothers, sisters, friends, and neighbours, most of whom had nursed several children. The idea of going to a physician, almost all of whom were men, to ask about breastfeeding, would have seemed a bizarre joke.

Once artificial feeding became more common, by the 1920’s, mothers needed help from physicians. Artificial feeding in bottles was complicated and risky. Babies were frequently ill, and some died, but it was not artificial feeding that was considered at fault (true even today, incidentally), it was that mothers made mistakes in not following instructions. But even with proper mixing and sterilizing, babies did not always do well. So changes in the formulas were made according to the baby’s age, weight, bowel movements and how the baby reacted to the chemical soup. Instructions were written down in great detail and meant to be followed to the letter. Physicians got more business because of the mother’s need to get instruction on the use of infant formulas, and got more business from the increased illnesses the artificially fed babies developed. And they got control. Women were now dependent on their advice in order to feed their babies. Who can reject such power easily? A little power was also apportioned out by the physician to the nurses who worked with new mothers and babies in hospital during the early days after birth. The nurses now had power over how much the baby was fed, the power to override such foolish old fashioned ideas such as “demand feeding”, and the power to push the use of bottles and supplements “for the good of the baby”.

In her novel The Group, Mary McCarthy describes very tellingly in chapter 10 how a new mother, at first wanting to breastfeed, is led by inaccurate information from physicians and nurses and family to wondering, by the end of the chapter, whether breastfeeding was really natural. Of course, the mother in the novel “failed” at breastfeeding. And in real life, of course, her story was not unique. Not by a long shot.

“Scientific infant feeding” was the driving force behind the scheduled feedings. Observations on formula fed babies determined how babies were to be breastfed. For example, nurses, from very early on, noticed that babies fed formula in the first few hours after birth would frequently be fussy and spit up their feedings. A policy was developed to deal with this “problem”. Babies were not to be fed for the first twenty-four hours of life.

This policy was virtually universal in North America for many years and continued until the early 1970’s in some hospitals. My most poignant memory of my fourth year medical school rotation in obstetrics was the babies’ screaming in the nursery, with no one who would pick them up or feed them, because this policy was felt to be right. It was a policy based on bottle feeding and artificial food, and it was wrong even for those babies, but it was a disaster for breastfeeding. Happily, this policy has been consigned to the dustbin of history.

Since babies were not being fed for the first day anyway, it seemed unnecessary to have them with their mothers. The babies could be kept separate in a nursery, a bizarre name, since rarely did any nursing (breastfeeding) take place there. Babies could be better observed, since mothers who were heavily sedated could not be trusted to do it themselves. By the 1950’s, the nursery had become the babies’ ward, and the mothers and babies were separated during the entire hospital stay, which was often 7 days or longer. Eventually, the idea arose, never stated openly, perhaps, that the baby actually “belonged” to the hospital, not to the parents, at least until they left the hospital. The belief that the mothers could not take care of their babies during the first 24 hours led insinuously and sinisterly to the notion that mothers were not competent to take care of their own babies at all. This attitude has not completely disappeared.

Today, as more women are breastfeeding again, other reasons are used to separate mothers and babies and interfere with breastfeeding. Many of these “reasons” are bogus, and once again have to do with health care professionals letting the parents know who is in charge (not the parents). For example, some hospitals have policies in which all babies are observed after birth by nurses for a few to up to 24 hours. This is not only unnecessary, but interferes with mother and baby bonding as well as the establishment of breastfeeding. This type of policy may be based, perhaps, on a desire to “make sure the baby is okay”, but very few nurses observe babies in the nursery as well as a mother observes her own newborn. In the days of hospital funding cutbacks, a lot of “routine” separation has more to do with justifying the staffing of the special care nursery, than observation of the baby.

Today, more than ever, many health professionals do not believe that new mothers produce enough milk during the first few days after the birth. This, of course, is based on the amounts of formula a bottle feeding baby will take, which is obviously much more than a breastfeeding baby will get at the breast during these early days. Secondly, as well, during the first few days, “breastfed” babies tend to want to stay on the breast for long periods of time and will often fuss if taken off the breast. These observations reinforce the notion that there is not enough milk in the first few days. But there is enough colostrum. The baby does not need much, but he needs some. The way to get the baby his colostrum is to make sure the baby starts nursing early and making sure the baby is latched on as well as possible. Because when the milk flow is not rapid, as it is not during the first few days, a baby has to latch on well to get milk well.

Thus, if there is a medical reason that a baby must start feeding early, there is a tendency to introduce supplements. The infant of a diabetic mother, for example, is at risk of developing a low blood sugar, and a low blood sugar can be quite serious. The way to deal with this risk is to get the baby feeding early. The best feeding for the baby is colostrum, as formula tends to raise the baby’s blood insulin, which then can decrease the blood sugar again. But since most health professionals do not believe there is enough colostrum, they will feed the baby formula, often without even trying the baby at the breast.

Furthermore, the fear of low blood sugars, has resulted in many hospitals adopting routine testing of newborns for sugar. This is completely inappropriate, and resulting in unnecessary pokes to the baby to get blood, anxiety in the parents, and unnecessary treatments and separations. More on this elsewhere.

So, despite many hospital policies which “encourage” early feeding at the breast and rooming-in, the practice in many of these hospitals is that babies are separated during the early hours and often fed inappropriately with bottles and formula.

So what is a good beginning?

It has been known for many years now that breastfeeding works best when mothers and babies get started as early as possible, if babies learn to latch on well, and supplements, especially when given by bottle are avoided. Here are some of the important first steps in preventing the problem of “not enough milk” and almost all breastfeeding problems, for that matter. It is not always necessary to fulfil all the steps below, as many mothers know very well, but the better the start, the less the risk of problems with milk supply developing. Many mothers develop an abundant milk supply regardless of a delayed start to breastfeeding, despite early introduction of bottles (almost always unnecessarily, incidentally), and despite not being with their babies 24 hours a day during the first few days. But for some mothers and babies, a poor start means an early end to breastfeeding. Since it is not possible to know which mother and baby will have difficulties, every effort should be made to ensure that all mothers and babies get the best start possible. Of course, sometimes infant or mother illness require separation and a delayed start to breastfeeding, though nowhere as frequently as is done in many hospitals. However, because a baby and mother are separated, it is not necessary to throw everything else important to a good beginning out the window. For example, just because, occasionally, babies do need supplements (though nowhere as frequently as they are given), it is not necessary to give them by bottle, as if the bottle were the only “natural” alternative. There is nothing natural about a bottle.

A. Breastfeeding should begin as soon as possible after birth.

An early start is definitely important for getting breastfeeding started right. UNICEF’s Baby Friendly Hospital Initiative, a programme to encourage hospital routines which will improve breastfeeding success, encourages trying the baby at the breast within 30 minutes of birth. This guideline, 30 minutes, is just a guideline, but emphasizes how early a baby can start breastfeeding. Indeed, work from Scandinavia has shown us that, not only can babies start breastfeeding within minutes of birth, they can actually crawl up to the breast and latch on all by themselves, without help.

Basically, it works like this. The just born baby is dried off, but then immediately placed on the mother’s abdomen. For about 20 minutes, on average, the baby will just lie there. Then, after this time, the baby starts moving his head from side to side, then starts to push with his feet (a reflex called the “stepping reflex” in medical textbooks). Slowly, the baby will work his way to the breast and take the breast and start suckling. On average this takes about an hour from the moment the baby is placed on the mother’s abdomen to the moment the baby latches on to the breast, all by himself, with no help. Not all babies will do this right away, and some will latch on immediately they placed anywhere near the breast. It is a fascinating thing to watch, and videos of the process are available. It is even more fascinating to observe first hand, and even more fascinating to experience first hand.

Very few new mothers have ever had the opportunity to experience this “self attachment”. One problem is that narcotics, and possibly other medications during labour could easily interfere with the baby’s ability to accomplish his crawl to the breast and self attachment. Of all the medications which interfere, the one most commonly used during labour for pain relief, meperidine (Demerol) is the worst. It gets to the baby very easily during labour and it stays around in his blood, affecting his ability to nurse very significantly for many days and even weeks.

There is debate about whether the medications from epidural or spinal anaesthesia can affect the baby in this way, but despite what is frequently said about these methods, some medication will get into the mother’s blood stream, and some will get to the baby. This does not mean that the baby will necessarily have difficulty crawling to the breast or difficulty suckling, but the evidence is difficult to interpret.

It is fascinating what we are learning about the newborn’s behaviour. The fact that a baby will crawl up to the breast and latch on all by himself should not be surprising. Most baby mammals find their way to the mother’s breast without help. The joey (baby kangaroo) accomplishes this by completing a voyage that is nothing less than amazing, travelling, in a much more immature state than the human baby, a distance which is many many times the length of his own tiny body. Pigs also find the sow’s breast, even fighting with his siblings for prime position. For many, this may seem threatening, a reminder of our relationship to other animals, something many would like to forget. But it should also remind us of how much we have forgotten, in our flight from nature.

Research has shown that smell may have something to do with the baby’s ability to latch on to the breast in the first hours. When researchers had mothers wash one breast, while leaving the other unwashed, the babies, allowed to crawl up to the breast and latch on on their own, almost always chose the unwashed nipple. Again, a reminder than in our haste to “make things better, cleaner, safer”, we may be interfering with things we are not even aware of, never mind understand.

Another reason few babies self attach is that they are not given the opportunity. Even in some of the more enlightened maternity departments, the opportunity for the mother staying with the baby skin to skin for an hour or more is just not in the cards. Hospital routines “must be followed”.

The baby must be examined by the paediatrician and suctioned and given an Apgar score. (In fact, he doesn’t. A baby who crawls up to the breast has an Apgar of 9 or 10. Suctioning is not necessary for the vast majority of newborns, and may even interfere with suckling. The baby can be examined later. In any case, giving an Apgar score takes only a few seconds and can be done while the baby and mother are together skin to skin.)

The baby and mother cannot be skin to skin because it’s too cold in the delivery room. (If it’s too cold, this is a problem for the mother’s comfort, though the baby stays as warm skin to skin with the mother as he would in an incubator. Delivery rooms have traditionally been kept cool because in the days when hospital staff wore gowns, masks and caps for deliveries, the staff would become very uncomfortable in a regularly warmed room. Also the work and “distraction” of labour was supposed to keep the mother from not feeling cold; but she did, once the baby was born.)

The baby has to get his injection of vitamin K and needs his eye drops. (Well, these can wait a couple of hours without any danger to the baby.)

The baby and mother have to go to their rooms. (Yes, but surely that does not mean the mother and baby cannot be together skin to skin. Furthermore, hospitals wishing to make labour and birth as pleasant an experience as possible for the mother and baby have developed rooms where the mother labours, gives birth and stays with the baby, without needing to be transferred to another place.)

The baby needs to be observed for abnormalities. (Really? And in what way does having the mother and baby skin to skin interfere with this observation? The baby’s colour, breathing and general activity can be observed while the baby and mother are together.)

Most babies and mothers would profit greatly from being together without interruption for the first couple of hours. It is one of the great mysteries, at least to me, how so often the excuse for the mother and baby being separated immediately after birth is that the mother is tired. Undoubtedly, the mother is tired, especially if her labour has been long and difficult, but surely, after that long and difficult labour, the mother has the right to have the fruit of that labour with her as compensation. Surely having the mother and baby skin to skin together, allowing the baby to learn to be with her, is not that tiring. Indeed, many mothers express anxiety at having their babies taken away from them, just at the time they wanted so much to see them.

Granted, it is not always possible to allow immediate contact between mother and baby, for a variety of legitimate reasons. Unfortunately, too often, mothers and babies are separated for reasons which are not legitimate. Here are a few:

1. The baby passed meconium before he was born.

A significant percentage of babies pass meconium before they are born. In some studies this may be as high as 1 in 5. Having passed meconium before birth does not mean a baby needs special observation. The vast majority of those who do, do not run into any problems. The tiny percentage of those who do, are obviously sick very soon after birth. Thus separation for observation of babies who pass meconium, just because they have done so before birth, is not a reasonable reason for separation of the mother and baby.

2. The baby was born by caesarean section.

Once again, if the baby was born by caesarean section, it may be that he is quite sick, or that the mother is quite sick. Nevertheless, in the majority of cases, caesarean sections are not done under those circumstances, especially in North America. Even if the caesarean section is done with general anaesthesia, it does not mean the mother and baby cannot be together as soon as the mother is awake. Until then, the baby can be with the father, and once the mother is awake and up to it (this does not necessarily take 4 hours or more), the mother and baby can be side by side, and skin to skin together.

3. There was evidence of fetal distress during the labour.

Well, if the interventions which occurred during labour as a result of the fetal distress resulted in a healthy baby at birth, why is it necessary to separate the mother from her baby? Congratulations to those who made the wise decisions and leave the mother and baby together.

“The benefits to the mother of immediate breastfeeding are innumerable, not the least of which after the weariness of labor and birth is the emotional gratification, the feeling of strength, the composure, and the sense of fulfilment that comes with the handling and suckling of the baby.” Ashley Montague.Touching. Harper & Row 1978

B. Babies should go to the breast when they are ready to go to the breast. There should be no restriction on the amount of time a baby breastfeeds.

Schedules and breastfeeding do not go together. Babies do not breastfeed better if they are forced to wait three or four hours so that they will be really hungry or so that the mother’s breasts will “fill up”. Nor do they do better if they are kept on the breast for only short periods of time. This is a throwback to the days when we thought that limiting time on the breast would prevent sore nipples. It doesn’t. It does prevent the smooth establishment of breastfeeding, however.

It is important to understand that there is a difference between a baby who is on the breast and actually getting milk, and a baby who is on the breast but not getting milk, or only getting a very little. Any advice from anyone to let the baby feed 20 minutes (10 minutes, 30 minutes, whatever) on each side indicates that that person does not really understand breastfeeding. A baby who drinks well from the breast for 20 minutes is unlikely to even be interested in the second side. A baby who sucks on the breast without drinking for 20 hours will still come off the breast hungry. It is because so many babies are not drinking milk at the breast that so many babies in the first few days seem unsatisfied, wanting always to return to the breast and suck. Of course, if the baby did drink well, and wants to stay at the breast for comfort, there is nothing wrong with this. Why shouldn’t a baby want to be comfortable? But the emphasis should be, if there is a concern, that the baby drink well, and if he has, then getting comfort from the breast is fine too.

What about the baby who is feeding less frequently than the schedule demands? Is it bad that a baby does not drink for 5 or 6 hours at a time during the first few days? Many mothers have been told that a baby must feed every 3 hours for the mother to establish a good milk supply. Modern management of obstetrics makes the answer to this question more difficult. Because many babies have been sedated by drugs given to the mother during labour, the baby may not wake up in response to hunger. Furthermore, in some hospitals, babies are wrapped up so warmly and tightly and the temperature of the room is so high, that the baby just sleeps comfortably on.

For this reason, it is best that mother and baby be close, skin to skin, in bed together, during the first days. Babies often give clues that they are ready to feed which can easily be missed if the baby is in the nursery, or even in a bassinet next to the mother. One of the most dramatic, because others often don’t notice, is the change in breathing that many babies demonstrate when they are starting to wake in order to feed. From a regular deep respiration, the baby may start panting, and this change of breathing will often awaken the mother if she is asleep.

Another cue is the baby’s lifting his hands to his face or mouth. He may even try to suck his hands. But, if the baby is tightly wrapped in a blanket, he may not be able to show this.

It should be obvious from the above that the mother and baby should be rooming in together 24 hours a day. Indeed, rooming in means 24 hours a day, and there is no such thing as rooming in 12 or 18 hours a day. It means that the baby is not separated from the mother for more than a few minutes at a time for the accomplishment of hospital routines. The offer to take the baby to the nursery for the night should be politely refused by the mother. This is not a favour that is being offered you. It is usually unnecessary, and often a mistake. The evidence suggests that mothers sleep better when the baby is with them than if the baby is in the nursery. Besides, it is a good habit to get into to sleep beside your baby, as you will get more rest once you are home if you can nurse lying down, and even sleep while your baby nurses.

C. Artificial teats or nipples should not be used for the breastfeeding baby.

Sometimes supplements do need to be given to the baby. I would like to emphasize that they are being given far too often, and often, quite unnecessarily, as infant formula, rather than expressed milk or sugar water. Nevertheless, if supplements are truly necessary, we now have methods of supplementing the baby without using an artificial nipple.

Is there such a thing as nipple confusion? This question and sometimes the strong feelings and debate around this question are unnecessary since we don’t need to use artificial nipples to feed breastfeeding babies supplements, if supplements are considered necessary. But let us consider this question anyway.

Nipple confusion, or nipple preference, if you prefer, is not an “all or nothing” situation. As mentioned earlier, the key, the basis of successful breastfeeding is a good latch. If the mother has a bountiful supply, the latch does not have to be great for the baby to do well. If the mother’s supply is just abundant enough, the baby really must have a good latch in order to do well.

Babies are not complicated. The want milk and if they get it, they are content. If they go to the breast and get lots to drink, and then get lots to drink from a bottle, they usually will do both breast and bottle. If they go to the breast and get little, and then get a bottle and get lots, it is also obvious that sooner or later, the baby will catch on, and realize that he gets his milk from the bottle. If he is not too hungry he may still take the breast, but if he is ravenous, he may refuse the breast. Indeed, some babies refuse the breast without ever having had an artificial nipple, if they do not get good flow from the breast.

In order for a baby to get milk from a bottle, he does not have to open particularly wide, for example. Thus, if the baby has had some experience with bottles, he may open his mouth only a little when going to the breast, but he won’t get milk quite as well. If the baby latches less well than he could, he depends more on the rapid flow of milk (caused by the “letdown” or milk ejection reflex), than on actually extracting milk from the breast. When the flow slows, he no longer drinks. Babies drink well when they get good flow, and in the early days, when the flow slows, they tend to fall asleep, even if they have not had enough. The less good the latch, the less well the baby will suckle. Because the baby suckles less well, sooner or later, the milk supply will decrease, and the baby will stop nursing earlier and earlier. Furthermore, the early use of bottles can lead to sore nipples because the baby tends not to open his mouth as well when he comes to the breast.

It is interesting that some of the loudest mockers of “nipple confusion” are often also the very same people who encourage the mother to start bottles early, or “the baby will never take one”. And it is sometimes true that a baby who is breastfeeding only, will refuse to take a bottle or pacifier. This may occur as early as a few weeks of age, or only after three or four months of age. It may also occur even if the baby is getting regular bottles from early on. Suddenly a baby who is taking both, stops taking the bottle when he is 3 or 4 months of age. Or, unfortunately, a baby who was taking both breast and bottle stops taking the breast. It is also patently obvious that some babies who are doing “both breast and bottle” are not. In fact they “pacify” on the breast, but actually feed from the bottle. They get virtually no milk from the breast.

One example. Lise is breastfeeding her five week old baby and is doing fine, as is the baby who is gaining weight very well. The mother has no problems with nipple soreness, no problems with milk supply. She is prescribed metronidazole (Flagyl™) for a problem unrelated to breastfeeding and incorrectly told she must stop breastfeeding during the 10 days she is on it. The mother takes the baby off the breast; she maintains her milk supply very well with pumping. After a week, she finds out that she did not have to take the baby off the breast. All efforts to put the baby back to the breast fail. How do we explain this phenomenon? Is it low milk supply? Well, it’s not a low milk supply, because the baby was able to grow subsequently on expressed milk (with no formula) at a tremendous rate.

I believe the conclusion is obvious. And this is only one example.

“Nipple confusion” is not a black and white issue. The use of artificial nipples may cause no problems for some babies, tremendous problems for others and everything in between. Since it is rarely necessary to use bottles to feed babies (more on this later) even if they need supplementation, and since it is not always possible to know which baby will be affected, we should do everything to avoid the use of bottles until breastfeeding is well established. And that certainly means no bottles in the first few days. Each baby is different. Each baby is an individual and so a mother who “fed her others both breast and bottle and the baby did well” may not do as well with this new baby.

Methods of supplementing which do not require a bottle

There are several methods of supplementing which do not require the baby getting an artificial nipple. The best is what I call a “lactation aid”, or others call a “nursing supplementer”. This device is best because the baby is at the breast and breastfeeding. Other methods include cup feeding, finger feeding, syringe feeding and feeding the baby with a tube put through his nose or mouth into his stomach. This last method should only be used with babies who are too premature or too ill to suck. All these methods, as with all tools, can be, and have been, misused. They are often used at inappropriate times; they are often used wrong; they are often used when another method would be better.

1. The Lactation Aid

This device can be made up from hospital materials: an ordinary feeding bottle with the nipple hole enlarged with scissors so that a 5 French, 91 cm (36 inch) feeding tube can pass through the hole. Or it can be bought ready made. In most cases, especially in the first day or so, there is no need to buy the manufactured device, as the supplement may be required for only a few feedings.

Generally a lactation aid is used as follows:

a) The baby must be latched on as well as possible. Of course, not all babies latch on perfectly in the first few days, but using a lactation aid to supplement before fixing the latch is a wrong use of the lactation aid. This is key! In the first place, the better the baby latches on, the less likely will the supplement actually be necessary. Secondly, the better the baby latches on, the easier the lactation aid is to use. Thirdly, the better the baby latches on, the shorter the time the device will be necessary.

b) The mother must be able to tell whether the baby is getting milk. This is easy to see once you’ve seen it, but difficult to describe. However, here goes. A baby who is getting milk in substantial quantities demonstrates a very definite pause in his chin as he opens his mouth to the maximum while he is sucking. The baby opens his mouth and as the “opening” phase of the suck comes to an end and he has opened wide (to the maximum opening) there is a delay, or a pause, just before he closes again. That pause tells you the baby just got a mouth full of milk. The longer the pause, the more milk he got; the shorter the pause, the less, but if there is a pause definitely there, the baby got a significant amount of milk. This pause can be seen on the first day of life if the baby is latched on well. You will see the pause when your milk supply is more abundant than on the first day or so even without a good latch. But if you see it on day one, the baby must be latched on well, or you have quite a lot of colostrum. This pause when you see it, is your guarantee that the baby just got milk. You don’t have to hear the baby swallow, unlikely in any case during the first days. Also, I mistrust “hearing the baby swallow”, though like the pause, once you hear it you know what it is. The trouble is that babies can make all sorts of noises while on the breast which can be mistaken for swallowing. The pause is more reliable.

c. The lactation aid is introduced only after the baby has nursed on both sides. A baby who is reasonably latched on should not have the tube introduced immediately. The mother should feed the baby on the first side until the baby does not appear to be drinking any more (no more pauses). Then she changes sides and feeds the baby some more, until the baby no longer drinks. If she wishes, she can offer the first side again, and, go back and forth several times if she wishes, but she should feed at least both sides before offering the supplement with the tube. The supplement is then given and the baby takes what he wants. In this way, as things improve, the mother will be introducing the tube later and later in the feeding, until, perhaps, the baby actually refuses the supplement.

2. Cup Feeding

Cup feeding has been around for thousands of years. Cups for feeding infants have been found in Egyptian tombs. All around the world, women feed their babies water (unnecessarily) using the oldest cup around, the human hand. It works just fine. I have seen a mother give her one day old baby water with the cup of her hand and the baby drinking it quite nicely. This giving of water to young babies is, in fact, not a good idea, especially in those parts of the world where the practice is most common, because the water supply is often unsafe, and breastmilk if far superior even to slake a baby’s thirst. It has been well shown in well designed studies that even in the hottest of climates, enough breastmilk also means enough water, as breastmilk is 90% water, more or less.

Cup feeding should not, in general be used when the baby is latching onto the breast and the baby needs a supplement. Cup feeding should be used only if the baby is not latching on, or when the mother must be separated from the baby. If the mother is present and the baby is latching on, and a supplement is truly necessary, it should be given with the lactation aid, as babies learn to breastfeed by breastfeeding. Babies do not learn to breastfeed by cup feeding, finger feeding or any other feeding. Babies can learn to bring their tongues forward by cup feeding. Babies can be stimulated to suck in a manner similar to what they would normally do on the breast with finger feeding, but babies learn to breastfeed by breastfeeding. Strange as it may seem, there are many who don’t understand this. There is only one way to learn how to ride a bicycle and that is to get on it and ride it until it works. You can’t learn by reading about it, or even practising on an exercise bicycle, though both might be helpful.

The cup is a good way of feeding the baby when the mother is separated from her baby, for whatever reason. It does not seem to interfere with breastfeeding as much as a bottle, and it is faster than finger feeding. It is a technique which can be used if the lactation aid does not work, as it does not with all mothers or babies. It is also simple to learn and safe to do.

An open cup, often a 30 ml (one ounce) medicine cup, should be used, though manufactured cups specifically designed for cup feeding premature babies and very young babies have started to show up on the market. The baby’s back is supported and the cup, with whatever is to be given in the cup (expressed breastmilk, is, of course, the best liquid to supplement in all but extraordinary cases) is brought to the baby’s lips. The lip of the cup is pressed lightly on the baby’s lower gum margin and the cup then tilted until the baby receives a little milk on his tongue or in his mouth. When the baby tastes that little bit of milk, he will start, usually, to stick out his tongue and try to lap up the milk. It is an amazing thing to watch, especially for those of us who were taught that babies cannot really start drinking from a cup until they are six months of age or older. Usually the baby drinks very quickly. Indeed, a baby, , even a premature baby, can often cup feed much faster than he can drink from a bottle.

3. Finger Feeding

Finger feeding is a technique which can be quite useful and helpful for the mother having difficulties latching a baby on to the breast. As with all techniques, however, it can be used in situations which are inappropriate and the technique itself can done wrong. As with all techniques, finger feeding will not work as well, and can even be harmful if it is done for the wrong reasons, or in the wrong way. Some have condemned the use of finger feeding, usually for no specific reasons, and often without having tried the technique, or tried it properly. I think finger feeding definitely has its uses.

To finger feed, you need the same equipment as you would need for a lactation aid. However, because the baby is refusing the breast (the most common reason by far for using this technique), you cannot use the tube at the breast. The idea of finger feeding is:

1. To calm the angry baby who is refusing the breast.

2. To encourage him to suck in a fashion similar to that he would best use at the breast, and thus help him to latch on to the breast.

3. To wake up a sleepy baby, particularly in the first few days of life, when some babies sleep for long periods, especially because they are feeding poorly or not at all.

The larger the finger used, the better, to encourage the baby to open his mouth wide. From the point of view of size and convenience, the index finger is the finger I find the best to use. Some lactation consultants use their thumb,which I find difficult. I believe the baby finger, which is often taught, is probably the worst of choices, because it is not only rather awkward, but also it doesn’t encourage the baby to open his mouth wide.

The tube of the lactation aid can be held between the thumb and the middle finger at about the position of the first joint in the finger closest to the knuckle. If the person doing the finger feeding holds the tube like this, the tube will often sit on his/her index finger and no tape, a real nuisance, is necessary. The baby is held in a comfortable position, but I prefer holding the baby facing me, my left hand (since I use my right hand index finger to finger feed) supporting the back of the baby’s shoulders and neck. This allows me to keep my finger flat (not pointed upwards to the roof of the baby’s mouth) which keeps the baby’s tongue forward and flat, which is what we want. The finger feeding finger should also be as far into the baby’s mouth as possible. (Most babies do not mind the finger quite far into their mouths). The baby will start sucking when he feels the finger in his mouth and if he sucks effectively, the supplement which is to be fed will be drawn up into the tube and into the baby’s mouth. At first some babies suck in a very ineffective manner, but once they start to get fluid, whatever it is, they start to suck in a manner much more similar to breastfeeding. That is, they will wrap their tongues around your finger, and draw backwards towards the back of their throat. Once the baby gets this, the feeding goes much more quickly. But the idea in the first instance is not to feed the baby, but to prepare the baby to take the breast. Thus, once the baby is calm and sucking well, the finger feeding should be stopped and the baby should be tried on the breast. This rarely takes more than a minute or two.

Unfortunately, finger feeding is often used incorrectly. Since the idea is to get the baby to the breast, finger feeding should not be done after many minutes or longer of unsuccessful attempts on the breast, but rather before everyone, including the baby, is fed up and tired. It takes only a few minutes to know the baby is not going to take the breast, so efforts should be stopped and the baby finger fed. Once finger feeding has calmed the baby and got him sucking right, there is a better chance of getting him to take the breast. If not, efforts should be halted temporarily for another minute or two of finger feeding, and then, the baby is brought back to the breast.

If the baby does not take the breast at that feeding, the whole feeding may be done as finger feeding, and this is fairly easy the first few days because the baby does not need very much. The main disadvantage of finger feeding is that it may be quite slow, so that as the baby gets older, finger feeding may take longer and longer for some babies. However, some babies finger feed as quickly as they would feed with any other method.

As with all methods which feed babies away from the breast, the baby can learn to prefer the finger to the breast, which is a good reason not to supplement this way. But the preference seems to develop much more slowly, at least partly because finger feeding does not give the rapid flow as comes from a bottle.

4. Other methods

Spoon feeding is a very old method (probably as old as spoons), an easy method, and used by many mothers around the world. If find no advantage to spoon feeding or to syringe feeding over the methods mentioned above. Mothers from many countries of the world where breastfeeding is the norm are very comfortable feeding babies with a spoon. Many mothers like the spoon because you don’t need special equipment—everyone has a spoon. It can be used in emergency situations, such as in one case when a mother rushed an injured older child to the hospital, her friend was able to spoonfeed the baby expressed breastmilk and keep the baby content until the mother returned five hours later.

Some mothers have also used sterile syringes (without the needle), to supplement their babies. They simply squirt a small amount of milk into the baby’s mouth, wait for the baby to swallow it, and then squirt a little more into his mouth. This can be used while the baby is at the breast as well, but has no advantage over a lactation aid and is more difficult to do as well.

The point is that there are many different ways to supplement your baby, even if you are temporarily separated, which do not involve the use of artificial nipples.

On the other hand, I believe that feeding a baby with a tube in his stomach, when other methods will do, is unnecessarily risky and no improvement over other methods. Of course, if there is no option, this is a good technique and preferably usually to intravenous feeding, but for a full term baby, just in order to avoid an artificial nipple, I think this is too risky.

And if no other methods work, is it okay to use a bottle? Well, of course, but the bottle is at the bottom of the choices, in my opinion. It is rare for a bottle to work in feeding a baby when no other method will work. If a baby won’t cup feed or finger feed, it is unlikely he will take a bottle and feed from it either. Maybe once a year I advise a mother to use a bottle because the other options are not working. But I see 1000-1200 mothers with their babies every year just for breastfeeding problems. And these babies who refuse other methods are relatively old and used to the bottle. In the first few days, it is rare to have to use a bottle, even for a baby with a cleft palate, for example, who, if he won’t latch on, can drink very well from a cup.

Most health professionals who skip the alternatives to a bottle do so simply because they do not have experience with the other methods. Or, in some cases, unfortunately, because they don’t care about helping the mother breastfeed. Or it may just seem easier to recommend the use of bottles. Of course, none of these methods is always easy to use. Of course, there are some mothers who have difficulty using a lactation aid, or finger feeding, or cup feeding. But the more experience the helper has, the easier it becomes for her to instruct the mother correctly so that it is easy for the mother, especially when the mother should be able get help at most feedings, while she and the baby are still in hospital.

D. Expressed Milk is the Best Supplement.

Sometimes, it is true that babies do need to receive supplements. As noted above, this does not mean they need to receive bottles. But if the baby does need a supplement, which is the best supplement to give.

There is no doubt that the best supplement to give, under all but the most extraordinary circumstances, is the mother’s own freshly expressed milk. Sometimes it is not easy to get the baby to latch on well right away or even in the first few days no matter how experienced the helper. If it is becoming urgent to feed the baby, the mother should be starting to express her milk for feeding her baby as soon as alternative feedings are being considered. The fact that the baby is not getting milk from the breast does not mean there is none available. (Most of the time, when a baby is not getting enough milk, it is not because the milk is not available, but rather that the baby is not getting the milk which is available). He may be able to get that milk more easily using other methods, though I believe there is often unseemly haste in starting alternate feedings. Remember, not so long ago, hospital policy dictated that babies were not to be fed at all for the first 24 hours of their lives.

Expression of milk using a pump may not always be the best policy during the first few days. Many mothers, properly instructed, can express more milk by hand when there is only a little to express, than they can get from even an industrial grade electric pump. Often mothers feel that if they cannot express more than a few drops they will not produce enough milk. This is false. A pump is not a well latched on vigorous baby, and a baby suckling properly with a good latch can get more milk than a pump, especially in the first few days. Furthermore, mothers expressing their milk in these circumstances are often feeling stressed and worried about their babies and this can make it difficult to get milk well by pumping.

So, the first choice for a supplement is the mother’s own milk (colostrum in the first few days, which is, incidentally milk, the first milk). If this is difficult to obtain in the first few days, it can be diluted in sugar water, so that colostrum diluted in sugar water will be the second choice at least for the first 24 to 48 hours. Even diluted colostrum, even a few drops of it, still has antibodies, white cells, protein to help the baby fight infection and get some appropriate protein and fat which the baby needs.

Remember that the best way of giving these supplements, even of expressed milk, is at the breast with a lactation aid, not other methods which are less desirable, and even harmful, depending on the circumstances.

Well, what if colostrum is not available at all? There are some mothers, who, by the way, almost always go on to produce tons of milk, who have difficulty expressing any colostrum at all, even a few drops.

The third choice is plain sugar water, which can be used for about 24 hours. The baby’s will remain well hydrated, will get some calories, and if the sugar water is used properly, then the baby will, we hope be breastfeeding by 24 hours of age. There is also sorts of worrying about babies becoming jaundiced because of the sugar water, but I don’t agree with this being an issue. The proper management of breastfeeding will prevent the development of excessive jaundice caused by inadequate intake of calories.

The fourth choice, and it is only fourth because it is not easy to get in most regions, is banked breastmilk. Unfortunately there are only a few breastmilk banks in the United States, and at writing, only one in Canada. This really is unfortunate, because banked milk could be so useful in so many situations when we now use formula.

Which then brings us to the fifth choice, formula, which unfortunately is all too often used as a first choice. And it is used as a first choice because of “convenience” (no expression necessary, no waiting, it’s always available thanks to the “generosity” of the formula companies) and because too many health professionals do not realize that they are using it as a drug, and, as with all drugs, we must be careful. There are side effects associated with using formula (see other sections). Some babies do not tolerate formulas, especially in the first few days. And, since formula is not necessary, most of the time, we should not be using it, unless there is no alternative.

Some have accused me of being “against formula”. This is not true. I am no more against formula than I am against ampicillin or any other drug for that matter. A drug can be lifesaving, on rare occasions, though this is unlikely in the immediate first few days when we speak of formula. A drug can be useful, but like all drugs, formula is overused, used too quickly, and too often used before alternatives have been explored.

When a health professional pushes (and this is frequently the correct word it is done in North American maternity or postpartum units) formula on a breastfeeding baby and his mother, the parents are given a very clear message: this stuff is not only harmless (it is not), it is good medicine. Furthermore, “you, the mother, don’t have enough milk”. Mothers tend to be very emotional and vulnerable during the first few days after giving birth, and they are naturally very concerned that they do the best for their new baby. The mother who is well informed about breastfeeding and is committed to succeeding may not be affected by this message too much, though even the strongest of the strong can be shaken. But not all breastfeeding mothers are strongly committed to breastfeeding. Many are “trying it out”. This is one reason formula companies fight each other tooth and nail in order to become exclusive providers for a hospital. The formula companies even pay huge amounts to the hospital for this privilege. Because they know it will pay off for them in the end. Because they know that most women will use the formula that is used in the hospital.

I am not saying that formula is never necessary. What I am saying is that it is only fifth choice. This does not mean that every other choice has to be tried and shown not to work before we try formula, but I am saying that health professionals who are helping the mother with breastfeeding, and the ones taking care of the baby, at least should consider the first choices before jumping to formula. This, I guarantee you, is not being done in the vast majority of hospitals in North America or Europe. And unfortunately, more and more not being done in the rest of the world either, as too many health professionals are happy to adopt the “Western” approach.

E. Proper followup is essential.

All breastfeeding mothers and babies should be seen within 24 to 48 hours after discharge by someone who knows about the practical aspects of breastfeeding and how to help mothers correct problems with their breastfeeding.

Here is a secret. Few physicians, including paediatricians, know anything about even the theory of breastfeeding, and fewer still have any knowledge or practical experience in helping mothers breastfeed. Most do not know how to know a baby is well latched on, how to know a baby is getting milk from the breast, or how to fix a problem when there is a problem. The same may be said about nurses, though more nurses do have a special interest in breastfeeding. The fact is that little if any breastfeeding is taught in medical or even nursing schools, and what physicians and nurses during their “on the job training” is merely a continuation of what the physicians and nurses before them learned on the job before them, much of it wrong or inappropriate for breastfeeding mothers and babies. Furthermore, much of what most physicians learn about infant feeding after they are in practice actually comes from formula company representatives. You can get a notion of prevalent this is from looking around the physician’s office and seeing how much formula company literature is sitting there (often passed off as breastfeeding information) and free samples are available. These things are rarely left in a physicians office without a few words to the physician about “our new improved formula” or “new improved breastfeeding information”.

Even some “lactation specialists” are nothing of the sort, having had no special training on breastfeeding or helping mothers overcome difficulties, but merely selected from the regular nursing staff with the idea that anyone with some nursing background can help with breastfeeding. Not true. Helping with breastfeeding takes a very special person, and it takes some very special skills, at least to do more than the basics.

Even midwives (in the North American, not British or Australian sense), are not always helpful. Used as they are to breastfeeding going well, they all too often refer mothers and babies only when the problems have been going on too long, and become too difficult to fix.

So, someone who is knowledgeable and skilful should be seeing the mothers and their babies within 48 hours after discharge from the hospital. If things are going well, great, it will be good for the mother to hear that. If things are okay, then adjustments can be made so that things are better than okay, or at least put the mother on the road to “better than okay”. And if things are not good at all, then it is usually not too late to fix things before either the mother or the baby are in too much trouble to turn things around.

What will this knowledgeable person be looking for? Well, one part of any new baby checkup will be weighing the baby.

Scales and a few more words about weights

Just as growth charts need interpretation so do scales. Since scales are used so often as the method of assessing adequate growth, it might be a good idea to look at their limitations as well.

Scales need to be calibrated fairly often. If they are not calibrated, they do not give accurate weights, even the digital electronic scales. If they do not give accurate weights, information about how well the baby is doing, if we are relying only on the scale, is useless or worse, because the weights may lead to unnecessary interventions.

Most scales results will vary with the person who is doing the weighing. This is especially true with balance scales. If we are following a baby’s weight on a daily basis for some reason, we like to see a 30 gram increase every day. But 30 grams is a small amount and a result could easily vary that much with the way different people weigh the baby, just from where they consider the weight balanced. This is less of a problem with digital readout scales.

The weights can vary with the baby as well. When a baby cries vigorously on the scale, the weight jumps all over the place. With balance scales, the reader takes the most likely weight, but it is a “ball park figure”. With digital readout scales, the “reader” is the scale itself, and, it also takes a “ball park” figure, a guess really.

It should not be forgotten that babies’ weights will vary according to whether or not they have just pooped and/or just peed. If the weight is being followed every few weeks or longer, this is not a concern. But if the baby’s weight is being followed closely for some reason, say every day, whether he emptied his bladder and bowels before or after the weighing could make a significant difference on the scale, when a bowel movement could easily weigh the 30 grams we would like the baby to gain in a day.

In some offices, babies are weighed with their clothes on, in others not. If we want to know the baby’s weight, we should not be weighing his clothes as well, particularly his diaper. I have personally weighed a heavy diaper at 260 grams (over half a pound). A baby should be weighed naked each time, or with a brand new dry diaper which is put on just before the weighing each time.

Scales vary from one to another. Even if one is calibrated, the other may not be, but even if the other is, it may be true to itself, but not to other scales. Thus, when a baby is weighed on one scale and then on another, possible variation must be taken into account. Some of the easiest referrals I have ever had were from a physician who would send one or two week old babies with a concern about “no weight gain” or “weight loss”. It turned out her scale weighed about 500 grams (over a pound) less than anyone else’s scale (including the hospital scale). In our clinic, we weighed the baby on two different scales to make sure our scale was not out. Furthermore, and this is vital, the babies are not assessed on weight alone, but how well they are breastfeeding and how to know they are getting milk. The babies were obviously getting lots of breastmilk while they were breastfeeding.

Scales, even when accurate, can be read wrong and/or the weight may be noted down wrong. I have seen, with my own eyes, the weight on the digital scale of 3.62 kg (7 pounds 15.5 ounces) written down as 3.26 kg (not quite 7 pounds 3 ounces). Errors such as this occur frequently, but are not always caught.

I am not saying that the scale is useless. Indeed, in my breastfeeding clinic we do weigh babies at every visit and record the information. But the weight is only one of the many factors which we take into consideration when we try to decide whether a baby is doing well on the breast or not. The scale is most helpful over an extended period of time when the limitations of the scale are less likely to have an effect on the interpretation of the information. In other words, if the baby gains 500 grams from age 4 months to age 5 months, this is not really significantly different from gaining 400 grams during the same period of time, both being good weight gains. But a difference of 100 grams in one week could very well be the difference between good weight gain and poor weight gain. A baby who gains 200 grams from week 2 to week 3 of his life is gaining well. A baby who gains 100 grams during that time is not, though this does not mean he needs to be supplemented. See below.

Back to rules about weight loss and weight gain

After years of railing against feeding by the clock and being concerned about exact weights, many lactation specialists are now back to the clock and back to the weights. There are now clinics where a decrease during the first days of 7% or 10% or whatever in the baby’s weight from birthweight is considered an automatic reason for supplementation. Whether or not this is given by lactation aid or other method, I believe this approach is wrong. Why?

I believe it is wrong because it relies absolutely too much on the scales and not an observation of the breastfeeding. Well, then, how do we can we know the baby is getting enough, especially in the first few days?

a) A baby sucks in a particular way.

The open—pause—close type of sucking for several minutes means the baby is getting a lot. In the first few days, most babies are getting some breastmilk, enough breastmilk, but not as much as a formula fed baby. But some open—pause—close type of sucking at every feeding will usually mean the baby is getting reasonable amounts of colostrum. The description of this pause is discussed elsewhere. Once the milk becomes abundant, the baby will show much more of this open—pause—close type of sucking, with the pause becoming much longer and much more obvious. It is not possible to say how many minutes are necessary for the baby to get as much as they “need”, but several minutes of this type of sucking means the baby has done well. The reason it is not possible to say how many minutes is that the length of the pause varies with the amount of milk the baby gets, longer pauses with more milk, shorter pauses with less milk. A baby who has a long pause with every suck could have had enough in just a few minutes, maybe even just five or ten minutes. A baby who has a short pause with every suck could take 30 or 40 minutes. A baby who has long pauses but only for short bursts of sucking between which he has mostly a “nibbling” type of sucking may take just as long or longer than a baby who has short pauses with every suck. The more the open—pause—close type of sucking there is and the more sustained it is, the less time a baby will need to be on the breast in order to get enough milk. The less open—pause—close type of sucking there is, the longer the baby will need to be on the breast in order to get enough milk. It is for this reason that “feed the baby every 3 hours for 20 minutes on each side” makes no sense. It is not how long the baby is on the breast—it is how long he actually is feeding on the breast. A baby who spends all or most of his time on the breast “nibbling” will not get enough even if he spends 24 hours a day on the breast.

b) The baby’s bowel movements.

Babies pass bowel movements called meconium during the first few days. Meconium accumulates during the baby’s time in the mother’s uterus and is expelled during the first few days. It is almost black in colour and usually quite sticky. Colostrum is a purgative and helps the baby expel the meconium more quickly. This is why early feeding and effective feeding will actually decrease the level of jaundice in the breastfed baby in the first few days of life that so many physicians and nurses worry about (more on jaundice elsewhere). As the baby drinks, the bowel movements become lighter and eventually turn to yellow-green (mustard colour). The more milk a baby gets in the first few days, the earlier the bowel movements will turn colour. Thus some exclusively breastfeeding babies will start having lighter bowel movements by the second day of life, though this is probably unusual. (Not because they couldn’t, but because so many babies are latched on not so well and given the amount of colostrum available, they are not getting what they could if they were better latched on.) Many parents will notice lighter bowel movements by day 3 or 4 with the bowel movements turning to yellow or mustardy on day four or five. This is the pattern of the baby who is doing well. The early change to mustard colour (by the fourth day of life) is a good sign.

If a baby is still having meconium-like bowel movements on the fourth day of life, this is a real reason for concern, and I would not be reassured if my scale showed that the baby’s weight was down only 5% or even less, or even, for that matter, that the weight was up, from birthweight. The change in colour of the bowel movements is a better sign than the weight of how well a baby is doing at least during these early days. A baby still having meconium-like bowel movements on the fifth day of life needs urgent evaluation preferably by someone who knows something about breastfeeding. It should never come to that, however, if we had good help for mothers in hospital as well as good followup once they are out of hospital.

Breastfed babies also have frequent bowel movements. Once the meconium has been completely expelled, a baby who is doing well will have at least 2 or 3 substantial mustardy bowel movements a day, plus some stains at the bottom of the diaper, usually with every feeding. What is substantial? Well, many babies will actually leak poop out of their side of their diapers. Not all will have that substantial a bowel movement several times a day, but most babies who are doing well will have at least an amount that requires some work cleaning it up off their bottoms.

During the first few weeks of life the baby will continue having substantial frequent bowel movements. If a baby passes even 24 hours during this time without a substantial bowel movement, I would be concerned and would ask the mother to come in so that I could observe a feeding. Though there are definite exceptions when it is obvious that the baby is doing well even though he is not passing bowel movements every day, these babies are the exception not the rule.

After about 3 weeks of age, some babies do change their patterns from many bowel movements every day to one bowel movement only every few days. Indeed, sometimes the time between bowel movements is more than a few days, the record of which I am aware, is 23 days without a bowel movement in a healthy normal happy well gaining exclusively breastfed baby. If the baby is happy and well gaining, there is no need for concern and no need for treatment, because this is a normal pattern of some babies and there is no need to treat or be concerned about something which is normal. Physicians unused to breastfed babies, especially exclusively breastfed babies, may worry about this pattern, but then, this is another example of taking the artificially fed baby as the model of normal.

It must be admitted that some mothers do complain that as the days go on without the baby having a bowel movement, the baby does start to become fussy and uncomfortable. Not the majority, but some. In that case, maybe the parents should help the baby have a bowel movement.

The most natural way to do this is to take advantage of the gastro-colic reflex that everyone is aware of. This reflex results in our wanting to have a bowel movement when the stomach fills up and becomes most obvious in the morning after we eat. Babies tend to have a more active gastro-colic reflex and often have a bowel movement with a feeding. Thus, what the mother can try if the baby is trying to have a bowel movement and not succeeding and being very fussy is put him to the breast. If the baby feeds, he may have his bowel movement and everyone will be happy, including the baby. Unfortunately, this does not always work because the baby is often not interested in taking the breast. Or maybe despite the gastro-colic reflex, the baby does not have a bowel movement. What now?

Well, not prune juice, and better not any other oral laxatives, or even sugar water. They may work, but they may not, and could cause the baby quite severe cramps, particularly the prune juice and laxatives. If necessary, the baby can be induced to have a bowel movement with the tip of a children’s glycerin suppository. These are available without a prescription at pharmacies. Take just the first 2 or 3 cm of the suppository (it cuts nicely with an ordinary kitchen knife) and pop it into the baby’s anus. Keep his buttocks squeezed together for a few minutes, and usually the baby will have a bowel movement. I would not suggest this be done as a routine even if the baby is 7 or 8 days between bowel movements or even longer. As long as the baby is content, don’t do anything.

A normal exclusively breastfed baby almost never (never say never) has hard constipated bowel movements. Hard constipated bowel movements in an exclusively breastfed baby, even if he is not gaining weight well, needs investigation. I have never heard of it occurring in a normal baby.

The colour of breastfed babies’ bowel movements can vary considerably. They may be mustard colour, they may be green, they may be orange. They may be one colour one day, and another the next. Green bowel movements even every one being green are normal, and no cause for concern if the baby is content and gaining weight well.

However, just like the scale, the use of information about bowel movements is only one piece of information, and basing decisions about the adequacy of breastmilk intake only on the bowel movements can be misleading. For example, some babies who are not getting enough milk may have frequent watery green or even yellow bowel movements. This may occur because they are getting mostly low fat milk which can result in their having many bowel movements without getting enough calories.

c. Urine output.

The number of wet diapers a baby has is probably the least useful of all the pieces of information which helps decide if the baby is getting enough. A baby who is getting enough to maintain his weight but not gain well, could be getting enough fluid so that he urinates fairly frequently. Furthermore, with the new diapers which do not feel wet, a new mother may not know if the diaper is wet or not. An experienced mother will know what a heavy diaper is, but if the baby has never had a heavy diaper, how can you know what a heavy diaper is?

In the early days, the urine output is even less useful than later on. Nobody knows what normal urine output should be in the exclusively breastfed baby during the first few days when most are getting small amounts of colostrum and many are getting virtually nothing (because they are not latched on well). We have for so long taken the formula fed baby as the model of normal that the tremendous urine output of those babies is taken as the rule. Even breastfed babies were so often supplemented (and still are, almost always unnecessarily) in the first few days, that we still do not have a notion of what the normal urine output of babies in the first few days should be.

What about brick coloured urine in the first few days? The appearance of red urine in the first few days is enough to convince some nurses and doctors that “the baby is dehydrated!” In truth, nobody really knows what it means. Textbooks at the beginning of the century, when no supplements were given say that it is normal to have red urine. I don’t think it is, because most of those babies were not fed as they should have been. There was a 6 hour separation between mother and baby (the 24 hour separation came later), and babies were fed by the clock only every four hours and only 5 minutes on each side on the first day, 10 minutes the second day and so on. Nevertheless, once supplementation became routine, the absence of red urine became the norm, and the mother who had dared not allow routine supplementation of her baby was shown the sorry results of her foolishness in the diaper of the baby.

In general, it is said that an exclusively breastfed baby should have 1 wet diaper on the first day of life, 2 wet diapers on the second and 3 on the third. Thereafter, the number should increase rapidly so that by the end of the first week, the baby will have 6 soaking wet diapers in a 24 hour day. Six wet diapers is not enough, they should be soaking wet. A baby having only six wet but not soaking or heavy diapers in a 24 hour day at a week of age or older is probably not getting enough milk.

d) The baby’s fontanelle.

This way of “knowing” about the baby’s state of hydration is mentioned only to be condemned. Many physicians have difficulty judging whether a baby’s fontanelle is sunken or not. Almost all babies have a “sunken” fontanelle if they are sitting up. By the time a baby is dehydrated enough to have a sunken fontanelle, the situation is late indeed, and the baby was showing signs for some time that he was not getting enough milk. The baby will not have been drinking while on the breast (no open—pause—close type of sucking). The bowel movements will have been scanty or absent completely. The urine output will have fallen. If parents are missing these signs of poor intake, it is because the system is failing new parents and their babies. It is not a big thing to show a mother the open—pause—close type of sucking while the baby is on the breast. It is not a big thing to let them know that if the baby is still having meconium bowel movements on day 4 then they should get help urgently. But the sunken fontanelle is mentioned more frequently than anything else it seems.

e) Other unhelpful signs.

The frequency of the baby’s feeding is not very useful. A baby may sleep longer than the now “engraved in stone” three hours either because he has had a really good feeding, or, because he got almost no milk at all and is becoming weak and lethargic. A baby who breastfeeds well (open—pause—close type of sucking) will wake up when he is hungry. A baby who does not breastfeed at all (nibbling type of sucking) may sleep for long periods of time. Waking the baby up so that he will not breastfeed at all, so that he will nibble at the breast eight times a day instead of six makes no sense. Eight times nothing is nothing, just like six times nothing is nothing. For that matter, so is twelve times nothing. It is true that babies who get very little to drink may sleep for long periods of time, and this is not a good thing. But if a baby is sleeping long periods because he is not drinking much at all, the idea is to fix the breastfeeding to get food into the baby, not wake the baby up more so that he drinks nothing more often. It should be emphasized again that just because a baby is on the breast frequently does not mean he is getting more milk than if he is on the breast less frequently. The same is true if the baby is on the breast for long periods of time.

Incidentally, a baby who has been doing well, does not, unless he is sick, suddenly stop waking up for feedings when he is hungry. A baby who has been doing well for a week or two, or a month or two, and then suddenly is getting less milk for some reason, will let the parents know he is hungry. He will cry until until picked up and fed, or until he cries himself to exhaustion.

The mother’s feeling full before a feeding, and less full after a feeding, is not bad as a sign, but the mother has to be feeling full in order for this to be useful. In the first 3 or 4 days, some mothers just do not feel full at all, so this is not too helpful in the first few days.

My 5 day old baby has lost 10.1332% of his birth weight. What do I do?

The essential point is not that the baby has lost x amount of weight. If we get the baby breastfeeding well today, the baby will gain back the weight and keep gaining. There is no need for supplementation just because the baby has lost a certain amount of weight. But the baby may need supplementation. You cannot tell this from the weight, however.

Here is what I would do if a mother came to me with this question.

1. I would do a general history and a history of the baby’s feeding, asking specifically about the baby’s drinking, the baby’s bowel movements and urine output.

2. I would weigh the baby and do a general physical examination.

3. I would observe a feeding. I would watch for the open—pause—close type of sucking and would point that out to the mother, so that she knows how to know the baby is getting milk. Without observing a feeding, any physician, pediatrician, nurse or midwife who tells the mother she needs to supplement or reassures the mother that all is fine is doing so inappropriately.

4. If the baby is drinking lots, I would reassure the mother, and followup the baby in the next day or two. If the mother had sore nipples I would help her latch the baby on better.

5. If the baby was not drinking lots, I would help the mother latch the baby on so that he could get more from the mother. I would also show the mother how to use “breast compression” to increase the amount of milk the baby gets. This technique is described below. I would encourage the mother to keep the baby on the first side until the baby is no longer drinking even with the compression and then change sides and repeat the process. If the baby seems to want more after the second side, there is no reason not to return to the first side and repeat the process yet again. Finally, I would discuss the use of herbs to increase the milk supply and/or flow of milk. If the open—pause—close type of sucking increased, as it usually does, I would followup the baby in the next day or two, or if things were really quite improved, in a week.

6. If the baby is not drinking at all, or if the baby is drinking only a little, too little, in my judgement (and this is a judgement call) to turn around, even after improving the latch, using the compression, switching back and forth a few times, I will suggest the mother that she needs to supplement the breastfeeding. Though expressed or banked milk would be ideal, these are not always easy to get, and it may have to be artificial baby milk. The idea of the lactation aid, though, is to get rid of the supplements, by improving the baby’s breastfeeding. Babies learn to breastfeed by breastfeeding. The mother does at least both sides, using the compression to keep the baby drinking as long as she can, before introducing the lactation aid tube. That way, the baby will drink as much as possible from the breast before getting any supplement, and as things improve, the mother will be introducing the supplement later and later in the feeding, until, one day, we hope, the baby will reject the supplement, at least at some feedings at first. This can take a short or long time or anything in between. But the baby is breastfeeding, and getting milk from the mother. And the mother and baby can breastfeed for as long as they want using a lactation aid. Rejection of the breast is very very unlikely to occur. Whereas, if the supplementation is done with a bottle, or even other methods, rejection of the breast becomes quite possible.

This same approach can be used with a baby of any age. Some examples will be described later which demonstrate what can be done. Before that, let’s talk about breast compression.

Breast compression

Breast compression is a technique which can help the baby get more milk. It is used, in one way or another all over the world, and I personally noticed women doing something similar in southern Africa when I worked there. Often you could notice them walking along the street, with the baby at the breast, and pumping their breasts. I never really thought too much about it, until a woman from South America came to the clinic with her baby and she was gently squeezing her breast while the baby was breastfeeding. I asked why, and her first response was that her mother had suggested she do it, which is a good reason, since the passing on of breastfeeding knowledge to the new generation used to be the domain of the more experienced mothers around the new mother. When I asked why her mother had suggested it, she looked at me as if I were from a different planet, and said “Because the baby gets more milk”. And the penny dropped for me. Of course, the baby gets more milk. It’s so obvious. And, it works. This technique does not, by the way, increase the risk of the mother getting blocked ducts, as many mothers are told in hospital.

Here is how I suggest to mothers that they use breast compression.

1. The mother needs to know when the baby is getting milk (open—pause—close type of sucking).

2. When the baby is drinking milk, there is no need to use any breast compression.

3. Once the baby is no longer drinking milk, just nibbling, the mother should start with the breast compression.

4. The baby should be sucking, but not actually drinking (open—pause—close type of sucking). As the baby sucks, the mother, who is holding her breast with one hand, the thumb on one side and her other fingers on the other side of the breast, with a good amount of breast in her hand, should just bring her thumb and fingers together, compressing the breast. This should be done firmly, but not so hard that it hurts.

5. The baby may start to drink again (open—pause—close type of sucking). If so, the mother keeps up the pressure until the baby is back to nibbling. Once the baby is nibbling only, the mother releases the pressure on the breast so that her hand does not get tired and also to allow milk to start flowing again.

6. When the mother releases the pressure, a young baby, say under two or three weeks of age, will stop sucking. He will restart sucking when he tastes milk again. If the baby drinks, fine. If not, the mother restarts the compression.

7. If compression has no effect at a particular moment, this does not mean the mother must immediately switch sides. Sometimes compression will work, other times not. But as the baby has nursed longer and longer, it will work less and less, as the flow of milk slows. This does not mean the breast is “empty”, but that the baby is getting less and less. Babies respond to flow of milk.

8. If compression is no longer having an effect, and the baby is getting sleepy, or starting to fuss because flow is slow, it is then, the mother should take the baby off the breast and offer the other side. The process is then repeated.

9. In fact, the mother should experiment. I have found the above technique works best, at least when the mothers are being shown how at the clinic, but whatever works best. As long as it does not hurt the mother to compress the breast, and the baby gets milk, the technique is working.

But what about keeping the baby on the breast longer so that he gets the “hindmilk”. Keeping the baby on the breast longer does not mean the baby will get more hindmilk. A baby who spends more time on the breast “nibbling” will not get more hindmilk. A better latch and the use of compression will help the baby get more milk and more hindmilk.

By the way, the change from foremilk to hindmilk is not sudden. The very first milk will contain some fat, and the amount of fat the baby gets increases as the amount of milk that is taken from the breast increases.

It is obvious, I hope, that the idea of keeping the baby on just one breast at each feeding makes no sense either. The mother should “finish” one side, and if the baby wants more, should offer the other. A baby has finished one side when he is falling asleep at the breast and doing no more, or very little of the open—pause—close type of sucking. A baby may let go of the breast of the breast when he is getting little from it, but not necessarily. If the baby comes off the breast on his own and then seems to want more, it may be worthwhile to try him again on the side he let go of, just to see if he will drink more milk. If not, change him over to the other breast.

Herbs

From the beginning of time, mothers have used various herbs to increase their milk supplies. This is just a confirmation of the fact that some mothers, indeed, do not produce enough. Do these herbs work? Maybe. There are modern drugs which definitely increase the milk supply, so there is no reason to believe that in nature there are not plants which produce compounds which act in a similar way to our modern drugs (which all act in a similar way), or perhaps in different ways altogether. Every culture had its own favourite herbal remedy. Some cultures had their special gods to whom new mothers prayed for a bountiful supply of milk. It is possible that some of these things worked and some worked only by giving the mother confidence, which is helpful, but not absolutely necessary, in succeeding with breastfeeding. (A lack of confidence is one reason, incidentally, that so many women in modern societies have so many problems with breastfeeding, and one that the formula companies exploit in their “helpful” information booklets).

In northern Europe, brewer’s yeast or beer, were thought to increase milk supply. Maybe. In southern China, fish and papaya soup. Maybe. In various places, different herbs, depending on what was available locally. Borage, alfalfa, fenugreek, raspberry leaf, fennel, blessed thistle, goat’s rue are just some of the various herbs which have been thought to increase milk supply.

It should be said that if an herb works to increase milk supply, really works, by stimulating some receptor in the mother’s breast or some hormone which she secretes, then an herb is a drug, despite the fact that it is a natural source drug. Digitalis, which can be rapidly fatal if taken in too large amounts, has been used for the treatment of heart problems for many years, and came originally from a plant, foxglove. All knowledgeable gardeners know that foxglove is poison. Furthermore, a problem with herbal remedies is that there is no quality control of how much of what active ingredient (or, more likely, active ingredients) is in any preparation. The amounts may vary not only from the preparation of one company to that of another, but also from lot to lot of the same company. Indeed, because in many cases we don’t know what the active ingredient in the herb even is, it is difficult to know how much of any herb should be taken.

It is our experience, however, that fenugreek and blessed thistle do seem to work for a lot of mothers, both in increasing the milk supply and in increasing the rate of milk flow. These two herbal remedies seem to work better in the early weeks than later on, but in some cases have seemed to work later as well.

Fenugreek is a food which is used to increase the milk supply in at least two fairly separated areas, India and Egypt. Several Egyptian and Indian women have told me that all nursing mothers take fenugreek tea when they are nursing. Fenugreek is an ingredient of curry and sometimes it is quite evident that a mother is taking it because of the smell that it gives her skin. Not all mothers like that smell, but as someone who quite appreciates Indian food, I like it a lot. Indeed, fenugreek is a natural deodorant. Side effects in the mothers we have suggested use it have been very few. It is said that it can cause cramps and diarrhea in large doses, but we have not heard many women mention this. It is said that fenugreek increases the flow of milk from the breast.

Blessed thistle has also been used for a long time to increase milk supply, but it is difficult getting reliable information about it. Most of the mothers that have taken it at the suggestion of our clinic have had no obvious side effects. The main complaint is that the tea and the tincture taste awful.

We have generally suggested that mothers take the herbs in capsule form, using both fenugreek and blessed thistle, 3 capsules of each 3 times a day. The response, if it occurs, is quite rapid, often in less than 24 hours, many mothers notice a difference. Almost always the response takes less than a week. As with all medications, some respond better than others. Some mothers not at all. Some mothers who seemed to have problems with supply, now seem not to know what to do with all the milk they produce.

The effect on the baby is likely to be none at all. As it is with almost all medication (see section on drugs and breastfeeding).

Other drugs for increasing the milk supply

There are many drugs which will increase the milk supply. None was specifically manufactured with this effect in mind, but most have been available for many years. Some drugs have milk production as a secondary effect only in the occasional user of the medication. Digitalis is one of these. Some drugs will have this effect on a fairly consistent basis. These drugs work by increasing the amount of prolactin (the hormone which stimulates milk production by the milk cells of the breast) produced by the mother’s pituitary gland. They do this by inhibiting the secretion of dopamine by the mother’s hypothalamus. Dopamine inhibits the release of prolactin. These will be discussed below.

1. Major Tranquilizers.

This group of drugs was first introduced in the early 1950’s as a treatment for schizophrenia. They are still being used for this reason. The group includes chlorpromazine (Largactil, Thorazine), haloperidol (Haldol), prochlorperazine (Compazine, Stemetil). The latter is used mainly as a treatment for nausea and vomiting, another effect of this group.

This group of drugs does increase the milk supply fairly consistently, but because of the possible side effects on the mother, are rarely used for this reason any more. Side effects which occur fairly regularly are sedation and fatigue. Others, include neurological symptoms such as tremor and uncontrollable movements of the eyes and limbs, occur less frequently, but are quite distressing though only very rarely permanent. Usually the symptoms disappear with discontinuation of the drug, but the risks are too great for the mother to use them for increasing milk supply.

2. Methyldopa.

Methyldopa (Aldomet) is a drug frequently used to treat high blood pressure. It also interferes with secretion of dopamine and therefore results in increased prolactin secretion. Its effect on milk supply, however, is not great enough to justify its use for this reason in women who are not hypertensive.

3. Sulpiride.

This drug is not available in Canada or the US. It is used as an antipsychotic. It inhibits the secretion of dopamine and has been shown to increase milk production. It has side effects similar to those of the major tranquilizers, and is probably best not used to increase milk supply.

4. Metoclopramide.

This drug (Reglan, Maxeran) has been used to increase milk supply and quite successfully. I don’t use it anymore because of the side effects on the mother, and I find domperidone (see below) far more helpful.

5. Domperidone.

Domperidone (Motilium) is not available in the USA, but it is most other countries of the world. Domperidone is generally used for disorders of the gastrointestinal tract (gut) and has not been released in Canada, or any other country, as far as I know, for use as a stimulant for milk production. This does not mean that it cannot be prescribed for this reason, but rather that the manufacturer does not back its use for increasing milk production. It has been used, for several years, in small infants who spit up and lose weight, but it has recently been replaced for this reason by a newer drug called cisapride (Prepulsid). Domperidone's ability to increase milk production has been recognized since it first became available. Another, related, but older medication, metoclopramide (Maxeran), is also known to increase milk production, but it has frequent side effects which have made its use for many nursing mothers unacceptable (fatigue, irritability, depression). Domperidone has many fewer side effects because it does not enter the brain tissue in significant amounts (does not pass the blood-brain barrier).

When is it appropriate to use domperidone?

Domperidone must never be used as the first approach to correcting breastfeeding difficulties. Domperidone is not a cure for all things. It must not be used unless all other factors which may result in insufficient milk supply have been dealt with first. These include:

1. correcting the baby's latch so that the baby can obtain as efficiently as possible the milk which the mother has available. Correcting the latch may be all that is necessary to change a situation of "not enough milk" to one of "plenty of milk".

2. using breast compression to increase the intake of milk.

3. using milk expression after feedings to increase the supply.

4. correcting sucking problems, stopping the use of artificial nipples and other stratagems.

Using domperidone for increasing milk production:

Domperidone works particularly well to increase milk production under the following circumstances:

it has frequently been noted that a mother who is pumping milk for a sick or premature baby in hospital has a decrease in the amount she pumps around 4 or 5 weeks after the baby is born. The reasons for this are likely many, but domperidone generally brings the amount of milk pumped back to where it was or even to higher levels.

when a mother has a decrease in milk supply, often associated with the use of birth control pills (avoid œstrogen containing birth control pills while breastfeeding), or on occasion for no obvious reason when the baby is 3 or 4 months old, domperidone will often bring the supply back to normal.

when the mother has had her milk decrease because of “emotional stress”. Though some will dispute that this can occur, it does indeed occur occasionally.

Domperidone still works, but often less dramatically when:

the mother is pumping for a sick or premature baby but has not managed to develop a full milk supply.

the mother is trying to develop a full milk supply while nursing an adopted baby.

the mother is trying to wean the baby from supplements.

Domperidone seems to work better when the mother is more than six weeks past the birth of the baby.

Side effects of domperidone:

As with all medications, side effects are possible, and many have been reported with domperidone (textbooks often list any side effect ever reported, but symptoms reported are not necessarily due to the drug a person is taking). There is no such thing as a 100% safe drug. However, our clinical experience has been that side effects in the mother are extremely uncommon, except for increasing milk supply. Some side effects which mothers we have treated have reported (very uncommonly, incidentally):

dry mouth

headache which disappeared when the dose was reduced

abdominal cramps

The amount that gets into the milk is so tiny that side effects in the baby should not be expected. Mothers have not reported any to us, in many years of use. Certainly the amount the baby gets through the milk is a tiny percentage of what babies would get if being treated for spitting up.

Are there long term concerns about the use of domperidone?

The manufacturer states in its literature that chronic treatment with domperidone in rodents has resulted in increased numbers of breast tumours in the rodents. The literature goes on to state that this has never been documented in humans. Note that toxicity studies of medication usually require treatment with huge doses over periods of time involving most or all of the animal's lifetime. Note also that not breastfeeding increases the risk of breast cancer, and breast cancer risk decreases the longer you breastfeed.

Using Domperidone:

Generally, we start domperidone at 20 milligrammes (two 10 mg tablets) four times a day. Printouts from the pharmacy often suggest taking domperidone 30 minutes before eating, but that is because of its use for digestive intolerance. The mother can take the domperidone about every 6 hours, when it is convenient (there is no need to wake up to keep to a 6 hour schedule—it does not make any difference). Most mothers take the domperidone for 3 to 8 weeks. Mothers who are nursing adopted babies may have to take the drug much longer.

After starting domperidone, it may take three or four days before you notice any effect, though sometimes mothers notice an effect within 24 hours. It appears to take two to three weeks to get a maximum effect.

After two or three weeks on the domperidone, the mother may or may not have gotten the desired effect. If not, she should continue the domperidone for another two or three weeks. If there has been no effect after a further 2 or 3 weeks, she should stop the domperidone. If the milk supply has increased as desired, the mother should slowly decrease the amount of domperidone she takes. Thus, if the result has been very good while taking 20 mg. four times a day, the mother should decrease the dose to 20 mg. three times a day for a week or so. If there has been no decrease in the milk supply (the usual situation), the mother can continue decreasing the amount of domperidone by a pill at a time, staying on the reduced dose for four or five days before dropping another pill. If the mother gets down to no medication, great. However, if the milk supply decreases at a certain point, the mother should up the dose of domperidone to the previous effective dose and stay there for a couple of weeks. Then she should try again to decrease the dose. Often the attempt will work the second time, or the third time, when it didn’t work the first. Some mothers find they need to be on the domperidone for several months, particularly if they are using the domperidone to maintain the milk supply for an adopted baby.

Drugs which decrease the milk supply

1. Herbs

It is said that sage and parsley decrease the milk supply. I don’t know anything about this. I have also heard that borage decreases the supply, but if you go back to the section on herbs to increase supply, borage is mentioned there as well. Borage does seem to decrease engorgement.

2. Drugs

a) Oestrogens definitely can decrease the milk supply. They are most likely to be taken by nursing mothers as one of the ingredients in the birth control pill. Oestrogens should be avoided by nursing mothers whenever possible. There is rarely a need for a nursing mother to take oestrogens in any case. If the mother really does require the birth control pill for contraception, there are progesterone only pills available.

However, the pill is not the only method of child spacing available to nursing mothers. In fact, breastfeeding is a good method of child spacing. Under the following circumstances, the chances of a breastfeeding mother becoming pregnant are about 2% (1% with the birth control pill).

the baby is breastfeeding exclusively, or virtually exclusively

the baby is younger than 6 months of age

the mother has not had a normal menstrual period (bleeding during the first 8-12 weeks does not really count)

After 6 months of age, or if the baby is taking other foods in addition to breastfeeding, then the protection against pregnancy afforded by breastfeeding becomes less, but still not negligible. On average, a mother who breastfeeds into the second year of her baby’s life, and does not use any form of artificial birth control, will have a baby about every 24 to 30 months. If the mother wants to be surer, there are barrier methods of birth control, the IUD and others. The pill is not for everyone, and sometimes other methods are definitely preferred by couples to the pill.

Some physicians will say that after 6 or 8 weeks, or even 4 months, there is no concern about the milk supply decreasing with the oestrogens, but this is not true. It is always a risk, and not a negligible one. It is true that not all mothers seem to have a decrease, but a significant number do.

b) Progesterones are not supposed to decrease the milk supply. Indeed, it has been said, without too much proof, that they may increase the supply. However there are some anecdotal reports of progesterones decreasing the milk supply. One relatively new method of birth control, long acting injected medroxyprogesterone (Depo Provera) is being used more and more. Even though the company that makes it states that it should be given to breastfeeding mothers only after 6 weeks after the birth, many mothers are getting the injection within a day or two of the birth. This may cause a significant decrease in milk supply.

Work in Australia has suggested that the drop in progesterone which occurs with the birth of the placenta is what sensitizes the milk producing cells of the breast to the action of prolactin. If the progesterone does not drop, the breasts do not produce milk. This is why a mother who has a piece of placenta remaining in her uterus does not get the increase in milk supply that is generally seen three or four days after birth. This may also explain why some women who got the injection of progesterone immediately after the birth of the baby did not produce enough milk. This is anecdotal, and may not be true, but it is best to avoid the injection in the mother just after birth. Indeed, I would suggest that if a mother is considering using progesterones for birth control, they should try a month of the progesterone only pill, so that if there is a decrease in the milk supply, the mother can always stop the pill. If there appears to be no negative effect from the pill, the mother can then get the injection. The injection, once given, cannot be turned off and the effect lasts at least three months.

c) Some drugs used to induce fertility in women may decrease the milk supply. Clomiphene (Clomid) is one such medication. It probably decreases the milk supply by stimulating the production of oestrogens in the mother. The drug is not contraindicated for a breastfeeding mother, as many gynaecologists claim, but the fact that the milk supply may be significantly depressed needs to be taken into account.

Another such drug is bromocriptine (Parlodil). Some women produce too much prolactin, due to a small tumour in the pituitary, the increase amounts of prolactin interfering with their ability to become pregnant. Some of these women also produce milk because of the high prolactin levels. However, some of the mothers treated for this condition, once they become pregnant and give birth, seem not to produce enough milk. Perhaps the long term use of bromocriptine has interfered with their ability to produce milk. This does not occur with all mothers who were on long term bromocriptine, but it has occurred with some, and it is noticeable, and sadly ironic, because these women often had a problem of leaking milk when they had never been pregnant. Bromocriptine will also interfere with breastfeeding if used while the mother is breastfeeding. There does not appear to be any need to use bromocriptine during lactation, since the main reason for using it was to decrease prolactin secretion, something which is not a bad thing if the mother is breastfeeding. There is no evidence that bromocriptine slows the growth of the pituitary tumour, which usually does not grow enough to cause pressure problems.

Are some women truly incapable of producing enough milk?

There is no doubt that some women are unable to produce enough milk. Just as some people do not produce enough insulin, or thyroid hormone. But this does not mean these mothers cannot breastfeed. Indeed, they can breastfeed as long as they wish. Many mothers have breastfed for two or three years or longer, using a nursing supplementer (lactation aid). Though breastmilk is important, there is more to breastfeeding than breastmilk. Besides, not enough milk does not mean “no milk” and the baby will continue getting breastmilk as long as the mother is putting him to the breast. I cannot fathom, really, the idea that “if I can’t breastfeed exclusively, I might as well not breastfeed at all”. Some breastmilk is better than none.

Other causes of decreased milk supply

Besides the drugs, already mentioned, that might decrease the milk supply, some women have decreased milk supply from surgical procedures on the breast. The most common of these is breast reduction surgery, but any surgery which is performed with an incision around the areola risks decreasing the milk supply significantly. Nevertheless, some mothers who have had breast reduction surgery, have managed to breastfeed exclusively without problems.

Breast augmentation surgery is usually done with the incision near the woman’s chest wall, and when done this way, does not interfere with milk production. However, some surgeons, for perverse reasons I cannot understand, will do the breast augmentation making the incisions around the areolas. And some surgeons, merely for something such as a breast biopsy, will do an incision around the areola. The argument, I suppose is that the “aesthetic result” is better. Besides being debatable, this type of incision might decrease the amount of milk the mother produces considerably on the side where the surgery is done. It is a mark of how breasts are perceived in our society that a surgeon would be willing to sacrifice the function of a part of the body for the “aesthetic result”. Imaging a plastic surgeon doing surgery on a nose to make it “look better” with a wonderful looking nose as a result, but also the patient being unable to breathe afterwards. No surgeon would ever deliberately aim for such a result. Except when the breast is the part being operated on.

The same can be said in many situations where a mother has wanted to have breasts of the same size, where one breast is much smaller than the other. In many cases I have seen, instead of augmenting the smaller breast, the breast which is not likely to produce enough because it hasn’t developed properly, the surgeon does reduction on the larger breast, and thus destroys the function of the breast which likely would have produced plenty.

Radiation to the breast, for the treatment of cancer is likely to decrease the milk supply, even turn it off completely because the milk producing cells are killed by the radiation. But the breast must be irradiated directly. Irradiation to the abdomen should not interfere with lactation.

An uncommon cause of a decreased milk supply is the retention in the womb of fragments of placenta. Because these fragments produce hormones, including oestrogens, and progesterone breastmilk production may be very low. The mother who has a retain placental fragment, will have longer than expected bleeding and cramping, or may have a return of cramping and bleeding after they had stopped. There are tests of blood (HCG) and ultrasound which can make the diagnosis. Treatment is to remove the fragments, and usually the milk supply will rise fairly dramatically.

Late onset slow weight gain

Some babies gain well during the first 2 to 4 months, and then problems with weight gain seem to occur. There are several reasons for this.

Probably one of the most common comes back to a poor latch (as does almost every problem with breastfeeding). The baby has not really been nursing well from the beginning, but because the mother has a good milk supply, the baby gains weight well for a while. As mentioned earlier, babies do not have to latch on well to get lots of milk when the mother has a lot. They wait for the milk ejection reflex (letdown reflex) and then they drink and drink. Once the flow slows down, the baby tends to sleep at the breast, and when the next milk ejection reflex comes, the baby drinks again for a while. The problem arises as the baby gets older and smarter. After four or five weeks of age, while some babies continue to be content to sleep at the breast when the flow slows down, most start to get impatient with slow flow. The baby who is content to sleep at the breast, may get several more letdown reflexes of milk pouring into his mouth and may do well as far as weight gain is concerned. As for the others, as the milk flow slows, they will pull at the breast, coming on and off the breast, and are obviously not content. Usually, if the mother switches sides, the baby will be content again for a period of time, only to repeat the the pulling at the breast once the flow slows down. As time passes, the milk supply actually might decrease, since the baby drinks less and less from the breast. As they get older, these babies may pull off the breast and suck they hands rather than continue on the breast.

This is also the problem of the baby who has been getting bottles. Some will begin to prefer the bottle, as the bottle gives fairly regular flow for as long as there is milk in the bottle. If the mother supplements her feedings with formula, this is milk her breasts do not have to make, and so production will decrease. As the production decreases, the baby will prefer the bottle more and more.

What can be done? Once again, the best treatment is prevention. However, the baby can be kept on the breast longer, using the breast compression technique. The mother should use this to keep him on the first side until he is obviously no longer drinking, or he is pulling off. She should then switch sides. Indeed, she can switch back and forth for as long as she can keep him drinking (open—pause—close type of suck).

Some mothers also seem to have a real decrease in their milk supplies around 3 or 4 months after the baby is born. This is not the “growth spurt” that may occur around this time, since the baby may actually lose weight, or not gain weight, something which does not occur with a growth spurt. It is obvious that the baby is getting less, as he pulls at the breast in frustration, coming on and off the breast and always wanting to drink more, but obviously not getting it. Sometimes this drop in milk supply is due to the birth control pill, but sometimes there is no obvious reason.

If the mother’s supply is down because she is on the birth control pill, she should stop the pill immediately. Domperidone often brings the milk supply back quickly.

In the above situations, which may be somewhat different manifestations of the same thing, breast compression may help, but if it does not fairly quickly, I will usually prescribe domperidone for the mother. This almost always brings a rapid increase in the mother’s supply and sets things right. After a 2 week treatment, the mother can usually decrease the dose slowly (see above) until she is off the medication. Usually, the milk supply will remain good and not decrease as the mother goes off the domperidone.

The one thing not to do, if the mother wants to maintain her breastfeeding, is to start bottles at this point, even of expressed milk. The baby will very quickly catch on. Some will continue “pacifying” at the breast, but most will soon reject the breast completely.

If the baby is over 4 months of age (though sometimes I have suggested this at 3 months), solids can be introduced. This will almost always result in an increase in weight gain, but some babies may still not be that patient at the breast. Again, babies like flow, and not all babies just like to suck at the breast if little milk is coming. They may be more patient if they are less hungry, so feeding them solids before putting them to the breast may help. (See section on introducing solid foods).

Some real life examples

Below are a number of stories of mothers and babies who were brought to the clinic for help with breastfeeding. The names are not the mothers’ real names and the baby was not always a boy, but will always be referred to as “he” since the mother is, obviously, always “she” and this avoids confusion. Their stories will not be the same as yours, but the general principles remain the same.

1. Fix the latch. The better the baby latches on, the more he will get of his mother’s milk, no matter how little she produces.

2. Teach the mother how to know the baby is getting milk.

3. Use compression to keep the baby drinking.

4. If the above does not seem to be working (decided over that feeding if the baby is really not getting much, or after a few days to a week if the baby does not too badly), the increase the baby’s intake.

5. If supplementation is necessary, the lactation aid is the way to go.

6. Work to do away with the supplementation. Encourage the mother because it is not always easy to keep going, especially with pressure from all around.

Situation #1: Disaster Narrowly Averted

This baby was brought to our clinic on his fourth day of life. The problem, according to his mother Susan, was that the baby would not latch onto the right breast. In fact, the baby was not taking the left breast either, only seeming to take the left breast. The mother had sore nipples in addition, but as with so many mothers, did not consider this a problem, because “breastfeeding is supposed to hurt” at first (a).

According to the mother, the baby was feeding about 8 times a day, every three hours. He would spend 15 to 20 minutes on the left side (b). The baby was calm after the feedings (c). The baby had, in the last 24 hours 2 black bowel movements, and 6 wet, but only just moist, diapers (d).

This was the first pregnancy for this 31 year old mother who is a physician (e). The pregnancy was unremarkable, and the labour started spontaneously at 38 weeks, lasted only four hours. The mother received no pain medication, and the baby was fine when he was born. He weighed 6 pounds 12 ounces (3.07 kg) at birth. He was not tried on the breast until a few hours after birth (f).

The hospital stay was about 24 hours, during which time the baby got some sugar water once by cup (g).

At the first visit at the clinic, the baby was moderately jaundiced (h). His weight was 2.64 kg (5 lb 13 oz) (i). The rest of the physical examination showed no abnormalities. The baby did not latch on to the left side, only appeared to latch on. It was easy to pull him off the breast even though he was sucking and awake. A hungry baby who is latched on will not slip off the breast as this baby did. So he was not latching on to either side.

I helped Susan latch the baby on better and the baby took both sides. He drank very well (open—pause—close type of sucking for several minutes) on both sides. The mother had less pain with the feeding, but still had significant pain. I taught the mother how to latch the baby on. She was able to duplicate that. I suggested she nurse the baby on the first side until he no longer drinks (open—pause—close type of suck) and then use breast compression to continue him drinking. Once the baby no longer drinks, the mother should change sides and repeat the process. The baby nursed quite well. The mother realized that the baby had never really breastfed before—in other words, never actually drank milk at the breast. He was “pretending” to breastfeed on the left side, and couldn’t bother pretending on the right side (j).

I could not follow the baby up the next day, but offered the mother followup with one of our lactation consultants. I did arrange to see the baby on Monday, 4 days after the initial visit. I phoned the mother the next day and left a message that if the baby was not drinking to get back to me.

At the second visit, the baby was latching on on both sides and drinking very well. The mother still had some soreness, but was improving. The baby’s weight was 2.8 kg (6 lb 3 oz) (k). He was obviously less jaundiced (l). His bowel movements were now yellow and he was having many every day, some quite large. He was also urinating much more than before. At writing, the baby is only about 5 weeks old, but he has continued to do well and gain well on breast only.

Notes on Situation #1

a) “breastfeeding is supposed to hurt”. No it is not. This is a common misconception which arises from the fact that women have been given such poor information and help for so long that the abnormal has come to be seen as the normal. More on this in the section on sore nipples.

b) The baby was breastfeeding every 3 hours for 15 to 20 minutes on each side. Actually, he was not. He was on the breast every 3 hours for 15 to 20 minutes, but he was not feeding. This case demonstrates the folly of depending on these sorts of rules. It is not how often or long the baby feeds, but how well. This point cannot be overemphasized. Unfortunately, it is a point that too many who are supposed to be helping mothers with breastfeeding do not seem to comprehend.

c) The baby was calm. Calm may not be a good sign in the first week. Indeed, babies who are not getting enough may be quite lethargic. A baby who drinks well and then sleeps is fine. A baby who does not drink and sleeps is in trouble. This is the basis of so many mothers’ being told to wake the baby to feed at least every 3 hours, but a baby who drinks nothing every three hours is not better off than a baby who drinks nothing every 4 hours.

d) The information about the bowel movements is worrisome. This was the fourth day and the bowel movements were still black. They shouldn’t be if the baby is doing well. The information about the urine is difficult to interpret.

e) The fact that the mother was a physician did not help her know how to help her baby breastfeed better, or, for that matter, even understand what the problem was. She felt it was a problem of the baby not breastfeeding on the right side. It was a problem of the baby not breastfeeding at all.

f) The baby was not tried on the breast until a few hours after birth. That is precisely a few hours too late.

g) The baby was given water by cup. Why? The mother was not sure. Was the nurse concerned about something? If so, the appropriate thing to have done was to have fixed the breastfeeding, not give water. In retrospect, it is obvious that there was a real problem, but giving the water did not fix it. I am sure that this nurse would protest that she was supportive of breastfeeding because she did not use a bottle, but she isn’t. If there is a problem, then the first thing to do is help the baby latch on well. If the supplement was truly necessary, it should have been given by lactation aid, not cup. Babies learn to breastfeed by breastfeeding. If the nurse used a cup because she realized the baby was not latching at, and therefore a lactation aid was not in the cards, she should still have attempted to get the baby to latch on well, which, apparently she did not. And if the baby was not latching on well on discharge, the mother should have been referred urgently to our clinic or someone else who could help her (she was not, she heard of our clinic by word of mouth).

h) The baby was moderately jaundiced. This jaundice represented “not enough breastmilk” jaundice. The baby was more jaundiced than average, because he was not feeding well. This is not what many physicians and nurses call “breastmilk” jaundice. See section on jaundice.

i) This represents a weigh loss of 17+%. A reason to supplement? The scale is different, so we are not sure of the percent weight loss. It may, in fact, be more, if the baby were weighed on the same scale, both times. This is not a reason to panic, or a reason to supplement, necessarily. If the baby can start getting milk, the weight loss will be made up. The milk does not have to be formula, and even supplementation of expressed milk would not be necessary if the starts drinking well from now on, as he did.

j) The baby only appeared to take the breast. This is the most common reason babies become dehydrated, and what happens is not “dehydration in breastfed babies” as is often written in the newspapers or said on television. If the baby were breastfeeding, the baby would not become dehydrated. The problem is that the baby is not feeding at all. Not because the mother does not have enough milk, but rather the baby appeared to take the breast, but did not. A baby who only appears to be taking the breast cannot get milk, and thus, becomes sleepier and sleepier drinks even less well. A vicious circle ensues.

k) This represents an increase of 160 grams (almost 6 ounces) in 4 days. Again, however, the scale is different from 4 days before. But, the way the baby nursed (open—pause—close type of sucking for several minutes) showed he was getting lots of milk. The change in bowel movements, the obvious increase in urine output support the observation that the baby was breastfeeding well. And all these facts support the the apparent weight gain the baby showed.

l) The jaundice was obviously less. Good evidence that the problem was insufficient intake. Many physicians would have told the mother to stop breastfeeding and feed the baby formula. Because the baby would have gotten food for the first time in his life (as he did once he was latched on well), the bilirubin would have dropped, and the doctor would have been reinforced in his/her mistaken notion that the problem was the breastmilk. No! The problem was the fact that the baby was not breastfeeding. Fix the breastfeeding, and the bilirubin comes down.

Here, then, is a case of disaster averted. Another day without help, perhaps, and the baby could have become so sleepy from dehydration that a different approach may have had to be taken. It might not have been possible to wake the baby up easily to latch him on properly. I would have probably, in that circumstance, got the mother expressing her milk (which was obviously sufficient), and finger feeding the baby. Once the baby started waking up (maybe the first feeding with finger feeding, or maybe in a feeding or two), we would work on latching him on. The first rule in such as situation is “feed the baby”. As noted above getting the baby fed fixes the problem. Unfortunately, the only approach in too many physicians’ repertoire is “supplement with formula”. This may be necessary, but nobody can tell without first observing the breastfeeding, and it is quite often possible, especially in this young a baby, to just get the baby latched on well and the mother and baby will never look back.

Incidentally, this whole problem was a near tragedy which could easily have been prevented on that first day in hospital. Note that the baby’s getting water did not fix anything at all. If someone knowledgeable and experienced with helping mothers with breastfeeding had spent just a little time helping the mother with the latching, we would have had one more mother wondering “how can anyone have problems with breastfeeding?”. In this case, the mother and baby were lucky to find appropriate help quickly. Too many do not.

Situation #2. Weight loss, no need for supplements.

This baby was seen at our clinic at 14 days of age, referred by a lactation consultant. The problem was weight loss.

This was the first pregnancy for Linda a 29 year old woman. Linda had some high blood pressure and high blood sugars during the pregnancy, but as there was no special treatment for either of these, presumably, they were not serious problems. The labour was at term (39 weeks) and the baby was born after 7 hours of labour. The baby weighed 3.61kg (7 lb 15 oz) and was fine.

The baby was tried at the breast within an hour of birth and apparently breastfed well (a). Linda was with him 24 hours a day, and he was discharged on the second day of life. The baby was given sugar water by cup because he “wasn’t urinating” (b).

At the first clinic visit, when the baby was 14 days old, his mother said that the baby was on the breast only. He fed 6 or 7 times a day, one feeding being between midnight and six a.m. He would stay on the breast for an hour. He would frequently fall asleep on the breast but cry when he was taken off (c). According Linda, the baby was having quite infrequent bowel movements (about every 2 or 3 days), and having only 3 soaked diapers in a day (d).

On examination, the baby looked reasonably well, and no abnormalities were noted. His weight was 3.23 kg (7 lb 1.5 oz). This represented a decrease in the weight from birthweight of 380 grams (e).

The observation of the feeding showed that the baby really was taking the breast poorly. He was doing a little drinking (open—pause—close type of sucking). I showed the mother how to latch him on better, and how to use the compression, and he breastfed very well.

One week later, Linda returned to the clinic with the baby and said she thought things were better (f). The baby’s urine output was much increased, and his bowel movements became larger and more frequent about two days after the visit (g). The weight, a week after the first visit, was 3.46 kg (7 lb 10 oz), or an increase of almost 9 ounces in the week. This weight gain was corroborated by the obvious drinking the baby was doing on the breast.

The mother was still breastfeeding exclusively at 5 months of age and doing well (telephone followup) (h).

Notes on Situation #2

a) “Apparently” feeding well, because of later developments. If the baby needed water, how could he have been breastfeeding well?

b) Same note as with case #1 with regards to the cup and the sugar water. I guess the baby urinated, but did that fix the real problem? Or prevent the weight loss later on?

c) There is a difference between being on the breast and breastfeeding. Babies tend to fall asleep at the breast when the flow of milk is slow, not necessarily because they have had enough to eat. This is particularly true in the first few weeks of age. Just because the baby falls asleep at the breast does not mean he’s had enough, nor, that the breast is “empty”. It means the flow of milk has slowed down and the baby is not getting much. Babies respond to milk flow, not what’s in the breast.

d) These are definite signs of inadequate intake. The fact that the mother was not aware of these as signs of poor intake speaks volumes about the sort of teaching that is being done for breastfeeding mothers. Or, perhaps, what they take in from our teaching.

e) But the scale is different, and we do not know exactly how much the baby actually did lose.

f) This does not always mean the baby is really doing better. Sometimes mothers are not able to assess how well the baby is doing. Nevertheless, in this case the mother was right.

g) Once the baby’s intake is increased, it may take a couple of days before the baby has regular bowel movements.

h) Most poor weight gain, or loss, is not due to insufficient milk production by the mother, but is due to the fact that the baby is not getting the milk that is available.

Situation #3. Weight loss, but again, no supplements to fix the problem.

This baby was first seen at our clinic when he was 15 days old, having been referred by the pediatrician. This was Maria’s first pregnancy and first baby, born at 38 weeks gestation. The labour lasted only two hours and although the baby was fine at birth, he was not tried on the breast until 3 or 4 hours after birth (3 or 4 hours too late). At that time, as frequently happens after the initial few hours when the most babies not too drugged by maternal medications are really interested in breastfeeding, this baby was no longer interested. As frequently happens. An opportunity lost to get breastfeeding started well (a). The baby weighed 3.1 kg (6lb 13oz) at birth.

The baby and mother roomed in 24 hours a day. No supplements were given.

When Maria brought the baby to the clinic, she said that the baby “breastfed” all the time and would stay on the breast “forever” if the she did not take him off (b). He slept four hour at night, however (c). The mother had sore nipples.

At the first visit to the clinic, the baby weighed 2.885 kg (6 lb 5 oz) (d). The baby was thin and moderately jaundiced. In fact, the baby was getting some milk and nursing not that badly, although his latch was somewhat less good than good.

I showed Maria how to latch the baby on better. This resulted in the feeding being absolutely painless, for the first time ever for this mother. I also taught her how to know the baby was getting milk (open—pause—close type of sucking). I taught her how to do the compression. And I taught her to switch the baby from one breast to the other when the baby was no longer drinking on the side he was on.

My assessment was that the baby was drinking well enough that he would not get into trouble over the next week and made a followup appointment for a week, but offered the parents a followup anytime beforehand if they were concerned.

The parents did return five days later because they were worried the baby was not getting enough milk. The baby’s weight at this point was 2.9 kg (e). I reassured the parents and asked them to keep the original appointment.

One week after the initial visit, the baby weighed 2.95 kg (only 70 grams, or a little more than 2 ounces more than seven days before) (f).

One week later, two weeks after the first visit, the baby weighed 3.13 kg (150 grams or about 5 ounces more than seven days before). In addition to the weight gain, the baby was obviously more content, would spend less time on the breast, was urinating more. The weight gain is not great, but acceptable, and is obviously on the upswing.

One week later, the baby weighed 3.43 kg (300 grams, or just over 10 ounces more than the week before). The baby was content and fed about every three hours.

A month later, Maria phoned to leave a message that the baby was continuing to gain weight at the rate of about an ounce a day.

When the baby was 5 months old, Maria left a message that the baby, on breastfeeding only, now weighed 6.1 kg (13 lb 9 oz) (g).

Notes on Situation #3

a) Babies are often very eager to breastfeed during the first 2 hours or so after birth. After the first couple of hours, they often lose interest and sleep, whether they have fed or not. On the other hand, as mentioned earlier, when given an opportunity, newborn babies will even crawl up to the breast and latch on all by themselves. I believe we would see far fewer breastfeeding problems if all babies were given this opportunity. In this case, no argument, except the convenience of the staff or adherence to hospital routines, can be made against an immediate attempt at breastfeeding. Not even the old chestnut about maternal fatigue in this mother, whose labour lasted only two hours in total.

b) Did this baby really “breastfeed” all the time? He certainly did not feed all the time. In fact, given his weight loss, he probably wasn’t feeding most of the time he was on the breast.

c) Sleeping 4 hours at night in the first two weeks of life is sometimes a tipoff that things are not going well. Obviously, if the baby is getting plenty of milk (open—pause—close type of sucking for several minutes at each feeding, lots of substantial yellow bowel movements, lots of soaking diapers), and sleeps four hours or even through the night at two weeks, this is fine. On the other hand, sometimes, long sleeps at night are a sign that the baby may not be getting enough to eat.

d) The scale is different than the hospital’s or the pediatrician’s, but other things tell us that the weight loss is probably a true one.

e) Only a little more than 5 days beforehand, but it was a different scale. What was important was that the baby was drinking well enough, and, in my assessment, actually drinking better than 5 days before.

f) This pattern of the weight “bottoming out” before starting to rise, is common when there has been a delay in fixing the breastfeeding problem. Again, what was important was that the baby was continuing to feed better than before.

g) This is not bad, but don’t forget that it took the baby almost a month to return to his birthweight. Note that the birthweight is not some sort of “holy number” which must be reached in a certain period of time, and if it is not reached, that some sort of supplementation must be given so that the baby will reach that “holy number” quick. In this case the baby was already 15 days old and nowhere near his birthweight. Giving formula might have gotten him up more quickly, but the mother quite reasonably did not want to go that route unless it was absolutely necessary. It turned out not to be necessary.

Note again in this case the “moderate jaundice” of the baby. Another example of “not enough breastmilk” jaundice. Many physicians would suggest the mother stop because this was “breastmilk” jaundice. It wasn’t but even if it were, this would not be a reason to stop breastfeeding.

This case is typical of many we see. It is important to understand that some babies will not turn around in one week as the baby in case #2 did. Because the baby was nursing poorly for two weeks, the mother’s milk supply had likely decreased, but luckily, not to the point of no return. Better nursing brought her supply up again, so that the baby could gain well.

Situation #4. How the lactation aid works

Celine brought her baby to the clinic at the age of 13 days. She was 29 years old woman, and the baby was her first pregnancy. The pregnancy was unremarkable, but Celine commented that she had had no breast changes during the pregnancy (a). The labour was unremarkable. The baby was tried on the breast immediately after birth and apparently latched on well (b). The mother and baby roomed in in the hospital, no supplements were given during the hospital stay, and they left hospital at 48 hours after birth. The baby’s birth weight was 9 pounds (4.09 kg).

At the first clinic visit, the baby weighed 4.245 kg (9 pound 5 ounces). He had been supplemented from the third day, because he was refusing the breast. The mother and baby were seen at another lactation clinic a few days before and the mother was taught finger feeding in order to help the baby get to the breast (c). For about 2 days before the baby was seen first at our clinic, he has been taking the breast. Nevertheless Celine was supplementing with 4 to 5 ounces (110-150 ml) of formula at each feeding. Furthermore, Celine was now experiencing sore nipples (d).

On examination of the baby, nothing unusual was noted. The baby was latched on poorly, but once the latch was corrected, the baby drank fairly well at the breast. I also showed Celine the breast compression technique and urged her to change sides when the baby no longer drank even with compression. It seemed unlikely that he was taking as much breastmilk as he took formula, so we showed the mother how to use a lactation aid. “Feed on the first side until the baby no longer drinks on his own. Then use breast compression until that no longer seems to work. Then switch sides and repeat the process. If you wish, switch sides again, but do at least both sides before introducing the lactation aid. Then let the baby drink as much as he will take (e).”

The baby and mother returned to the clinic a week after the first visit. The baby weighed 4.53 kg (10 pounds). He was down to taking four or five ounces (110-150 ml) of formula over a whole 24 hour day. Celine complained that the baby awoke more frequently to feed. However, she was happy about no longer being sore. The baby breastfed very well, and it was obvious he was taking lots of milk, much more than at the first visit. I encouraged the mother to continue working on the latch, the compression and the switching, but having done all that as best possible, not to limit the baby’s supplementation. The baby will take what he wants.

Here is an excerpt from a letter I received from the mother later.

“J. is just turning 4 months, the last 3 of which he has been solely on breastmilk. He now weighs over 16 pounds (7.27 kg). We are both very well now. I love breastfeeding! I never thought it could be so easy and so rewarding!” (f)

I also received a call from the mother when the baby was about 6 months old. She was asking about solids for the baby. The baby was breastfeeding exclusively at the time and gaining well.

Notes on Situation #4

a) It is often said, and it can be read in information for new mothers, that if a mother does not get breast changes during the pregnancy, she will not produce enough milk. This is not our experience. Although, many of the mothers seen at the clinic who, I am convinced, are unable to produce enough milk stated their breasts did not change during the pregnancy, some had very definite changes and enlargement, and most of those who said they had no changes still produced enough milk. Indeed, the very first mother we saw in the clinic with the problems of “overproduction” claimed she had had no changes during the pregnancy. I remember this still, because at the time I believed this “no enlargement, no milk” mantra, and here was this woman overflowing, literally, who insisted she had had no breast changes during the pregnancy.

Breast changes during the second and later pregnancies tend to be much less dramatic than during a first pregnancy.

b) “Apparently” latched on well, because I don’t really buy it. A baby “who latches on well” and then refuses the breast when the mother becomes engorged, as the bay did in this case, probably never latched on at all, but really was only allowing the breast into his mouth. When the engorgement occurred, and engorgement is usually worse when the baby has not been nursing well, the baby found it hard to do what he was doing before, and actively refused the breast (instead of passively doing it as he had before)

c) See chapter on the baby who refuses to latch on.

d) This soreness means that even though the baby has taken the breast, he has not been latching on well. This is also suggested by the fact that he seems to need so much formula supplementation.

e) Some mothers will keep the baby on each breast until he falls asleep. This is not necessary, since if the baby is not doing the open—pause—close type of sucking, he is not getting much to eat. Waiting until the baby is asleep or almost asleep makes the feedings longer without necessarily decreasing the amount of supplement the baby will take. Indeed, the baby, almost asleep, may take a while to wake up before he will take the second side, further lengthening the feeding.

Very important. The better the baby latches on, the less the lactation aid will be necessary. And the better the baby latches on, the easier it is to use the lactation aid. A well placed tube, with a baby well latched on, will result in the baby taking about 30-60 ml (1 to 2 ounces) of supplement every 10 to 20 minutes. If it is taking an hour to give the baby 30 ml (1 ounce), something is not right. Get help from someone with experience helping mothers with breastfeeding.

f) The lactation aid does not always work so well or so quickly. It is even possible that with this mother we could have gotten away with not using it at all. However, my impression was that it was needed, partly because I was not convinced the mother was going to manage without it. Her commitment, perhaps strong in the early days, certainly seemed to have flagged.

Sometimes it takes several weeks to get off the lactation aid. Some mothers cannot get off it at all, since once the milk supply is down, it may be impossible to bring it back completely. Some mothers can get off the lactation aid when the baby starts to take solids, but even then some cannot. The reason is that babies like fast flow. If they get fast flow, they are content. Thus, some babies will breastfeed only as long as the flow is rapid, only a short time if the lactation aid is not there keeping up rapid flow. This is a particular problem once the baby is older (say, older than three months), and obviously knows what’s going on.

Situation #5. Premature twins

Ruth’s twins were born 7 weeks early (33 weeks gestation). The labour was unremarkable and the babies were born without the mother receiving any medication. The mother had previously nursed 2 other children (not twins) without problems for about 7 months. One twin weighed 2.02 kg (4 pounds 7 ounces), the other 1.6 kg (3 pounds 8 ounces). There were no complications of prematurity, the twins not needing help with breathing, not even oxygen, and no problems with jaundice. The babies remained in hospital for 5 weeks, 3 weeks where they were born (and where the problems with breastfeeding were initiated), and 2 weeks in another (where the problems were continued).

The babies received intravenous fluids for the first four days. They got formula from very early on, at first by a tube into their stomachs, and then by bottles which were started within the first week after birth. Breastfeeding apparently was not even attempted until several weeks after the babies’ birth (a). At some point along the line, Ruth was started on domperidone (b). The babies were discharged from the hospital essentially being bottle fed.

At the first visit to our clinic, the babies were almost 3 months old. The babies took the left breast a little, but were refusing the right side completely. Each feeding consisted of expressed milk, about 30 ml (1 ounce), and formula 60 ml (2 ounces). At this first visit, the babies weighed 3.35 kg (7 pounds 6 ounces) and 3.25 kg (7 pounds 2 ounces) (c).

At this first visit, neither baby would go near the right breast, arching and screaming rather than latching on (d). They appeared to take the left side, but in fact, they merely allowed the breast into their mouths, which is not the same as latching on. They did not actually breastfeed while hanging on to the left breast.

I showed Ruth how to use the lactation aid to give the babies a supplement at the left breast. With the lactation aid they did take the right side a little, but not much. They did take more supplement on the left side, but they really didn’t have it.

It was important at this stage to increase the mother’s milk supply, so I suggested she take the herbs (fenugreek and blessed thistle) and I prescribed domperidone for her as well.

I asked Ruth to continue working with the lactation aid and the latching at home, and to return with the babies in a week, though I was not confident the mother would manage.

Well, the next week things were obviously much better. The babies were taking the left breast and breastfeeding. The three were managing well with the lactation aid. The babies were still getting some bottles, especially at night, when the mother felt she needed some relief. The babies weighed 3.49 kg (7 pounds 11 ounces) and 3.35 kg (7 pounds 6 ounces). This was a reasonable weight gain for both.

Two weeks after the first visit, the babies were now taking the right breast and were nursing well on the left side. The weights at this visit were lost, or we forgot to weigh them.

Four weeks after the initial visit, the babies weighed 4.02 kg (8 pounds 13 ounces) and 3.81 kg (8 pounds 6 ounces). At this point the babies were getting only about 60 ml (2 ounces) of supplemental formula a day. The babies nursed very well on both sides. The father who was initially not supportive, believing the babies would be fussier when breastfeeding, now was very supportive because he had seen that the one baby who was getting formula during the night was always the one who was fussier at night.

By the fifth week after the initial visit, the babies were breastfeeding exclusively and gaining weight appropriately. The babies were still breastfeeding exclusively at 6 months of age, when I last saw them (e).

Notes on case #5

a) These babies were apparently both quite well, and they were fair sized premature babies. There was no reason not to try them at the breast within a few hours after birth, once it was obvious they were not running into immediate problems. Of course, it is quite possible that neither would take the breast, but if they don’t start learning as soon as possible, it takes longer. Staff in special care units often will argue that the premature baby has to learn how to take a bottle before they can breastfeed and that it is less stressful for a premature baby to bottle feed than breastfeed. This is nonsense, pure and simple. Research has produced clear evidence that breastfeeding is less stressful for the premature baby than bottle feeding. Furthermore, there is no need to start bottles, since cup feeding seems to cause fewer problems than the bottle, and can be used if the baby is not taking the breast. Not only will getting the babies to the breast earlier result in them more likely taking the breast, but also, the mother’s supply would have been better with closer contact with her babies.

Formula should only have been used if the mother was not expressing enough. There is no reason to suppose that Ruth could not have expressed plenty of milk for her babies, except poor support for the breastfeeding, especially since, in retrospect we know the mother could produce enough for twins. In spite of the rationale that we “must” supplement breastmilk with formula or “fortifiers” when babies are born prematurely, these babies actually did not gain weight as they would have in the mother’s womb, which is one of the major reason given for using the fortifiers in the first place.

b) The mother was started on domperidone! Typical of the approach to many problems in all of medicine, but particularly in the breastfeeding domain. Don’t fix the problem (poor latch, or in this case, no latch), give the mother a drug.

c) Nowhere near intrauterine growth rate.

d) If this is not nipple confusion, what is it?

e) From virtually exclusive bottle feeding (with some breastmilk feeding) to exclusive breastfeeding in five weeks. These babies were in hospital for five weeks. I strongly believe that had a decent effort been made to get them breastfeeding from the start, the mother and babies would have done very well from the beginning. There is no doubt that Ruth’s determination made it happen, but she needed support and practical help. Unfortunately, many many health professionals do not believe that breastfeeding twins is practical or possible, and many of them obviously work in special care units. With the help this mother got in the first few weeks, which is too typical, it is not surprising that breastfeeding twins turns out to be impractical or even impossible.

The above examples are fairly typical and are common in the clinic where I work. Unfortunately, it is not always possible to get results as satisfying as the ones described. On the other hand, it should be pointed out again, that so many of the problems we have seen over the years could have been avoided. Even if the mother doesn’t produce anything close to the amount the baby needs, the better the start, the more of that milk the baby will get. And the mother can breastfeed for as long as she and her baby want, though supplementation with a lactation aid or nursing supplementer may be necessary. After all, there is more to breastfeeding than breastmilk. Why should the mother and baby miss out on breastfeeding because the mother is not producing enough milk? The mother usually feels very unhappy that she needs to supplement, but she can still have the satisfaction of a successful breastfeeding relationship.

Everything which has been said above, which is geared to the healthy baby, is also true for the baby who has special problems, such as a baby with Trisomy 21, or other congenital problems or medical problems. Indeed, with very few fairly rare exceptions, babies with problems don’t need breastmilk (and breastfeeding, which is not the same thing), they need it more. Unfortunately, as with the premature twins above, too many health professionals just assume that breastfeeding is not in the cards for the sick baby. Indeed, many believe that formulas are better. This is almost never true.

End Chapter “Not Enough Milk”

Protocol for “Not Enough Milk”

Here is the way I proceed for "insufficient milk supply" (actually, most mothers have lots, but the problem is that the baby is not getting the milk which is available).

1. Get the best latch possible. This needs to be shown by someone who knows what they are doing. Anyone can look at the baby at the breast and say the latch is good. The accompanying diagram, or the one available at the websites below shows how to get a good latch.

2. Know how to know the baby is getting milk (open mouth wide-->pause-->close mouth type of sucking). See handout: How to know my baby is getting enough milk at the websites below.

3. Once the baby is no longer drinking on his own, use compression to increase flow to the baby. See handout Breast Compression at the websites below.

4. When the baby no longer drinks even with compression, switch sides and repeat the process. Keep going back and forth until the baby does not drink even with compression.

5. Try fenugreek and blessed thistle. These two herbs seem to increase milk supply and increase rate of milk flow. There is more information on the handout Treatments for Problems 2 at the websites below.

6. In the evening when babies often want to be at the breast for long periods, get help to position the baby so that you can feed lying down. Let the baby nurse and maybe you will fall asleep. Or rent videos and let the baby nurse while you watch.

7. It is not always easy to decide if a baby needs supplementation. Sometimes more rapid growth is necessary. If possible get banked breastmilk to use as a supplement if you can. If not available, formula may be necessary. However, sometimes slow but steady growth is acceptable. The main reason to worry about growth is that good growth is one sign of good health. A baby who grows well is usually in good health, but this is not necessarily so. Neither is a baby who grows slowly in poor health, but physicians worry about a baby who is growing more slowly than average.

8. If it is decided to supplement, the best way is at the breast with a lactation aid. Introduce the supplement with a nursing supplementer (lactation aid), not bottle, syringe, cup or finger feeding. See handout on Lactation Aid at the websites below. Supplement only after steps 3 and 4 above and the baby has nursed on at least both sides. A baby learns to breastfeed by breastfeeding, and there is more to breastfeeding than the breastmilk. Keep the baby at the breast!

9. If the baby is older than 3 or 4 months, formula is not necessary and extra calories can be given to the baby as solid foods. First solids may include: mashed banana, mashed avocado, mashed potato or sweet potato, infant cereals, as much as the baby will take, and after the baby has nursed, if he is still hungry.

10. Domperidone is a possibility. It is not a panacea (a magic bullet). Check the handout on Domperidone at the websites below.

http://users.erols.com/cindyrn/newman.htm

or

http://www.breastfeedingonline.com

or

http://www.firstfeast.com/articles/articles.html

Jack Newman, MD, FRCPC

Revised: April 16, 2001

Induced Lactation: The Milk Making Protocols 

Induced Lactation Information Lenore Goldfarb, B. Comm, B. Sc.

Dear Mother-to-be,

Congratulations on your impending arrival!

If you are committed to breastfeeding your adopted baby or your baby born via surrogacy, you can do it. Any amount of breastmilk you are able to provide for your baby is a precious gift. I am not the first to try this. I personally know of at least 40 other mothers who were successful at inducing lactation. Induced lactation is more commonly known as "adoptive breastfeeding” and refers to the ability for a woman to breastfeed without going through a pregnancy. I'm very proud of my ability to breastfeed and you too will find that it is well worth the effort.

Please be aware that I am not a doctor thus the information and recommendations that follow are from my own experience with induced lactation. I highly recommend that you consult a doctor who is familiar with lactation as well as an internationally board certified lactation consultant (IBCLC) www.IBLCE.org and forward this information to them so that you can acquire the medications that you will need and have access to follow-up medical and technical support. Contact the hospital where your baby is to be born and let them know that you are planning to breastfeed. They may have a lactation consultant who can help you. You may also wish to make copies of this information to give to any family members, friends, or medical staff, who may be unfamiliar with induced lactation and who may try to discourage you from giving your baby this precious gift.

First, My Story:

After several failed pregnancies my husband and I decided to explore the option of “gestational surrogacy”. This is a procedure where our baby is carried by a surrogate mother impregnated with our embryo. Since I’ve always believed in the importance of breastfeeding, I was determined to find out how I could breastfeed my baby without having gone through the pregnancy. I contacted La Leche League and read their information on adoptive breastfeeding. I found a lactation consultant through La Leche who had successfully breastfed her adopted child.

I searched the internet and found Dr. Jack Newman in Toronto, Canada, who was helping women who were having trouble with their milk production after undergoing a normal pregnancy. I asked him if he would be willing to help me to bring in my milk without a pregnancy. I discovered that he had a lot of experience helping adoptive mothers and so my treatment began. I was treated with special birth control pills, a medication called Domperidone, and was required to use an electric breast pump.

Induced Lactation page 2

In my case, our baby was born two months prematurely. I had only three weeks notice to accelerate my medication and pumping (see my protocol below). I pumped every three hours around the clock to catch up. Ultimately I was successful and provided breastmilk for my son from his second day of life. Still, because he was a preemie, it was nearly 10 days before he was able to nurse. Initially my son had some digestive problems and so I was told by the doctor that my son could only take my "premilk". This is milk that I pumped for only 5 min. After a couple of days he was able to consume a full breast. At that point the hospital insisted that he have human milk fortifier mixed in with my breastmilk, telling me that he needed this because he was premature. I have since found out that this is not necessarily true.  A 32 weeks gestation baby does not necessarily need fortifier. I have also since found out that the “premilk” vs. all my breastmilk should not have been an issue.

Now that I look back on the situation I realize that out of all the preemie babies in that ward, mine was the ONLY breastfed baby. This leads me to believe that although for the most part the staff at that hospital was very supportive of my efforts to breastfeed, the hospital itself was not “breastfeeding friendly”. I spent about two weeks after that, breastfeeding my son exclusively, overruling the objections of the hospital, following which we decided to supplement about an ounce of iron fortified preemie infant formula with each feeding. I was told by the hospital at that point that the formula was necessary in our case because our son was born premature and severely anaemic. I have since found out that this is also not necessarily true either. If he was iron deficient, he could have had just plain iron.  Not all premature babies need fortifier or supplements in addition to breastmilk. Ask your baby’s doctor to advise you. Although I did supplement, I made sure to give my son breastmilk with every feeding and continued until he was eight months old and 20 pounds.

Why Breast is Best

First and foremost, human milk is for human babies. There are at least 100 biological ingredients in breastmilk that cannot be duplicated with the use of formula. The most important of these ingredients are the numerous protective antibodies, growth factors, and enzymes that are present in breastmilk. The baby absorbs the iron and fat that are present in breastmilk much more efficiently than the iron or fat from formula. Breastmilk constantly changes to meet the needs of the baby and there is never a concern about allergy to breastmilk as there is with formula.

Along with the nutritional benefits, there is the unique bonding benefit that occurs when a mother breastfeeds her infant. Babies breastfeed for milk and comfort. As a mother who was unable to carry her infant, I must tell you that breastfeeding eliminated the “void” that I felt when I learned that I would not experience a natural pregnancy and birth. The feelings of helplessness, and inadequacy vanished the moment I held my newborn son to my breast. I felt that the preparation and actual nursing experience were essential in helping me to bond with my baby. There is something about giving something to your

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baby that only you can provide that will make you feel really good about yourself. Do it yourself, and you’ll see what I mean.

The Biology of Induced Lactation in a Nutshell

It is not necessary to have been pregnant in order to breastfeed. During pregnancy a woman’s body produces increasing amounts of progesterone, estrogen, and prolactin. These hormones ready the breasts for breastfeeding. Once the pregnancy is completed, progesterone and estrogen levels drop and prolactin levels increase resulting in lactation. The protocols outlined later in this document are designed to mimic what happens during and after pregnancy. I go into more detail about this later on in the “Introduction to the Protocols”.

Once your milk supply is established it works on a “supply and demand” basis under your baby’s control if you are nursing and under your control if you are pumping. The more often and the more efficiently a baby nurses (or you pump), the more milk will be produced by the breast to meet the baby’s demand. Once the baby (or pump) is put to the breast, a signal is sent to the brain from the breast that causes the release of oxytocin initiating the milk ejection (or letdown) reflex causing the milk to flow. The release of oxytocin coupled with the draining of milk from the breast, causes the breast to produce more milk. (Riordan p. 277). This is one of the reasons for the use of the double electric breast pump during the protocols. The double pump actually fools your body into thinking your are nursing twins.

Introduction to the Newman Protocols

Until recently, the only advice that lactation consultants and members of the medical profession could tell women who were interesting in adoptive breastfeeding was to do nothing before the baby arrives, just put the baby to the breast when you pick him/her up at the hospital and in a while you'll have milk, that milk isn't the most important thing, that there is more to breastfeeding than milk supply. That's fine, except it usually doesn't really work out and you end up feeding your baby formula. If you’re lucky, you'll have a few drops of breastmilk per feeding and it will take weeks or months to achieve it. By then you may be so frustrated that you will most likely go for the bottle. Think about this...it takes a woman 40 weeks to gestate a baby and all the while her breasts are being prepared for nursing. How can anyone expect milk to miraculously arrive without either a pregnancy or medications to simulate a pregnancy? It is true that there is more to breastfeeding than breastmilk. There is the intimacy and the bonding and the development of the baby's jaw and jaw muscles and so on. The reason that most lactation consultants and medical personnel are not aware of the protocols is because they were only published in Dr. Jack Newman's book in 2000 and I only published my guide on the web in July 2001. The nice thing about these protocols is that they are easy to do and the results are often miraculous to say the least. 

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I was the first to try the regular protocol. In early 1998, I contacted Dr. Jack Newman and asked him to help me to bring in a milk supply without a pregnancy when I learned that I was expecting a baby via gestational surrogacy. Since my success with the protocol, I've been working under Dr. Newman’s supervision to help other mothers to bring in their milk supplies. Dr. Newman is one of the foremost lactation experts in North America. Together we worked out a milk making protocol that works. At my peak, was able to bring in 32 oz a day! I did the regular protocol and at the time I didn't know about herbs or pumping schedules. I just muddled along. I was very lucky to find a board certified lactation consultant (IBCLC) who had done adoptive breastfeeding the old fashioned way, with the Lact-aid and tubes to her breast to "simulate" breastfeeding. She was very helpful. Since that time I've worked with over 40 adoptive breastfeeding moms to help them bring in a good milk supply (always under Dr. Newman's supervision).

There are basically two ways to go about this. There is the regular protocol and the accelerated protocol. As a rule, the longer you can be on the protocol, the more milk you'll end up with. In both cases you'll need to take a monophasic large dose birth control pill non-stop, only active pills, no sugar pills (Ortho 1/35 or Necon 1/35 in the US/ the largest dose pill available in Canada is Ovral) together with a medication called domperidone. (see the medications and herbs 1,2,3 below).

Domperidone is an anti-emetic or anti-nausea drug that was initially prescribed for people with upper gastrointestinal problems. Domperidone is not a hormone but it has a side effect that results in an increase in prolactin levels. It was discovered that when some women would take the drug this increase in prolactin levels could in turn cause lactation. As with most drugs, very little of the Domperidone ends up in the milk. The baby gets only very tiny amounts. There is another drug that is found in the US called Reglan (Metoclopramide). I do not recommend the use of Reglan. It crosses the blood-brain barrier and can cause neurological problems and depression. It is not recommended for long-term use. Domperidone is not known to cross the blood brain barrier and is used to treat chronic conditions that require it’s long-term use. It is not known to cause depression. Note that Reglan is not approved by the American Academy of Pediatrics for use in breastfeeding mothers (Hale p 442).

Since domperidone does not cross the blood brain barrier it is much safer for mother and baby. They even give domperidone to babies in Canada suffering from projectile vomiting. Right now domperidone is not available in the US but domperidone has been approved for use in breastfeeding moms by the American Academy of Pediatrics. (see below). I wish the FDA would get with it and approve it. Unfortunately that costs money and since the same pharmaceutical co makes both Reglan and domperidone, they didn't see the need to spend the money or the effort to continue to try to get domperidone approved by the FDA after Reglan was approved even though Reglan is associated with lots of side effects, severe depression among them.  Thus, domperidone was placed on the back burner so to speak.

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Domperidone is widely available in every country in the world except the United States. We are very lucky here in Canada that domperidone was approved more than 20 years ago. This made it possible for a generic version to come onto the market enabling Canadians to obtain this medication economically.

Note that: It is perfectly legal for a US doctor to prescribe domperidone even though it isn’t available in the US.  And it is legal for a US citizen to bring domperidone into the US for personal use provided it is accompanied by a doctor's prescription, a letter stating that the medication is for the patient's personal use, and the shipment does not exceed a 3 month supply. (see FDA regulations below). Here is what Dr. Thomas Hale says about domperidone in his book "Medications and Mother's Milk, 2000", Pharmasoft Publishing, p. 217 Note: Please check with your doctor before beginning any medication.

1) “Domperidone

Trade name: Motilium
Can/Aus/ UK: Motilium
Uses: Nausea and vomiting, stimulates lactation
AAP: Approved by the Academy of Pediatrics for use in breastfeeding mothers

Domperidone (Motilium) is a peripheral dopamine antagonist (similar to Reglan) generally used for controlling nausea and vomiting, dyspepsia, and gastric reflux.  It is an investigational drug in the USA, and available only for compassionate use. It blocks peripheral dopamine receptors in the GI wall and in the CTZ (nausea center) in the brain stem and is currently used in Canada as an antiemetic [anti nausea]. Unlike Reglan, it does not enter the brain compartment and it has few CNS effects such as depression.

It is also known to produce significant increases in prolactin levels and has proven useful as a galactagogue (lactation inducer). Concentrations of domperidone reported in milk vary according to dose but following a dose of 10 mg three times daily; the average concentration in milk was 2.6 ug/L. The usual oral dose for controlling GI distress is 20-40 mg three to four times daily. The galactagogue [milk making] dose is suggested to be 20-40 mg orally 3-4 times daily. At present, this product is unavailable in the USA.

Lactation Risk Category L2….Drug which has been studied in a limited number of breastfeeding women without an increase in adverse effects in the infant. And/or, the evidence of a demonstrated risk which is likely to follow use of this medication in a breastfeeding woman is remote.

Adult Concerns: Dry mouth, skin rash, itching, headache, thirst, abdominal cramps, diarrhea, drowsiness. Seizures have occurred rarely.

Pediatric Concerns: None reported.

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Drug Interactions: Cimetidine, famotidine, niztidine, ranitidine (H-2 blockers) reduce absorption of domperidone. Prior use of bicarbonate reduces absorption of domperidone.

Adult dosage: 20-40 mg 3-4 times daily"  (end of quote from Dr. Hale’s book)

Note: for best results it’s a good idea to take domperidone 1/2 hour before meals and at least 1 hour before pumping or nursing.

FDA regulations state that the following criteria must be met to import medications into the US. It is legal for US residents to import medications from outside the US provided the following conditions are met.

a) The product was purchased for personal use and does not exceed a 3 month supply.

b) The product is not for resale.

c) The intended us of the product is appropriately identified.

d) The patient seeking to import the product affirms in writing that it’s for the patient’s own use.

e) The patient provides the name and address of the doctor licensed in the US responsible for his or her treatment with the product.

f) The medication is not a controlled substance, e.g. sleeping pills, Valium, narcotics.

Although domperidone is not readily available in the US, you may still obtain the medication as follows:

Any Canadian pharmacy can send you Domperidone if you get a prescription from your doctor. Note: It is perfectly legal for a US doctor to write a prescription for domperidone even though it isn’t available in the US. Murray Shore Pharmacy has experience with this. Tel: 1-800-201-8590, Fax: 1-800-201-8591 or visit their website at http:/www.mshorepharmacy.com. Simply fax your doctor’s prescription along with your name, address, phone number, and social insurance number. There is a one time US$10 set up fee and then it costs approximately US$98 for a bottle of 500 Domperidone 10mg and US$18 for FedEx. You will need approximately 3 - 4 bottles. They will ship anywhere in the world. This is the safest option.

Domperidone is available without a prescription, COD from Mexico. For best results you should fax your order. Just fax them your name, address, telephone number, and how many boxes of pills you would like and whether you want overnight delivery or two days and they will send them FedEx, C.O.D. You will need to prepare a money order or cashier's check made out to KCR, Inc. It's a good idea to write in block letters on the fax so there is no chance of error with your name and address. The minimum order is 8 boxes. There are 30 pills in a box. That makes 240 pills. The price is US$112. FedEx 2 days is an additional US$20 or FedEx overnight is US$30. To Fax from the US dial 011-526-654-5522. It's a good idea to back it up with a telephone call. There is a person there that speaks English. To call from the US dial 011-526-654-1834. It may take a while to get through. They have been very reliable to deal with.

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There are several online sources for domperidone. Some of these include the following:

At http://www.1onlinepharmacy.com they ship domperidone anywhere in the world without a prescription. Look for the generic brand (variable sources) US$18 for 100 tabs (10 mg). Shipping is free if shipped by regular airmail. Delivery in 10 -30 days. They also offer express shipping but they don’t recommend it because it can take up to 21 days with new customs regulations in place.

At http://www.1drugstore-online.com you can get domperidone without a prescription. Look for the generic brand by Jassen-Cilag which is domperidone maleate (Motilium) They sell 100 tabs (10 mg) for $25. The minimum order is US$50 but shipping is free worldwide and takes 10-15 days. If you need the medication fast, they'll ship it
express for US$30. They will accept orders from everywhere EXCEPT Canada.

For Canadians who can't find a doctor to prescribe domperidone, you can get it here
http://www.pharmagroup.com without a prescription. Look for Motilium 10 mg 30
tabs for US$12. This comes out to US$120 for 300 tabs. They will ship
worldwide including Canada and the US under regular shipping for 6% of their
order or a minimum of US$16. If you want the order within 3 business days
you’ll have to pay 10% of your order or a minimum of US$40.

Domperidone is available here http://www.canadameds.com with a prescription, for
CAN $82.29 (about $54 US, depending on exchange rate) for a bottle of 500, 10 mg
tablets. They ship anywhere in the world for CAN$18 shipping fee (about US$12). Delivery within 21 days.

Note: Domperidone used to be available from New Zealand without a prescription but as of Nov. 3, 2001 the pharmacies there are no longer able to do this because of a new law that was passed stating that a doctor must have at least one face-to-face visit with a patient before writing a prescription. This law put www.pharmacycare.com out of business.

The maximum dose for Domperidone is 20 mg four times per day. Don't rush to get to that dose, always increase the medication gradually. I never stopped the medication while I was nursing. I discovered that when I forgot a dose, my milk supply would decrease. At its peak, my output was 4 ounces per feeding.

For more information on Domperidone visit the “Bright Future Lactation Resource Center” website at http:/www.bflrc.com/newman/breastfeeding/domperid.htm

2) Special Birth Control Pill. (please check with your doctor before beginning any medication)

You will need to find a birth control pill that is equivalent to Ortho 1/35 (1 mg norethindrone + 0.035 mg ethinyl estradiol).

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Acceptable birth control pills include: Ortho Novum 1/35, Necon 1/35, Demulen 1/35, Norethin 1/35E, Norinyl 1 +35, and Zovia 1/35. Note: It is extremely important that your doctor understand that the birth control pill is not being used to control menses but rather to develop the milk making apparatus of your breasts. This is why your bcp must contain at least 1 mg of progesterone and no more than 0.035 mg of estrogen. You can get the bcp online without a prescription at www.getthepill.com

Begin taking the birth control pill 6 months before the baby is due (the longer the better, if you can start as soon as you know a baby is on the way it would be great) and continue without stopping (active pills only) until 2 months before the baby is due. Do not be alarmed if you do not get your period for the duration of your breastfeeding experience. I did not have a period for 1 year. After you stop the birth control pill you should continue to use an alternative method of birth control if you are fertile and sexually active. Breastfeeding and/or lack of a period do not guard against pregnancy.

3) Herbs

In addition to the medications described above, I recommend the following herbs that have been consistently helpful in increasing milk supply:

Fenugreek seed - 3 capsules (580-610 mg each) 3 times a day with food

Blessed Thistle herb - 3 capsules (325-360mg each) 3 times a day with food

You’ll know that you are taking enough herbs when you begin to smell like maple syrup.

The Most Frequently Asked Question is this:

“Why the need for the birth control pill non-stop (only active pills) and domperidone for the adoptive breastfeeding protocol?”

Answer: During pregnancy several changes take place in the breasts that are hormonally driven. Estrogen and Progesterone exert specific effects. Estrogen causes the proliferation and differentiation of the ductile system and progesterone causes the lobes, lobules and alveoli of the milk making apparatus of the breasts to increase in size. In addition, prolactin is released by the anterior pituitary gland and plays a significant part in increasing breast mass. Without prolactin, lactation does not occur. (Riordan & Auerbach p. 98)

We can produce these breast changes to a large extent in a non-pregnant woman artificially by the use of medications. A birth control pill containing at least 1 mg of progesterone and approximately 0.035 mg estrogen ( i.e. Ortho 1/35 or Necon 1/35,) together with domperidone 80 mg per day will cause significant breast changes that result in lactogenesis. The birth control pill is taken once a day non-stop, only active pills for several months. The reasoning behind taking the birth control pill non-stop is to simulate

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a pregnancy and cause breast changes. Ceasing the birth control pill for even a few days will inhibit this effect. Once significant breast changes have occurred the birth control pill is discontinued while maintaining the domperidone. A pumping schedule then begins as often as possible, usually every three hours, using a double electric breast pump. (Newman p. 252-253)

If you are in the position where you have just found out that a baby is available and you have no time to prepare you can still do this. Although the best results are obtained using a sustained protocol, there is a newly developed accelerated protocol based on the same principles as above (see the accelerated protocol below). The adoptive breastfeeding protocol and the reasoning behind it, is outlined in Dr. Jack Newman's book "Dr. Jack Newman's Guide to Breastfeeding", Harper Collins, 2000 on pages 252-254. This is called the Ultimate Breastfeeding Book of Answers in the US (Prima Publishing). 

The anatomy and physiology of lactation is fully explained in a book by Jan Riordan and Kathleen Auerbach entitled "Breastfeeding and Human Lactation", 2nd Edition, Jones and Bartlett, 1998 on pages 98-101.

Another Frequently Asked Question is:

“Someone told me that my milk will not be the same as a birthmother’s milk and that the hormones resulting from the medications are dangerous…is this true?”

Answer: There is no known difference between the breastmilk that is produced via the protocols and the breastmilk produced by a birthmother. However, women who do the

protocols are unable to produce colostrum. Colostrom is a specialized breastmilk that is

produced by birth mothers prior to their breastmilk coming in. The protocols do not cause the production of colostrum to occur. (Riordan, p 280) The reason that colostrum is not produced using the protocols is that in order to produce colostrum you need “human placental lactogen” which is only available with a placenta which in turn is only available with a pregnancy. As for the hormones being dangerous, this is simply not the case. The hormones that a woman’s body generates while pregnant are so much higher than we can ever hope to achieve with medications. Oral contraceptives are approved by the American Academy of Pediatrics for use in breastfeeding mothers. (Hale p 503). Neither the hormones nor the medications nor the herbs are a problem.

The Newman Protocols:

The Regular Protocol (suitable for intended mothers expecting a baby via surrogacy or adoptive mothers with a long lead time) Most of the women who follow this protocol are able to bring in 50% to 100% supply of breast milk and sustain until weaning.

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1) Six months (the longer the better, if you can start as soon as you know a baby is on the way it would be great) before your baby is due, take an “active” birth control pill each day + 10 mg Domperidone three times a day . Your breasts will swell. This is normal. The birth control pill actually suppresses your milk supply mimicking what happens during pregnancy.

2) Five months before your baby is due, take an “active” birth control pill each day + increase the Domperidone dosage to 10 mg four times a day. Your milk supply will still be suppressed.

 3) Four months before your baby is due take an “active” birth control pill each day + gradually increase the Domperidone dosage to 20 mg four times a day over the course of a week. Do not exceed this dosage. Your milk supply will still be suppressed.

4) Two months before your baby is due, stop the birth control pill and continue the Domperidone dosage of 20 mg 4 times a day. You may experience vaginal bleeding, this is OK. Over the next two weeks, start pumping for 5 minutes on the low or medium setting three times a day, gradually increasing to 20 minutes on the medium setting three times a day. If you can pump more often than this, even better. Note: Stopping the birth control pill should cause your milk supply to come in, mimicking what happens after birth. This is normal.

5) One month before your baby is due, continue the Domperidone dosage of 20 mg four times a day. Pump for 20 minutes on the medium setting three times a day and once during the night. Again, the more often you pump, the more milk you can store, and the better your supply will be.

6) Once your baby arrives, continue the Domperidone dosage of 20 mg four times a day and do not stop until you are ready to wean your baby off the breast. Put your baby to your breast as soon as possible, in the delivery room if you can. Feed your baby “on demand” as often as possible. Pump after each feeding, to help increase your milk supply, until it is well established. Begin to take the herbs fenugreek and blessed thistle and continue until your milk supply is well established and throughout the entire time you are breastfeeding if necessary. If your milk supply is well established it might be possible for you to slowly decrease the domperidone and even eliminate it completely. See the section on “stopping the domperidone” below.

The Accelerated Protocol (suitable for intended mothers or adoptive mothers who have little time to prepare, or for women who wish to relactate) Most of the women who follow this protocol are able to bring in 1/4 to 1/2 supply of breastmilk. Relactating mothers are often able to bring in 50% to 100% supply of breastmilk and sustain until weaning.

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The birth control pill is taken for 30-60 days non-stop, only active pills, together with the domperidone 80 mg per day. If significant breast changes occur within 30 days, the birth control pill is stopped while maintaining the domperidone, and the pumping schedule of 15-20 min every three hours begins. Significant breast changes include an increase in breast size (1 cup) and breasts that feel full, heavy and very painful. Note: stopping the protocol before these breast changes occur is not recommended. Milk production is not as great on the accelerated protocol but the supply is usually sufficient to provide 1/4 to 1/2 of the baby's needs. You can use the Lact-aid filled with either breastmilk or formula to breastfeed your child while you are going through the protocol. There are milk banks and milk exchange services that can provide you with breastmilk if it is not feasible for you to ask the birthmother to provide breastmilk. It is worth a try to ask though…you would be surprised at how many birth moms are willing to provide the child with a healthy start in life.

If you have 4 weeks or less or if your baby has arrived and you suddenly decide that you want to do the accelerated protocol, you can still do this. Start the birth control pill ( see the section that describes the medications above) together with 20 mg of domperidone 4 times a day immediately and pump every three hours and once during the night. You can expect to feel tired as your prolactin level rises. If you can be on the birth control pill for

at least 30 days you will have a better result. If you have been on the birth control pill for 30 days and are experiencing significant breast changes, please stop now, continue your domperidone and start pumping. Remember that if you are fertile, you must use an alternative method of contraception. Store as much milk as you can. Once your baby arrives, or if your baby is already here, feed him/her on demand and supplement if necessary using the supplemental nursing system or Lact-aid filled with either your stored milk, donor milk from a milk bank or milk exchange service, or formula until your milk supply is well established. Remember, not all the milk has to come from you. Whatever

amount of breastmilk you provide to your baby is a precious gift. Note that the birth

control pill and domperidone are both approved by the American Academy of Pediatrics for use in breastfeeding mothers.

My Protocol Five months before our baby was due, I started to take 1 active birth control pill and 10 mg of Domperidone three times a day. Four months before our baby was due, our surrogate mom was diagnosed with placenta previa and I began to pump three times a day: in the morning, dinnertime, and bedtime. Although I had some milk within 10 days, I did not understand that the birth control pill was actually suppressing my milk production thus giving my breasts an opportunity to fully mature. One week after I began pumping, our surrogate mom went into preterm labor. She was only at 29 weeks, less than 7 months pregnant. I took immediate action and put myself on an accelerated protocol. I stopped the birth control pill, increased my Domperidone dosage to 20 mg three times a day, and began pumping four times a day: in the morning, at lunch time, at dinner time, and at bedtime (I would watch TV to alleviate the boredom). One week later

I began to pump four times a day and once during the night for 20 min on “medium”.

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Our son was born at 32 weeks and was immediately placed in the neonatal intensive care unit, on a respirator, with intravenous lines. At the time of our son’s birth, I increased the Domperidone to 20 mg 4 times per day, began pumping every three hours around the clock, and froze my breastmilk. After 24 hours, my son was weaned from the respirator and I began to hold him skin to skin. This is called “Kangaroo Care” and is one of the best things you can do for a premature baby. I held his head next to my breast each day. Two days after our son was born, the hospital began tube feeding him with my breastmilk. I know now that I probably should have put a few drops of my breastmilk to my son’s lips those first few days, even while he was on the respirator, to help him to develop digestive enzymes. This would have helped him to tolerate his feedings much easier. My output was two ounces per feeding which was more than he needed. I found that if I pumped next to his incubator my output was greater. I continued to hold our son for many hours each day, and from time to time, holding his head next to my breast. After a few days, I began to slowly train our son to breastfeed. It was nine days before he was able to get the hang of it and take a full breast.

I cannot tell you how profoundly grateful I was that I was able to do this for my son. Breastfeeding my premature baby was absolutely, without question, the best thing for him. Although I was able to keep up with our son’s demand, the hospital strongly encouraged me to supplement his feedings with a special infant formula designed for preemies because the doctors said that his needs were different than a full term newborn. Our baby was very pale when he was born and required two blood transfusions so the doctors told me that his iron requirements were more than I could give him with my breastmilk. If I could do this over again, I would have breastfed exclusively and given my son an iron supplement instead of a formula supplement.

While our son was in the neonatal intensive care unit (6 weeks) I pumped after every feeding to increase my milk supply. I stored all my excess milk and supplemented with it when I could avoid giving him the special preemie infant formula. When our son came home, I was advised by my pediatrician to supplement with regular iron fortified infant formula to increase his iron consumption once again. To solve the iron problem and to avoid a decrease in my milk supply, I started to give my son infant vitamin drops with iron. Most feedings he would take only breastmilk and other feedings, I would give him an ounce of iron fortified formula if he was still hungry and had fully depleted my breastmilk.

As time went on and my son’s demand for breastmilk began to exceed my output, I would supplement 50:50 breast and formula. At my peak, I was giving him 4 ounces of breastmilk per feeding. When he was 8 months old I started to wean him from the breast but continued with a bottle and pumping. He was given 6 -7 ounces per feeding and of that, 2 ounces were breastmilk, the rest was iron-fortified formula. I continued this way throughout his eighth month until he was on formula alone and my breastmilk output had decreased to 1 ounce per feeding. At this point I stopped pumping. I did not experience any discomfort when I stopped. I have since learned that babies of 8 months do not need formula. They can eat food and drink regular milk. They also don’t need to be weaned at

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that age. You can go on breastfeeding for as long as you and your baby are both willing to continue to enjoy your nursing relationship…years in fact.

How to Decide Which Protocol is Right for You

Depending on when you expect your baby to arrive you have to think like this...you'll need to pump for at least a month. You need to be off the bcp when you start pumping, you will need to be on the bcp-domperidone combination for at least 30 days non-stop. The longer you can be on the combination the better. So if you have three months...you'll be on the combo for 2 months straight. If you have 2 months...you'll be on the combo for at least 1 month straight. After you're off the bcp and still on the domperidone, you'll begin to pump. You'll need to use a double electric breast pump like either the Medela Pump n Style or Medela Lactina Select (hospital pump). And then you'll need to take herbs...fenugreek and blessed thistle.

What to do if you do not experience "significant" breast changes:

Significant breast changes include: 

Breasts increasing in size by at least 1 cup size.

Breasts full, heavy, and very painful.

If you do not experience significant breast changes within 15 days of beginning either of the protocols, you may want to consider increasing your progesterone intake. There are two reliable ways to do this. 1) Replace your current birth control pill with Diane 35. This medication has twice the amount of progesterone that is in the "1/35" type birth control pills. 2) Continue on your current "1/35" birth control pill and add 1 mg of progesterone another way such as by adding 1/2 a pill of Provera 2.5.  Adding progesterone usually solves the problem.

A word of caution about creams. Creams do not provide the needed level of progesterone in a reliable manner. You are much better off with an oral form of progesterone.

It is very important to follow the protocols as written. If you leave out any of the ingredients for success, you can be sure to have problems with your milk supply. Each element of the protocol serves a specific function.

Breast Pump

You will need to acquire a breast pump. I felt that the "Pump in Style" by Medela was the best one for me. It is a double electric pump and has a special cold-storage space with ice packs for the milk. There is also the Medela Lactina Select double electric pump that can be rented from either your lactation consultant or your local hospital. Start by pumping three times a day for 5 min on the low to medium setting, increasing to 20 min on the medium setting. You should have milk within 10 days to three weeks. At the beginning, I pumped once in the morning, once at dinnertime, and once before bed. I took my medication about an hour before I pumped. I also learned to “hand express” for the times when I could not pump due to lack of electricity or privacy.

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Supplementary Nursing Systems

There are two basic types of supplementary nursing systems on the market. They are the SNS by Medella and the Lact-aid. Basically, this is a bottle or bag filled with formula that is worn around the neck or clipped to your clothing or hidden in a shirt pocket. Thin tubes leading from the bottle or bag attach to both breasts. The baby then nurses from the breast normally. This is an excellent way to supplement your baby’s feedings until you are able to bring in your milk supply, and to take the pressure off you, if you do need to supplement your baby’s feedings once your milk supply comes in. Alternatively, there is the improvised lactation aid suggested by Dr. Newman that you can find in his book on pages 80 – 81.

Once your milk supply is starting to come in or is established. The best way to use the supplementer is to allow your baby to feed on each breast with the supplementer in place but not flowing until he/she doesn’t drink anymore from your breasts. You can tell because the baby will stop the suck>pause (downward motion of chin)> suck motion. Use breast compression to get as much breastmilk to your baby as possible from the first breast and when that stops working and your baby stops drinking switch sides and do the same thing. Allow the supplement to flow only when the baby has done both sides at least (not necessarily spent an hour or whatever, just as long as he's drinking).  That way, if the baby doesn't want any more, he won't take any more and you’ll know that your baby had as much breastmilk as possible.

What to Do With the Milk

Save all the milk you pump and freeze it in one-ounce portions. Medela makes freezer bags for breastmilk available at most baby stores. You should mark the date and time on each bag so you can use them in the order in which they were obtained. Make sure your freezer is colder than 0 degrees Fahrenheit. Use a fridge/freezer thermometer to check the temperature. I washed everything with antibacterial soap and poured boiling water through the bottles and breast attachments each time I used them to make sure they were sterile. You may want to boil them in a pot once a week. You can store your milk for a

year this way. This way you can supplement your baby’s feedings with your own breastmilk if you need to. You will be most successful if you use the supplemental nursing system filled with your previously stored breastmilk. If you find that you have finished all your previously stored milk, you can use formula in the supplemental system.

Lactation Consultants

I highly recommend that you contact an Internationally Board Certified Lactation Consultant (IBCLC) who has experience with adoptive breastfeeding or who is at least open minded about the protocols. You can find a listing for the US at http://iblce.org/us_regional_registry.htm and for the rest of the world at http://iblce.org/international_registry.htm If for some reason you are unable to find a board certified lactation consultant you can try a La Leche leader through La Leche, Tel: 1-800-La Leche. La Leche representatives have a wide variety of products available.

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La Leche has a website at http://www.lalecheleague.org/ . Again, it is important for you to find someone who is familiar with adoptive breastfeeding or who is at least open minded about the protocols. Breastfeeding and pumping should not be painful. I recommend someone who is experienced with "Adoptive Breastfeeding". She will teach you how to use your pump and how to “hand express” your milk. You can also buy your equipment from her. Then later on she can help to show you how to get a good latch when you’re nursing your child. The most important job for the LC is to support your efforts. You should know that the vast majority of LC’s are unfamiliar with the protocols and will try to persuade you to do nothing until the baby arrives. They will try to convince you that all you need to do is put your baby to the breast and this will be enough to stimulate milk production. They will tell you to use either the SNS or the Lactaid device while you’re waiting for you milk. My dear, you will end up waiting a long time and you will be very disappointed if you follow this approach.

Breastfeeding Your Baby

As soon as your baby is born and you are able to hold him, put him to your breast (in the delivery room if you can). You may leave him on your breast to nurse each side at will, burping your baby between breasts. Initially, if you feed your baby on demand, your milk supply should increase to match it. This may mean feedings 1 or 2 hours apart. Within a week to ten days, your baby should be on a fairly regular schedule of his own making but don’t get overly involved with this. Schedules are for trains not babies. You will need to continue breastfeeding around the clock until your baby can go four or five hours between the midnight feeding and the early morning feeding. Sleep is important for your milk supply. Try to sleep when your baby sleeps. If you can, I recommend pumping for at least 10 minutes after every feeding until your milk supply is well established. Whenever you notice a diminished milk supply, pump after every feeding and your milk supply should increase.

Breastfeeding should not be painful. If it is, most likely, your baby is not “latching on” properly. The most common problem is that the baby does not have enough of the breast in his mouth and needs to be repositioned. A common mistake is to put the baby only on the nipple when in fact the baby needs to take in the nipple and the surrounding areola as well. To begin nursing, your baby will “suck” in the breast tissue, then your baby “milks” the breast with his jaws as opposed to “sucking” only on the nipple.

The Latch

Above all, if you are nursing, the number 1 most important thing is to have a good latch. If your baby is not latching on properly, he/she will not be able to get the milk that is available as well, no matter how much milk you have. If you do have an abundant milk supply, your baby might still do well as far as weight gain is concerned, but the feedings may be long and frequent if the baby is not latched on as well as he/she could be. The key is to make sure that the baby takes in the nipple AND as much of the surrounding tissue

Induced Lactation page 16

as possible. There are no milk ducts in the nipple. They are under the areola surrounding the nipple. The baby needs to “pump” this area with his/her jaw in order to get the milk. The more efficiently your breasts are emptied either by baby, pump, or hand expression…the more milk you will have. Watch for your baby to do the following motion while on the breast…suck>chin moves downward towards baby’s chest>pause>baby closes mouth. Here’s a way for you to understand this. Suck some liquid from a straw and you will experience the pause in the chin. The baby does the same thing. Every time your baby’s chin moves down and pauses, your baby is getting a mouth full of milk. When you see the suck, suck, suck motion or no motion at all there is no milk getting to the baby and either you’ll need to adjust the latch or use breast compression to get more milk to the baby.

Breastfeeding should not hurt. Your baby needs to take in as much breast tissue as possible. Dr. Newman uses the "cross cradle"' hold and an "asymmetric latch". (Newman pp 53 –58). Using your left breast as an example, hold your baby with your right hand under her neck, fingers holding her head, your right forearm supporting her body. You may or may not wish to use a nursing pillow or regular pillow to help you to support your baby's weight. Then use your left hand to shape your breast. Hold your left hand in front of you, palm towards you, pinky side towards the floor and thumb pointed to the ceiling and forefinger pointed to the right. Place your hand in this position directly under your breast and use your hand to form a "c". Cup your breast, lift it and squeeze the "c" so that you have shaped your breast and have control of it. Aim for the middle of your baby's top lip (not the bottom one as some LC's suggest) so that your baby's tongue will be in the right position. As soon as she's opened up, shove your breast right under her top lip, straight into her mouth.

Once your baby is latched, remove your hand and use it to help you to support your baby. Take your other hand out from underneath and use it to thread the Lact-aid tubing into

your baby's mouth (see the section on supplemental nursing systems above). If the latch is good, you will have shoved more breast tissue from the bottom of your breast than the top. "This is what is meant by the "asymmetric latch". This will better enable your baby to "milk" the milk sinuses that are located inside your breast just under the areola. You may or may not see a bit of the areola on top. All areolas are different. Some women have huge ones that a baby could never cover and some women have small ones. As long as you're not in pain, and your baby is doing the suck>pause(chin down, mouth filling with milk)>suck...you've got a good latch. The same technique applies to the right breast in reverse. If breastfeeding becomes painful after you've started, it means that your baby has adjusted the latch and you have to insert your pinky finger into the corner of his/her mouth to break the suction, get the baby off your nipple, and reposition the latch. You can repeat this as often as necessary until you're comfortable. Visit the following website for more information, illustrations, and video clips: http://www.breastfeeding.com . 

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Common Problems and Solutions:

Breastfeeding the Premature Infant

Breastmilk is absolutely, without question, the best food you can give a premature infant. In the case of very premature infants who are unable to take the breast because they are too weak to suck and who are being tube fed, I recommend pumping your milk and having the hospital staff tube feed your infant with your breastmilk. This was the case with my son. He had to be tube fed for the first nine days until he was strong enough to breastfeed. I insisted that the tube contain my breastmilk. You may have to be insistent, not all staff in NICU's are supportive of breastfeeding or even breastmilk feeding. I advise putting your baby to your breast as soon as you are able to hold him. Have a lactation consultant show you how to train a preemie to breastfeed. It may take several days or weeks for your baby to get the hang of it. Don’t despair, be patient, it’s worth the effort.

Once your baby is able to breastfeed, it may take alternate feedings of breast and tube feeding until your baby is strong enough to breastfeed at every feeding. If your milk supply is low (which often happens due to the stress) you may want to use the supplementary nursing system (SNS) or Lactaid filled with either your previously stored breastmilk or special premature infant formula. As soon as your baby is established on the breast, I recommend that you discontinue the tube feedings. Many hospitals advocate the use of bottles with “preemie” nipples. This is not advisable and leads to “nipple confusion”. You may end up with a baby who will reject the breast in favour of the bottle. The SNS or Lactaid is much better for your baby and for your milk supply. Cup feeding when you are not with the baby is better than bottle-feeding. If you are caught off guard and faced with an emergency premature birth or sudden adoption situation you can try the accelerated protocol below. Another option that you can explore is the use of a milk bank.

Jaundice

Jaundice is yellowing of the baby’s skin and eyes caused by the normal breakdown of red blood cells in the baby’s body. The blood cells release a substance called bilirubin that causes the yellow color. Bilirubin in turn is processed by the baby’s liver so that it can be expelled from his body. Jaundiced babies have livers that are not able to process the bilirubin efficiently yet. This common form of jaundice, which appears within the first few days of life, is normal and usually disappears with time. In severe cases of Jaundice, the baby will need to spend some time under the “bili-lights” (phototherapy). It is not completely understood why bili-lights work but they do. There is no reason to discontinue breastfeeding. In fact, breastfeeding your infant more often will actually help the situation. If your baby has jaundice it is important to visit your doctor for a bilirubin assessment. There are some forms of jaundice, which are not normal, and in rare cases,

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extremely high bilirubin levels can cause problems, even brain damage if not treated. It is still not necessary to stop breastfeeding. For more information visit: http://users.erols.com/cindyrn/newman.htm

Sore or Cracked Nipples

The best way to avoid cracked nipples is to learn how to breastfeed your baby so that he is properly "latched on” (see “The Latch” above) and to learn how to properly use your breast pump. As you are learning, if you do experience nipple cracks use Blistex to heal them until the baby arrives. Once your milk comes in you can use a little of your milk on your nipples to heal them. Breastmilk has healing properties. When the baby arrives, you can use a product called Purlan or Lansinoh that is safe for the baby and does not need to be removed before breastfeeding. When washing your nipples, avoid soap as it has a tendency to dry out the nipples. Plain water works best.

In some cases cracked nipples can give rise to “thrush”. Thrush is caused by a fungal infection (candida) and can lead to the growth of a white substance on your nipples that you can’t wipe off. If you are nursing, it can appear as white
patches on your baby’s tongue and the inside of his/her cheeks. It is also known to cause “burning pain” in the nursing mother’s nipples that persists throughout a feeding and lingers afterwards as well as deep breast pain without necessarily showing the white substance. Pain from a poor latch differs from the pain of thrush in that the latch pain stops soon after the baby begins nursing or as soon as the baby is removed from the breast. (Newman pp113-118). Dr. Newman suggests the following treatment protocol for thrush:

Dr. Newman’s Candida Protocol (thrush)

Dr. Newman starts with local treatment consisting of:

1. Gentian violet (look under that title at the websites below). Once a day for 4 to 7 days.

If pain gone after 4 days, stop gentian violet. If better, but not gone after four days, continue for 7 days. Stop after 7 days no matter what. If not better at all at 4 days, stop the gentian violet, continue with the ointment as below and call. 

Plus:

2. Dr. Newman's All Purpose Nipple ointment as below:

mupirocin 2% ointment (15 grams)
nystatin 100,000 unit/ml ointment (15 grams)
clotrimazole 10% (vaginal cream) (15 grams) (best to omit, unless 10% available) [newman] maybe best to omit altogether, including from here.
betamethasone 0.1% ointment (15 grams)

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The pharmacist mixes it all together and it is applied sparingly after each feeding (except the feeding when the mother uses gentian violet). Do not wash or wipe it off, even if the pharmacist asks you to. You need a prescription for it. [Newman] maybe you can decide if any of this is necessary: Clotrimazole 10% is difficult to find in Canada, and apparently not available in the US. It can be left out if it is a problem to find. Clotrimazole 2% should not be used instead. The addition of any ingredient dilutes the other ingredients and the other ingredients dilute the clotrimazole 2% making it 0.5%. In Canada, Kenacomb (easier to find) or Viaderm KC (less expensive) ointment can be substituted for the above combination.

This is used until pain free and then use less frequently over a week or two until stopped. (See Treatments for Problems 1 under “all purpose nipple ointment”).

3. If pain continues and it is sure the problem is Candida, or at least reasonably sure, add fluconazole 400 mg loading, then 100 mg twice daily for at least 2 weeks, until the mother is pain free for a week. If fluconazole too expensive, ketoconazole 400 mg loading, then 200 mg twice daily for same period of time. If Candida resistant, itraconazole, same dose and time period as fluconazole, though Candida actually is less sensitive to itraconazole, generally, than it is to fluconazole. (See handout Fluconazole). Fluconazole is apparently now available as a generic product (therefore less expensive).

4. For deep breast pain, ibuprofen 400 mg every four hours may be used until definitive treatment is working (maximum daily dose is 2400 mg/day).

5. Grapefruit seed extract 250 mg three times a day orally taken by the mother can be used instead of fluconazole, or in addition to fluconazole for resistant cases.

http://users.erols.com/cindyrn/newman.htm or

http://www.breastfeedingonline.com or

http://www.firstfeast.com/articles/articles.html

Jack Newman, MD, FRCPC

Revised: April 16, 2001

Tongue Tie

The dreaded tongue tie (ankyloglossia) is easy to fix. A circumcision is so much more of a big deal. Your baby has a tongue tie if he/she cannot extend his/her tongue out past his/her bottom lip. Look underneath the tip of your baby’s tongue and you’ll see the short band of tissue restricting the tongue’s movement. This makes nursing difficult for the baby and painful for you. The treatment for this is to clip the tongue tie…the sooner the better. Note, if the band of tissue is not at the tip of your baby’s tongue and the baby’s tongue can extend past his/her bottom lip, there is no tongue tie and more than likely your nipple pain is due to a poor latch. See “The Latch “ above.

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It’s a good idea to see a pediatric dentist to clip the tongue-tie. The way it's done...(don't do this yourself because if you cut a vessel your baby will be in big trouble!!!) the dentist uses a little scissors and cuts only the band of tissue that is pearly grey with no vessels in it which is holding the tip of the baby's tongue to the floor of it's mouth. As soon as it's done, the baby is put to the breast to nurse. It doesn't hurt but it may bleed a little bit. It heals in a day or two. The breastmilk keeps it clean. Sutures are not usually needed with newborns but it depends on the thickness of the tongue tie. And it can be done right away…no need to wait for the baby to be weeks, months or a year old. The results are miraculous.

Lenore’s Recipe for Increasing Milk Supply

If you are interested in increasing your milk supply and are not adverse to the idea of domperidone and herbs here is a recipe for success.

1) If you are an adoptive breastfeeding mother or an intended mother and are not already taking domperidone, it is a good idea to do so now. Take domperidone 10 mg 4 times a day for 1 week and then if you feel ok, not too tired and your stomach isn't too upset, increase the domperidone to 20 mg 4 times a day. It's a good idea to take domperidone 1/2 hour before meals and at least an hour before pumping. Don’t start your herbs until you are comfortable with the domperidone…wait at least a week before you add the herbs or you can get a really upset stomach. And if you are already taking herbs…stop until you are comfortable with the domperidone.

2) www.breastfeeding.com for a video clip on breast compression. For best results pumping or hand expressing every 3 hours and once during the night does wonders. Keep a cooler with an ice pack by your bed at night so you can hand express your milk into a bottle and keep it in the cooler until morning when you can transfer it into a bag and either use it in the Lact-aid if you are nursing or freeze it. You can also use this cooler idea at work if you don’t have a fridge available to you. Freeze the milk when you get home or use it in the Lact-aid. Keep in mind that it may take a while for your breasts to get the message. You could be pumping and getting very little for days and then suddenly…boom you have a lot more milk!

3) When you are ready to add the herbs, take Fenugreek (610 mg per capsule) and Blessed Thistle (390 mg per capsule). Take 3 capsules of each, three times a day with food.

4) Drink as much water as you can without making yourself sick. 6 – 8 glasses would be great.

5) Eat oatmeal for breakfast 3 times a week. This is good for milk supply.

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6) Above all, if you are nursing, the number 1 most important thing is to have a good latch. If your baby is not latching on, he/she will not be able to get the milk that is available no matter how much you have. See “The Latch” above. Watch for your baby to do the following motion while on the breast…suck>chin moves downward towards baby’s chest>pause>repeat. Every time your baby’s chin moves down and pauses, your baby is getting a mouth full of milk. When you see the suck, suck, suck motion or no motion at all…there is no milk getting to the baby and either you’ll need to adjust the latch or use breast compression to get more milk to the baby.

7) If you have to supplement your baby’s feedings, use a Lact-aid device. This will help your milk supply while at the same time keep your baby breastfeeding. It may seem silly to state the obvious but I’m going to say this anyway…a baby learns to breastfeed by breastfeeding. If you introduce the bottle, you will teach your baby that there is another way to get nourishment and often baby’s will go for the bottle because it’s less work. That doesn’t mean you can’t go out and leave your baby with a caregiver to handle a feeding or two…just don’t make a habit of bottles at every feeding and you’ll be fine.

8) Don’t make yourself nuts over this. There is more to breastfeeding than breastmilk. Your baby only needs a small amount of breastmilk with each feeding in order to benefit.

For more information on increasing milk supply, see "Dr. Newman's Protocol for Not Enough Milk at this site: http://users.erols.com/cindyrn/notenough.htm.

Milk Banks

Milk banks are a wonderful resource and, for a fee, will provide donated breastmilk to infants upon request. You often need a prescription and the cost is about $2 to $3 per ounce. You may want to use donated milk until your own milk comes in or as a supplement in place of formula. Milk banks screen their donors and most of them pasteurize the donor milk. Pasteurized breastmilk does not contain the same immunological benefits as unpasteurized breastmilk because the
heat kills the antibodies as well as the germs but the nutritive composition is similar. There are 7 milk banks in the US and 1 in Canada. For the milk bank nearest to you, visit: http://www.hmbana.org/milkbanks.html

Note: Although breastmilk from the biological mother is preferred, it is not necessary. There is no known difference between biological breastmilk and induced breastmilk. According the World Health Organization (WHO), the rating of what to feed babies is

as follows (Newman p10):

1) The biological mother's breastmilk via breastfeeding

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2) The biological mother's breastmilk via pumping or hand expression,  provided in a supplementary feeding system, or small cup. This is second best because antibodies are created at the breast.

3) Donated milk from a breastmilk bank.

4) Formula

A Word About Bottles

It is best to avoid bottle feedings as much as possible while you are breastfeeding. The more you breastfeed, the more milk you will have. If you introduce the bottle, your milk supply may decrease. Besides hindering milk production, the use of bottles can lead to “nipple confusion” in your baby...and not in your favour. If you need to supplement with formula, use the supplemental nursing system or Lact-aid. Introduce a cup from time to time when your baby is about 6 months old. Then when you are ready to wean your baby off the breast, you can wean him straight onto the cup.

Now I know that in reality this is a hard choice. Throughout my experience with breastfeeding, my son did receive some bottle feedings either from my husband or a baby sitter when I was unavailable. And as I was weaning my son, I alternated bottle-feedings and breastfeedings and let me tell you...there is a difference. If I had it to do over again, I

would have weaned my son directly from the breast onto the cup. There is more to breastfeeding than breastmilk, and when the baby is on a bottle he is not breastfeeding. The point is, keep the use of bottles to a minimum.

Stopping the Domperidone

I very slowly began to decrease my dose of Domperidone as follows. When my son was 8 months old I decreased the Domperidone to 20 mg 3 times a day for 2 weeks. Then I the Domperidone to 10 mg 4 times a day for two weeks. I continued decreasing the Domperidone to 10 mg 3 times a day for two weeks. Then 10 mg 2 times a day for two weeks. Then 10 mg once a day for two weeks. Then I stopped. It is very important to stop the Domperidone very slowly. Although most women do not experience discomfort when stopping the medication, gradual weaning from the medication will help you to gradually wean your baby from the breast without frustrating him. So go slow.

A Word About Menopause/ Lack of Uterus

If you are in Menopause or no longer have your uterus, you can still breastfeed. But your protocol must be tailor made as the adjustment to your hormone levels must be made on an individual basis. Please contact me by e-mail (see my information below) and I will be happy to help.

Additional Tips

Rest is very important for your milk supply. Drink a lot of water, 6-8 glasses of water a day would be good but don't "drown" yourself. I found a wonderful herbal tea called

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"Mother's Milk" by Traditional Medicines, which is available in the health food stores in the US. I also recommend the "Olga" and “Medella” nursing bras and "Gerber" cotton nursing pads. Medella has a “hands free kit” which enables you to pump while you work or watch TV. It has elastic bands that attach the “Pump in Style” plastic parts to the Medella nursing bras. Medella also makes a cigarette lighter adapter for the car enabling you to use the breast pump on long trips while someone else drives.

Bibliography and Recommended Reading

“The Ultimate Breastfeeding Book of Answers” by Dr. Jack Newman, in the USA, Prima Publishing, 2000, or “Dr. Jack Newman's Guide to Breastfeeding”, in Canada, HarperCollins Publishing, 2000. (Dr. Newman is one of the foremost experts on lactation in North America. He is a Toronto Pediatrician who established the first hospital based breastfeeding clinic in Canada at Toronto's Hospital for Sick Children. He is a consultant

with UNICEF's Baby Friendly Hospital Initiative and is a popular speaker at

breastfeeding conferences throughout the world. His book is a wonderful guide and answers most breastfeeding questions. Dr. Newman has devoted a chapter to Adoptive Breastfeeding that is extremely helpful. The protocols are derived from information from Dr. Newman’s book)

“The Breastfeeding Answer Book” by Nancy Mohrbacher and Julie Stock, 2000, published by La Leche League International. ( This book is basically exactly what the title indicates. If you have a question, this book will answer it. It is written by two IBCLC board certified lactation consultants.)

"Medications and Mother's Milk, Ninth Edition, 2000", by Thomas Hale, Ph.D., published by Pharmasoft, 2000 (Dr. Hale is an associate professor of Pediatrics and Pharmacology at Texas Tech University School of Medicine in Amarillo, Texas. His book is widely respected as being the definitive guide to medications for breastfeeding mothers)

"Breastfeeding, A Guide for the Medical Profession" by Robert and Ruth Lawrence, published by Mosby, 1999 (Both of these authors are MD's working in New York, Dr. Ruth Lawrence is a professor of Pediatrics, Obstetrics and Gynecology at the University of Rochester School of Medicine and Dentistry and Dr.Robert Lawrence is an associate professor of Pediatrics and Microbiology at New York University School of Medicine. They have written an excellent resource book for understanding the physiology of lactation and related issues. This book is required reading for the IBLCE exam)

“Breastfeeding the Adopted Baby” by Debra Stewart Peterson, 1999, Published by Corona (written by a mom who breastfed her three adopted children. Although Debra

doesn’t support the use of medication because the protocols were not available when her

book came out, there is a lot of helpful information.)

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"Breastfeeding and Human Lactation, Second Edition" by Jan Riordan and Kathleen Auerbach, published by Jones and Bartlett,1998 (These authors are both internationally board certified lactation consultants. They have written an excellent resource book for understanding in great detail the physiology of lactation and related issues. This book is required reading for the IBLCE exam)

“The Complete Book of Breastfeeding” by Dr. Marvin S. Eiger & Sally Wendkos Olds, 1998, published by Workman (this is another excellent instruction guide)

“The Womanly Art of Breastfeeding” by La Leche League International Authors, 1997, published by Penguin (this is an excellent instruction guide)

"A Practical Guide to Breastfeeding" by Jan Riordan, published by Jones and Bartlett, 1991 (excellent source of information to understand the physiology of lactation and practical instructions, there is also a chapter on induced lactation which includes a comparative study between birth mother’s milk and induced milk) 

“Nursing Your Adopted Baby” by Kathryn Anderson, 1986, published by La Leche League International (Publication No. 55) (Written by a mom who breastfed her adoptive baby, but again she does not advocate the use of medication because the protocols were not available when her book cam out. This guide offers a lot of helpful information. It was one of the first books published that was exclusively devoted to the topic of adoptive breastfeeding.)

Additional Information

For more information on induced lactation see the Adoptive Breastfeeding Resource Website, http:/www.fourfriends.com/abrw/ and visit my forum “Ask Lenore” by clicking on “Ask Lenore” at the bottom of the list that appears here: http://www.fourfriends.com/board/

Dr. Jack Newman’s articles are available on the following websites:

http://users.erols.com/cindyrn/newman.htm http://www.bflrc.com/newman/articles.htm

http://babiestoday.com/breastfeeding/drjack/ http://breastfeed.com/resources/articles/drjack/

Questions?
I hope that this information has been helpful. If you need further assistance, you can e-mail me, Lenore Goldfarb, in Montreal, Canada, at lengold@sprynet.com and I’ll be happy to help. I wish you and your child a long and happy nursing relationship.

Warm Regards,

Lenore Goldfarb

ãLenore Goldfarb October, 2001. All rights reserved.