Fielding questions about breastfeeding

April 1, 1999

As more mothers breastfeed, and for a longer time, pediatricians and their staffs are being called on to answer a wide variety of questions. These lactation experts show you how to respond to worries ranging from babies with too many or too few bowel movements to concerns about engorged breasts.

Fielding questions about breastfeeding

Jump to:Choose article section...Too many bowel movementsToo few bowel movementsFluoride and well waterVitamin supplementsMedications and breastfeedingThe sleepy babyNewborn sleeps through the nightPainful breastsPreparing to breastfeedFalling on the growth chartsThe message is out

By Barbara L. Philipp, MD, IBCLC, and Karin Cadwell, PhD, RN, IBCLC

As more mothers breastfeed, and for a longer time, pediatriciansand their staffs are being called on to answer a wide variety of questions.These lactation experts show you how to respond to worries ranging frombabies with too many or too few bowel movements to concerns about engorgedbreasts.

Do you and your staff know the appropriate answers to the questions aboutbreastfeeding that are heading your way? Here is a sampling of common questionswe hear in our practices, often over the phone. We show you how to respondwith a brief discussion of the issues each question raises.

Too many bowel movements

My babyhas very loose bowel movements. He is 2 weeks old and is beingbreastfed exclusively.I'm not worried about my milk supply and I'm thoroughlyenjoying nursing, but I am concerned that the baby may have diarrhea.

Bowel movements--too much, too little, wrong color, odd size, interestingsmell--are frequently the subject of calls to the pediatrician's office.

This baby was born at term and roomed in with the mother during the two-dayhospital stay. He wants to nurse 10 times a day, seems content after eachfeeding, is not spitting up or vomiting, and has no fever; no one at homeis sick. That is, he is a breastfeeding champion who is having normal "breastmilk stools," which often look like diarrhea to an anxious first-timemother. They are loose, yellowish, and seedy and could be described as lookinglike mustard mixed with small-curd cottage cheese. They may be passed asfrequently as every feeding and announce their arrival with a rumble.

The breastfed infant with true diarrhea would have loose bowel movementsthat have become much more frequent than usual, watery, foul smelling, andperhaps associated with fussiness, fever, spitting up, or loss of appetite.Any of these signs would warrant close telephone contact and perhaps directingthe mother to come to the office for further evaluation.

Too few bowel movements

My 7-week-old baby has not had a bowel movement for four days. She isdrinking only breast milk. Is something wrong with her?

An extensive history reveals that nothing is wrong with this baby. Sheis hungry and happy. Weight gain at the check-up a week earlier was excellent.The bowel habits in breastfed infants undergo many changes and several moredays may pass before a baby the age of this one has a bowel movement. Inthe nursery, newborns pass thick, sticky, dark-green meconium stools forseveral days; their passage is aided by the cathartic action of colostrum.This stage is followed by a day or two of transition stools.

Once breastfeeding is established, babies pass frequent, loose, yellow,seedy breastmilk stools as described in the preceding question. At about6 to 8 weeks of age, bowel movements may cease--as they have in this infant--forup to a week, much to the concern of parents, who have finally become usedto the frequent, loose stools.1 Even if the baby continues tobe without symptoms, it may comfort the family to have the clinician seethe baby, reassure the parents that nothing is wrong, and present them witha plan for following up. For the baby who is not brought to the office,follow up over the phone is a good idea. This infant was followed with dailyphone calls and passed a large bowel movement on day eight.

Fluoride and well water

Should I give my 2-month-old baby fluoride drops? She is exclusivelybreastfed, and the water in our home comes from a well.

Fluoride supplementation is no longer recommended for infants from birthto 6 months, whether the baby is fed with breast milk or formula. The AAPchanged its guidelines in 1995 to decrease the incidence of dental fluorosisin children living in the US. As shown in Table 1, it recommends fluoridesupplementation for breastfed and formula-fed infants from 6 months to 3years only if the water supply is severely deficient in fluoride (<0.3ppm).2

Vitamin supplements

Why didn't the pediatrician give my baby vitamin drops? One of the mothersI met at my parent group is also breastfeeding a 2-month-old, and her pediatriciangave her baby a prescription for vitamins.

Most healthy infants do not need any vitamin supplementation.3Even though the vitamin D content of human milk appears to be low, breastfedinfants rarely develop rickets. Some authorities believe rickets is unusualin breastfed babies because most of the vitamin D in human milk is in theform of a Vitamin D sulfate analog, which is more readily absorbed thanother forms of the vitamin.4 A similar principle applies to theabsorption of iron in breast milk.

In 1979, investigators reported 24 cases of vitamin D­deficiencyrickets seen over four years at Children's Hospital in Philadelphia.5All 24 patients were black and had been breastfed, and 16 were in familiesof Black Muslims. Investigators hypothesized that the mothers were vitaminD deficient because of their dark skin, occlusive clothing, and restricteddiets.

The AAP recommends that vitamin D be given to infants younger than 6months who are at particular risk for a deficiency: babies whose mothersare vitamin D deficient and those who are not exposed to adequate sunlightbecause of a dark skin color or heavy clothing.6

Vitamin A and vitamin E deficiency are rare in breastfed infants so supplementationwith these vitamins also is not necessary. Vitamin B12 deficiencyhas been reported in North America, but only rarely. Breastfed infants ofstrict vegetarian mothers occasionally have a deficiency in vitamin B12,so pediatricians may consider supplementation in these infants. Prematureinfants, and those who are anemic and therefore have low iron stores, shouldhave iron supplements.

Medications and breastfeeding

Can I take over-the-counter cough medicine and continue to breastfeed?

Most medications, including nonprescription cough medicines, are safefor breastfed infants. Many medications appear in breast milk but only insmall amounts, so the pediatrician should find out about the effects ofa particular medication before advising a mother to stop breastfeeding.There are several resources for medication questions, including the excellentarticle "The transfer of drugs and other chemicals into human milk"andMedications and Mothers' Milk 1998­1999.7­10

A few categories of drugs are not compatible with breastfeeding: chemotherapeuticagents, radiopharmaceuticals, tetracyclines, and drugs of abuse. When packageinserts and other resources describe a medication as having an "unknowneffect," the mother should ask her doctor about finding a substitutemedication that is compatible with breastfeeding. Once an infant has stoppedbreastfeeding it may be difficult to restart, especially if the infant isyoung. If breastfeeding must be stopped, advise the mother about how toobtain and use a hospital-grade, double set-up electric breast pump so hermilk supply can be maintained until she can resume breastfeeding ("pumpand dump" technique).

The sleepy baby

My 7-day-old infant's grandmother has just arrived from out of town andis concerned that the baby is sleeping too much. I thought I just had areally "good baby."Should I worry?

Many mothers assume that if a baby is hungry she will scream and demandfood. But some breastfed infants in the first few weeks of life are "contentto starve," and fail to signal their hunger. These infants seem happyto sleep, fooling parents into thinking they are simply "good babies."

This baby was born at term and sent home on day two. The baby was putto breast while in the nursery but received bottles of formula at nightso the mother could get some sleep. Since arriving home the baby has beenfed only breast milk and is nursing five or six times a day. The infantfalls asleep shortly after starting to breastfeed and sleeps most of theday. She is passing one bowel movement a day; urine output is difficultto quantify because absorbent diapers are being used. The baby needs tobe seen immediately to assess hydration status, weight gain, and latching-ontechniques. The mothers' breasts also should be inspected for inverted nipplesand inadequate or asymmetric breast tissue.

The adequately fed infant will not lose more than 8% of birth weightin the first three to four days of life and then will gain enough weightto return to birth weight by 10 to 14 days.1,11 The mother'smilk will come in by the second to fourth day after birth, During the firstthree months, the baby will feed at least eight to 12 times every 24 hoursand have a daily weight gain of 0.5 to 1 oz (15 to 30 grams). The baby whois being successfully breastfed will produce three or more bowel movementseach day. Some babies are constantly at the breast, but may be unable toextract milk efficiently. The number of stools an infant passes is thereforea more important measure of breastfeeding success than the number of feedsor wet diapers. Table 2 summarizes criteria for assessing adequate nutritionin a breastfed baby.

When a parent asks about a sleepy baby over the phone, it is difficultto determine if the baby needs to be seen. We recommend being conservativeand having the infant brought to the office for a weight check and evaluation.

Newborn sleeps through the night

I'm calling because my wife and I just woke up to discover that our 17-day-oldinfant slept from 11 p.m. to 8 a.m. He is now breastfeeding vigorously andseems fine. Should we be worried?

After asking this panicked father a few questions, we could reassurehim that the baby was healthy and thriving. The infant had nursed frequentlybefore falling asleep--11 times in the last 24 hours--which allowed fora longer sleep. It also was reassuring that the infant was passing frequentbowel movements and had eight wet diapers a day.

Not all babies nurse in the same pattern. Once breastfeeding is established,babies listen to their nutritional and nurturing needs, not the tick ofthe clock. Although most young breastfed babies awaken once or twice duringthe night to nurse, this baby's cluster feeding and elimination patternshowed that he was being adequately fed.

Painful breasts

Please help. Why do my breasts hurt so much and what can I do?

This mother with engorged breasts was in such pain she was crying overthe phone. She had delivered her baby three days earlier and arrived homefrom the hospital the day before she called. The baby had been nursing atthe breast often, but only a small amount of breast milk was coming out.The mother's breasts had become hard and very tender. The baby was findingit difficult to latch on and was crying frequently.

The irony of this situation is that while this mother was in the hospital,she had plenty of help and little milk. Now at home, she has plenty of milkand little help. The key to relieving the engorgement is to express theoverabundant supply of milk to make it less painful for the mother and easierfor the baby to latch on. The mother's options include manual expressionof milk, perhaps in a warm shower; breast soaks in a basin of warm water;expression by pump; and cool compresses or warm packs for pain relief.

To soak the breasts, the mother half fills a clean container with tepidwater. She undresses to the waist and leans over the container--a dishpanis a good size--gently dangling her breasts in the water. The effect ofgravity and the warmth of the water stimulate the flow of milk. After someof the milk has been released and the area at the base of the nipple issoftened, the mother puts the baby to breast. Softening of the nipple andareolar area makes it easier for the infant to latch on and relieve thebreasts of more milk. The mother should be encouraged to breastfeed herinfant frequently for the next few days--and to check in with your officewithin the next 24 hours to report her progress. This mother can be reassuredthat an oversupply of milk and firm breasts are common problems when breastmilk comes in and that relief is on the way.

Preparing to breastfeed

I'm expecting my first child and want to be more successful at breastfeedingthan my sister was. Is there anything I can do in the hospital to improvemy chances?

These tips should be helpful for expectant mothers:

  • The baby should be put to breast as soon as possible after birth, ideally skin to skin within 30 minutes and to breast within the first hour. Usually, the infant is alert the first hour of life, then enters deep sleep for six to eight hours. The baby should also stay with the mother as much as possible during the first few days.
  • Being together 24 hours a day (rooming-in) encourages breastfeeding because the mother can more easily breastfeed frequently and learn the baby's feeding cues. Early cues include rooting, mouthing, increased alertness, hand sucking, and eye movements. Crying, on the other hand, is a late indication of hunger. The new mother should expect her newborn to suck at the breast frequently and for long spells to help initiate milk production. The baby will lose some weight initially; before the milk comes in, the breasts produce small amounts of colostrum, a clear to yellow fluid packed with immune components. For most mothers, copious amounts of breast milk arrive between the second and fourth day of the infant's life.
  • Avoid giving the baby formula, water, glucose water, or pacifiers, and ask the nursery staff to withhold these, too.
  • Ask for a health professional who is knowledgeable about breastfeeding to help with latching-on techniques.
  • If offered a samples of formula to take home from the hospital, say "No, thanks."
  • Check in with the pediatrician or a breastfeeding support person within the first week of delivery.

Every health professional who answers a pregnant woman's questions aboutbreastfeeding should reinforce the mother's decision to breastfeed: "It'sgreat you are interested in breastfeeding since it will give your infantthe healthiest start possible. You can always call us if you have questions."This is a simple but powerful statement.

Falling on the growth charts

At my baby's 6-month checkup her weight was in the 75th percentile, adrop from the 90th percentile when she was 4 months old. Should I be concerned?

Recent studies indicate that breastfed infants grow at different ratesfrom the rates in the National Center for Health Statistics (NCHS) referencegrowth charts, which were derived mostly from bottle-fed babies. The chartsare based on body measurements of 867 children, most of them followed longitudinallyat the Fels Research Institute in Yellow Springs, OH, some years ago.12Recent evidence indicates that breastfed infants grow faster than formula-fedinfants in the first two months of life and less rapidly from three to 12months.13,14 In their second year, breastfed infants gain weightmore rapidly than is the norm on the NCHS charts, so that by 24 months theaverage weight of the breastfed infant is close to the chart median.15

Growth charts for exclusively breastfed babies are available (see "Breastfeedingaids"). Pediatricians may want to plot breastfed infants' growth onthese charts to give breastfeeding moms a different--and more reassuring--assessmentof their babies' growth than the standard charts provide.15

The message is out

The rate of breastfeeding is on the rise, as described in the box,"Encouragingbreastfeeding." As pediatricians support this trend, they also needto prepare for its corollary--an upsurge in questions and concerns. Whetheryou handle these yourself or follow a telephone triage system,18,19you and your staff need to feel comfortable about the information you areprovidingon breastfeeding.

DR. PHILIPP is Assistant Professor of Pediatrics, Boston UniversitySchool of Medicine, Boston, MA, and Medical Director, The BreastfeedingCenter at Boston Medical College.

DR. CADWELL is Lead Faculty at the Healthy Children Project Center forBreastfeeding, Sandwich, MA.

REFERENCES

1. Neifert M: Early assessment of the breastfeeding infant. ContemporaryPediatrics 1996;13(10):142

2. American Academy of Pediatrics, Fluoride Supplementation for Children:Interim Policy Recommendations.Pediatrics 1995;95:777

3. American Academy of Pediatrics, Committee on Nutrition: Vitamin andmineral supplement needs in normal children in the United States. Pediatrics1980;66:1015

4. Lakdawala D, Widdowson E: Vitamin D in human milk. Lancet 1997;1:167

5. Bachrach S, Fisher J, Parks JS: An outbreak of vitamin D­ deficiencyrickets in a susceptible population. Pediatrics 1979;64:871

6. American Academy of Pediatrics Work Group on Breastfeeding: Breastfeedingand the Use of Human Milk. Pediatrics 1997;100:1035

7. American Academy of Pediatrics, Committee on Drugs: The transfer ofdrugs and other chemicals into human milk. Pediatrics 1994;93:137

8. Hale T: Medications and Mothers' Milk 1998­1999. Amarillo, TX,Pharmasoft Medical Publishing, 1998

9. Churchill RB, Pickering LK: The pros (many) and cons (a few) of breastfeeding.Contemporary Pediatrics 1988;15(12):108

10. Lawrence RA: Breastfeeding, A Guide for the Medical Profession, ed5. St. Louis, MO, Mosby, 1998

11. DeMarzo S, Seacat J, Neifert M: Initial weight loss and return tobirth-weight criteria for breast-fed infants: Challenging the "rulesof thumb." Am J Dis Child 1991;145:402

12. Monthly Vital Statistics Report, Health Examination Survey Data fromthe National Center for Health Statistics. HRA 76-1120. Vol 25, No 3 suppl,June 22, 1976

13. Dewey KG, Heinig JM, Nommsen LA, et al: Growth of breastfed and formula-fedinfants From 0 to 18 months: The DARLING study. Pediatrics. 1992;89:1035

14. Dewey KG, Peerson JM, Brown KH, et al: WHO Working Group on InfantGrowth. Pediatrics 1995;96:495

15. WHO Working Group on Infant Growth: An Evaluation of Infant Growth.Geneva, Switzerland, Nutrition Unit, World Health Organization, 1994

16. Ryan AS: The resurgence of breastfeeding in the United States. Pediatrics1997;99(4):e12

17. Healthy People 2000: National Health Promotion and Disease PreventionObjectives. US Dept of Health and Human Services publication PHS 91-50212.Washington, DC, Government Printing Office, 1990

18. Schmitt BD: Calls about sick children: A triage system for the office.Contemporary Pediatrics. 1998;15(7):138

19. Schmitt BD: Calls about sick children: Launching your own triagesystem. Contemporary Pediatrics. 1998; 15(8):49