Jack Newman, MD, FRCPC

A lactation aid is a device which allows a breastfeeding mother to supplement her baby with expressed breastmilk, formula or glucose water with added colostrum (glucose water alone should only be used, in general, in the first day or two after birth) without using an artificial nipple. The early use of an artificial nipple may result in the baby becoming "bottle spoiled" or "nipple confused" because it interferes with the way a baby latches on to the breast. The better a baby latches on, the easier it is for him to get milk. If the baby does not get milk well from the breast, he may fall asleep or push away from the breast when the flow of milk slows down. Thus the baby may refuse the breast, be very fussy at the breast, gain weight poorly, lose weight or even become dehydrated. The mother may develop sore nipples. Though artificial nipples do not 

 cause problems, their use when things are already going badly will rarely make things better, and usually make things worse. The lactation aid is 

. (However, proper latching on of the baby

 usually allows the baby to get more milk, and thus it is often possible to avoid the supplement). It is better than using a syringe, cup feeding, finger feeding or any other method, since the baby is at the breast and breastfeeding. Babies, like adults, learn by doing. Furthermore, the baby supplemented 

 is also getting breastmilk from the breast. 
 
 A lactation aid consists of a container for the supplement-usually a feeding bottle with an enlarged nipple hole-and a long, thin tube leading from this container. Manufactured lactation aids are available and are easier to use in 

 situations, but not necessarily so. Manufactured lactation aids are particularly useful when the need for a lactation aid arises in an older baby, when a mother needs to supplement twins, when the need for a lactation aid will be long term, or whenever difficulty arises using the improvised lactation aid. Though the manufactured lactation aid is not inexpensive, the cost is about equal to 2 weeks of the usual milk based formula. 
 

 Using a tube with a syringe, with or without a plunger, instead of the setup mentioned above, seems unnecessarily complicated and adds nothing to the effectiveness of the technique. On the contrary, it is more cumbersome. 
 
 

 The baby may be latched on to the breast first, and the tube slipped into the baby's mouth at the appropriate time. The better the latch, the better the baby will get your milk and the easier the aid will be to use, and the more quickly you will be able to get rid of the supplements. The breast should be 

 eased out of the way so that the corner of the baby's mouth is seen, and the tube, held between the index finger and thumb, should be slipped into the corner of the baby's mouth so that it enters 

 towards the back of the baby's mouth and at the same time, upwards towards the roof of the mouth. The tube is well placed when the supplemental fluid works its way down the tube at a rather rapid rate. There is usually no need to fill the tube with supplemental fluid before putting it into the baby's mouth. 
 
 

 Or, the baby is latched on to the breast and the tube, which is run along the mother's breast and nipple, at the same time. The better the baby's latch, the easier the lactation aid is to use. Also, the better the latch, the more likely and the more rapidly the baby will be able to do without the lactation aid. Therefore, proper positioning and latching on of the baby are still very important. 
 
 

 The tube may be taped to the breast if the mother desires, though this is not really necessary and not always helpful. 
 
 

 The tube does not need to pass the end of the nipple and needs to be only just past the baby's gums to function properly. It does seem to function better if the tube is placed in the corner of the baby's mouth and enters 

 into the baby's mouth over the tongue. (Point it to the roof of the baby's mouth). It is occasionally helpful for the mother to hold the tube in place with her finger, as some babies tend to push the tube out of position with their tongues. 
 
 

 The bottle containing the supplement should 

 ordinarily be higher than the baby's head. If the lactation aid functions 

 when the bottle is held higher than the baby's head, something is wrong. Keep the bottle higher only if this is suggested by the doctor or lactation specialist. 
 
 

 Unless otherwise instructed, it is best to use the tube with every feed, though some mothers find it easier not to use it during the night. 
 
 

 Do not cut off the end of the tube. It works fine as it is. 
 
 

 It should not take an hour for the baby to drink an ounce of milk from the lactation aid. If it is taking this long, the tube is probably not well positioned, or the baby is poorly latched on, or both. When the lactation aid is functioning well, it takes 15-20 minutes, usually less, for the baby to take an ounce of the supplement. 
 
 

 Do not boil the tube of the non-manufactured aid. It is not made to be boiled. 
 
 

 After using the device, clean the bottle and nipple as usual. Do 

boil the tube. The tube should be emptied after use and then rinsed through with hot water (suck up hot water into the tube from a cup) and then hung up to dry. Soap, though not necessary, may be used if desired, but rinse the tube well. Tubes may become stiff and unsuitable for use after about a week. 
 
 

Weaning the Baby from the Lactation Device

 Maintain contact with the breastfeeding clinic for advice about weaning the baby from the lactation aid. 
 
 

 Weaning the baby from the aid may take several weeks or only a short while. Do not be discouraged and do not try to force the weaning. Usually, the amount of milk required in the lactation aid increases over 1-2 weeks, then levels out for a variable period of time before decreasing. The whole process may take 2-8 weeks, although some mothers have used the device only a few days, whereas others have not been able to stop it at all. Rapid improvement sometimes occurs after a long period of little change. 
 
 

 Observe the baby's nursing. If you do not know how to know if the baby is drinking, ask. Put the baby onto the breast, allow the baby to nurse as long as he is suckling and 

, then use breast compression (handout #15 

; then repeat the process on the second breast. You can return to the first breast and continue back and forth as long as the baby is 

. After you have finished feeding on both breasts, insert the tube into the baby's mouth. Allow the baby to nurse until satisfied using the lactation aid. 
 
 

 The bottle of the lactation aid can be lowered 6-12 inches below the baby's head, but do this only if the baby is drinking 

Handout #5. Lactation Aid. Revised January 1998

JACK NEWMAN, MD, FRCPC is a pediatrician, a graduate of the University of Toronto medical school. He started the first hospital-based breastfeeding clinic in Canada in 1984. He has been a consultant with UNICEF for the Baby Friendly Hospital Initiative in Africa. Dr. Newman has practiced as a physician in Canada, New Zealand, and South Africa.

May be copied and distributed without further permission.

Articles

A lactation aid is a device which allows a breastfeeding mother to supplement her baby with expressed breastmilk, formula or glucose water with added colostrum (glucose water alone should only be used, in general, in the first day or two after birth) without using an artificial nipple.

Using a Lactation Aid

Breastfeeding mothers frequently ask how to know their babies are getting enough milk. The breast is not the bottle, and it is not possible to hold the breast up to the light to see how many ounces or millilitres of milk the baby drank. Our number obsessed society makes it difficult for some mothers to accept not seeing exactly how much milk the baby receives. However, there are ways of knowing that the baby is getting enough. In the long run, weight gain is the best indication whether the baby is getting enough, but rules about weight gain appropriate for bottle fed babies 

 who is obtaining lots of milk at the breast sucks in a very characteristic way. The baby generally opens his mouth fairly wide as he sucks and the rhythm is slow and steady. His lips are turned out. At the maximum opening of his mouth, 

. Then, the baby closes his mouth again. This pause does 

 refer to the pause between suckles, but rather to the pause 

 as the baby opens his mouth to its maximum. 

Each one of these pauses corresponds to a mouthful of milk

 and the longer the pause, the more milk the baby got. At times, the baby can even be heard to be swallowing, and this is perhaps reassuring, but the baby can be getting lots of milk without making noise. Usually, the baby's suckle will change during the feeding, so that the above type of suck will alternate with sucks that could be described as "nibbling". This is normal. The baby who suckles as described above, with several minutes of pausing type sucks at each feeding, and then comes off the breast satisfied, is getting enough. The baby who nibbles only, or has the drinking type of suckle for a short period of time only, is probably not. This is the 

 of knowing the baby is getting enough. This type of suckling can be seen on the very first day of life, though it is not as obvious as later when the mother has lots more milk. 
 
 

 For the first few days after delivery, the baby passes meconium, a dark green, almost black, substance. Meconium accumulates in the baby's gut during pregnancy. Meconium is passed during the first few days, and by the 3rd day, the bowel movements start becoming lighter, as more breast milk is taken. Usually by the fifth day, the bowel movements have taken on the appearance of the normal breast milk stool. The normal breast milk stool is pasty to watery, mustard coloured, and usually has little odour. However, bowel movements may vary considerably from this description. They may be green or orange, may contain curds or mucus, or may resemble shaving lotion in consistency (from air bubbles). The variation in colour does not mean something is wrong. A baby who is breastfeeding only, and is starting to have bowel movements which are becoming lighter by day 3 of life, is doing well. 
 
 Without your becoming obsessive about it, monitoring the frequency and quantity of bowel motions is one of the best ways of knowing if the baby is getting enough milk. After the first 3-4 days, the baby should have increasing bowel movements so that by the end of the first week he should be passing at least 2-3 

 yellow stools each day. In addition, many infants have a stained diaper with almost each feeding. 

A baby who is still passing meconium on the fifth day

 should be seen at the clinic the same day. A baby who is passing only brown bowel movements is probably not getting enough, but this is not yet definite. 
 
 Some breastfed babies, after the first 3-4 weeks of life, may suddenly change their stool pattern from many each day, to one every 3 days or even less. Some babies have gone as long as 15 days or more without a bowel movement. As long as the baby is otherwise well, and the stool is the usual pasty or soft, yellow movement, this is not constipation and is of no concern. 

, because no treatment is necessary or desirable for something that is normal. 
 
 Any baby between 5 and 21 days of age who does not pass at least one substantial bowel movement within a 24 hour period should be seen at the breastfeeding clinic the same day. Generally, small infrequent bowel movements during this time period means insufficient intake. There 

 definite exceptions and everything may be fine, but it is better to check. 
 
 

(not just wet) diapers in a 24 hours hour period, after about 4-5 days of life, you can be sure that the baby is getting a lot of milk. Unfortunately, the new super dry "disposable" diapers often do indeed feel dry even when full of urine, but when soaked with urine they are heavy. It should be obvious that this indication of milk intake does not apply if you are giving the baby extra water (which, in any case, is unnecessary for breastfed babies, and if given by bottle, may interfere with breastfeeding). The baby's urine should be clear as water after the first few days, though an occasional darker urine is not of concern. 
 
 During the first 2-3 days of life, some babies pass pink or red urine. This is not a reason to panic and does not mean the baby is dehydrated. No one knows what it means, or even if it is abnormal. It is undoubtedly associated with the lesser intake of the breastfed baby compared with the bottle fed baby during this time, but the bottle feeding baby is 

 the standard on which to measure breastfeeding. However, the appearance of this colour urine should result in attention to getting the baby well latched on and making sure the baby is 

only if the baby is well latched on can he get his mother's milk.

 Giving water by bottle or cup or finger feeding at this point does not fix the problem. It only gets the baby out of hospital with urine which is not red. If relatching and breast compression do not result in better intake, there are ways of giving extra fluid without giving a bottle directly (handout #5 

). Limiting the duration or frequency of feedings can also contribute to decreased intake of milk. 
 
 

The following are NOT good ways of judging
 

 After the first few days or weeks, it is usual for most mothers not to feel full. Your body adjusts to your baby's requirements. This change may occur quite suddenly. Some mothers breastfeeding perfectly well never feel engorged or full. 
 
 

 Not necessarily. A baby who is sleeping through the night at 10 days of age, for example, may, in fact, not be getting enough milk. A baby who is too sleepy and has to be awakened for feeds or who is "too good" may not be getting enough milk. There are many exceptions, but get help quickly. 
 
 

 Although the baby may cry after feeding because of hunger, there are also many other reasons for crying. See also handout #2 

4. The baby feeds often and/or for a long time.

 For one mother every 3 hours or so feedings may be often; for another, 3 hours or so may be a long period between feeds. For one a feeding that lasts for 30 minutes is a long feeding; for another it is a short one. There are no rules how often or for how long a baby should nurse. It is 

 that the baby gets 90% of the feed in the first 10 minutes. Let the baby determine his own feeding schedule and things usually come right, if the baby is suckling and 

 at the breast and having at least 2-3 substantial yellow bowel movements each day. If that is the case, feeding on one breast each feeding (or at least finishing on one breast before switching over) will often lengthen the time between feedings. Remember, a baby may be on the breast for 2 hours, but if he is actually breastfeeding (open-

-close type of sucking) for only 2 minutes, he will come off the breast hungry. If the baby falls asleep quickly at the breast, you can 

compress the breast to continue the flow of milk

). Contact the breastfeeding clinic with any concerns, but wait to start supplementing. If supplementation is truly necessary, there are ways of supplementing which do not use an artificial nipple (handout #5 

5. "I can express only half an ounce of milk".

 This means nothing and should not influence you. Therefore, you should not pump your breasts "just to know". Most mothers have plenty of milk. The problem usually is that the baby is not getting the milk that is there, either because he is latched on poorly, or the suckle is ineffective or both. These problems can often be fixed easily. 
 
 

6. The baby will take a bottle after feeding.

 This does not necessarily mean that the baby is still hungry. This is not a good test, as bottles may interfere with breastfeeding. 
 
 

7. The 5 week old is suddenly pulling away from the breast but still seems hungry.

 This does not mean your milk has "dried up" or decreased. During the first few weeks of life, babies often fall asleep at the breast when the flow of milk slows down even if they have not had their fill. When they are older (4-6 weeks of age), they no longer are content to fall asleep, but rather start to pull away or get upset. The milk supply has not changed; the baby has. Compress the breast (handout #15 

) to increase flow. 
 
 Please Note: On occasion, it may be necessary to supplement a baby who is breastfeeding. If this is done by bottle, a bad situation may become worse. A lactation aid is a method of supplementing without giving a bottle and may allow you to supplement temporarily and get back to exclusive breastfeeding. It is generally easy to use. In an "emergency" situation, extra fluid can be given by spoon, cup or eyedropper until a lactation aid can be started. 
 
 

 Scales are all different. We have documented significant differences from one scale to another. Weights have often been written down wrong. A soaked cloth diaper may weigh several hundred grams (half a pound or more), so babies should be weighed naked. 
 
 

 Many rules about weight gain are taken from observations of growth of formula feeding babies. They do not necessarily apply to breastfeeding babies. 

A slow start may be compensated for later, by fixing the breastfeeding.

Handout #4. Is My Baby Getting Enough? Revised January 1998

Breastfeeding mothers frequently ask how to know their babies are getting enough milk. The breast is not the bottle, and it is not possible to hold the breast up to the light to see how many ounces or millilitres of milk the baby drank.

Is My Baby Getting Enough Milk?

 
 
 The best treatment of sore nipples is 

. The best prevention is latching the baby on properly from the first day. 
 
 Sore nipples are usually due to one or both of two causes. 

Either the baby is not positioned and latched properly, or the baby is not suckling properly, or both.

 Incidentally, babies learn to suck properly by getting milk from the breast when they are latched on well. (They learn by doing). Fungal infection (due to 

), may also cause sore nipples. The soreness caused by poor latching and ineffective suckle hurts most as you latch the baby on and usually improves as the baby nurses. The pain from the fungal infection goes on throughout the feed and may continue even after the feed is over. Women describe knifelike pain from the first two causes. The pain of the fungal infection is often described as burning, but may not have this character. 

 of nipple pain when feedings had previously been painless is a tip-off that the pain may be due to a yeast infection, but the pain may come on gradually or may be superimposed on pain due to other causes. Cracks may be due to a yeast infection. 
 
 

 
 It is not uncommon for women to experience difficulty positioning and latching the baby on. Proper positioning facilitates a good latch and good latching reduces the baby's chances of becoming "gassy", and also allows the baby to control the flow of milk. Thus, poor latching may also result in the baby not gaining adequately, or feeding frequently, or being colicky (handout #2 

-For the purposes of explanation, let us assume that you are feeding on the 

Good positioning facilitates a good latch. A lot of what follows under latching comes 

 if the baby is well positioned in the first place. 
 


 At first, it may be easiest to use the 

 to position your baby for latching on. Hold the baby in your right arm, the web between your thumb and index finger 

(not behind his head) with your fingers (except for the thumb) supporting the baby's face from underneath, and your forearm supporting his back and buttocks. Hold the baby's buttocks between your chest and your forearm-this should give you good control. The baby should be almost horizontal across your body and should be turned so that his chest, belly and thighs are against you with a slight tilt so the baby can look at you. Hold the breast with your left hand, with the thumb on top and the other fingers underneath, fairly far back from the nipple and areola. 
 
 The baby should be approaching the breast with the head 

tilted backwards. The nipple then automatically points to the roof of the baby's mouth. 

(See handout on positioning and latching on.)

 
 1. Now, get the baby to open up his mouth 

. The way to do this is to run your nipple, still pointing to the roof of the baby's mouth, along the baby's mouth, 

, from one corner of the mouth to the other. Or you can run the baby along your nipple, something some mothers find easier. 

Wait for the baby to open up as if yawning. WAIT FOR HIM. 

As you bring the baby toward the breast, his 

 should touch your breast first. 
 
 2. When the baby opens up his mouth, use the arm that is holding him to bring him onto the breast. Don't worry about the baby's breathing. If he is properly positioned and latched on, he will breathe without any problem. If he cannot breathe, he will pull away from the breast. Don't be afraid to be vigorous. 
 
 3. If the nipple still hurts, use your index finger to pull down on the baby's chin in order to bring the lower lip out. You may have to do this for the duration of the feed, but this is usually not necessary. 
 
 4. The same principles apply whether you are sitting or lying down with the baby or using the football hold. Get the baby to open wide, don't let the baby latch onto the nipple, but get as much of the areola (brown part of breast) into the mouth as possible (not necessarily the whole areola). 
 
 5. There is no "normal" length of feeding time. If you have questions, call the clinic. 
 
 6. A baby properly latched on will be covering more of the areola with his lower lip than with the upper lip. 
 
 

 
 The baby learns to suckle properly by nursing and by getting milk into his mouth. The baby's suckle may be made ineffective or not appropriate for breastfeeding by the early use of artificial nipples or from poor latching on from the beginning. Some babies just seem to take their time developing an effective suckle. Suck training and/or finger feeding (handout #8 

"My nipple turns white after the baby comes off the breast"


 The pain associated with this blanching of the nipple is frequently described by mothers as "burning", but generally begins only after the feeding is over. It may last several minutes or more, after which the nipple returns to its normal colour, but then a new pain develops which is usually described by mothers as "throbbing". The throbbing part of the pain may last for seconds or minutes and may even blanch again. The cause would seem to be a spasm of the blood vessels in the nipple (when the nipple is white), followed by relaxation of these blood vessels (when the nipple returns to its normal colour). Sometimes this pain continues even after the nipple pain during the feeding no longer is a problem, so that the mother has pain only after the feeding, but not during it. What can be done? 
 
 1. Pay careful attention to getting the baby to latch onto the breast properly. This type of pain is almost always associated with, and probably caused by whatever is causing your pain during the feeding. The best treatment is the treatment of the other causes of nipple pain. 
 
 2. Heat (hot washcloth, hot water bottle, hair dryer) applied to the nipple immediately after nursing may prevent or decrease the reaction. Dry heat is usually better than wet heat, because wet heat may cause further damage to the nipples. 
 
 3. On occasion, we have had to use a medicated paste (nitroglycerine) or an oral medication (nifedipine) to prevent this type of reaction. 
 
 

 
 
 l. Nipples can be warmed for short periods of time after each feeding, using a hair dryer on low setting. 
 
 2. Nipples should be exposed to air as much as possible. 
 
 3. When it is not possible to expose nipples to air, plastic dome-shaped breast shells (

 nipple shields) can be worn to protect your nipples from rubbing by your clothing. Nursing pads keep moisture against the nipple and may cause damage that way. They also tend to stick to damaged nipples. If you leak a lot you can wear the pad over the breast shell. 
 
 4. Ointments can sometimes be helpful. If you do use an ointment, use just a very small amount 

 wash it off. 
 
 5. Do not wash your nipples frequently. Daily bathing is more than enough. 
 
 6. If your baby is gaining weight well, there is no good reason the baby must be fed on both breasts at each feeding. It may save you pain, and speed healing if you feed your baby on only one breast each feed. It will help to compress the breast (handout #15 

), once the baby is no longer swallowing on his own in order to continue his getting milk. You may be able to manage this some feedings, but not others. In very difficult situations, a lactation aid can be used to supplement (preferably expressed milk), so that the baby will finish the feeding on the first side. 
 
 If you are unable to put the baby to the breast because of pain, in spite of trying all the above measures, it may still be possible to continue breastfeeding after a temporary (3-5 days) cessation to allow the nipples to heal. During this time, it would be better that the baby 

 be fed with a rubber nipple. Of course it is also best for you and the baby if the baby is fed your expressed milk. Use the technique called "finger feeding" (handout #8 

) or cup feeding. 
 
 Nipples shields are not recommended for sore nipples, because, although they 

 help temporarily, they usually do not. They may also cut down the milk supply dramatically, and the baby may become fussy and not gain weight well. Once the baby is used to them, it may be impossible to get the baby back onto the breast. In fact, many women who have tried nipple shields find that they do not help with soreness. Use as a last resort only, but 

Handout #3 Sore nipples. Revised January 1998

Sore nipples are usually due to one or both of two causes. Either the baby is not positioned and latched properly, or the baby is not suckling properly, or both. Incidentally, babies learn to suck properly by getting milk from the breast when they are latched on well.

Sore Nipples

Colic is one of the mysteries of nature. Nobody knows what it really is, but everyone has an opinion. In the typical situation, the baby starts to have crying periods about two to three weeks after birth. These occur mainly in the evening, and finally stop when the baby is about 3 months of age (occasionally older ). When the baby cries, he is often inconsolable, though if he is walked, rocked or taken for a drive, he may settle temporarily. For a baby to be called colicky, it is necessary that he be gaining weight well and be otherwise healthy.

The notion of colic has been extended to include almost any fussiness or crying in the baby, and this may be valid, since we do not really know what colic is. There is no treatment for colic, though many medications and behaviour strategies have been tried, without any proved benefit. It is admitted that everyone knows someone whose baby was cured of colic by a particular treatment. It is also admitted that almost every treatment seems to work-for a short time, anyhow.

Aside from the colic that any baby may have, there are three known situations in the breastfed baby which may result in fussiness or colic. Once again, it is assumed that the baby is gaining adequately and that the baby is healthy.

Human milk changes during a feeding. One of the ways in which it changes is that the amount of fat increases as the baby nurses longer at the breast. If the mother automatically switches the baby from one breast to the other during the feed, before the baby has "finished" the first side, the baby may get a relatively low amount of fat during the feeding. This may result in the baby getting fewer calories, and thus feeding more frequently. If the baby takes in a lot of milk (to make up for the reduced concentration of calories), he may spit up. Because of the relatively low fat content of the milk, the stomach empties quickly, and a large load of milk sugar (lactose) arrives in the intestine all at once. The protein which digests the sugar (lactase) may not be able to handle so much milk sugar at one time and the baby will have the symptoms of lactose intolerance--crying, gas, and explosive, watery, greenish bowel movements. This may occur even during the feeding. These babies are 

 lactose intolerant. They have problems with lactose because of the sort of information women get about breastfeeding. 

 a reason to switch to lactose free formula.

a) Do not time feedings. Mothers all over the world have breastfed babies successfully without being able to tell time. Breastfeeding problems are greatest in societies where everyone has a watch and least where no one has a watch.

b) The mother should feed the baby on one breast, as long as the baby breastfeeds, until the baby comes off himself, or is asleep at the breast. If the baby feeds for only a short time only, the mother can compress the breast (handout #15 Breast Compression) to keep the baby nursing. Please note that a baby may be on the breast for two hours, but may actually feed for only a few minutes. In that case the milk taken by the baby may still be relatively low in fat. This is the rationale for compressing the breast.

 If, after "finishing" on the first side, the baby still wants to feed, offer the other side.

c) The next feeding, the mother should start the baby on the other breast in the same way.

d) The mother's body will adjust quickly to the new method, and she will not become engorged or lop sided.

e) Just as there should be no "rule" for feeding both breasts at each feeding, there should be no rule for one breast per feeding. Let the baby finish on one breast (compress milk into his mouth if necessary to keep him swallowing longer) but if he wants more, then offer the other side.

f) In some cases, it may be helpful to feed the baby two or more feedings on one side before switching over to the other side for two or more feedings.

g) This problem is made worse if the baby is not well latched on to the breast. A proper latch is the key to easy breastfeeding.

A baby who gets too much milk too quickly, may become very fussy, very irritable at the breast and may be considered "colicky". Typically, the baby is gaining very well. Typically, also, the baby starts nursing, and after a few seconds or minutes, starts to cough, choke or struggle at the breast. He may come off, and often, the mother's milk will spray. After this, the baby frequently returns to the breast, but may be fussy and repeat the performance. He may be unhappy with the rapid flow, and impatient when the flow slows. This can be a very trying time for everyone. On rare occasions, a baby may even start refusing to take the breast after several weeks, typically around three months of age.

a) If you have not already done so, try feeding the baby one breast/feed. In some situations, feeding even two or three feedings on one breast before changing to the other breast may be helpful. If you experience engorgement on the unused breast, express just enough to feel comfortable.

b) Feed the baby before he is ravenous. Do not hold off the feeding by giving water (a breastfeeding baby does not need water even in very hot weather) or a pacifier. A ravenous baby will "attack" the breast and cause a very active letdown reflex. Feed the baby as soon as he shows any sign of hunger. If he is still half asleep, all the better.

c) Feed the baby in a calm, relaxed atmosphere, if possible. Loud music, bright lights and lots of action are not conducive to a successful feeding.

d) Lying down to nurse sometimes works very well. If lying sideways to feed does not help, try lying flat on your back with the baby lying on top of you to nurse. Gravity helps decrease the flow rate.

e) If you have time, express some milk (an ounce or so) before you feed the baby.

f) The baby may dislike the rapid flow, but also become fussy when the flow slows too much. If you think the baby is fussy because the flow is too slow, it will help to compress the breast to keep up the flow (handout #15 Breast Compression).

h) This problem is made worse if the baby is not well latched on to the breast. A good latch is the key to easy breastfeeding.

i) On occasion giving the baby commercial lactase (the enzyme that metabolizes lactose), 2-4 drops before each feeding, relieves the symptoms. It is available without prescription, but fairly expensive, and works only occasionally.

j) A nipple shield may help, but use this only if nothing else has helped and only if you have gotten good help without any relief.

k) As a last resort, rather than switching to formula, give the baby your expressed milk by bottle.

It has been shown that some proteins present in the mother's diet may be excreted into her milk and may affect the baby. It would seem that the most common of these is cow's milk protein. Other proteins have also been shown to be excreted into some mothers' milk. 

 The fact that these proteins and other substances appear in the mother's milk is not necessarily a bad thing. Indeed, it should be considered a good thing. 

 Ask about this if you have any questions.

Thus, in the treatment of the colicky breastfed baby, one step would be for the mother to stop taking dairy products. These includes milk, cheese, yogurt, ice cream and anything else which may contain milk. When the milk protein has been changed (denatured), as in cooking for example, there should be no problem. Ask if you have any questions.

Please note: Intolerance to milk protein has nothing to do with lactose intolerance. A mother who is herself lactose intolerant should also still breastfeed her baby.

a) The mother should eliminate all milk products for 7-10 days.

b) If there has been no change, the mother can reintroduce milk products.

c) If there has been a change for the better, the mother should then slowly reintroduce milk products into her diet, if these are 

 part of her diet. (There is no need to drink milk in order to make milk). Some babies tolerate absolutely no milk products in the mother's diet. Most tolerate some. The mother will learn what amount of dairy products she can take without the baby reacting.

d) If there is concern about your calcium intake, calcium can be had without taking dairy products. Ask if you have any questions. One week off milk products will not cause any problems. Actually, evidence suggests that breastfeeding may protect the woman against the development of osteoporosis even if she does not take extra calcium. And the baby will get all he needs.

e) The mother should be careful about eliminating too many things from her diet. Everyone will know someone whose baby got better when the mother stopped broccoli, beef, bananas, bread etc. The mother may find that she is eating white rice only. Our diets are too complex to be sure exactly what, if anything, is affecting the baby.

Be patient, the problem usually gets better no matter what. 

, though, because of the more regular flow, some babies do improve on it. But formula is not breast milk. In fact, 

the baby would also improve on breast milk from the bottle

 because of the regularity of the flow. Even if nothing works, time usually helps. The days and nights may seem eternal, but the weeks will fly by.

Handout #2 Colic in the breastfed baby. Revised January 1998

Colic is one of the mysteries of nature. Nobody knows what it really is, but everyone has an opinion. In the typical situation, the baby starts to have crying periods about two to three weeks after birth.

Colic in the Breastfed Baby

Breastfeeding is the natural, physiologic way of feeding infants and young children milk, and human milk is the milk made specifically for human infants. Formulas made from cow’s milk or soy beans (most of them) are only superficially similar, and advertising which states otherwise is misleading. Breastfeeding should be easy and trouble free for most mothers. A good start helps to assure breastfeeding is a happy experience for both mother and baby. 
 
 The vast majority of mothers are perfectly capable of breastfeeding their babies exclusively for four to six months. In fact, most mothers produce more than enough milk. Unfortunately, outdated hospital routines based on bottle feeding still predominate in many health care institutions and make breastfeeding difficult, even impossible, for some mothers and babies. For breastfeeding to be well and properly established, a good early few days can be crucial. Admittedly, even with a terrible start, many mothers and babies manage. 
 
 The trick to breastfeeding is getting the baby to latch on well. A baby who latches on well, gets milk well. A baby who latches on poorly has difficulty getting milk, especially if the supply is low. A poor latch is similar to giving a baby a bottle with a nipple hole which is too small-the bottle is full of milk, but the baby will not get much. When a baby is latching on poorly, he may also cause the mother nipple pain. And if he does not get milk well, he will usually stay on the breast for long periods, thus aggravating the pain. Here are a few ways breastfeeding can be made easy: 
 
 1. The baby should be at the breast immediately after birth. The vast majority of newborns can be put to breast within minutes of birth. Indeed, research has shown that, given the chance, babies only minutes old will often crawl up to the breast from the mother’s abdomen, and start breastfeeding all by themselves. This process may take up to an hour or longer, but the mother and baby should be given this time together to start learning about each other. Babies who "self-attach" run into far fewer breastfeeding problems. This process does not take any effort on the mother’s part, and the excuse that it cannot be done because the mother is tired after labour is nonsense, pure and simple. Incidentally, studies have also shown that skin to skin contact between mothers and babies keeps the baby as warm as an incubator. 
 
 2. The mother and baby

 should room in together. There is absolutely no medial reason for healthy mothers and babies to be separated from each other, even for short periods. Health facilities which have routine separations of mothers and babies after birth are years behind the times, and the reasons for the separation often have to do with letting parents know who is in control (the hospital) and who is not (the parents). Often bogus reasons are given for separations. One example is the baby passed meconium before birth. A baby who passes meconium and is fine a few minutes after birth will be fine and does not need to be in an incubator for several hours’ "observation". 
 
 There is no evidence that mothers who are separated from their babies are better rested. On the contrary, they are more rested and less stressed when they are with their babies. Mothers and babies learn how to sleep in the same rhythm. Thus, when the baby starts waking for a feed, the mother is also starting to wake up naturally. This is not as tiring for the mother as being awakened from deep sleep, as she often is if the baby is elsewhere when he wakes up. 
 
 The baby shows long before he starts crying that he is ready to feed. His breathing may change, for example. Or he may start to stretch. The mother, being in light sleep, will awaken, her milk will start to flow and the calm baby will be content to nurse. A baby who has been crying for some time before being tried on the breast may refuse to take the breast even if he is ravenous. Mothers and babies should be encouraged to sleep side by side in hospital. This is a great way for mothers to rest while the baby nurses. Breastfeeding should be relaxing, not tiring. 
 
 3. Artificial nipples should not be given to the baby. There seems to be some controversy about whether "nipple confusion" exists. Babies will take whatever method gives them a rapid flow of fluid and may refuse others that do not. Thus, in the first few days, when the mother is producing only a little milk (as nature intended), and the baby gets a bottle (as nature intended?) from which he gets rapid flow, he will tend to prefer the rapid flow method. You don’t have to be a rocket scientist to figure that one out, though many health professionals, who are supposed to be helping you, don’t seem to be able to manage it. Nipple confusion includes not just the baby refusing the breast, but also the baby not taking the breast as well as he could and thus not getting milk well and /or the mother getting sore nipples. Just because a baby will "take both" does not mean that the bottle is not having a negative effect. Since there are now alternatives available if the baby needs to be supplemented (see handout #5 Using a Lactation Aid, and handout #8 Finger Feeding) why use an artificial nipple? 
 
 4. No restriction on length or frequency of breastfeedings. A baby who drinks well will not be on the breast for hours at a time. Thus, if he is, it is usually because he is not latching on well and not getting the milk which is available. Get help to fix the baby’s latch, and use compression to get the baby more milk (handout #15 Breast Compression). This, not a pacifier, not a bottle, not taking the baby to the nursery, will help. 
 
 5. Supplements of water, sugar water, or formula are rarely needed. Most supplements could be avoided by getting the baby to take the breast properly and get the milk that is available. If you are being told you need to supplement without someone having observed you breastfeeding, ask for someone to help who knows what they are doing. There are rare indications for supplementation, but usually supplements are suggested for the convenience of the hospital staff. If supplements are required, they should be given by lactation aid (see handout #5), not cup, finger feeding, syringe or bottle. The best supplement is your own colostrum. It can be mixed with sugar water if you are not able to express much at first. Formula is hardly ever necessary in the first few days. 
 
 6. A proper latch is crucial to success. This is the key to successful breastfeeding. Unfortunately, too many mothers are being "helped" by people who don’t know what a proper latch is. If you are being told your two day old’s latch is good despite your having very sore nipples, be skeptical, and ask for help from someone who knows. 
 
 Before you leave the hospital, you should be shown that your baby is latched on properly, and that he is actually getting milk from the breast and that you know how to know he is getting milk from the breast (open-pause-close type of suck). If you and the baby are leaving hospital not knowing this, get help quickly. 
 
 7. Free formula samples and formula company literature are not gifts. There is only one purpose for these "gifts" and that is to get you to use formula. It is very effective, and very unethical, marketing. If you get any from any health professional, you should be wondering about his/her knowledge of breastfeeding and his/her commitment to breastfeeding. "But I need formula because the baby is not getting enough!". Maybe, but, more likely, you weren’t given good help and the baby is simply not getting your milk well. Get good help. Formula samples are not help. 
 
 Under some circumstances, it may be impossible to start breastfeeding early. However, most medical reasons (maternal medication, for example) are not true reasons for stopping or delaying breastfeeding, and you are getting misinformation. Get good help. Premature babies can start breastfeeding much, much earlier than they do in many health facilities. In fact, studies are now quite definite that it is easier for a premature baby to breastfeed than to bottle feed. Unfortunately, too many health professionals dealing with premature babies do not seem to be aware of this.

Handout #1. Breastfeeding-Starting Out Right. Revised January 1998

Breastfeeding is the natural, physiologic way of feeding infants and young children milk, and human milk is the milk made specifically for human infants.

Breastfeeding--Starting Out Right

Breastfeeding is as good as combined contraceptive pills (about 2% failure rate) if 

the following conditions apply (no exceptions):

3. the baby is exclusively breastfeeding (or near exclusively)

4. there is no prolonged period (greater than 6 hours?) when the baby does not nurse

For those of little faith, breastfeeding can be combined with other contraceptive methods. However, the "other methods" do not have to be the pill.

the pill is often used because it is easy     for the physician and too often the needs of the couple are 

breastfeeding is hardly ever a consideration     in the equation

contraception is an intimate issue, and has     complex and multiple facets including:

the question of when to return to sexual     relations, and what that might entail

a mother might not want to have an iud     inserted, or have to take the pill

it takes longer for a man to become a father     than for a woman to become a mother

non artificial methods (coitus interruptus)

medroxyprogesterone injections (DepoProvera)

Conception before about 4 weeks postpartum     must be extremely uncommon

there is virtually no risk of ovulation in     the fully breastfeeding woman up to about 6 weeks

use progestin only pills, which have not     been shown to decrease milk supply

combined pills should not be used until at     least the baby is feeding other foods (not usually earlier than 4 months of     age) so that a decrease in the milk supply can be compensated by an intake     in food

Babies respond to milk flow, not the     "amount of milk in the breast". Thus, they may not breastfeed     well, even if the decrease in supply is relatively minor

a little harder to use, and may result in     pregnancy if not taken consistently

they may result in menstrual irregularities,     not usually a problem in the first few months as women are amenorrheic     anyway

Hartmann has theorized that the     sensitization of alveolar cells to the stimulating effect of prolactin     happens in response to a 

this might have great significance in     situations where the injection is given on hospital discharge

there have been anecdotal reports of     women’s milk supply decreasing with progesterone and/or     medroxyprogesterone injections

the manufacturer recommends waiting six     weeks postpartum before giving the injection

If the mother is to be given medroxyprogesterone injections:

1. do not give injection on discharge from hospital

 in     milk supply after first cycle, give medroxyprogesterone

if there is, stop progestin only pill     immediately and do not give medroxyprogesterone

1. WHO task force on oral contraceptives. Effects of hormonal contraceptives on breastmilk composition and infant growth. Studies in Family Planning. 1988;19:361-9

2. Fraser IS. A review of the use of progesteron-only minipills for contraception during lactation. Reprod Fertil Dev 1991;3;245-54

3. Visness CM, Rivera R. Progestin only pill use and pill switching during breastfeeding. Contraception 1995;51:279-81

Breastfeeding is as good as combined contraceptive pills (about 2% failure rate) if all the following conditions apply (no exceptions):