Breast is Best... Unless it's Not

We've all heard the well-intentioned slogan "Breast Is Best" in reference to supporting breastfeeding. Breastmilk is made just for our babies, so yes, it is a great source of nutrition. But it isn't the only option and there are many reasons mothers give formula and even with exclusive breastfeeding there comes a time that infants need additional sources of nutrition.

I decided to write on this topic because I see so many mothers struggle to feed their baby and they feel like a failure if they don't exclusively breastfeed. And then to top it off I saw a blog that encouraged exclusive breastfeeding without any foods or supplements until one year of age. I knew someone had to counter that thought before it becomes popular. It shouldn't be a badge of honor to breastfeed to the point of potential harm to the infant, and some ultra-crunchy moms are bragging about it as if it is.

You're not a failure if you feed your baby, regardless of what you feed your baby as long as it's age appropriate. Your baby needs nutrition and hydration. While most babies under 6 months of age can get all their nutrition from breastmilk, some need a boost, especially at the beginning of life. If you’re not producing enough milk, you’ll need to give your baby some formula as well (or use a milk donor). Usually this is temporary - just until your own milk supply increases or until your baby starts enough solid foods that the supplement isn’t needed. I'm not suggesting that every newborn who struggles at the breast should be supplemented, but if your doctor says the baby's blood sugar is low or the baby is losing too much weight, it's not only okay, but it's necessary to supplement.

Benefits of Breast Milk

Most of us have heard by now the many benefits of breastfeeding for the baby, including:

• Immune system benefits. (Which means fewer infections, meaning not only helping babies stay healthy, but also leading to fewer lost work days for working parents and fewer sleepless nights for all parents.)
• Decreased risk of Sudden Infant Death Syndrome.
• Decreased risk of asthma in a child who has breastfed.
• Decreased risk of diabetes when the baby grows up.
• Decreased risk of obesity as the baby grows up.
• Decreased risk of certain cancers in the child, such as leukemia.
• Improved cognitive development of the child.

Benefits for mothers include:

• Less bleeding, both in the immediate postpartum period from contracting the uterus after birth, and fewer menstrual cycles during breastfeeding. 
• Decreased risk of getting pregnant while breastfeeding - though this is not 100% effective! If you're not wanting to get pregnant don't rely on breastfeeding alone.
• Easier return to pre-pregnancy weight.
• Decreased risk of ovarian and breast cancers.
• Decreased risk of Type II diabetes.
• Decreased risk of postpartum depression.
• Decreased risk of heart disease.
• Less missed work (see immune system benefits above).
• Cost - breastmilk is free and formula is expensive. Breast pumps should be covered by insurance. 

When Breast Milk Isn't Enough, Isn't Desired, or Isn't Safe

Despite the benefits, breastfeeding not always possible or desired. In the US, 8 out of 10 mothers start breastfeeding during the newborn period. Only half are still nursing at 6 months, and less than a third are still nursing at 12 months.

The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for approximately 6 months, followed by continued breastfeeding for 1 year or longer, as mutually desired by mother and child. Some AAP sources indicate starting foods at 4-6 months. The American Academy of Allergy, Asthma & Immunology (AAAAI) recommends introducing foods between 4 and 6 months to prevent certain allergies.


There are very few contraindications to breastfeeding:

• Classic galactosemia. Classic galactosemia is a rare genetic condition in which a baby is unable to metabolize galactose. It is one of the conditions we screen on the newborn screen. Galactose is the sugar made from the lactose in milk. When galactose is not metabolized, it will reach high levels in the blood and become toxic, causing cataracts in the eyes, damage to the liver and kidneys, and brain damage. The galactosemic baby will fail to thrive on breast milk or formula based on cow's milk. The treatment for this condition is to remove all sources of lactose from the baby's diet and give soy formula.
• HIV. Mothers who have HIV and are able to feed formula made with safe water should not breastfeed according to current guidelines. However, there is growing evidence that HIV positive mothers who take proper medications can safely breastfeed.
• Untreated active tuberculosis.
• Chemotherapy or radiation treatment.
• Certain drugs. Most medications are compatible with breastfeeding. You can look on Lactmed to learn if a particular medicine is safe or what other options are recommended. 

Some mothers do not want to breastfeed for various reasons. That's okay. It isn't for everyone. No one should say things that make these mothers feel guilty. They brought new life into the world. That alone is an amazing feat. As long as the baby is fed age-appropriate and formula that has been approved for use in infants, it is great.

Babies can thrive on formula. Just be careful of the many alternate formulas and milks that are advertised online. Discuss with your child's pediatrician if you plan on making your own formula or giving another alternative milk. There are many concerns with these, as discussed in Please Don’t Feed Your Baby Homemade Formula!

Some mothers really want to exclusively breastfeed but they have problems. Working with a lactation consultant and physicians (both mother's and baby's doctors) might help if there is a correctable condition, such as

• insufficient breastfeeding attempts per 24 hours - not feeding frequently decreases supply
• tongue tie treatment can improve latch and milk transfer from the breast into baby
• jaundice, which makes baby sleepy and not feed as effectively
• identifying and treating hormonal problems in mother
• identifying and stopping medicines or herbs that might be inhibiting milk supply
• stopping nipple shields as soon as possible - the use of nipple shields can decrease breast stimulation and lower supply
• avoid unnecessary supplements - supplementing with formula can decrease supply overall because the mother's breast makes milk based on how much is used (This does not mean you should avoid formula if it is medically necessary.)

Even when breastfeeding goes well for both Mother and Baby, it is not sufficient to be the sole source of nutrition for the entire first year of life. There are some mom blogs that support exclusive breastfeeding for the first year of life, and that is not safe. I'm not linking any of them here because I don't want to promote them, but if you don't believe me just do a quick search and you will find some.

While breast milk is fantastic for young infants, it does not have the nutritional components to exclusively feed for the second half of the first year. Feeding with food from fingers or a spoon also encourages healthy development of fine motor skills.

It is important for older infants to learn to eat from a developmental standpoint. Once they can sit fairly well, turn away from food or open their mouth in response to food, they are showing signs that they are ready to start eating. They don't need teeth to move foods around in their mouth and make chewing motions. 

They are much less averse to new things typically when they're younger, so if babies are delayed past a year they are much more likely to be picky eaters and not get the nutrition they need during childhood.

Then there's the research that shows that delaying certain foods past a year increases the risk of allergy. If you've ever seen a child with anaphylaxis to peanuts, you won't want to increase this risk for your child! See the AAP's guidance on introduction of high-risk allergenic foods. 

Babies need a source of iron after about 4-6 months of age. If they are not eating foods rich in iron (meats, legumes, egg yolk, leafy greens) they will need an iron supplement. Many of the bloggers who support exclusive breastfeeding do not want any supplements at all. Just breast milk. It simply isn't enough to support the older infant's growing brain and body. 

Vitamin D is important for us all, but it is not passed through breast milk well unless a mother is taking at least 6400 IU/day. Historically we could make vitamin D with the help of the sun, but we now know that sun damages our skin so it is safer to protect against excessive sun exposure. This puts us at risk for vitamin D deficiency. The AAP recommends that newborns begin supplementing with 400 IU/day of vitamin D soon after birth, and increase to 600 IU/day at 6 months of age. The supplement should continue even if they transition to Vitamin D fortified cow's milk at 1 year of age.

Any problems feeding should be discussed with your child's doctor

If your baby struggles with feeding, whether it's breastfeeding, formula feeding, or eating foods, please discuss it with your child's doctor. There are many reasons feeding might not go well, and we need to insure that your baby is being adequately fed. We will look at your baby's overall growth and development in addition to discussing the specific details of the problems. 

Resources

Breastfeeding landing page for the American Academy of Pediatrics
Vitamin D & Iron Supplements for Babies: AAP Recommendations

Related Blogs on Quest for Health

Over and Under Supply of Breast Milk

Feeding Your Newborn

Breastfeeding: Easier for Working Moms with New Insurance Rules

New SIDS Prevention Guidelines

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Stool colors & patterns in infants: What's normal & when should you worry?

Help! My baby is constipated. She hasn't pooped for days.

We hear versions of this all the time.

Constipation isn't defined by how often babies have a bowel movement. A breastfed baby might have a bowel movement every time he eats (and in between) or he might go less than once a week. (Watch out when it finally comes - it often escapes the diaper!) Most formula fed babies have a bowel movement 1-3 times a day. Babies who get some breast milk and some formula can have characteristics of each feeding type.

During the first few days of life the stool looks black and is thick. This is called meconium. It occurs in both breast fed and formula fed babies. If your baby doesn't have meconium within 24 hours of birth an evaluation to decide if there's a problem should be done. Be sure to talk with your baby's doctor if he doesn't poop within 24 hours of birth or if the meconium is formed like a plug. (See a photo on Stanford's newborn page.)

Meconium stool. Photo by Azoreg via Wikimedia Commons

After the first few days there is a period of transition stool. The stools become more green and sticky. This is the meconium mixed with breastmilk or formula stools. It happens earlier in formula babies and after mother's milk comes in for breast fed babies.

After the transitional stools, the stools will vary in color and consistency depending on if the baby gets breastmilk or formula. If breastmilk is the primary food, the stools can vary quite a bit. They often look like yellow cottage cheese, with a lot of liquid and chunks. It often becomes a bit thicker (like pudding) as a baby gets older. It is not diarrhea just because it is watery. Breast fed stools can vary in shades of yellow to brown or green, often changing depending on what the mother ate. Bright green and frothy stools can indicate a low fat diet in a breast fed baby. The fore milk has less fat than the hind milk, so if the baby consistently has frothy bright green stools we will monitor the baby's weight closely to ensure adequate growth and evaluate the amount of milk the mother is producing and baby is drinking.

If a baby is taking formula, the stools can look shades of yellow and brown and be the consistency of peanut butter, pudding, or thick oatmeal. Formula fed stools tend to smell more foul than breast milk stools, but even breast fed baby poops can stink.

Once a baby eats solids (or pureed foods) the stools can thicken a bit but should never be hard. They usually become more foul smelling at this time. Sometimes chunks of food (especially carrots, corn, and raisins) can be seen in the stool. This is normal.

If a baby takes an iron supplement the stools might turn dark green or black. This is normal and not a concern. This does not happen from the amount of iron in baby formula. All formula should have iron. It is an important nutrient for all babies and low iron formula is not recommended.

What's important?

• A term baby should gain about 15-30 grams per day after the first week of life.
• Blood in the stool can be from swallowed blood (often from a crack in mother's nipple), constipation, food allergy (usually cow's milk protein), or infection and should be evaluated.
• It is normal to have different shades of yellow, brown, and green stools.
• A baby with a swollen (distended) abdomen and discomfort or a change in feeding patterns should be examined.
• A baby should not have formed stools as long as they are on primarily breast milk or formula.
• Poop should never be a shade of white (liver concerns), red (blood), or black -if not on iron supplements (digested blood).
• Mucus in stool could be simply swallowed mucus but can be a sign of infection or food allergy.

Feeding Your Newborn

I wrote today's blog as a new web page for our office website, but it works well for here too...

Determining what to feed your baby is a big decision when you become a parent. Regardless of whether babies get breastmilk, formula, or a combination of both, the most important thing to remember is that they need to be hydrated and get the nutrition needed to grow. Many parents are guilted into choosing one feeding over another based on friend's or family's opinions. Some parents have a feeding plan that simply doesn't work. You must choose what works best for you and your baby! Remain flexible if needs change.

Breastfeeding is the ideal way for many babies to be fed. Just a few reasons breast is best: it protects against illness, helps prevent allergies, is inexpensive, and even helps the mother in many ways! The American Academy of Pediatrics recommends breastfeeding for as long as mother and baby mutually desire. We think it is ideal to use exclusive breastmilk for 4-6 months, then add foods with breastmilk until at least 1 year of age.

Ideal does not mean this is the only option. Despite being natural, it is not always easy (or even possible) for mothers to breastfeed. We recognize this and support all parents in feeding their infants a nutritionally sound milk - whether it is formula or breastmilk.

Problems breastfeeding? We have several pages of breastfeeding topics on this link.

Some babies are born with a short frenulum under the tongue. Many people refer to this condition as "tongue-tied" (medically called ankyloglossia). Sometimes affected children may have trouble feeding or later talking. If it is a problem feeding in the newborn period, one of our physicians can clip the frenulum (the part that "ties" the tongue down) and release the tongue so it can move better. We will be happy to discuss and evaluate if you feel your child will benefit from this procedure.

We also have a Nurse Practitioner and nurse available in our office who have additional breastfeeding education (not IBLCE certified) and can coordinate a lactation consultant (IBLCE certified) to visit with you in our office or at your home. Just ask!

Formula has come a long way over the years to becoming more tolerable and nutritious. There are as many reasons parents use formua as there are brands available. There are even several varieties within each brand, making which formula to use a difficult choice for some. We support partially hydrolyzed formula as an initial formula for most babies who will take formula to reduce risks of milk protein sensitization. Soy formulas and lactose free formulas are not generally recommended unless there are specific medical needs. Discussion of why we have these recommendations is found on How to Choose What to Feed. There may also be benefit to whey formulas over casein products. Discuss any formula changes with your provider. We don't want babies to be on a new formula every other day... they don't tend to tolerate that well and it is difficult to determine their response to changes if they are made too frequently.

How much to feed? This common question varies by age and size of your baby. In general the first few feedings are measured in milliliters, regardless if breast or bottle feeding. Too much too soon tends to come back up!

Breastfed babies usually do well on colostrum alone until milk comes in (around day 3-4). They typically feed immediately after birth, but then are sleepy until about 24 hours of age, so might need encouragement to eat. We expect them to lose up to 10% of their birth weight during the first week. We want them to feed at least 8 times per 24 hours, which averages to about every 3 hours. They should wet at least 1 diaper the first day, 2 wet diapers the 2nd day, and 3 diapers the 3rd day. By day 4, milk should be in and they should have wet diapers about every time they eat. Some urine might hide in stool, so if they are feeding well, stooling, and not losing excessive weight, don't worry if they don't seem to be making urine. Most mothers will work with a lactation consultant and their nursery nurse while in the hospital. We watch their weight carefully until weight gain is established. Term babies should be back to birth weight by 2 weeks of age.  

Formula fed infants typically take 10-15 ml with the initial feed. They eat about every 3 hours (range 2-4 hours), and slowly increase the amount of formula to about 30ml (one ounce) per feed over the first days. When they show hunger sooner than their schedule, it means they are ready to increase the volume per feed. Like breastfed babies, we expect them to lose weight the first week, although typically less is lost compared to a breastfed baby. By the end of the first week they take about 60ml (2 ounces) every 3 hours. They should be back to birth weight by their 2nd week birthday. By the end of the first month they take about 24 ounces per 24 hours (average 3 oz every 3 hours).

For more on feeding volumes, see Feeding Your 0-2 Month Old.