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	ask the experts kathleen bruce

Kathleen Bruce RN/IBCLC
Breastfeeding

• Babies and water
• Delayed letdown
• Glycerin enema for a five month old
• Buying a used breastpump
• Breastfeeding if the mother has Hepatitis C
• Breastfeeding while taking a (thyroid) hormone replacement.
• 16 months old exclusively breastfeeding, waking every hour at night
• Breastfeeding, sick with a cold, and medications
• Baby with oral thrush
• Breastfeeding and birth control pills

Is it okay for my one month old baby to drink water?

Dear new mother: your one month old breastfed baby does not need water. Breastmilk has a large percentage of water, and therefore, there is no need for the baby to have extra water if she is offered breastmilk and breastfeeding whenever she likes, and she is producing copious amounts of clear urine. If you think your baby is thirsty, offer her small snacks of breastmilk, in addition to full nursing sessions at least 8-10 times in a 24 hour period.

I have a nine month old baby boy, whom I'm breastfeeding. I have noticed that I take very long to get a let down: up to two or three minutes. In those two-three minutes, my son does not seem to swallow any milk at all and he gets very frustrated sometimes. I know it does not sound like a long time but other mothers say their baby has two to three sucks and the letdown is there. Please can you tell me why this is so and if it is normal. I express milk with difficulty as well.

Hi there. It is not unusual, in my experience, for mothers to have a slower letdown reflex as their babies approach one year. One thing to check is to make sure that your milk supply is plentiful. Have you had your period lately? Been ill with a cold or minor illness? Is your baby growing well? Have you been using a lot of bottles with your baby, and has he grown accustomed to the unnaturally fast bottle flow? When you pump, is your pump in good working condition?  Are you giving your baby a lot of solid foods? Babies at this age should be taking a small amount of solids, but breastmilk is still the best food for baby until the baby reaches a year old, and solids can be an important addition, but still in smaller amounts. Are you on any medications that can cause a reduced supply, such as hormonal birth control medications or cold/flu preparations? Have you cut down on the number of times where you breastfeed your baby directly each day? Any of these things can lower your supply, or down-regulate it. This can cause frustration for a baby, especially if the baby is getting used to an abnormally fast bottle flow.

Some quick points to try:

• Consider taking herbs to bolster your supply. Check with your own IBCLC professional for advice, or with your herbalist. Make sure you are not allergic to the herb before taking it.
• Breastfeed your baby more often, especially at night. Use as few bottles as possible, and begin the switch over to a sippee cup if you haven?t begun this already.
• If you have been ill, take a few days to rest up, going to bed with your baby and taking it easy, nursing as much as you can. Avoid medications that cut down on supply such as cold and flu preparations. If you have a head cold, simple saline nose rinses can help, as well as topical nose sprays used on a very limited basis for a few days can cut down on congestion without affecting your milk supply. Ask your doctor for specific recommendations.
• Have your pump checked to make sure that it is working well.  Replace old or worn out rubber gaskets, etc, and call the company to troubleshoot if you think there is a problem when pumping. If you are menstruating, breastfeed more often, resting more and drinking and eating well. Your supply will bounce back in a day or two.
• If you are taking hormonal birth control medication, discuss this with your doctor.  These medications can cause a change in supply, and in letdown as well, as supply drops. Not all mothers react this way, but it does happen with fair frequency in my experience.
• Take every opportunity to breastfeed your baby so that your supply is good.  This will help your letdown happen quickly, as your supply will be plentiful.  It?s easy for some moms to drift into a nursing less/pumping less=I?ve got less milk situation as baby passes the middle of the first year, and mom returns to work, and resumes all the responsibilities of work plus the house, shopping, cleaning.  Get help with some of these, and share the work with your spouse so that you can spend more time with your baby. Babies grow quickly, and the dust will wait, as they say.

My baby is five months old and since the time he was seven weeks old, he only has a bowel movement once a week. If he goes longer than that, I give him a glycerin enema. He eats well and seems otherwise to be healthy. He is exclusively breastfed. Is this normal? Do other babies go this long between pooping? Will the weekly enema harm him? Anything I can do to help the frequency? Last week, stomach massage in a clockwise direction seemed to help.

It is normal for some babies to have infrequent bowel movements. If your baby is one of these babies, and is growing well, happy, healthy, and otherwise doing well, and if the bowel movement does not hurt your baby or cause any discomfort, then things are fine, and no interventions are needed. In any case, babies should not receive glycerin suppositories to promote bowel movements. Babies can become accustomed to this, and may lose their own capacity to have normal regular bowel movements. Some practitioners believe that humans should have multiple bowel movements every day, but this is not what I observe in my practice with infants. Some babies do have frequent bowel movements, but some, like your baby, are perfectly healthy, and have a bowel movement every seven days. Breastfeeding usually helps babies have soft bowel movements, whereas formula with iron can cause constipation, i.e. hard dry bowel movements. Glycerin enemas or suppositories can harm the baby, and therefore, should not be given. I recommend that you keep breastfeeding your baby often. When you start feeding your baby solid foods, at about the middle of the first year, you can begin to include fruits and vegetables in your baby's diet. Massage can help your baby if there is discomfort. But I don't think there is anything really wrong here that needs fixing.

Is it safe to buy a used breastpump? If so, what steps need to be taken to make sure it's sanitary?

The answer to this depends on what type of pump you are considering. Many pumps are personal care items, and cannot be safely shared among mothers. I would suggest contacting the manufacturer of the pump, and checking in to see if their pumps can be safely shared among mothers, depending on design, etc, before purchasing a used unit. Consider the overall working of the pump as well as the cleanliness... Some used pumps have been used extensively, and may not be performing well. These two considerations, cleanliness, and performance, must be considered before purchasing a used breastpump. Manufacturers have information on using pre-owned units, usually by calling customer service, or checking online, or in the original paperwork that comes with each pump. Don't buy unless you are assured of safety and quality. It may be worth an investment to purchase a clean, new unit that is functioning well and that poses no possibility of cross infection.

Is it safe to breastfeed a newborn if the mother has Hep C?

In general, there are very few instances in which mothers should not breastfeed their babies. Mothers with Hepatitis C generally can feel free to breastfeed their babies, according to Ruth Lawrence MD, author of Breastfeeding, A Guide for the Medical Profession. (6th edition). However, mothers with Hepatitis C should note that this decision should be discussed with their health care provider, taking into account other factors that may contribute to the decision. According to the American Academy of Pediatrics, " Breastfeeding is not contraindicated for infants born to mothers who are infected with hepatitis C virus (persons with hepatitis C virus antibody or hepatitis C virus-RNA–positive blood)." (American Academy of Pediatrics. Transmission of infectious agents via human milk. In: Pickering LK, ed. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003:118 –121)

It is hard to measure the risk of transmission of Hepatitis C to a baby via breastfeeding. Nancy Wight MD, a neonatologist active in the breastfeeding
community, in her online article on this subject, states that "Overall the risk of perinatal transmission of HCV appears very low if the mother is
HCV-antibody positive and HCV-PCR negative at the time of delivery. " Also, she notes that " a recent study (where breastfeeding occurred for 3 weeks-4
months) concluded that although anti-HCV antibody and HCV-RNA are present in the colostrum of HCV carrier mothers without HIV coinfection, breastfeeding usually does not cause HCV transmission in their infants and thus should not be discouraged."

Dr. Wight further describes stated that " Prior to nursing, HCV antibody-positive mothers should be counseled regarding breastfeeding. The
known benefits of breastfeeding must be weighed against the probably small, but unknown potential risk of viral transmission with possible later chronic
hepatitis, cirrhosis and liver failure in the infant. The World Health Organization and the American Academy of Pediatrics have not, as yet, come
out with recommendations for developed nations. The US Centers for Disease Control (CDC) does not recommend that breastfeeding be eliminated or
curtailed in mothers positive for anti-HCV."

Any mother who is Hepatitis C positive should talk to her health care provider to discuss her situation, and to get full counseling, including
breastfeeding support and assistance. See Dr. Wights's bibliography and references and the 2005 AAP statement on breastfeeding for more information.

I have a 5 month old daughter and was just diagnosed with hypothroidism and given a prescription for Levoxyl, a (thyroid) hormone replacement. The doctors I've spoken to say that it is fine to breastfeed while taking this hormone replacement. I am wondering what you know about postpartum hypothyroidism and the effects on my baby.

It is not uncommon for post partum mothers to have low thyroid levels, and many times, low thyroid levels are noticed at this time. Extremely low thyroid levels can lower breastmilk supply. Normally, though, if a mother has enough thyroid hormone to become pregnant and maintain a pregnancy, her levels will be fine to maintain lactation. If a breastfeeding mother needs to take thyroid hormone replacement, it is perfectly compatible with breastfeeding. The mother will feel better with the replacement medication, and it is perfectly safe for the breastfeeding baby, because the medication will just bring the mother up to normal thyroid levels. Mothers who do not take hormone replacement can have a variety of health problems, including disturbances in other metabolic levels, exhaustion, hair loss, lack of appetitie, etc. It is unhealthy to remain in this state, and therefore virtually all mothers who are hypothyroid will be given replacement hormone, and that is perfectly compatible with breastfeeding.

If mothers do have this condition, they will want to regularly have their medications adjusted and their levels checked by simple blood test. It would
be important to keep in touch with the health care provider.

I am having two problems that I would love help with. My son is almost 16 months old and he is still exclusively breastfeeding. He refuses all solids. If he does put them in his mouth, he'll chew them up into mush and then spit them out. However, he seems hungry all the time and is nursing around the clock every hour day and night. We are cosleeping and I'd like to move him into his own crib soon but not until I know he's not hungry at night. We are very, very tired, and he seems tired too. My pediatrician has not been very helpful, but we're starting early intervention soon. Have you ever heard of something like this? Is there treatment or resources somewhere that I can look at? Also, how can I know if he's waking every hour at night out of hunger or habit?

I have heard of nursing toddlers like yours, and having had one myself, I can offer you the assurance that he will grow, take solid foods,drink froma cup, and move into his own sleeping space when he is ready. I know that sometimes it seems like forever... But really, they all make this move when the time is right. Do you offer the solids by spoon, or do you sit him next to you in his high chair at meal times and offer him bits of what you are eating, on his tray? I find that that what works best at this age is to put him in his high chair, at meal times, and offer him bits of what you are having, cut very small, placed on his plate on his tray. Don't try to feed him with a spoon. Keep it lowkey, and allow him to experiment with the food, and eat what he wants, even if it is just tiny bits now. You will find the things he enjoys and the things he doesn't, and I recommend putting out different items such as small bits of meat, well cooked veggies, and soft fruits, tiny pieces of whole grain bread, the heal of the loaf toasted, etc. No pressure to eat, no offering on a spoon, just allow him to take care of it. Meal times are social, and he will likely enjoy the time at table with mom and dad. He may spit some out (good thing we had a dog!). I do believe that eventually, he will learn to enjoy food, as the vast majority of children do. Make sure what you put down is healthy, and not fixed with extra sugar or fat, just fresh good food will do. Healthy liquids from a sippee cup will also be good. Breastmilk, water, etc. Solids can provide wonderful nutrients at this time, such as
iron, etc, and are important for proper growth and development, and a good and necessary complement to breastmilk during toddlerhood.

If you are concerned about his spitting food out, having him checked by your pediatrician is a great idea. Did you begin solids at the middle of his first year? Often, a baby will take well to solids when he shows eagerness and readiness for solid foods, sometime in the middle of the first year.

At that time, when baby can sit up alone, and has a pincer grasp (can grasp a small object between his thumb and forefinger, instead of a palmar grasp) is the time when most babies are ready to begin solids. LLLI has a great article on this: Begin the Best Foods at the Best Times

Maybe a second opinion with another health care provider would be good if you didn't get a good response from the first person you worked with. Rarely, children and young toddlers who refuse solid food have other health concerns, and it's a good idea that you are in close touch with your health care provider for support and evaluation, and intervention, if need be.

As for the frequent nursing, it is lucky that he has you and this connection, although I know it can be very tiring to have a toddler who feeds so often. He is fortunate to have such an excellent source of nutrition, and it is important for you to get rest when you can, sleep when he naps, and take good care of your body and your spirit by frequent napping, eating good food, and having some regular exercise. Is he gaining weight well and on his normal growth curve? If so, this is a very good sign. I would investigate other things that might make him unsettled at night such as being cold, teething, painful diaper rash, possible secondary health concerns (is he coming down with a cold, does he have a painful diaper rash? etc.). A thorough health check up is in order to rule out anything out of the ordinary.

It is hard to know, in any case, if it is hunger or habit. It is a baby/toddler's habit to look for comfort where they can find it, and it is the lucky baby to have a place to find it with a nursing mom. If you are all tired, and it's not working well, I suggest that you protect your rest times, and seek further help from your health care provider, and reassurance from organizations such as La Leche League. Many toddlers are up at night, and it can be very tiring. It is a short
period, usually, though, in the scheme of one's life.... And if you can find ways to work around it, and if he is healthy and normal in general, it will pass
quickly. If there do appear to be additional health concerns, you can find support with your health care provider.

I’ve been hearing some good reports concerning this book: The Happiest Baby on the Block: The New Way to Calm Crying and Help Your Baby Sleep Longer by Harvey Karp MD. There are also some great books about this subject available from La Leche League, and one on-line article called Sleeping Like a Baby available from La Leche League

Other written materials that might help from are: Sweet Dreams, Good Nights: The Happy Parent’s Guide to the Family Bed (And a Peaceful Night’s Sleep), Nighttime Parenting, and The No-Cry Sleep Solution available here in the Mothering Shop and at La Leche League.

La Leche League also includes safe sleep guidelines based on Good Nights by Jay Gordon, MD and Maria Goodavage. A good book on feeding infants and toddlers solids is Feeding the Whole Family by Michelle Brode. A good article on keeping family meal times calm and peaceful and toddler-friendly is Food Fight by Joan Randle. Lastly, Jack Newman MD and Theresa Pitman

IBCLC have a great book out entitled The Ultimate Breastfeeding Book of Answers, and in this book is a good chapter on starting solid foods, and feeding solids in general.

I hope this helps. Happy Mothering!

I have been breastfeeding for 6 weeks now and my engorgement has subsided. I have a bad cold, and I would like to know if I should continue to breastfeed, or will this cause my baby to become sick? Are there any medications I can take for this cold, also? Do you know if these would decrease milk supply substantially?

Both babies and adults get colds, and this exposure is what helps us to build strong immune systems. The good news is that when you or your baby catch a cold, breastfeeding will only help you both heal, and may help your baby to have a cold that is much less severe than yours. When you breastfeed, your breast can act as part of your immune system, producing antibodies against whatever virus, etc that causes the initial cold infection. The antibodies can limit the virus’s ability to cause a more severe infection in the infant, and this is why it is important to continue to breastfeed when one has a cold. It is a pro-active and important form of protection for the breastfeeding infant/child. Babies will sometimes become ill when exposed to many viruses and bacteria, but breastfed babies will be able to build their strong immune systems with the mitigating effect that breastfeeding brings to the situation. Children may often get a milder case of an illness due to breastfeeding and the special live properties of helpful and wonderful to settle into a slower pattern of life. Warm drinks, rest, and time can help the healing.

Breastfeeding mothers find that breastfeeding while lying down is a great way to get rest while caring for baby. It is best to talk to your doctor before using medications such as antihistamine/decongestant preparations, as they may not work that well symptomatically, and can have side effects such as sedation, especially in young infants. Caution must been used with over the counter cold medications, especially any product containing pseudoephedrine, as a very recent study shows that these can significantly lower the milk supply. It is not because pseudoephedrine “dries up,” the milk; it is because the prolactin levels do not rise as effectively during breastfeeding the baby when mothers take this drug. 1. (Br J Clin Pharmacol. 2003 Jul;56(1):18-24. Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk. Aljazaf K, Hale TW, Ilett KF, Hartmann PE, Mitoulas LR, Kristensen JH, Hackett LP.)

Some mothers find relief of symptoms by using some over the counter pain relievers, and normal saline nasal spray, both available at the pharmacy. Other nasal medications may be effective as well in reducing significant cold symptoms of congestion, as can nasal rinsing with normal saline (.9%) via a nasal irrigation system such as a Neti pot. Check with your doctor for recommendations on medication use.

If symptoms don’t improve within a 5-7 day time, do see your health care practitioner. Of course, hot soup and a daily nap are always useful.

My 7 week baby seems to have oral thrush but no pain for me, the breastfeeding mama. I am also tandem nursing his 2 year old brother. I started to use grapeseed extract diluted on white patches but no luck there. No poops from the baby for 2 days. Is there any connection? Should I continue GSE? How serious can thrush become?

It is good to have your baby checked by your care provider to make the diagnose of thrush. Thrush is a fungal infection that can occur in both moms and babies. Sometimes, breastfeeding mothers with infected babies have no symptoms, while others can have a great deal of nipple of breast pain. Prior use of antibiotics can make it more likely that candida infections will occur in susceptible mothers. It can also occur in those who have weakened immune systems, diabetes, or serious infections. Once there is a definitive diagnosis of thrush, then treatment can begin for mother and baby and toddler. Have your baby weighed at this time, as well, because if he is not having regular bowel movements, you will want to check in to make sure he is gaining and growing well. There is no clear connection between whitepatches and reduced number of bowel movements. Young babies should have frequent and plentiful bowel movements. If the problem continues, and number of bowel movements is reduced, check with your care provider.

The incidence of candidal infections (thrush or yeast) is increasing due to frequent use of antibiotics. Candida can cause a spectrum of symptoms. For mothers, symptoms can range from no symptoms of pain, to mild itching/soreness to severe pain both in the nipple area, and inside the breast tissue itself. The pain for a breastfeeding mother can be described as shooting or burning pain, and can reach around to the back, being most painful at the end of feedings and in between feedings. It is good that you do not have pain at this time. However, if your baby does have oral thrush, you will want to stop the infection from becoming painful in this way. If candida is present, mothers and babies (including nursing siblings) need to be treated together. This is very important.

Jack Newman MD and T. Pitman IBCLC have an excellent Candida Protocol in their book, The Ultimate Breastfeeding Book of Answers. I suggest this as a good approach to treating yeast. The treatment protocol may include topical medication such as Gentian Violet treatment, (limited time use and effective), compounded ointments for topical use on breast and nipple tissue, oral medication such as Nystatin for baby and toddler, and diluted grapeFRUIT seed extract (not to be confused with grape extract). Note that Nystatin is not very effective against candida. Good hygiene, including washing bras in very hot water, hand washing in between feedings and diaper changes (yeast can be present in the diaper area, presenting as a raised small red rash, fire-engine red, around anal area...), and limiting sugars in the diet have also been suggested. Dr. Newman's candida treatment protocol is a wonderful complete approach to the problem of candida in breastfeeding mothers and babies. It is reproduced, with permission, below.

Your doctor will advise you on which medications are best to use when breastfeeding. For coughs, codeine is considered compatible with breastfeeding when taken for short durations. When taking medications, take them, when possible, after breastfeeding, at the lowest effective dose and for the shortest possible duration. Watch your baby for possible negative effects such as insomnia, irritability, or unusal sleepiness. Avoid products with aspirin, or combination products containing caffeine. 2. (“Use of cough and cold preparations during breastfeeding.” Mitchell JL. J Hum Lact. 1999 Dec;15(4):347-9. Use of cough and cold preparations during breastfeeding. )

It is wise now to get help from your care provider and from a lactation professional such as an IBCLC. (To find an IBCLC in your area, go to the International Lactation Consultant Associations website. If candida is diagnosed in a breastfeeding family, mother and her baby and/or nursing toddler need evaluation and treatment. Sometimes infection can be passed back and forth in a family, with fathers carrying the infection in their genitourinary tract without symptom. Careful family evaluation and treatment can curtail or prevent or shorten candidal infections.

Click here to download the Candida Protocol by Jack Newman MD in pdf format.

I am still breastfeeding my 18-month daughter, and I plan to go on the Minesse birth control pill. I still have an abundant supply of milk and even feel the let-down effect. Will this pill affect my milk production?

Although I realize that hormonal methods of birth control may be convenient for some mothers, they are not my first choice for breastfeeding mothers. While some mothers have no milk supply fluctuations when using hormonal birth control methods, other mothers may experience serious changes in their breastmilk supplies. For this reason, I would suggest checking with your doctor or midwife to explore options for birth control. Although oral medications can be stopped if they are causing negative reactions such as lowered milk supply, it can take time to build supply back it is has been lowered. For mothers who are working outside the home, and who may not be breastfeeding as frequently as they once were, this can be a challenge that is not particular welcome.

My main advice is to consider all the options for birth control, and then to choose what fits most easily into your lifestyle, with the help of your care provider. When considering birth control when breastfeeding, choosing non-hormonal methods of birth control would be my first choice, as it has the least affect of disturbing or decreasing supply of breastmilk, or of impacting breastfeeding.

For more information on medications and breastfeeding, check out the book, Medications in Mothers' Milk by Thomas Hale PhD, RPh. It is available on the web and in bookstores, through La Leche League and here at Mothering. It is a wonderful and inexpensive reference to medications and breastfeeding, and is up to date and well-referenced by this knowledgeable expert, Dr. Thomas Hale.