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How long should I breastfeed?

Babies were born to breastfeed.  It is not just best; it is normal.  Anything other than human breast milk has known and well-documented risks and harms that don’t just last while a baby is nursing but can pervade throughout a person’s life.  For example, scientific research continues to show that formula-fed babies get sick more often and more severely than their breastfeeding counterparts.  Babies who are sustained on formula have higher instances of asthma, ear infections, allergies, diabetes, obesity, childhood cancers, respiratory and gastrointestinal illnesses, and Multiple Sclerosis, to name a few.  Mothers who don’t breastfeed their babies have higher rates of breast, ovarian, and endometrial cancers, retain their baby weight longer, have higher rates of anemia and diabetes, and see an immediate return to menses without sustaining the luxury of natural contraception through breastfeeding (LAM).

Armed with this information, moms who may not have been inclined to breastfeed may decide to try and mothers who were only going to breastfeeding for a couple months may decide to nurse longer. That is wonderful!  But how long should you nurse your child?  What is necessary to garner these benefits and when is breast milk no longer beneficial to your baby?

The World Health Organization states the following:

Breastfeeding is the normal way of providing young infants with the nutrients they need for healthy growth and development.  Virtually all mothers can breastfeed, provided they have accurate information, and the support of their family, the health care system and society at large…Exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond. 1

The American Academy of Pediatrics recommends, “exclusive breastfeeding for about the first six months of a baby’s life, followed by breastfeeding in combination with the introduction of complementary foods until at least 12 months of age, and continuation of breastfeeding for as long as mutually desired by mother and baby.” 2

Great Britain recommends exclusive breastfeeding, “for around the first six months of a baby’s life.  After this, breastfeed alongside other foods for as long as you and your baby wish. This might be into their second year or beyond.” 3

The Public Health Association of Australia recommends breastfeeding according to WHO guidelines, as do most countries around the world.

So, how long should you breastfeed your baby?

Ideally, you would nurse exclusively for the first six months and continue alongside solids for at least the first two years of life.  Then carry on as long as you and your child are happy with your breastfeeding relationship; even considering allowing your child to wean gradually on his own timing.  If left to make the decision on their own (without cultural and sociological factors influencing a child) babies typically self-wean between the ages of 2 ½ – 7, with most being between ages 3-4. 4  This is not always the message women hear in the Western world though!

Breast milk is always beneficial to your baby no matter how long you nurse.  Even toddlers, especially toddlers, need the immunological properties to help fight off all the germs and bacteria that is going in their mouth from toys and playing and that they are contacting daily. Their immature immune systems need mother’s milk to help them fight these bacteria!  Breast milk continues to benefit your child every time she receives it, and there is no age limit for these benefits.

When and how to wean your child are personal decisions.  Being informed about the benefits of breast milk, optimum feeding practices, worldwide health association recommendations for breastfeeding, and listening to you and your baby’s needs are all important pieces to consider.  In the end, weaning because of pressure from family, friends or society as a whole is usually not going to bring a big fanfare for your decision, or a sense a peace and closure to you if everything had been going well but you felt societal pressure to begin the weaning process. As you are pregnant and thinking about breastfeeding, it can be a huge stress reliever and quite relaxing to follow your baby’s breastfeeding cues and make a conscience decision to find joy in this phase of your life and not rush it long.  Get excellent lactation support in the beginning to help get nursing off to a great start, and then follow your heart and your baby’s needs and see where it takes you in your breastfeeding journey.  You may even want to join the ranks of other moms nursing toddlers and be a part of changing our western culture’s idea of breastfeeding duration.  Whatever you choose to do, arm yourself with information and make the decision that is best for you and your baby!


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Medications and Breast Milk

Medications and Breast MilkIntroduction

Most breastfeeding mothers will use some sort of medication while breastfeeding whether it is prescribed from a doctor or herbal in nature.  Many doctors will suggest a mother wean when taking a drug.  However, in actual fact, this is almost always not necessary.  Though most everything which a mother ingests, including medications, will enter her milk, the amount is usually small and the impact on her baby minimal.

How does a drug pass into breast milk?

There are several avenues (passive diffusion, lipid solubility, molecular weight, ion trapping, protein binding, and/or cellular transport system) by which a drug may be able to pass into breast milk.

Passive Diffusion

The most common is passive diffusion – which means that the concentration of a drug in maternal plasma is the same as that in breast milk.  Alcohol is a prime example.  As a mother’s blood plasma levels increase, so does the amount in her milk.  As her levels decrease, the quantity in her milk does as well.  This is why “pumping and dumping” breast milk is not effective to remove alcohol.  Knowing that most drugs pass into breast milk by passive diffusion is immensely helpful in choosing a medication.  Drugs with a short half-life (rather than “long-lasting”) will clear from breast milk quicker.  In fact, many times it is possible to time feedings so that the baby will nurse when levels of a drug in breast milk are already very low for example, right before taking a dose.

Lipid Solubility

The lipid solubility of the medication is another means by which it may transfer to breast milk.  Breast milk has more lipids (fat) than plasma. Therefore, the more lipid soluble a drug, the more likely it is to be found in breast milk.  In fact, a highly lipid soluble drug may have higher concentrations in breast milk than maternal plasma. 1

Molecular Weight

A drug’s molecular weight can be a factor impacting transfer into breast milk.  Medications with a smaller weight (300 daltons or less) can pass into milk more readily that those with weights exceeding 500-800 daltons.  Thus, drugs with high molecular weights (such as insulin) rarely enter breast milk. 2

Ion Trapping

While blood plasma maintains a pH of 7.4, breast milk is slightly more acidic with a pH of 7.2.  A highly alkaline drug may change its ionic state in breast milk and then be unable to pass back out to maternal serum. Therefore it is best to select medications with a lower pKa – ie. drugs that are more acidic. 3

Protein Binding

The ability of a medication to bind to protein (albumin) in the mother’s plasma is yet another factor.  Only the portion of a drug that is unbound can transfer into breast milk.  Ibuprofen is an example of a drug that is highly bound; therefore, little transfers to breast milk. 4

Cellular Transport System

Finally, there are few drugs that seem to have their own cellular pumping system.  Some medications are transported in, and others transported out.  Iodine (especially radioactive) is the most relevant to breastfeeding as this drug is actively pumped into breast milk.  5

Is it true that there are greater concentrations of a drug in breast milk during the first few days following birth?

Yes, this is typically the case.  However, it does not mean that your baby is getting greater doses of the medication through your milk.  The reason for greater drug transfer during the first few days postpartum is due to hormones surrounding lactation.  But since a baby’s total colostrum/milk intake is small, the total amount of drug he receives is still usually negligible.

What should I consider about taking a medication while breastfeeding?

Though any medication has the potential to enter breast milk, it is almost always in small amounts that are not considered harmful to your baby.  Formula has known risks associated with it.  Breast milk is a living substance that is perfectly suited for your baby each and every day.  It is resilient enough to withstand the times a mother has a need for medication and still make milk of excellent quality.  In fact, typically when a drug does enter breast milk, it is in a dose much lower than if the baby were prescribed the medication outright!  So, here are a few things to consider about taking a medication while breastfeeding:

  • Can I delay treatment?
  • Is there an alternative medication that is still effective and would be safer for my baby than what is prescribed?
  • Can I time feeds around the medication so that my baby gets less – ie. nurse then take the medication; not taking a “long-lasting” drug; etc.
  • What is the Relative Infant Dose (RID)?  If it is less than 10% most drugs are considered safe. The RID for most drugs is less than 1%! 6
  • Talk with your doctor about choosing medications that have high protein binding, high molecular weight, poor penetration to central nervous system, short half-life and low oral bioavailability.
  • Select drugs that are commonly considered safe to use with pediatric patients.
  • Watch your baby for any side effects to see how medications affect your baby.

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Toddler Nursing

Why nurse a toddler?

Nursing my Toddler in Public

Nursing my Toddler in Public

Before having children, you probably never gave much thought to nursing a baby, especially beyond the first year.  Then you had a baby and perhaps your breastfeeding relationship was wonderful from the beginning, or perhaps you overcame many struggles to get where you are.  But now, you and your baby are enjoying the special bond that nursing offers, not just with nutrition but also with mothering.  You aren’t  ready to wean and your baby is still going strong, so now you find yourself contemplating nursing a toddler.

Does breast milk continue to provide health benefits?

While the benefits of exclusive breastfeeding for the first six months are an established fact, breast milk continues to have a beneficial impact throughout the toddler years.   The World Health Organization recommends all children be breastfed until age two or beyond.  In fact, there are always nutritional benefits to breast milk, no matter how old your child. 

Breast milk is a living substance with unique properties and antibodies that are made specifically for the bacteria and germs your child is fighting every single day.  As your growing baby becomes more mobile she is confronted with an increasing number of germs from other children and the environment.  Your breast milk will create antibodies to help your child fight these invaders.  As long as you are breastfeeding, your milk provides immunities that will keep your toddler from getting sick as often, and not being as sick when a bug hits.  Breast milk offers health benefits that extend throughout a person’s entire life and the longer a woman breastfeeds the more benefits her body receives as well.

Toddler nursing can help with mothering

There are other reasons to continue nursing your toddler besides just health benefits.  You have probably found it to be a gentle and compassionate way of mothering.  When your toddler falls, or another child takes her toy, or she is tired, or you are traveling, or there are extra stimulants and your child just needs to wind down. . . nursing is a wonderful way to help your child relax, get away, and spend quality time with you. 

And it can be a much-needed respite in your day to have an occasional excuse to sit down and relax for a few minutes.  It can allow you, perhaps remind you even, to soak in your growing toddler and enjoy these fleeting moments that go by so quickly in the busyness of taking care of all the day-to-day things that must be done.

What are the negatives?

On the other hand, you may begin to resent how much time it takes, or wish your child would fall asleep more readily on her own.  This is a common concern of mothers, but, despite what the “sleep experts” say, your toddler still needs you (whether she is fed with a bottle or breast).  These years will pass all too quickly and she will no longer want this quality time with you every day.  With the advent of so much technology, many moms find it easier than ever before to multi-task by using their iPhone, iPad, etc. to catch up on emails, news, or just to make lists, going through what needs to be done and prioritizing.  Alternatively, you can make nursing a time when you “turn off the world around” by either reading a book or taking a little nap yourself while breastfeeding.

What about public breastfeeding?

There seems to be a social stigma attached to nursing a toddler.  Many moms who have already weaned their baby, or perhaps didn’t nurse in the first place, cannot understand why you would still nurse your toddler.  It takes grace to respond in some of these situations, and you may want to consider your answer before someone asks why you “haven’t weaned yet.”  Quite simply, it is a personal decision and if both you and your baby are happy with your relationship there really is no need to stop. . . especially due to pressure of others!

To get around this, some mothers decide to only nurse their toddler in the privacy of their home.  Others choose to try to make toddler nursing more visible by purposely, and respectfully, nursing their toddlers when they are out and about as well.  There is no right or wrong.  What is important is that you do what’s best for you and your baby.  If that is nursing in the toddler years, then don’t let others discourage you!

Getting involved with a breastfeeding support group is a great way to meet other like-minded moms who can support and encourage one another in their breastfeeding journeys.

How do I wean a toddler?

When the time does come for weaning, there are several options.  First, you could wait and allow your toddler to self-wean.  This typically occurs between 2 ½ – 7 years of age.  If you would like to wean your child before she self-weans you can do so gradually or abruptly.  Doing so over a period of a few weeks allows your baby to settle in more readily to the transition.  And, since your child is now a toddler you have the added advantage of being able to talk with her and prepare her gradually.  If you must do so abruptly, make sure to take care of yourself so you don’t end up with engorgement, plugged ducts, or mastitis.


Gradual Weaning

Gradual Weaning

When you first start your breastfeeding journey the thought of weaning seems like a long way away.  Every major pediatric association in the world recommends exclusive breastfeeding for the first six months of life with complementary solids offered alongside breast milk thereafter.  The World Health Organization recommends breastfeeding to continue for up to two years or beyond.  No matter how long you choose to breastfeed your babies, breast milk continues to have benefits for both mother and babies.

But, no matter what your breastfeeding goals, your child will one day wean.  There are several approaches to weaning: mother-led, baby-led, or a combination of both. Mothers may need to wean abruptly, though if this isn’t required then it is easier on a mother’s body and for her baby for gradual weaning to take place.

How old should my baby be when he weans?

Worldwide, taking cultural norms and values out of the equation, human babies will typically wean between the ages of 2 ½ – 7 years old.  1 This is not to say that your baby has to self-wean, or wean between these years.  But, most babies have a need and desire for nursing until this time.

Physically, your baby needs breast milk for the first year of life and if you wean before this time then your milk must be replaced with a substitute (either artificial milk or donor milk). After this time, breast milk can be replaced with foods – which could be foods that the rest of the family already enjoys.  If your baby seems to “wean” before a year, it is actually a nursing strike and you can use strategies for resolving a nursing strike to get through the situation.

What is baby-led weaning and how do I do it?

Baby-led weaning watches your baby’s cues and goes with it.  Sometime around the second half of her first year of life your baby will begin to take an interest in solid foods.  Adding these complementary foods in addition to breastfeeding makes weaning a gradual transition that takes years.  Ideally, during a baby’s first year of life her mainstay would be breast milk.  It is the most nutritious food she can eat, and the various flavors of the milk based on maternal diet help to develop her tastes for a wide variety of foods.  At the same time, babies can explore family foods during mealtime by touching, playing, tasting, and even swallowing them while the rest of the family shares a meal together.  Gradually, your baby will begin to eat more solids and ask to nurse less.  Then she will go through periods where she will want to nurse more (perhaps due to illness, growth spurt, comfort with her favorite person in the world, etc.). What is important is watching your baby’s cues and meeting her needs.  Nursing when she asks/needs and enjoying watching her grow and discover new foods and tastes at the dinner table.  Throughout her toddler years she will continue to nurse alongside food.  With this approach, babies will typically self-wean between the ages of 2 ½ – 7, with most weaning between ages 3-4.  Every baby is different.  Some will sleep through the night from early on and nurse throughout the day.  Others will be so busy throughout the day their rarely nurse during the day, but nurse at night several times.  Some babies want to nurse to go to sleep, or first thing in the morning, or both.

Some mothers find this approach works well, but need to set some parameters – some mother-led weaning as well.  You may decide nursing in the middle of the night is too much and your toddler, who is old enough to understand and negotiate with words, has to wait for the sun to come up to have milk, for example.  The important thing is you find what works for you as you lovingly and gently meet your child’s needs.

What is mother-led weaning and how do I do it?

Mother-led weaning is initiated by the mother, but can be done in a gradual way that helps to make the transition gentle for your baby.  Before beginning to wean, many mothers find it helpful to reflect on their nursing experience and the reasons why they want to wean. Some reasons may include the following:

If you are unsure if you really want to wean your child, make sure to talk with a supportive breastfeeding friend, La Leche League leader, etc. It may be this support is all you need to find clarity and peace in your situation.  Also, realize that it doesn’t have to be all or nothing.  You might reduce the number of times you nurse during the day (say if you must return to work and won’t be able to pump) but continue to nurse at night.  Alternatively, you may negotiate with your child that you only nurse during the day but not during the night. Continuing to nurse when either you or your baby no longer want to can be detrimental to your relationship so it is important to find a solution that works for you both.

Some strategies mothers find helpful in weaning include the following:

  • Not offering to breastfeed but not refusing if baby asks
  • Changing up the daily routine so baby is busy and doesn’t ask to nurse
  • Having snacks prepared and ready so baby eats more solids and is less hungry
  • Postponing breastfeeding or breastfeeding for a shorter duration
  • Having dad take over the bedtime and/or morning routine so the transition is different and easier for baby
  • Avoiding the place(s) where baby was usually nursed
  • Discussing and talking with an older child who can understand with words

Most mothers do a combination of both approaches. What is most important is finding the balance that works for you.  Ultimately it is your breastfeeding journey.  Celebrate your story with all the ups and downs, joys and sorrows, and loving bond with your child that will last a lifetime!

 


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Weaning Twins

Sometimes my twins sat in Bumbo seats while they ate solid foods.

Sometimes my twins sat in Bumbo seats while they ate solid foods.

Twins and higher order multiples (HOMs) have the same needs for breast milk as a singleton.  Every major pediatric association in the world recommends exclusive breastfeeding for the first six months of life with complementary solids offered alongside breast milk thereafter.  The World Health Organization recommends breastfeeding to continue for up to two years or beyond.  No matter how long you choose to breastfeed your babies, breast milk continues to have benefits for both mother and babies.

Though your babies may have been preterm, you may have struggled to build your milk supply while you were separated from your babies in the early days, and/or transitioning to breastfeeding was challenging, if you were able to overcome these obstacles and find yourself nursing your babies there will come a day when they will wean. Worldwide, taking cultural norms and values out of the equation, human babies will typically wean between the ages of 2 ½ – 7 years old.  1 This is not to say that your babies have to self-wean, or wean between these years though.

DSC03559_edited-1There are several approaches to weaning twins: mother-led, baby-led, or a combination of both. Mothers may need to wean abruptly, though if this isn’t required then it is easier on a mother’s body and for her baby for weaning to take place gradually.  Baby-led is directed by the baby and his cues, rather than directed by the mother.  Most twin moms use a combination of both approaches – with the mother watching her babies’ cues but sometimes dropping a feed when necessary. There is no right or wrong way; nursing should be enjoyable for both mothers and babies and if either of you are unhappy then the nursing relationship could cause more harm than good by forcing it to continue.

Physically, your babies need breast milk for the first year of life and if you wean before this time then your milk must be replaced with a substitute (either artificial milk or donor milk). After this time, breast milk can be replaced with foods – which could be foods that the rest of the family already enjoys.  If your babies seem to “wean” before a year, it is actually a nursing strike and you can use strategies for resolving a nursing strike to get through the situation.

It is also important to remember that your babies are individuals and it is completely normal for one baby to self-wean while the other baby continues to nurse – sometimes for months, other times for years!  Watching and responding to your babies cues in this fashion will truly allow you to meet each baby’s unique and individual needs.


Weaning from Pumping

Weaning from Pumping

When the time comes to wean from exclusive pumping there are ways to do this both safely and comfortably.  The following strategies are effective methods for weaning from pumping without having to stop abruptly (which can cause incredible discomfort, clogged ducts, mastitis, and more).  Weaning from pumping gradually will be more comfortable and decrease your chances for difficulties.  Here are three methods:

  1. Delay pumping schedule.
    If you are on a schedule where you have been pumping every 3 hours, for example, then delay pumping to 4-5 hours.  As your body adjusts, delay even longer between sessions. 1
  2. Drop a pumping session.
    If, for example, you have been pumping six times a day, reduce it to five for several days.  Once your body adjusts (usually within 2-3 days) eliminate another pumping session.  After a few weeks you will have eliminated all nursing sessions.  Make sure that as you drop a session you space out the other sessions so that they are about the same interval apart.
  3. Maintain the same number of pumping sessions, but reduce pumping time.
    If you have been expressing for 10 minutes, decrease expression time to 5 minutes, and so forth.  Or, if you have been expressing 3 ounces, only express long enough to acquire 2 ounces.  Do this for a few days as your body adjusts, then repeat reducing the time/amount until you no longer have milk to express.

With any of these strategies, you will be gradually decreasing the amount of milk your body is making.  By draining your breasts more slowly, your body will not replenish milk as quickly.  The longer you are able to go without expressing, the slower your milk production will be.  An empty breast makes more milk.  Therefore, you are trying to delay pumping so milk is not drained as frequently, thereby slowing milk production. 2

Occasionally a mother must wean abruptly.  Please read this information if you find yourself in that situation.

At any point, if your breasts feel full and uncomfortable, you can hand express just enough to relieve your pain.  You don’t want to get in a cycle where you are expressing too much, but you also don’t need to walk around engorged and in tears either!  Remember, if your breasts are too full for too long you increase your chances of plugged ducts and mastitis – the very thing you want to avoid as you are weaning.  Alternatively, rather than expressing just enough to relieve the pain, some women express their breasts completely, but then wait for a longer stretch before pumping again.  Whatever strategy you use, know that your milk supply will decrease and soon dry up completely.  If, at a later time, you have a need or desire to relactate, this, too, has also been done successfully by women all over the world.

Finally, know that you have much to be proud of!  Give yourself a pat on the back for the hard work and dedication you put into expressing your breast milk, either for your little one or a donor milk bank.  Pumping is a labor of love and your determination has been a gift that will impact the health and wellness of your baby throughout his entire life.


Abrupt Weaning

Abrupt Weaning

Weaning begins when a baby is given anything other than breast milk.  For a breastfeeding mother, this typically begins somewhere around the middle of the first year of life when solid foods are introduced and will take place gradually over months or years until a baby is completely weaned from the breast.

Sometimes, however, a mother is in a situation where she must wean abruptly. This can be a very emotional time, especially if this is not what she was planning.  Perhaps there is a medication that is completely incompatible with breastfeeding, a baby has died, or there is another difficult situation.  Whatever the case, there are several things that you should know and do.

  1. Consider mother and baby’s feelings.
    Weaning abruptly can not only be physically painful (due to engorgement, etc.) but it can also be very emotional.  A breastfeeding mother is usually the center of an infant’s world and he will not understand why suckling at the breast is no longer possible.  A mother needs time and support from those around her to grieve, as well as help to make the transition as smooth as possible for both her and her baby.
  2. Change up the daily routine.
    The quick transition to bottles rather than breast will be easier for your baby if you can change up the daily routines, especially where breastfeeding is concerned.  If mom always put baby to bed at night by nursing, for example, it may be helpful for mom to instead give baby a bath, sing songs, read books, and cuddle in another room, and then have dad lie down with baby to go to sleep.  During the day, if the mother is primarily the one at home and baby comes to her throughout the day for nursing, it would be helpful to have a friend or dad home to help with the bottles.  Have plenty of fun foods for baby to eat (if he is over 6 months) and plan some fun things – going to the park, zoo, play group, playground, etc.  Keep him busy and distracted from breastfeeding for a few days.  If your baby is still really young, holding her in a sling can help her feel the closeness that came from breastfeeding.  Ultimately, you are helping your baby understand that there are still lots and lots of love, fun, and cuddles with mom – all throughout the day – but that milk is different and can be fed by another.  Make sure to talk and reassure baby often that mother is still the center of his life; it’s just breastfeeding that is gone.
  3. Watch your breast health closely.
    The possibility of developing engorgement, clogged ducts, and mastitis is strong when abrupt weaning takes place.  You can watch your body’s cues and proactively take precautions to help make this less likely.  Applying ice packs wrapped in cloth to engorged breasts can soothe the pain as can taking an anti-inflammatory such as Ibuprofen.  Wearing a comfortable (larger) bra that is supportive is very helpful.  Chilled cabbage leaves worn inside the bra can provide relief, and be sure to change them every few hours.  Also, many women find drinking sage tea helps to decrease milk supply.
  4. Expression for engorgement may help.
    At any point, if your breasts feel full and uncomfortable, you can hand express just enough to relieve your pain.  You don’t want to get in a cycle where you are expressing too much, but you also don’t need to walk around engorged and in tears either!  Remember, if your breasts are too full for too long you increase your chances of plugged ducts and mastitis – the very thing you want to avoid as you are weaning.
  5. Be proud of the breast milk you gave!
    Every drop of breast milk makes a difference.  You may not have nursed your baby as long as you had hoped, but you gave him the best start to his life possible.  Breastfeeding develops a wonderful bond between you and your baby that can last a lifetime.  You may now be moving into a new stage in your relationship but you have a strong bond at the core.  Celebrate what you were able to give and look forward to watching and being mommy to this sweet little one you have been blessed with as he continues to grow!

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How Much Milk Does My Baby Drink?

How much does my baby drink during a day?

A healthy, full-term baby typically drinks between 25-32 ounces in a 24 hour period between months 1-6.1   This amount remains consistent during months 1-6. So, if you are producing enough milk for your 6 week old then you have enough to exclusively breastfeed your 6 month old as well!

Around the sixth month mark many babies begin to eat solids, resulting in their milk intake slowly declining. However, it is important to note that solids should not replace breast milk during your baby’s first year of life – only compliment your milk.

How much milk will my baby drink while away from me?

Between months 1-6, most babies drink 25-32 ounces a day. If your baby nurses 8 times in a 24 hour period, this is roughly 3 oz per feed.

However babies, like adults, may eat more during one meal and less another. Also, some babies reverse cycle when they are away from their mom during the day – they may drink less milk and then nurse much more frequently when with mom in the late afternoon, evening, and throughout the night.

Safe bed sharing or co-sleeping can be a tremendous benefit in this situation so you can still get rest while your baby gets milk! You will learn what volume of milk your baby needs while you are away, but these numbers can serve as a guide. For example, if you are away for 8 hours, you may need 12 oz (4 – 3 oz feeds, 6 oz – 2 feeds, or something in between). Send extra milk the first few days until you find a rhythm and know about how much your baby needs.


How Medications Affect Baby

Introduction

Knowledge of how a drug enters breast milk is important to understanding how a particular medication can affect your baby, but it is only part of the picture.  It is also critical to evaluate how a baby’s body metabolizes the drug.  Some medications, though they enter the baby’s system via breast milk, are still not able to circulate throughout his body.  Others, though only small amounts may be ingested, are fully utilized and should be used with greater caution.  Therefore, understanding what happens in a baby’s body once the drug enters via breast milk will help in selecting the best medication with the least risk to your baby.  Understanding a drug’s oral bioavailability and half live, as well as evaluating the amount of breast milk consumed and age of baby are all important factors.

What is oral bioavailability?

A drug’s ability to pass into breast milk is only part of the picture.  It is also important to know what happens to the medication once it enters the baby’s system.  A drug’s oral bioavailability is the amount of medication that can reach a baby’s systemic circulation.  This is the only amount of a drug that will usually have an impact.  Some drugs are so poorly absorbed in the infant they are unlikely to cause any problems what so ever.  Therefore, choosing drugs with poor bioavailability is a good strategy.  (Others, though not well absorbed, can become concentrated in the gastrointestinal system and can cause diarrhea, thrush, etc.)

What drugs have poor bioavailability in infants?

According to Breastfeeding and Human Lactation, 4th ed. by Riordan and Wambach, there are a variety of medications with poor bioavailability, thus having a low risk in babies.  These medications are as follows:

  • Heparin
  • Insulin
  • Large molecular weight proteins
  • Interferons
  • Infliximab
  • Etanercept
  • Omeprazole
  • Lansoprazole
  • Aminoglycoside antibiotics
  • Third generation cephalosporins
  • Inhaled beta agonists
  • Inhaled steroids
  • Most topical preparations
  • One-time injection of local anesthetic
  • Acute use of medications (as the overall dose transferred to infant over time is so low)

Half Life

A drug’s “half life” is the time it takes a drug to reduce its plasma concentration by half. So, from the time of ingestion, how long does it take the drug to reduce by half?  Some drugs have a short half life, just a few minutes or hours.  Others have a much longer half life – a few days even.  With breastfeeding, drugs with a shorter half life are better.  It takes five half lives to fully clear a drug from maternal plasma – reducing 50% each time.

A drug with a short half life of say 1-3 hours, could be strategically taken between feeds.  Nursing your baby and then taking the medication could mean the drug is already reduced by half before your baby nurses again.  (Think:  even at the maximum amount of the drug in maternal serum it is probably less than 1% that the baby will ingest via breast milk.  Add to this the ability to time feedings and the amount ingested by the baby will be even less.)

If given the choice between a medication that you take every few hours versus a long-lasting dose ingested less frequently, select the dose you can take more often.

Age and Stage of Baby

The ability of a baby to metabolize a drug is different based on his age. Newborns generally metabolize a drug more slowly than a six month old.  Older infants, 6-18 months, can usually metabolize and handle drugs much more efficiently.  Caffeine is a good example.  It’s half-life in a newborn is 97.5 hours, but 2.6 hours by the time a baby reaches 6 months.

Not only is the age of the baby important, but the quantity of breast milk ingested.  Though more of a medication is able to pass into breast milk during the first few days postpartum, the amount of milk a baby is able to drink is so small he is not ingesting a greater volume of a medication.  Also, a toddler who is only drinking milk a couple times a day is receiving much less of a medication via breast milk than a two month old solely fed on breast milk.

How much of a drug is considered safe?

For most drugs, ingesting 10% of the maternal dose is considered safe. 1  With some drugs (for example, fluconazole and metronidazole) the dose can be much higher than this.  And usually, the dose ingested is less than 1%.  Thus, most medications truly are compatible to take while breastfeeding.  This is especially true in light of the 1000s of studies that show the detrimental side effects of formula.


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Tips for Starting Solids

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Baby-led weaning allows baby to decide what he wants to eat.

When I had my firstborn, I had no idea what to expect as far as breastfeeding and weaning. I only knew I didn’t want to give formula – which meant my goal for nursing was twelve months. Somewhere along the way I realized that breastfeeding was about so much more than nutrition and it was also a wonderful way of mothering.

I loved the closeness we shared, the bond we forged, and the fleeting moments I could steal away with my little girl every day when she was hungry and needed my milk. Being a new mom and not having experience, I listened to everyone’s advice and tried to introduce her to food around the six month mark.

We started with avocado, banana, plain yogurt…and she didn’t care about any of it. All she wanted was her mama’s milk. A month went by and I tried again. . . with no luck. Others advised me to keep trying. . . one mom even said if she didn’t learn how to eat now she never would! This seemed ridiculous and, thankfully, I decided to just go with her cues rather than what everyone advised.

Now that I’ve been through this with three kids, and starting with my fourth, I thought I’d share my “Top 5” list of things I’ve learning about weaning.

    1. Weaning begins from the first time you give something other than your milk.
      But this doesn’t mean that your breastfeeding relationship also has to end right then. Even though babies begin to show an interest in food somewhere around the 6 month mark and can begin to eat complementary foods alongside nursing, breast milk should continue to be the primary nutrition for the first year of a baby’s life. When I first heard that starting solids was the definition of weaning I was so sad! I loved nursing and didn’t want to stop. Thankfully, weaning doesn’t have to go quickly.
    2. Weaning can (and should) take years.
      The World Health Organization says that babies should be breastfed for up to two years or beyond. Now that’s not what we typically hear or see in the western world. . . but it’s what is best for both mom and baby!  We know that breast milk continues to impart nutrition and living enzymes for as long as a baby nurses.And we know that the longer a woman breastfeeds, the lower her chances for developing breast cancer. Of course, there are MANY more health benefits for mom and baby, not to mention the ease in mothering to be able to scoop your toddler in your arms after a fall, a fight, or just for fun and nurse him.  Allowing your baby to wean gradually and slowly is best for both mother and baby.
    3. Baby-led weaning is pretty easy.
      With baby-led weaning there’s no making separate meals, spoon feeding, or extra effort in the kitchen. Your baby joins you at the table and eats (or plays as he learns to eat!) foods that you are already serving. And it allows breast milk to continue to be his primary nutrition throughout the first year of life.My preemie twins were a different story. It was around 8 months that I remember feeling like a cow! Whereas the boys had been nursing 6-8 times a day they both increased to 12-15 times. Each. Developmentally they didn’t act ready for food (they could barely sit up unsupported, didn’t have teeth, couldn’t pinch food with their fingers, and didn’t act terribly interested in our food when we ate).Reluctantly, though, I gave them some plain yogurt and, to my surprise, one of the boys ate the entire bowl – the first time he ever tasted food! His little tongue knew exactly what to do with food. . . and he enjoyed it too! It was a lot of work feeding my boys. And sometimes spoon feeding is necessary. But, in a healthy, full-term baby, I have found baby-led weaning is the way to go.
    4. It’s messy.
      No matter the age when they start feeding themselves, there will be a mess. Some argue that spoon feeding saves them from cleaning up a big mess. I agree. But at some point your baby will have to learn to feed himself and there will be a mess.
    5. It’s a new phase.
      I need to tell myself this every day. I’m one of those moms who absolutely loves nursing my babies and never wants it to end. Yet, it’s a good thing my milk has helped them grow and now they’re ready to eat. It’s exciting to think of this next adventure in their little lives. And, rather than mourning a loss, it should be a time to celebrate a gift and enjoy what’s to come in the next stage.