News

Breastfeeding is a subject that affects and interests new mothers universally. In fact, it seems that everyone - maternal or not - has an opinion on the matter.

Dr. Jack Newman, who specializes in helping mothers succeed with breastfeeding,  will be answering reader questions on breastfeeding, along with his associate Edith Kernerman.

Answers to select questions are available at the bottom of this page.

Dr. Jack Newman has worked as a physician in Central America, New Zealand and South Africa. He founded the first hospital-based breastfeeding clinic in Canada in 1984.

He was a staff pediatrician at the Hospital for Sick Children emergency department from 1983 to 1992. Once the breastfeeding clinic started functioning, he eventually worked full time helping mothers and babies succeed with breastfeeding. He now works out of one clinic based at the Canadian College of Naturopathic Medicine.

Dr. Newman has several publications on breastfeeding, and in 2000 published, along with Teresa Pitman, a help guide for professionals and mothers on breastfeeding, called Dr. Jack Newman's Guide to Breastfeeding. In 2005, he and others brought out a DVD for breastfeeding called Dr. Jack Newman's Visual Guide to Breastfeeding.

Edith Kernerman is an IBCLC and a lactation educator in Toronto, Canada and she is co-founder, co-owner, and co-director of the Newman Breastfeeding Clinic & Institute. She is the author of the Gameplan for Protecting and Supporting Breastfeeding in the First 24 hours of life and Beyond: A Guide for Healthcare Professionals, and is the co-creator of the new lactation tool: L-eat: the Elite way to Latch: Empower, Attach, Transfer. She helped redesign and update the Immediate Post Partum Breastfeeding Decision Tree by Jack Newman.

In 2005, Ms. Kernerman founded the International Meeting of the Minds, and continues her work toward minimizing contradictory and conflicting information in the lactation world by encouraging discourse among experts in particular areas of lactation. She is researching the Importance of Skin to Skin Care: Breastfeeding and Empowerment in the First Hour of Life for her book, How to Breastfeed the Baby Who Does Not Latch. Ms. Kernerman is the mother of two breastfed daughters.

Editor's Note: The usual guidelines that apply to live discussions will also apply to this Q&A. globeandmail.com editors will read and allow or reject each question/comment. Comments/questions may be edited for length or clarity. We will not publish questions/comments that include personal attacks on participants in these discussions, that make false or unsubstantiated allegations, that purport to quote people or reports where the purported quote or fact cannot be easily verified, or questions/comments that include vulgar language or libellous statements. Preference will be given to readers who submit questions/comments using their full name and home town, rather than a pseudonym.

S R Frostad from Regina Beach, SK Canada writes: I nursed my first child for 15 months. My second child only nursed for nine months. I am now pregnant with my third child and would like to nurse past the first year again. I am interested in knowing what suggestions you have to prolong nursing when the infant doesn't seem too interested. Thank-you.

Jack Newman: Often mothers are told or think a baby is "self-weaning". However babies do not self wean at 9 months. Usually something has happened. Either the milk supply has decreased or the baby is getting a lot of bottles (or both). We have a patient information sheet at www.drjacknewman.com that discusses reasons milk supply might decrease after a mother has had a good or even abundant milk supply. The point is then, to avoid these situations that may result in the milk supply decreasing.

For example, and this may have nothing to do with your situation, mothers are often told that they should feed the baby only one breast at a feeding. It is not a good idea to feed the baby on just one side, to follow a rule. Yes, making sure the baby "finishes" the first side before offering the second can help treat poor weight gain or colic in the baby, but rules and breastfeeding do not go together well. If the baby is not drinking, actually getting milk, there is no point in just keeping the baby sucking without getting any milk for long periods of time. You should "finish" one side and if the baby wants more, offer the other.

How do you know the baby is "finished" the first side? Because the baby is no longer drinking, even with compression (see the video clip and information sheet on compression at the website www.drjacknewman.com . This does not mean you must take the baby off the breast as soon as the baby doesn't drink at all for a minute or two (you may get another milk ejection reflex or letdown reflex, so give it a little time), but if it is obvious the baby is not drinking, take the baby off the breast and if the baby wants more, offer the other side. How do you know the baby is drinking or not? See the video clips at the above website.

If the baby lets go of the breast on his own, does it mean that the baby has "finished" that side? Not necessarily. Babies often let go of the breast when the flow of milk slows, or sometimes when the mother gets a milk ejection reflex and the baby, surprised by the sudden rapid flow, pulls off. Try him again on that side if he wants more, but if the baby is obviously not drinking even with compression, switch sides.

Krystyne Ferguson from Toronto Canada writes: I am wondering how to increase my breastmilk production without using the herbs or medications as they are contraindicated with my current blood pressure medications? I have been breastfeeding my 4 month old part time (because I don't produce enough breastmilk, she is still hungry after I breastfeed her) about 3 times per day. I also try and pump about 2-3 times per day. I'd like to continue breastfeeding her but am starting to give up hope as she is always hungry post feeding. Is there any advice you can offer to me so I can continue to breastfeed? Thank you, Krystyne from Toronto

Jack Newman: Although you don't mention which medications you are taking, I don't think it is true that you cannot take domperidone or herbs with the medication. Indeed I'd be very surprised if this were the case. So I would reconsider the situation again and think seriously about domperidone.

Also, it would be important to get the baby off the bottles. Give the baby solids instead off a spoon. Yes, you can. The recommendation from Health Canada is to breastfeed exclusively to about 6 months, not "no solids to six months". Since you are already not breastfeeding exclusively, why not solids instead of bottles. You can add formula to the solids. See the website www.drjacknewman.com for the information sheet on starting solids.

M B from Canada writes: I am a mother of a 10 month old daughter and am returning to work next week. I would like to continue breastfeeding whenever possible and have heard that I can feed in the morning and in the evening and anytime she wants it on the weekend. My milk supply has never been great, however. Any advice on how I can keep my milk supply up? On a related note, how long does it take for your milk to change volume when demand changes?

Thank you.

Jack Newman: Yes, you can express your milk at work. Canada is a signatory of the International Labour Organization's document that breastfeeding mothers get an extra 30 minutes twice a day to go home and breastfeed or express their milk (1919, yes, almost 100 years ago). Your employer should be happy to provide you with space and encouragement. You can also take your baby into bed with you at night so that she has the opportunity to breastfeed more frequently. Often babies will find the breast at night without even waking the baby up. Also I would make sure whoever is taking the baby during the day doesn't feed the babies bottles. A baby this age should be able to drink from a cup or milk can be added to the solids she eats.

I would add that formula is not necessary at this age. Indeed, the "need" for formula to a year does not apply to breastfed babies and in fact, is not necessary for artificially fed babies either if they are eating a wide variety of foods in adequate amounts.

Your milk production should change rather rapidly with change in demand. Often within a few days.

Catherine Bosworth from Toronto Canada writes: I have been breastfeeding my newborn son with varying degrees of success for just about a month now. Things were going reasonably well until a few days ago, when he started to continually pull himself off the breast and start fussing. Even when he is clearly hungry, he latches on fine and then pulls himself right back off. Any thoughts on why this would be happening, and what I might be able to do to get him back on track?

Thanks.

Jack Newman: Babies pull, fuss or cry at the breast and get angry for several reasons:

a. the flow is too slow for them (this is the most common reason)

b. the flow is too rapid for them.

c. the baby is full, but wants to continue to suck

d. possibly due to reaction to something in the milk (see colic, at our website)

e. nursing strike (see my book Dr. Jack Newman's Guide to Breastfeeding. It has a chapter on breast rejection which includes information on a nursing strike, but given the age of the baby this seems an unlikely reason).

f. reflux is a possibility here, but this is a "diagnosis" which is made too often.

g. a combination of a and b (too fast early in the feeding, too slow later).

You can decide which of the first three your baby is doing, by watching the baby drink at the breast. If the baby is nibbling, it is likely a. above, "I want more milk faster". If the baby is drinking really well, it is probably because flow is too rapid for the baby to handle (this usually occurs early in the feeding), or, a variation of b., the baby is full, got full very quickly, and so wants to continue to suck but does not want more milk. See the website www.drjacknewman.com for the video clips that show how to know the baby is getting milk. Once you know this, you also know when the baby is not getting milk. If the baby is full, the pulling usually occurs several minutes into the feeding when the baby was still drinking very well. Often the baby, after the initial rapid drinking, is content when nibbling and not getting much milk, but if the milk flow begins again, the baby will start to get upset again.

It would be a good idea to get good hands on help.

Marta Munoz from Edmonton Canada writes: How does the many drugs administered to a mother during labour and /or a C-section, affect the newborn through breastfeeding?

Jack Newman: The amount of any drug that gets into the milk is tiny so that the worry about their affecting the baby is vastly overstated. Let us look at a drug that many people know, the antibiotic amoxicillin (Amoxil). The usual dose for an adult is 500 mg three times a day or 1500 mg a day. Amoxicillin is a pretty typical drug in that about 1% of the mother's dose gets into the milk. Thus over 24 hours about 15 mg a day will get into the milk. This is much less than we would give a baby who is newborn.

Mothers have the baby skin to skin after birth for at least an hour or two and allow the baby to take the breast. And if the baby takes the breast they should be confident that the baby will get a lot less of the drugs of labour and caesarean than the baby got during the labour and birth.

Edith Kernerman:Hi Marta, During labour and delivery any medication given to the mother will bet to the baby via the placenta. This could take anywhere from seconds to two minutes for baby to get the drug if mother is given it through an IV or with her epidural/or spinal anesthetic. There is some research to suggest that the effects of medication given during labour and delivery may last up to 30 days or more. Certainly, we do see immediate effects like lethargy or delayed hand movement (important when babies are beginning to crawl up to the breast right after birth) or sucking difficulties. So, how to counteract these effects? Keep baby skin to skin as much as possible in between feedings and during feedings throughout the day and night—whatever the mother can do. As baby shows very early cues (even tiny ones) allow the baby to search for the breast (easy to do when skin to skin—impossible to do when swaddled and sleeping in someone else's arms or a cradle) and help baby to latch and eat; ..i.e. use compressions if baby is sucking and not drinking. Compressions will increase the speed of flow and thus encourage the sleepier baby to keep going as babies respond to flow and will continue to drink even though their eyes may be closed. Of course, avoiding the c-section in the first place (not always possible) or the epidural (again, not always possible) prevents any effects of labour medication getting to baby.

Jill Lowe from Chicago United States writes: 1)Can you give me some words to say to a newly lactating mother who says she is 'supplementing with formula until the milk comes in'
I am fairly sure you agree with me that supplementing will delay getting supply to equal demand, but other than to urge a lactation consultant, do you have any short non- militant words to say?

2)Are their mothers who never can get supply to equal demand?............. even though they are willing to be helped?
Thanks so much
Jill

Jack Newman: Not only will the supplementing interfere with the milk production, but also the baby may refuse the breast if the mother is giving the supplement by bottle. The mother is probably doing this on the mistaken impression that there is not enough milk in the first few days. But there is enough milk if the baby gets it. But in order to get the milk the baby needs to take the breast with the best possible latch. Unfortunately, the teaching of "good latching" is often less than ideal. Again, I would refer this mother to the website www.drjacknewman.com which shows both how to latch on a new baby and how to know a baby is getting milk and how to help that baby get the milk. Nature didn't mess up. There is enough milk.

O Nugent from Toronto Canada writes: I am still breastfeeding my son who turned 2 earlier this month approx. 3 times a day. I think I would like to wean him but he is still very attached to breastfeeding and it is hard to refuse him. In your experience, what is the average age that children naturally wean? Or do you have any suggestions to help me wean him in a gentle way?

Edith Kernerman: Weaning can be a tough one if baby is not leading the way. Around the world, babies tend to wean somewhere between the ages of 2 and 7, believe it or not, and maybe a bit more commonly by age 4 or so. The reason for this partly has to do with the comfort and security a young child gets from knowing his/her mother is available to him/her whenever needed. Now, before one starts to get all concerned about dependency and spoiling, let me point this out. Research does show that a child who is held more during the day cries less at night. Research also shows that a baby whose cries are responded to immediately is more patient with the mother as that baby gets older—calling to the parent and waiting patiently while the parent takes time to come. The opposite is true for the baby who cries out to the parent and is allowed to cry. That baby, later on, will continues to cry and cry even though the parent calls out and says "I'm coming". It is though the baby does not believe the parent as no sense of confidence has been instilled in the baby. So, we find the same is true with breastfeeding. Research shows that a baby who is breastfed longer will be more secure and confident, feeling bold enough to venture off into the world (watch what happens in the playground) fully knowing that the mother is there to provide comfort as/when needed. That's not to say you won't find a clingy breastfed baby—sure, you will as with all babies. And now watch that same clingy breastfed baby when he or she becomes 7 or 8 or 10 years of age and see how independent, self confident and self assured that child is. And that confidence stays for life!!

If weaning is something you are truly determined to do, then gently distracting the child as he approaches you will work sometimes. As your milk begins to slow the child will become less interested. If you become pregnant, often that will slow milk down enough that the child moves on.

Think this through carefully. I urge you to wait. You will never have this time back with your baby//child and there is so much that you two gain from breastfeeding longer.

M Dee from Toronto Canada writes:I breastfed my child for year. She is quite small for her age according to her pediatrician. Are the growth charts these babies are measured up against for breastfed or formula fed babies? Are formula fed babies larger than breastfed babies?

Edith Kernerman: Ahh growth charts…how I loathe them. You maybe be surprised to know Jack and I don't ever use them in our clinic—in fact, I would have to dig one out of the filing cabinet somewhere to find one!! So, yes, the older growth charts were based on formula-fed babies—a very unfortunate thing too as so many breastfed babies were unnecessarily supplemented to get their weights up (and still are to this day). New growth charts based on breastfed babies were released a recently and many informed docs have been quick to switch. Problem is, people judge a baby's place on the growth charts instead of a baby's progress on the growth charts—and there is a very big difference between placement and progress. Placement (where a baby falls on the chart) is measured in percentiles, and we as a society have got it into our heads that if you are not in the higher percentiles there must be something wrong with you. So, a baby who falls at the 40th percentile and stays on his/her own growth curve always around 40th percentile is doing great!! But how many parents do you hear brag about the 40th percentile—wouldn't 100th percentile be better? No!! If a baby's parents are smaller people, then baby is likely to be at a smaller percentile—that's not a bad thing, that's a normal thing. If baby's parents are very big people, then baby will likely be a higher percentile. These are not marks they get a school!! Judging one percentile over another as being better is likely saying it is better to have brown hair than blonde or vice versa. You will have the hair you were genetically meant to have. And the same goes for the weights of a healthy well-gaining baby. As Jack always says, someone has to be on the 1st percentile—because there are averages. That's not a bad thing. Where we get concerned is looking at whether a baby falls off his/her own growth curve.

z ja from Courtenay BC Canada writes: Question for the panel:

I had a breast reduction (15 years ago) and am expecting in March. This will be my first child and I'm wondering if you have special tips for getting ready to breastfeed for women like me, who have had a reduction?

Thanks

Edith Kernerman: Well the breastfeeding part is easy. The breastmilk part may be a challenge or not. Any woman with a breast and nipple can breastfeed her baby. Breast surgery may complicate the bringing in of a full milk supply or the delivering of that to baby for 3 reasons. 1, the ducts around the areola have been severed (caused by a peri-areolar incision—so it goes along the edge of the areola), or a biopsy or surgery was one on the outer part of the breast and done going around the perimeter of the breast and not downward toward the nipple. Sometimes ducts do re-canalize and the more time that has elapsed between surgery and pregnancy the better. Also, the more breastfeeding the mother does after the surgery the more likely things will go better (so, with the second baby there may be fewer challenges than with the first). 2. We now know so much more about breast anatomy than we used to a few years ago. We now know that any breast surgery that removes tissue is likely removing not just fatty tissue but also milk making alveoli clusters and ducts. 3. If the nerve responsible for giving the message s to the brain about making milk has been severed than no milk will be made at all in that breast.

So, let's say we have all or any of the above—does that mean the mother cannot breastfeed? No!! Of course she can. What we do is get mother off to the best start. See the handouts on our website on

1. Starting out right 2. Importance of skin to skin 3. When latching, 4. Protocol to increase breastmilk intake. 5. Herbal remedies for milk supply 6. Domperidone, getting started 7. Enough, 8. Using a lactation aid

Mother should get baby skin to skin as much as possible—this will help increase her milk supply. Baby should be encouraged to do baby—led mother-guided latching where baby comes to the breast when ready and the mother helps guide baby into a comfortable position and supports baby while latching on. Then mother needs to know the difference between sucking and drinking. If baby is sucking and not drinking then the mother should take action and use breast compressions to increase the speed of flow when these no longer work the mother can offer the baby the other side. If baby comes back to the first breast and still is not drinking and only sucking, then a lactation aid ( a very thin long tube ) is inserted into the baby's mouth and the other end of the tube sits in a container of supplement (1st choice: mother's own milk, or 2nd: donor milk, or 3rd :artificial baby milk).

The mother should be encouraged to take herbal galactogogues (milk-making herbs or medications) as soon as she is up to it after giving birth—i.e. the same day. And also, we recommend the mother get started on a medication called domperidone which also helps mother to make more milk.

g n from Ottawa Canada writes: What do you make of the dairy crisis in China? Does that speak to a trend in developing countries of the decline in breastfeeding? If so, what would you recommend to health authorities there and at the WHO to raise breastfeeding awareness as the only practical and healthy option?

Jack Newman: Greedy people will stop at nothing, it seems. Worse perhaps than the fact that the companies adulterated the milk is the fact that there were concerns going back many months and yet nothing was done about it.

There have been recalls in North America of improperly made baby formula. There are several in the past 30 years ago, the most recent ones since 2000. I do not suggest at all that the formula companies adulterated or deliberately made formula that was improperly constituted in North America, but infant formula is made in factories by humans and humans make mistakes.

Governments in Canada, with the exception of Quebec's, have been particularly unconcerned that even formula manufactured properly is very much inferior to breastmilk. Ontario's government stands out by it's complete resistance to understanding the importance of health for the child, the mother and society. It is important that all governments make breastfeeding a priority in their health planning.

The trend in developing countries has been away from breastfeeding for some time now. China is not unique. All countries are affected. Much of the push to formula feeding comes from marketing by formula companies. Unless governments do something about controlling this marketing, the situation will only worsen.

Charles Kantor from Barrie Canada writes: Hello Doctor: My question deals with breast cream. My wife was using 'breast nipple numbing' cream almost 3 or 4 times per day due to painful and sore nipples. She has now stopped using it in fear of how safe the product is. The product says that it is safe, but who knows. Anyway, she expects that her nipples will become less sensitive. Is this something that she should be expecting? Do the nipples become less sensitive over time, much like our skin adapts. Can breast nipples 'toughen' up so to speak? What are your thoughts on the over- the -counter nipple cream for breastfeeding women who have sensitive or sore nipples? Thank you for all your work in this important field.

Jack Newman: I have no idea what product you are referring to, so I cannot make any comment on it. My impression with "over the counter" creams for sore nipples is that they help as much as time does, but I could be wrong because in our clinic we see only mothers for whom the creams have not worked.

We prescribe our own ointment which I think works well and is safe.

But there is more to treating sore nipples. First of all, of course, is prevention. Once again getting a good start with good help is very important. A baby who latches on well does not cause his mother pain. Nipples do not need to toughen up. The baby has to latch on properly. See the video clips at the website www.drjacknewman.com .

Virginia Mackay from Canada writes: Hello Dr. Newman - my first daughter who is now two, had no sucking reflex for the first 3 days of her life - nurses were surprised that when they put a finger in her mouth, she did nothing. After (stressfully) dropper feeding her for the first three days, she latched and I breastfed successfully for a year. About 6 weeks postpartum, I happened on an article of a small British study that said babies with head trauma (from forceps or vacuum delivery) had a diminished sucking reflex. I'm convinced this was the case for me, my doctor suggested we use the vacuum, for no medical reason other than 'lets get this baby out'. I asked what the risks were, she said none other than mild bruising, so I said ok. Meanwhile (I wasn't aware at the time) a team of 5 specialists came in which I later learned were b/c the chances of having a C-section are greatly increased with a vacuum. This lack of information, and also lack of medical necessity in using the vacuum is a part of the reason I've chosen to use a midwife with my current pregnancy. What is your position on babies born with head trauma and problems with sucking reflex, or have you seen any correlation in your experience?

Jack Newman: There are several things that can cause the baby not to suckle well. I think the evidence is very good that many things we do during labour and birth will result in babies not suckling well. Even the intravenous fluids the baby get may affect the way the baby breastfeeds because the mothers often get fluid swelling of the nipples and areolas so the babies cannot grasp the breast. Having an epidural can affect breastfeeding as well. Getting medication as well. It is quite possible that vacuum extraction may cause the baby difficulties though I have no information on this particular intervention.

Unfortunately too many interventions are being done during labour and birth without consideration of the consequences for the baby and the mother and the breastfeeding.

Beverly Mt.Pleasant from Canada writes: I would like to hear comments on a type 1 diabetic mom nursing her young child. How does her being diabetic affect the baby?

Really there should be no issues about a type 1 diabetic and breastfeeding. However, babies of diabetics are at risk for developing low blood sugars after birth and so are frequently separated from their mothers and given formula, often by bottle. By doing this, we may prevent the baby from having low blood sugar, which can be dangerous to the baby's brain, but we also at the same time may completely mess up the breastfeeding.

If there were no options but to give the baby formula by bottle, well there is no choice. But there are choices.

First of all, the baby could receive banked breastmilk from a breastmilk bank. The reason for preferring this is that there is a concern that early cow milk exposure (as most formulas are made from cow's milk) will set up the genetically predisposed baby to developing type 1 diabetes too.

However, we have been encouraging type 1 diabetics to "pre-express" colostrum. Starting at about 35 weeks gestation, the mother starts expressing colostrum and storing it. If the mother is able to express only 1 or 2 ml. a day, if she manages to get to 37 weeks, she will have stored up 14-28 ml of breastmilk to be given to the baby instead. This is not only preventing exposure to cow milk protein but also breastmilk (or colostrum) is far more effective in protecting the baby's brain than formula, any formula.

Of course, the mother should get help to start breastfeeding as soon as possible, starting with skin to skin contact immediately after birth. Skin to skin contact maintains the baby's blood sugar better than separation of the mother and baby. And if the baby breastfeeds well (and he should with good help), there may be no reason to be concerned about his blood sugar.

If it's not possible to maintain the baby's blood sugar, then an intravenous infusion of glucose will protect the baby's blood sugar while the mother continues breastfeeding.

Glenda Cameron from Dorval Canada writes: Have you found any link between breast feeding and postpartum depression? Any literature I've found states that breastfeeding can reduce the effects of postpartum depression. I have been successfully breastfeeding my daughter for six months however almost every time she nurses, I have a very overwhelming feeling of sadness that seems to be concurrent with the milk letdown. It doesn't last very long but happens at almost every nursing session. It hasn't deterred me from nursing yet because I know it's the one of the best things I can do for her and overall I have really enjoyed the bond that nursing has brought us. I'm hoping to continue to nurse until she is 1 yr old. I've searched various books and the net but haven't found any link. Just curious if this is a unique experience or if there have been any studies done.

Jack Newman: I don't think what you experience has any relation to postpartum depression. Women get many symptoms associated with the milk ejection reflex (milk ejection reflex), including profuse sweating, hunger, thirst, headache and these feelings of depression or dread. However, I cannot imagine how this has any relation to what we call postpartum depression. What is unusual in your case is how long it has lasted. Most mothers no longer have these symptoms by 6 weeks after birth.

Heather Pouliot from Edmonton Canada writes: Hi Dr.Newman. I recently went to my daughter's paediatrician and he told me that my daughter is not gaining enough weight and that she must take both cereal and formula 2-3 times a day at only 4 months old. she gained 1 lb. in the past 3 months, however, when I look back at my baby books, that is all that I gained at the same age, and I'm a perfectly healthy adult. I am trying to eat some healthy oils and fats more often now, and am making sure that she does a proper suck swallow feed, instead of suck nothing. Should this be enough, or should I be supplementing her even part time with formula and milk?

Thank you,
Heather N. Pouliot

Jack Newman: I don't think starting the baby on formula, especially by bottle is a good idea. If your milk supply has decreased, then the baby will stop breastfeeding by rejecting the breast. This would be a shame.

Watch the video clips at our website www.drjacknewman.com

In addition, go to the website and find:

1. When Latching (You may not be able to change the way the baby latches on at this point, but bring her in close as when she was a newborn) 2. Breast compression 3. Starting solids 4. Using a lactation aid (Many babies over 2 or 3 months won't like using this gadget. But some will, and it's better than a cup or bottle or finger feeding, because the baby is still on the breast and breastfeeding) 5. The importance of skin to skin contact 6. Domperidone 1 and 2

If something in addition to breastfeeding needs to be started, then adding solids (not necessarily cereals which are expensive for what you get) is an option. But increasing the milk supply is more important.

Rumon Faskater from Yuho United States Outlying writes: My wife has breastfed our child for 6 months. My question is, what period of time is the most beneficial. Would she receive the nutrients/antibodies she needs within that period of time?

As well, I had a general question on breastfeeding itself. I find that it is pushed so much on women in general that if something doesn't work out, they feel horrible about themselves. I am wondering why the hospitals don't encourage it to an extent but also promote other methods if its painful or not working well. We found that even the fact that we were using a breast pump and bottle instead of direct feeding was looked down on. Can you help us understand why the medical profession pushes it so hard?

Edith Kernerman: Breastfeeding provides nutrients and antibodies for as long as baby breastfeeds. In fact, there are some protective factors that seem to increase as baby gets older. The world health organization and American Academy of Pediatrics, the Canadian Pediatric Society, Health Canada, IBFAN, and the Global Strategies on Infant Feeding all recommend exclusive breastfeeding 'till around 6 months and then to continue on until the child self weans at least to 1 or 2 years and beyond (they all word the recommendation a bit differently).

Interesting that you find that women have breastfeeding pushed on them. True, there is much around that talks about "breast is best" (not a slogan I ever use as breastfeeding is not better, it is the norm). so, yes, I can see how a woman who feels that if everyone else is doing it and she feels she "cannot" then she may experience feelings of frustration, anger, disappointment, inadequacy—and yes, feel horrible. So, instead of questioning why we push women to breastfeed (a normal act that our bodies are built to do), maybe it might be helpful to examine why woman feel this way when breastfeeding has been challenging or too hard for them. Do women feel inadequate because they have a c-section after 24 hours of labour? Not usually. They may feel much frustration and disappointment that the birth did not go well, but most women do not blame themselves. So, why, when a mother has been horribly failed by the medical system does a mother blame herself? Her frustration, I believe, is better directed to the healthcare practitioners who give her contradictory and inconsistent advice, and who do not have enough quality lactation education to adequately support her; to the hospital or clinic policy makers who create breastfeeding policies not based on evidence. Most importantly, why are we not looking at the government for having inadequate polices on breastfeeding education for healthcare professionals? I think we have enough messages out there telling women to breastfeed, informing women of the risks of not breastfeeding—what we need is to stop doing the "cruelty of breast is best" and start supporting women in their own breastfeeding goals. Particularly in the U.S. where women must return to paid work when breastfeeding has barely been established!! At least in Canada we have 6 months paid maternity leave. Yet, still, here we bombard women with inaccurate incorrect information on breastfeeding and that information and so-called advice makes it so difficult for so many women to continue.

If you made the decision to breastmilk feed your baby with a bottle—good for you for getting your baby fed and doing it with the normative and appropriate food for him/her. I just wish you had the help you needed to be able to feed your baby the way you wanted instead of being judged when the same healthcare practitioners failed you. Would we ever tolerate a cardiology ward not providing the adequate and correct follow up and imparting of consistent information after heart surgery? No way!!! Staff would be fired left and right. So, why do we tolerate it with breastfeeding?

So, I have to disagree with some of what you say Rumon, the medical profession doesn't push breastfeeding—they talk the talk and do not walk the walk—and that is what I think we should all be so angry about. E.

Jorden Bartlett from Oakville Canada writes: I have recently returned to the workplace and left my seven month old son at home with my husband. My son is still breastfed. I feed him in the morning before work and several times in the evening after work. During the day my husband gives him bottles of breastmilk. I use a pump a few times a day at work. I know that while the pump attempts to simulate breastfeeding it does not stimulate any hormones in the way that babies can. What types of things can I do to maintain my breastmilk supply even though I am relying on a pump during the day?

Edith Kernerman: I wouldn't say that pumping does not stimulate hormones—you need hormonal activity in order to make breastmilk and in order to get it out. However, for some women, the pump is not as effective as the baby—after all, a well latched baby is extremely effective at milk transfer and, a baby is often whole lot cuter than a pump, smells better, and smiles more sweetly!!! Regular removal of milk will maintain your supply and breastfeeding baby when you get home and before you leave and as much as possible in between will go a long way to keeping the supply where you want it. You can use breast compressions while feeding and while pumping (see handout on our website called Breast Compressions) and if you feel a dip you can look into some herbal remedies found on our handout Herbal Remedies. Good luck, E.

Darren Frake from Toronto Canada writes: Good afternoon Doctors. I am sitting with my wife in Mount Sinai Hospital right now. Our new baby girl is about 30 hours old and has a very health appetite. I believe this stage is called cluster feeding. Our question is, when does this, non stop, feeding start to slow down? Thanks.

Edith Kernerman: Cluster feeding usually lasts anywhere from 12-48 hours and is a very necessary part of baby's first days out in the real world. This does not mean that it has to be an onerous period or terribly difficult for the parents. Cluster feeding addresses many needs for baby and mother:

1] Keeps baby close to the mother skin to skin and this regulates baby's heart rate, breathing rate, oxygen saturation, and body temperature. So the last thing one wants to do during this period is to take baby away from the mother and swaddle the little thing. No, the best place for baby is naked on mother's chest, vertically between her breasts—wrap a blanket around the two and keep them skin to skin as much as possible throughout day and night and especially in between feedings.

2] The next thing cluster feeding does is help to establish mother's milk supply. Think of it this way: the more the customer gives the waiter orders for food the more food the chef will prepare over the next few months. This is so important for getting the supply up where it will need to be as baby's stomach grows bigger.

3] The cluster feeding helps mother's uterus to contract back to normal as mother's oxytocin (a feel-good hormone responsible for contracting various things in the body like the uterus and milk-making cells) is released again and again.

4] baby also experiences an oxytocin release while sucking and this oxytocin makes baby feel good and provides comfort to the baby —much needed when a whole lot of new things are going on that baby never knew about while in his/her mother's uterus!

So, latch baby well. If the latch hurts avoid delatching and relatching. Instead, fix the latch you have. Use breast compressions and keep baby skin to skin and you will get through it with flying colours!! Congratulations on the new baby!!

Kelly Derlago from Calgary Canada writes: Our son is now 15 months old. He isn't showing any loss of interest in breastfeeding. My wife breast feeds him about twice a day. First thing in the morning then at bed time. The little guy is eating great and enjoys drinking dairy milk from a sippy cup. So it doesn't appear to be an issue of hunger. With my wife's busy work schedule, she would like to stop but has read that cutting him off could be traumatic. What are your thoughts on weaning our son off breastfeeding?

Edith Kernerman: Early weaning can be difficult for both the mother and the baby—sometimes even traumatic. (See earlier question/answer on weaning). What about feeding him in the morning before she goes to work and again a couple of times when she gets home? This kind of feeding can go on for months and years and both the mother and the baby derive so much benefit from it. After all, one can never get this time back. Once baby weans that's it—done, no more. And the closeness mother and baby have during that time is not repeated at any other time. Not that we are no ever going to be close to our babies again—that's not what I am saying at all. It's just that that relationship is so unique and specific to that time in baby's and mother's life. Not only that, but sometimes children become so "busy" as they start to walk and explore life and interact with other kids that the breastfeeding time is the only opportunity the mother gets to truly cuddle her child. Once they wean, this cuddling becomes more difficult—and the mothers often miss that the most. As the milk slows down he will wean himself and that is the most relaxing and least stressful for all. If your wife would truly like to cut back a bit, then she might try to distract the little guy or offer another food or pick him up and play with him when he is about to go for the breast. If she is truly committed to weaning I would recommend doing it as slowly as possible to cause the least amount of distress for both. Again, waiting it out a little longer and enjoying this time is my best recommendation! Hope that helps, E

David Guy from Canada writes: There seems to be a great deal of drama and fuss lately from pro-breastfeeding mothers. It makes mothers who choose to bottle-feed feel inadequate or even bad mothers as a result. Are there any harmful effects from bottle feeding an infant? Are there cases in which you actually recommend bottle feeding to mothers?

Edith Kernerman: See my answer to Rumon, above. When you say bottle feed—I am not sure if you are referring to using breastmilk in the bottle or artificial baby milk. Either way, as Jack always says, there is more to breastfeeding than the breastmilk. We are not sure of the totality of the risks of not breastfeeding—we do know there are many. As for risks specifically of bottle-feeding regardless of whether it is breastmilk or artificial baby milk in the bottle, research has identified the following risks:

1] Obesity: bottle feeding tends to prime the stomach: parents and caregivers are often encouraging the baby to 'finish" the bottle regardless of whether baby seems to need it. This helps the stomach to expand beyond the point of being full. Next feeding, baby expects to get fed that amount at the least and after a while no longer feels full as the stomach can continue to stretch. Also, babies tend to eat faster on the bottle without taking any breaks. So, there is little to no time to get the message to baby's brain that baby is full. Therefore, there is a tendency to constantly eat more than baby requires.

2] Orthodontic/tooth: the use of the bottle can affect the placement and growth of the teeth and can have an effect on the temperomandibular joint (jaw joint).

3] Palate: Babies tend to be born with rather narrow palates (the roof of the mouth), breastfeeding helps to widen this palate over time and allow for a nice size airway for breathing as an adult. Bottle-feeding not only prevents this necessary widening but it also causes narrowing of the palate. It is possible that this narrowing of the palate can lead to sleep apnea later in life (a condition where one stops breathing periodically while sleeping—common nowadays in adults) and is a risk for heart attack and stroke. There is some evidence to suggest that there is a correlation between bottle-feeding and sleep apnea. More research certainly needs to be done on this most serious issue.

4] Ear infection: There seems to be a correlation between bottle-feeding and (otitis media) ear infection.

5] Respiration: Bottle-feeding in the young, very new, very small, or premature baby can raise baby's heart rate and breathing rate and decrease baby's oxygen saturation. This is because baby needs to hold his/her breath while feeding on a bottle, which is the opposite to what s/he does on the breast, and that is coordinate his/her breathing in a nice and relaxed suck-swallow-breathe pattern.

6] Face shape: Bottle-feeding may contribute to irregular jaw shape and facial structure. See website www.brianpalmerdds.com for more information on this.

Now, here's my two cents: why go to the trouble of using a bottle? If the mother truly decides she does not want to or has not been able to breastfeed, then why not use a cup? Not a sippy cup, just a regular cup. After all, every child needs to use a cup by the time s/he goes to nursery school or kindergarten—why not teach that now? With the cup there are none of the risks mentioned above. And also no worries about BPA (a chemical found in many plastic baby bottles); or chemicals in the bottle teat/nipples (we have no idea what will be found in those—rubber or latex); or cleaning/sterilizing; etc. etc. Cups are easy—can start with a little medicine cup or shot glass and graduate to a real glass. See the video clip on our website on cup feeding at www.drjacknewman.com . Sure, cup feeding might make a mess the first few times but after a while the caregiver and baby get really good at it. No extra paraphernalia to buy—cheap, easy, and no risks. Of course, still not as good as breastfeeding—but you knew I would say that! E

Rasha Mourtada, Globe Life web editor: Many thanks to Dr. Newman and Ms. Kernerman for taking so much time to answer questions. To our readers, we're sorry we didn't get to all of your questions.