Breastfeeding Extravaganza! – PediaCast 195

Topic

  • Breastfeeding

Guests

Dr Nehal Parikh
Neonatologist
Nationwide Children’s Hospital

Megan Harrison
Registered Nurse
Advanced Certified Lactation Consultant
Nationwide Children’s Hospital

Links

Transcript

 

Announcer: This is PediaCast.

[Music]

Announcer: Welcome to PediaCast: a pediatric podcast for parents. And now, direct from the campus of Nationwide Children’s, here is your host: Dr. Mike.

Dr. Mike: Hello everyone, and welcome once again to PediaCast: a pediatric podcast for moms and dads. It is episode 195 for January 11, 2012. I was still trying to decide, do I say two thousand twelve or twenty twelve? I don’t know. I think that’s going to, kind of, sort itself out here. I want to welcome everyone to the show. This is our breastfeeding extravaganza. And I do know that when you use the word ‘extravaganza,’ you have to kind of live up to that.

But we are going to cover breastfeeding from lots of angles. We’re going to talk about the value of human breast milk itself, sort of the basics, you know, the things that new moms are just sort of expected to know, but don’t necessarily get the right information. So how do you get started breastfeeding? When do you stop? How do you stop? How long do you nurse? How often? I mean all those kind of common basic questions we’re going to cover.

We’re also going to look at common pitfalls and some strategies for success. And then we’re going to have a few special topics for you too: breastfeeding in public, pumping at work, milk storage, mom’s diet. So we have really lots coming your way. And I hope those of you out there, if you aren’t breastfeeding or you’re not currently breastfeeding, please don’t discount this show because I’m sure you probably know someone who is nursing or who will be nursing soon and maybe you could pass along the information so that your family and friends can listen to the show as well.

00:01:53

Now I also know that when you have an extravaganza, you can’t just have the host during the show. So we have a couple of great studio guests with us today. Dr. Nehal Parikh is a neonatologist here in Nationwide Children’s Hospital. And we also have Megan Harrison joining us. She is a registered nurse and advanced certified lactation consultant also here at Nationwide Children’s.

Before we get started, I want to remind you that it’s easy to get a hold of this. If there’s a topic that you would like us to talk about or you have a question for us here at PediaCast, it’s easy to get a hold of me. Just go to pediacast.org and you can click on the contact link. You can also email: pediacast@gmail.com, or call our voice line at 347-404-KIDS. That’s 347-404-5437. I also want to remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.

So, as always, if you have a concern about your child’s health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination. Also your use of this audio program is subject to the PediaCast terms of use agreement, which you can find over at pediacast.org.

All right. So let’s turn our attention to our studio guests. Dr. Nehal Parikh is a physician with the Section of Neonatology here at Nationwide Children’s Hospital and an associate professor of pediatrics at the Ohio State University, College of Medicine. Dr. Parikh attended medical school at the New York Institute of Technology and holds a master’s degree in clinical research from the University of Texas Health Science Center at Houston.

00:03:29

He completed a pediatric residency with the Winthrop University Hospital at State University of New York at Stony Brook and a neonatal-perinatal medicine fellowship at Thomas Jefferson University Hospital in Philadelphia. In addition to practicing clinical neonatology, Dr. Parikh is a principal investigator with the Center for Perinatal Research here at Nationwide Children’s. And now, he joins us on PediaCast to talk about breastfeeding. So welcome to the show, Dr. Parikh.

Dr. Nehal Parikh: Thanks so much, Mike. It’s a pleasure to be here.

Dr. Mike: Great. It’s good having you. We also want to welcome Megan Harrison. And Megan — sorry about that, kind of blended your first and last name together there. Megan has seven years experience working as a registered nurse in the neonatal intensive care unit at Nationwide Children’s Hospital.

In addition to her BSN, Megan has a degree in early childhood development and a certified in early intervention. She’s also an advanced certified lactation consultant. And in this role, Megan guides mothers along the path of breastfeeding and has a wealth of experience providing tips to help nursing moms stick with it. So we’re in PediaCast welcome to you as well.

Megan Harrison: Thank you.

00:04:29

Dr. Mike: Really appreciate you stopping by. So let’s start with you, Megan. Why is it important for new mothers to ask and receive help with breastfeeding?

Megan Harrison: Breastfeeding in America, we have seen that it’s hard for women to have experience seeing other women breastfeed based on the culture here in America. And each hospital has lactation consultants in their institution to help mothers start with lactation and breastfeeding. But there are so many different avenues of needing help with breastfeeding and having just general questions. But it’s really important for the mom to seek out and get information.

Dr. Mike: Sure. So here in the U.S., I mean, really, it’s more of private, you know? And people kind of maintain privacy. And so they don’t like to talk about these kinds of things. And so, moms don’t have the local support, you know, in their community that they need.

Megan Harrison: Yes. And I think in the recent years, it is getting better with having women more open and wanting to talk about breastfeeding and educating other women, but it’s still something that is growing and things that way.

Dr. Mike: Sure. Yep. And, of course, moms want to find a trusted source of information. I mean a lot of people offered advice that’s not always the right advice. And that’s what we’re trying to do here.

Megan Harrison: Yes. There’s a lot of misconceptions that are related to breastfeeding. And, for example, a lot of people think it’s still OK to provide water to infants as a source of nutrition. And that’s actually inaccurate.

00:05:59

Dr. Mike: Sure. Yep. Now, Dr. Parikh, we often hear breast milk is best. And I’m assuming this is true. And can you just talk a little bit about why breast milk is the first choice?

Dr. Nehal Parikh: Absolutely. Breast milk is, without a doubt, best as this fact is backed by irrefutable scientific evidence that has been observed repeatedly in every population, setting or conditions imaginable. Human milk is a life-giving force literally. And it’s designed perfectly by Mother Nature to provide the right combination of nutrients and protective factors for a human infant, whereas formula basically originates from cows and it was perfectly designed for cows.

So to make it suitable for human consumption, it’s been artificially engineered and, I would add, imperfectly at that. And we know now that there are enumerable benefits of breast milk or human milk to infants, mothers and society at large. Just an abbreviated list includes enhanced brain development with improved cognitive abilities; reduced risk of hospitalization; reduced risk of infection in that urinary tract, gastrointestinal tract, respiratory tract; reduced risk of reflux and allergies.

There’s even some evidence of reduction in sudden infant death syndrome and obesity. However, this evidence is still not as strong as we would like. When you look at infants that have been exposed to cows-milk based formulas, they have a higher risk of Type 1 diabetes, hypertension, asthma and even childhood cancers, such as lymphoma and leukemia.

00:07:34

Dr. Mike: Let’s talk just a little bit about the specifics of why those kinds of things are true. I would assume that a lot of the negatives that you’re talking about have to do with proteins that the human body isn’t meant to be exposed to during early childhood. And so, the baby’s body responds by making antibodies against these proteins. And then those are, you know, what you see then, such as allergy-type reactions, diabetes, perhaps even reflux if there’s inflammation in the GI tract. Is that true?

Dr. Nehal Parikh: That’s absolutely correct. And more and more evidence is linking some of these diseases to the casein, which is the unique protein in cow’s milk, that’s not present in human milk. And without a doubt, it’s not only linked with these short-term problems, which are very dramatic, such as type 1 diabetes, but also long-term adult cancers. There’s at least animal data to support that.

Dr. Mike: Sure. You talked about better brain development with breast milk. Why is that the case?

Dr. Nehal Parikh: We think there are lots of protective elements in human milk that are not quite there in a formula. Some of those include the omega-3 fatty acids that so much of us have learned about. But there yet other nutritional factors, micronutrients, that we’ve still yet not uncovered. And so, without a doubt, the formula makers will always be in a catch-up mode to try and improve that product based on the gold standard of human milk.

00:09:05

Dr. Mike: Right. When I was training, it was kind of thought that increased cognitive skills in breastfed babies and the fact that there was less SIDS deaths in breastfed babies was because of the socioeconomic status of people who are more likely to breastfeed. But more recent studies show that that’s not necessarily true.

Dr. Nehal Parikh: I will tell you that there’s still some that will refute the link between breast milk and human development or brain development. However, more…

Dr. Mike: The formula companies.

Dr. Nehal Parikh: Yes. Exactly, exactly. And there are scientists that are paid by the formula companies. But without a doubt, better epidemiologic data — and I would say even from our own research, we do lot of those advanced MRI imaging. And we’re seeing differences in the brain of babies that have been breastfed longer versus those that have not. So there are mechanistic things that we can also show in human infants that clearly point towards better brain development in these babies.

00:10:05

Dr. Mike: Megan, let’s talk a little bit about the nuts and bolts of breastfeeding. I guess, you know, one question that a lot of new moms ask is, how long should I — and I’m talking, you know, at the breast, you know? What’s the ideal time to nurse?

Megan Harrison: Well, on average, every baby, each session to lasts anywhere from 20 to 40 minutes. But one of the things that moms really need to focus on are the cues that the baby are giving. Are they catching them at the beginning with an early waking up, seeing the eyes move like flittering a little bit? Are they putting their hands to their mouth? Actually, one of the last cues that a baby is hungry is crying. So hopefully they catch that baby prior to that.

And the other thing that moms need to remember to do is rotating their breasts. So if they start on the left side, they need to finish on the right side. And then to the next feeding session, start on the side that they’ve had stopped on. So, like, this example would be starting on the right and then ending on the left.

00:11:00

Dr. Mike: Sure. Now, how do moms know when they should switch from left to right and from right to left like in the middle of feeding?

Megan Harrison: In the middle of feeding. So a lot of times what you’ll see is babies will start pretty aggressively wanting to eat because they’re very hungry. They’re completely empty. And as they continue to feed, they get a little sleepy. One of the things I actually have moms look at, which is not scientifically have researched, but is actually look at their arm. If they pick up their arm from where they’re laying on their side, if there’s any tension, then that tells me that the belly is not full yet.

Because when the baby is completely full, typically they delatch themselves and they are completely asleep. The other thing a mom can do is if they put the baby in kangaroo, which is skin to skin on their chest, and the baby stays asleep for at least 15 or 20 minutes after they put the baby down, then the baby is most likely finished. But a lot of times, I tell moms it should lasts in 10, 15, 20 minutes on their first side.

And as the baby kind of starts to fall asleep and not as aggressively or actively swallowing, I have them sit them up, burp, maybe change the diaper to wake the baby up because there are hormones released when you’re breastfeeding called oxytocin that makes both mom and baby sleepy. And the goal is to make sure this baby takes the full feeding and not just a snack.

00:12:25

Dr. Mike: Sure. So you may have to stimulate the baby a little bit and get them to wake up in between.

Megan Harrison: Yes. Yeah.

Dr. Mike: Great. Now, how often should mothers nurse, in between feedings I know we’re talking about?

Megan Harrison: Yeah. So the one thing in a lot of things I remind moms about is that the breastfeeding session may take up to an hour because if baby breastfeeds on the first side for 15 minutes and takes a 20-minute nap and then breastfeed for another 10 minutes. That’s an hour duration.

And every baby breastfeeds for between every hour and a half to three hours. But it’s always from the beginning of the session, not when you’ve finished the breastfeeding. So if the baby starts at, say, 10 am and is finished at 11 am, the baby could be ready to eat again by 11:30 am because they started at 10.

00:13:07

Dr. Mike: Got you. What is the sort of in vague phrase out there on feeding on demand. What does that mean?

Megan Harrison: So what feeding on demand means is your feeding the baby every time that they look hungry. And what that means is you could breastfeed the baby eight times in one day. And the next day, you could breastfeed them 12 or 14 times. It’s all just based on where that baby is that day.
Are they more hungry today? It’s kind of just like in America on how we eat. We should be eating small, frequent meals. And that’s what babies are taught to do with breastfeeding is eating small, frequent meals. And when you’re full, you stop. You don’t continue to finish what’s on your plate.

Dr. Mike: Sure. And I think it’s really important here to say to moms, if you’re worried about this and, you know, is my baby eating long enough and are they eating frequently enough or too frequently, is really to get the advice of your pediatrician or a lactation consultant because they are, you know, looking at the baby’s weight.

And, you know, because there are babies who cry and, of course, they stop crying when mom puts them on the breast, but that doesn’t necessarily mean to eat every half an hour.

00:14:10

Megan Harrison: Exactly. And the other thing I think a lot of women need to also realize is our breasts are a nutritional source for the baby, but it’s also a development and a comfort source. So sometimes, say, you just fed the baby half hour and you go to your pediatrician. They give their monthly shot that they need. The baby starts crying, we can also use our breast to comfort our babies. It’s called comfort nursing. So they may nurse for five or six minutes. They are going to get a little bit of nutrition, but it’s really to calm that baby down and to tell them it’s a safe place.

Dr. Mike: Got you. Now should moms, you think, wake their babies after breastfeed?

Megan Harrison: The first month of life, we encourage them to wake them up at three hours during the day and let the baby wake them up at night. The reason you’re waking them up frequently is they’re just very sleepy enough in the first month of life trying to transition.

And, you know, every baby that is breastfed gets what’ causing jaundice, which I know we’re going to talk about here a little bit later. So just waking them up and telling them it’s time to eat, because what happens if you don’t wake them up is they’ll just keep sleeping longer and longer and not get enough nutrition source then.

00:15:14

Dr. Mike: Sure. And, Dr. Parikh, how can a mom know that a baby is getting enough breast milk? We talked about, you know, she obviously had to consult with her doctor or a lactation consultant, but are there some cues that mom can use to know that their getting — because I think that’s one of the big things with the bottle of formula. They can say, “Oh, he took this many ounces this often.” But with the breastfeeding, it’s kind of a mystery how much exactly their getting. So how can moms be sure?

Dr. Nehal Parikh: Yeah. This is a source of tension for a lot of moms, especially new moms that are nursing for the first time. And there are several signs that they can look to ensure adequate milk intake. A combination of things such as frequent wet diapers at least four to six a day, frequent stooling anywhere between after every feeding in the first week of life to eventually they’ll have pattern of just perhaps one to two a day.

But whenever their pattern changes, that should be a red flag for them. They will intuitively know when their breast have emptied, so looking at that. Although, again, I would emphasize a combination of these things should be looked at. And then usually breastfed babies and moms are asked to come back to the pediatrician within two days of new hospital discharge.

And the weight check is very important to assess that they haven’t lost too much weight and that eventually that they are gaining adequate weight. So all of those things combined should give them reassurance that their babies are getting enough.

00:16:39

Dr. Mike: Right. And ultimately if they’re concerned, they can always talk to their doctor about, you know, and the doctor will tease out these specific things that we talked about to just give them some reassurance that, yeah, things are going well.

Dr. Nehal Parikh: Absolutely.

Dr. Mike: We talked about breast milk being best and first choice. Are there some legitimate reasons for choosing formula over breast milk?

Dr. Nehal Parikh: Yes, absolutely. And sometimes moms can feel very guilty about their choices and they should understand that there are some absolute medical contraindications. For example, where one should choose formula over breast milk, these include active infection such as HIV or HToV viral infections, untreated tuberculosis, active herpes lesions on the breast.

There’s a very high risk of infectious transmission of these organism, these viruses, into the breast milk. And therefore, these mothers should refrain from breastfeeding, at least until the infections are taken care of.

00:17:37

Mothers that are prescribed medications that are known to be harmful should also discontinue breastfeeding. We’ll talk about that specific medications in a little bit. But in some instances, some of these medications have unknown harms. And there are good alternatives that they can turn to their pediatrician or obstetrician to help them select a better alternative.

Dr. Mike: Sure. So chemotherapy obviously would be one or radiation?

Dr. Nehal Parikh: Exactly, so especially chemotherapeutic agents, radiopharmaceuticals that are especially used for diagnostic studies, for that you can just discontinue for a few days depending on the type of radiopharmaceutical that’s being used.

Dr. Mike: Sure. Now radiation therapy itself though is only effective or only effective at that point when they’re giving the radiation.

Dr. Nehal Parikh: Right. It’s local. That’s right. So that’s a little bit different. And in each situation, their physician should help them decide that.

00:18:33

Dr. Mike: Right. You talked about HIV. And I want to kind of spend just a little extra time on this because we have had some controversies with this in the past on PediaCast. In countries other than the United States where there’s not a safe water supply, the World Health Organization has said that as long as the mother and/or child is on medication that combats the HIV virus that perhaps breastfeeding is safer for those kids than formula. Can you just speak to that a little bit?

Dr. Nehal Parikh: Yes. Absolutely. And what I was speaking to is primarily in the United States. And the recommendations here in the U.S. are that, by and large, the risks of HIV transmission through breastfeeding outweigh the benefits. However, in developing nations where some of these constraints are very real, most other recommendations are now to go ahead and nurse those babies and adequately treat both mom and baby and get the viral load down.

Dr. Mike: Sure. And again that’s because the water supply may not be safe and the quality of the infant formula that’s available, I mean, maybe black market infant formula that’s not really what it says it is.

Dr. Nehal Parikh: You’re absolutely right. That’s right.

00:19:42

Dr. Mike: So let’s talk a little bit about parents who choose formula over breastfeeding and there’s not one of these contraindications. Are they bad parents?

Dr. Nehal Parikh: No, I don’t think so. Most of the time due to our mass media and marketing hype culture, I think many of these moms truly believe that formula is very comparable to a human milk. And even in those that know that breast milk is better, there are maternal surveys that have found that they choose not to nurse because there are too many rules, rules about how to feed, about dietary restrictions, about restrictions on their alcohol, caffeine or medication intake during nursing.

The alternative with formula for them seems to be much simpler and more appealing. They found that breastfeeding is too overwhelming and certainly non-physiologic or natural as we advocate to them. So I think as medical professionals, it’s our role to provide the facts to these parents, to these moms. And then let them make the best decision for themselves and their families and for us to do so without passing judgment.

00:20:51

Dr. Mike: It does seem to be a lot of guilt, you know, for parents, especially folks out there who may have decided to use formula and they’re listening to this now and we’re talking about how wonderful breast milk is. And so I just, I mean, we’re all human and we’re saying this is really is the best way to go and the evidence suggests that it’s the best way to go. But at the same time, you know, we can say we’re compassionate and people need to make decisions and accept those consequences.

Dr. Nehal Parikh: Yeah. Learn through their own mistakes sometimes.

Dr. Mike: Yep, to the next baby breastfeed, right, Megan?

[Laughter]

Megan Harrison: Yes. And one thing I also wanted to add into was when you’re talking about the breastfeeding and contraindications is also that, you know, we mentioned that there’s interruptions with breastfeeding based on medications, things like that. And the one thing that moms seemed to realize is, you know what, maybe only for a short duration and that they need to look at alternative modes of removing milk, which would be pumping, because our milk is made on demand.

So if you don’t demand it, it can decrease milk supply. So to have those moms think of, “Oh, if I can’t breastfeed for, you know, four or five days because of X, Y and Z, I need to look at an alternative way to keep my milk supply there so I can resume breastfeeding after my treatment is over,” things like that.

00:22:05

Dr. Mike: Sure. And this is why it’s important to be in touched with the lactation consultant when these little questions come up that you have someone that you can contact and ask.

Megan Harrison: Yes. And your local lactation is always a great source, as well as the pediatricians and, you know, pharmacy. There’s all different kinds of resources out there to help you with this.

Dr. Mike: Sure. And at the end of the show, we’ll kind of outline some of those and include some links in the show, notes for folks too. Megan, what are some issues at the breast itself that nursing mothers might face?

Megan Harrison: Every mom-baby diet is unique to breastfeeding. So even if you have a mom that’s breastfed before and a baby that’s never breastfed, latch can always be a challenge initially. And it’s based on just the physique of the mother as well as the baby’s mouth structure. So with the nipple, a lot of times we’ll see some crack or bleeding nipples, but typically looking unrelated.

It’s usually related to poor latch or a shallow latch where the baby is mainly on the nipple and not on the breast. So teaching these mothers to get a deep latch is really important in those first initial times, especially for the first several days because the baby is eating almost every hour.

00:23:16

Dr. Mike: What about infection?

Megan Harrison: Some of the things as they go on through nursing that they have an increased risk are for bacterial infection or yeast infection because of the breast milk is a very good nutrient source for those kinds of things. And also…

Dr. Mike: Mastitis is what we’re talking about here?

Megan Harrison: Yes, mastitis.

Dr. Mike:  So you get that milk and it’s kind of a substrate for the bacteria to grow.

Megan Harrison: To grow.

00:23:50

Dr. Mike: Is that true with an antibiotic?

Megan Harrison: Yes. And typically tell the moms to call their OB for recommendations because lactation we can kind of look and see what’s going on. Is it really this or that? Because a lot of times they’re complaining of breast and it could be something that’s superficial where you’ve got a crack versus an actual infection in the breast. But if moms all of a sudden are telling me I have a fever, I’m not feeling good like flu-like symptoms. I typically encourage them to call their OB to be assessed by a physician to see what’s actually going on.

Dr. Mike: And should they continue breastfeeding through that infection?

Megan Harrison: Yes. It’s really important to continue even when you’re not feeling well, even if you have a cold or anything else, because antibodies are passed to your baby to help with protection. So you’re not actually transmitting the infection, you’re actually providing the positive aspect of antibodies in your breast milk.

00:24:42

Dr. Mike: Are there things that moms can do to prevent that from happening, from getting bacterial infection or yeast infections at the breast?

Megan Harrison: Frequent milk removal is really important, so that you’re not having fullness. So then the baby naturally should help with this. The other thing that’s actually a misconception and I hear a lot of moms is they feel like they need to clean their breasts prior to breastfeeding. And that naturally can cause trauma to your nipples, which can have open sores, which of a great source of a way for a mom to get infection.

And if they are having sore nipples or ouchy nipples, they really should be assessed by either OB or a lactation consultant so that we can actually see what’s going on because there’s ways to assess with sore nipples, cracked, bleeding nipples.

Dr. Mike: Right. And the advice really depends on what the cause of the soreness is and that’s why it’s important for them to be seen.

Megan Harrison: Exactly. And it’s important to see both mom and baby because it could be everything is OK with mom except, not the best latch, but then we look at the baby and the baby could be tongue-tied. So that may need to be assessed by physician.

00:25:50

Dr. Mike: Sure. Dr. Parikh, what dietary and fluid considerations are important for nursing moms?

Dr. Nehal Parikh: So it’s recommended that mothers add about 500 kilo calories to their diet during lactation. And it’s very important to stay well hydrated so their milk supply remains robust. There really isn’t any need to drink milk to enhance their own milk supply. Some moms tend to believe that.

Although there are older studies do not find the link between maternal diet and human milk content, I think emerging studies are showing that perhaps what you eat may influence what your baby is receiving. But I think we need more science here before we can really advice moms to change their diet. But at the minimum, I think they can refrain from alcohol, smoking and high doses of caffeine.

Dr. Mike: What about vitamins?

Dr. Nehal Parikh: So usually dietary supplements are not necessary unless you have a poor diet. If you don’t have a well-balanced diet, then you would need multivitamin supplements. But otherwise, generally, you do not need it. Unless you’re a strict vegetarian or vegan, in those cases, you need to supplement with 0.4 micrograms of vitamin B12 daily.

00:27:05

Dr. Mike: And it used to be the advised or maybe it still is just to keep taking your prenatal vitamin through the breastfeeding period. Is that still common advice?

Dr. Nehal Parikh: That or just finish them out. You don’t necessarily need them again if you have a well-balanced diet. Although in our western standard diet, many of us can’t claim that we have a well-balanced diet, so it’s probably a good idea to finish those out. And the body naturally excretes most of this out when there’s an excess.

Dr. Mike: What are some problems associated with smoking and breastfeeding. I mean, I thought you’d mention that, and it’s not really a diet-related thing. Cigarettes and other tobacco products, what are those do to breastfeeding moms?

Dr. Nehal Parikh: Yeah. So the role of smoking and breastfeeding has been evolving. It used to be that the American Academy of Pediatrics recommended that you don’t nurse if you were also smoking. But newer studies have shown that even though these babies were at high risk for sudden death infant syndrome, respiratory illnesses, in the first year of life, perhaps even colic, when you compare these babies to bottle-fed, excuse me, a baby that also lives in household where mothers smoke or others smoke, those that are breastfed tend to do better.

So if the choice is to continue smoking and, of course, we should encourage moms — it’s a great opportunity to educate them and then encourage them to quit smoking. But if they choose not to, then I think it’s best to encourage them to continue nursing. Many of these moms select themselves out and stop nursing earlier than non-smoking mothers.

00:28:45

Dr. Mike: Sure. And the pregnancy itself is a great opportunity to do something great for your baby and stop smoking.

Dr. Nehal Parikh: That’s exactly right.

Dr. Mike: And so, hopefully, don’t pick it back up during that. Well, don’t pick it back up, period, but in particular, during the breastfeeding. Right. And I also read some things that smoking can decrease breast production as well.

Dr. Nehal Parikh: Yeah. And I think that’s still controversial. And there are more recent AAP recommendations. I think AAP acknowledged that the role on the influence of smoking on weight gain is controversial. And in some studies, there has been a lower weight gain possibly related to the reduced amount of breast milk production. I think that scientific evidences are still waiting to be discovered.

Dr. Mike: And I think that’s one of the great things about PediaCast. I mean, you know, a lot of people, “Oh, it decreases production, it does this, it does that.” We really want to be evidence-based and say, you know, we don’t want you to smoke when you nurse but we also don’t want to make up things either.

Dr. Nehal Parikh: That’s right. That’s right.

00:29:47

Dr. Mike: And then we talked a little bit about prescription medication. I mean, there are some, especially when you’re looking at the chemotherapy and radioactive-type medicines that are absolute contraindications, but there’s also other medicines that may or may not be an issue. And rather than go through a big list of those, really, just mom should check with their doctor.

The FDA maintained to database a breastfeeding categories, you know, where they know whether things are safe, not safe or we just don’t know, when you have to look the risks versus benefits and that kind of thing. So talk to your doctors about that. What about alcohol use?

Dr. Nehal Parikh: Yes. So, alcohol, we know very clearly, scientifically that it is rapidly and completely excreted into human milk with infant levels that equal to or higher than the maternal blood alcohol levels. So this is a very important concern. And in the short run, we know that even small amount of alcohol affects infant sleep-wake cycles. And we also know that large, chronic exposure can lead to developmental delays.

However, this evidence, we still need more of it. And especially on long term brain development, how alcohol may adversely affect human brain growth. So it is best to avoid alcohol during nursing. And this is a physician that the American Academy of Pediatric takes as well. And if mom does decide to take, say, one salivatory drink, it’s best that she avoid breastfeeding for at least two hours.

00:31:13

Dr. Mike: So the rule of thumb — and we’ve talked about this on PediaCast before too — is that if you’re going to drink two hours to metabolize a single alcoholic beverage. And the definition of that is a 12-ounce beer, 5 ounces of wine or 1.5 ounce shot of 80-proof liquor. So two hours in one drink. But, again, excessive alcohol exposure, you know, can lead also to decrease milk production I believe. I think I’ve seen that as well.

Dr. Nehal Parikh: Yeah. I’ve heard that as well. Maybe Megan can comment on that.

Dr. Mike: With alcohol being an issue with that. I mean chronic alcohol exposure can decrease milk production.

Megan Harrison: Yes, it does. And the other thing to add into it, if mom chooses to have a drink because it’s, as an adult, that is something, you know, that we all to make choices. But to remember, if you do want to have a drink is pump before you leave, A, to leave breast milk for the baby if you guys are going to be separated but, B, you’ve got that milk utilized while you are potentially discarding the last feeding session.

00:32:13

Dr. Mike: Well, that’s a good point. Yeah, good point. What medical conditions are associated with an inability to breastfeed at the breast? So it’s something still moms could pump and give through her bottle. But are there instances where actually at the breast may not be possible?

Dr. Nehal Parikh: The biggest one is prematurity. So little ones don’t have the motor coordination, their suck, swallow coordination to be able to nurse at the breast, but by all means, these babies benefit even more so than full-term infants from the human milk. So it’s a great idea to express the breast milk and to give it to their baby via feeding tube. Babies that have multiple genetic problems, neurological problems, can also have an inability to suck, swallow at the breast and sometimes may do better with the bottle or more likely tube feedings.

Dr. Mike: Cleft palate is another one that we actually did a whole show on that with PediaCast 174. Dr. Kirschner came on. And we talked at link about cleft palate. But that’s another one that maybe difficult to nurse.

Dr. Nehal Parikh: Maybe. However, more and more, we’re seeing with these special types of bottles that are available. We can, with the bottle, at least improve their suck, swallow coordination and they can do well. But you’re right. With the breast, it’s difficult for them.

00:33:35

Megan Harrison: And one thing to add in with remembering that sometimes babies can’t nutritively breastfeed as with each individual case and the doctors assessing the situation is that there is still that comfort nursing that we can offer mothers. So just because they can’t get the milk out doesn’t mean they can’t have that bonding experience with mom and baby at the breast.

Dr. Mike: That’s right. It’s a great point. How does breastfeeding and reflux — kind of talk about that interaction a little bit. So babies who have gastro-esophageal reflux, they spit up a lot. We talked a little bit about formula causing that. In terms of the breastfed baby, just discuss that a little bit.

Dr. Nehal Parikh: Yeah. So there’s actually some evidence to support that breastfed babies have less gastro-esophageal reflux. But when they do have it, some of these symptoms can resemble colic. So it’s important to distinguish the two. And usually with reflux, it’s going to be during or immediately after the nursing event, not necessarily at a particular time of day such as with colic.

Placing these infants semi-upright during the feeding event and placing them, say, in an inclined seat after the feed should improve their symptoms. And certain circumstances maybe best for mothers to refrain from dairy products or cow’s milk protein in their diet. And there’s some fair amount of evidence to support that practice as well.

00:34:58

Dr. Mike: It used to be that bad colic was treated by thickening the formula. And that’s a little bit difficult to do obviously at the breast as well. Although you could pump and express and thicken it that way…

Megan Harrison: There’s currently actually nothing to thicken breast milk at this time.

Dr. Mike: So you can’t add rice cereal?

Megan Harrison: What we used to utilize is not available.

Dr. Nehal Parikh: It’s off the market now.

Dr. Mike: Got you. And it’s not recommended that they use rice cereal like you would with a formula?

Dr. Nehal Parikh: No. I don’t think it’s currently recommended.

Megan Harrison: Yeah.

00:35:32

Dr. Mike: In terms of colic, you hear a lot of parents say, “Well, when I eat spaghetti sauce or, you know, certain things in my diet make the baby fuzzy.” Is there any evidence to suggest that particular foods in mom’s diet may result in babies being more fuzzy?

Dr. Nehal Parikh: I would say not strong scientific evidence, but some parents will swore by it. So if it’s not an essential nutrient, you can always withdraw that from your diet and see. I don’t think there’s any harm in doing so.

Megan Harrison: A lot of times what I tell my moms is to look at because, like, well, I noticed today my baby got really gassy after dinner. And what they really need to focus on is what did they have that previous meal. Because if they sat down and ate a whole head of cauliflower, that’s a very gaseous substance, which will definitely impact that baby.

So really to have moms just look at and make sure that they’re having a well-balanced diet, but if they notice routinely when I eat Brussels sprouts or something that makes me gassy and I've noticed it also made my baby gassy, and just limiting those things because it’s really an individual thing.

00:36:35

Dr. Mike: Sure. So if it’s just, you know, anecdotal, there’s one food that tends to do it, it’s not a big deal just to avoid that food. And, hey, if you think it helps, great. There’s not a lot of science to suggest it would help. But in your situation, you know, if it seems like it is, then do it. But if it’s an entire food group, you know, they’re now vegetarian because every time I eat meat the baby seems fuzzy, you know? Then that is an issue.

Dr. Nehal Parikh: Yes.

Megan Harrison: And when moms are altering their diet, I’d really encourage them to talk to the physician about possibly seeing a dietician or nutritionist just because at that point we want to also make sure and continue to make sure that that mom is still eating those extra calories. So when you’re altering your diet on something that you’re not used to, I’d really recommend getting some professional help.

Dr. Mike: Absolutely. So let’s say a mom is breastfeeding and she seems to be doing everything right, but the baby is losing weight or not gaining weight well during breastfeeding. What’s the next step?

00:37:31

Dr. Nehal Parikh: So this can happen for a variety of reasons. If there is associated significant dehydration, then these infants should be seen right away and potentially hospitalized for rehydration with IV fluids to begin with. But more often the problem is not diet and can be picked up early, and in these circumstances, formula supplementation is reasonable until the underlying problem is addressed.

Often this problem could stand from lack of experience, so just help supporting this mom, especially new moms that have limited experience and little social support can benefit from just that attention that we give to them. And if the breast milk supply is adequate but the caloric content is suspected to be low, this problem can also be fixed with addition of human milk fortifiers as often as needed in preterm infants.

Dr. Mike: And that’s, again, something that you don’t want to tackle on your own. You want to be talking to a lactation consultant and pediatrician and trying to come up with a plan for why the baby maybe losing weight.

Megan Harrison: And, Dr. Parikh, you did mention you can use formula if we’re seeing that the baby needs more. The other thing the mom can do is breastfeed and then pump after if she really has a strong need of not wanting to use any formula with her baby. There are ways because it could be something as supply issue. A lot of time if we get them on pumping after and the baby is doing with expressed breast milk through a bottle as well as breastfeeding a lot of times, that’ll naturally increased.

00:39:00

Dr. Mike: And we talked a little bit about moms and vitamins. What about breastfed babies? Do the babies need extra vitamins?

Dr. Nehal Parikh: So, yes, the American Academy of Pediatrics recommends that breastfed babies received 400 international units of vitamin D daily. Aside from that, there really isn’t any need for additional iron supplementation or fluoride supplementation, which has been out there in the past. But the current recommendations say all you need to do is supplement with 400 international units of vitamin D.

Dr. Mike: I suspected that’s not necessarily a practice that’s happening out there, you know, out in communities everywhere. That there’s certainly pharmaceutical companies that market baby vitamins. And, of course, they have a reason to do that because they're making money at it. But really from the standpoint of medical recommendations based on evidence, vitamin D is really the only issue.

Dr. Nehal Parikh: That’s right. And there’s a lot of interest with omega-3 supplements and all of that. But I think the evidence is still lacking for such a practice.

00:40:07

Dr. Mike: Sure. Now, when should moms introduce solid foods to breastfed babies?

Dr. Nehal Parikh: So, again, going back to the American Academy of Pediatrics, they’ve done a lot of the work of synthesizing as well as putting together the evidence summaries. And they say that there’s really no need to introduce solid foods until six months of age. It used to be four months. But now, the current recommendation is six months.

And we know that about at this time, a normal infant begins to deplete his or her iron source. And therefore introduction of iron-containing solid foods at this time makes rational sense. In addition to World Health Organization, they did a summary of research that has been found that there is no advantage of introducing solid foods earlier than six months of age.

Dr. Mike: So six months is the new time.

Dr. Nehal Parikh: Absolutely.

Megan Harrison:  And that goes right along with growth and development of where the infant is and their stage of development because they should be started to sit out and interacting. And so, it goes right along with that development aspect of the baby.

00:41:08

Dr. Mike: There are a lot of parents out there who are anxious to start foods, and so things get started before six months. But I guess there’s also some evidence that suggest — we talked about antigen exposure with cow’s milk. And that that could cause some disease processes down the road. That’s really true with solid foods as well.

Dr. Nehal Parikh: I think that while the evidence isn’t as strong with that, absolutely, especially a certain nuts or eggs. So I think we have to be very prudent and generally discuss this with the pediatrician or dietician before you introduce solid foods.

Dr. Mike: Sure. We talked a little bit about the mechanics of breastfeeding and latching and sucking and making sure you get a deep latch and talking to a lactation consultant, you know, when problems arise with that. Another term that, kind of, floats out there with, sort of, the mechanics of breastfeeding is nipple confusion. What is that?

Megan Harrison:  That’s a misconception actually. And what typically happens is just like we all are learning people, it’s usually that there has been two different things introduced to this baby in a very short window, which is at first month of life. When you have a breastfed baby, the soft tissue to the top of the palate tells the baby to start to suck and eat.

00:42:29

When introducing any artificial teeth such as a bottle or a pacifier in that first month of life, it actually interrupts the breastfeeding learning curve because breastfeeding in general should take the baby to be a very effective good eater, takes anywhere from 6 to 12 weeks depending on the baby. Now, as the baby after day one, breastfeeding, absolutely, but to be just the best that they can at breastfeeding, it’s a learning curve just like anything else.

Bottle feeding has a shorter learning curve. And the reason why is bottle feeding has less mechanics than breastfeeding because breastfeeding have to — it’s all changes with the structure of their teeth, how the nipple and the breast start compress and the swallowing mechanism are different between breast and bottle.

Dr. Mike: Sure. What is the role of pacifiers in the breastfed infant? Is there a rule at all?

Megan Harrison: There is a recommendation out there through World Health Organization as well as I believe American Pediatrics follows the same guideline of not introducing any artificial teeth for at least the first month of life to assess. But if you can delay that, it does help with the baby’s success at breast.

00:43:46

Dr. Mike: And I guess the issue here is that babies do have a need for non-nutritive sucking. And sometimes, because of where you are or, you know, the situation that you’re in, at the breast may not be the most appropriate.

Megan Harrison: Yes. And, you know, if it’s the father, you know, they don’t have the ability to breastfeed their baby when they’re upset. So having that as a backup for the father, absolutely. But if they could hold off for the first four weeks of introducing and really letting that mom and baby learned the style of breastfeeding as well as, you know, eventually parents do have to go back to work, so bottles obviously eventually will have to be introduced.

Dr. Mike: And let’s talk about that a little bit, just the role of breast pumping and what are some strategies to make that successful.

Megan Harrison: So if mom and baby are going to be separated anytime and the baby is going to be eating the recommendation is that mom needs to pump. We’re talking that there are several different types of pumps out there. There are manuals. There are single-users. This means one breast is pump at a time or what’s typically used is dual pump where both breast are pump at the same time.

And usually the recommendation is if you work an eight-hour job, also making sure that factoring your drive time. But if you’re working eight-hour job, that takes you maybe nine hours away from the house, you should be pumping twice from the time, you know, you breastfeed before you leave or pump if you choose, pump twice at work and then breastfeed right when you get back home. If it’s a longer day like a 12-hour day then you need to remove milk three times, which is about every three hours.

00:45:17

Dr. Mike: So eight-hour shift, you should be pumping twice. And if it’s a longer shift, then three times.

Megan Harrison: Yes. And you have to remember, and this is where you’re keeping contact with your lactation team that you’ve worked with because as the baby olders, things progress. So a baby that is maybe 10 months old and if you’re at home on an off day and the baby only breastfeeds one time during those 8 hours, then you realistically only need to be pumping once. But keeping in contact well as the baby ages is really important.

Dr. Mike: Sure. A lot of parents — when the moms pump for the first time, they’re kind of surprised that not as much comes out as they thought that the baby was getting. Is that less efficient than a baby at expressing all the milk in the breast?

Megan Harrison: That is actually true. The baby does the best job because the natural hormones are released to your baby. This is not a baby, it’s a pump. So it’s really telling moms to relax, have pictures of the baby, listen on their phones maybe, record your pictures of your baby playing or hearing the cooing sounds, things that can relax you to be able to let down your milk are really important.

00:46:24

Dr. Mike: And then talk a little bit about once you expressed the breast milk with the pump, how do you store it?

Megan Harrison: If you’re at home and it’s going to be utilized within for a healthy term baby, it can be sitting on the counter for up to four hours. If you’re not going to be around in the baby, say you’re at work, this should be put in an approved collection container whether it’s a bag or a bottle and then store it in the refrigerator for use. Breast milk for a term healthy baby in the refrigerator is good for up to four to seven days.
And then if you don’t think you’re going to utilize it, that’s when I would encourage moms to put them in a freezer, depending on your freezer whether it’s a refrigerator freezer together, it’s good up to three to six months. But if you have a deep freezer, it’s actually good for up to a year.

Dr. Mike: Do you recommend storing it in a big volume or smaller like individual feeding volumes?

Megan Harrison: That’s really based on what the mother is going to be utilizing the breast milk for. If she really has an oversupply and doesn’t need the milk, then store it in bigger quantities. But if she’s utilizing the milk, it can be stored for each feeding. The biggest thing to remember is everything has to be at the same temperature.

So you can’t combine fresh milk with refrigerator milk at the same time that you pump because you’re warming that milk and essentially impacting the nutrients inside of it. But to remember to portion off, you know? if you’re going to give your baby to take only two ounces, don’t warm three ounces. Because when it’s warm and when the baby has eaten from it has to be utilized within that hour or thrown out because it’s impacting the nutrients.

00:48:09

Dr. Mike: Right. When you store it, is there any advantage to plastic versus glass and, you know, there’s the whole BPA concerns. And can you just talk about that for a moment?

Megan Harrison: Sure. There are, as you’ve mentioned, there is bags versus, you know, glass bottles, things like that. But the first thing that the family needs to look at is their economics, like how much do they want to pay for things. Glass bottles are very expensive if that’s the way you want to go. A lot of things are BPA free. The bags or the bottles, everything is BPA free. So whether you want to do bag or bottle, that’s really your choice.

The one thing, if with the bags note to be careful of is if you’re putting in a place that the bag is getting friction where it’s moving a lot. When you go to thaw it, it potentially could have a hole in the bag. So a lot of times if you choose to utilize the bags, I always tell moms to double bag the milk when they’re thawing. Just in case that there is a hole, it’s caught into the bag and not put into the water that you’re thawing in.

Dr. Mike:  Good. And I just want to point out briefly when we talk about BPA. That’s beyond the scope of this discussion but there’s a lot of controversy. And we’re not here saying BPA is a problem whether it’s not a problem that the verdict still just kind of out on that.

Megan Harrison: I typically encourage the family to just talk about it.

00:49:24

Dr. Nehal Parikh: Although I would say the evidence is really mounting. And the formula maker or the bottle makers have really heated those warnings. And there’s mostly BPA-free stuff now.

Dr. Mike: It’s easily accessible.

Megan Harrison: And economical, it’s not outrageously priced.

Dr. Mike: Great. What about when moms have multiple babies? So we have twins, triplets and beyond. Are they still able to breastfeed?

Megan Harrison: Absolutely. Again, this still needs to be assessed individually of what was going on if mom has any risk factors for providing breast milk of not having a full milk supply such as does she have breast development. Sometimes, there’s not complete research showing but premature moms making milk supply versus a term healthy, they haven’t gone through all the developmental process of their breast.

00:50:19

Dr. Nehal Parikh: If I may add just also I think just having an additional support person makes a huge difference when you have twins and triplets as we’ve seen often in the NICU. So providing those moms additional support can mean a difference between success and failure.

Megan Harrison: And remembering that the baby still needs to have their own time to learn to breastfeed. So sometimes, initially, you have to start breastfeeding one. And so they’re not, what’s called, tandem feeding. But eventually that mom can be successful in tandem feeding. So both babies are breastfed at the same time, which decreases the time and duration that their breastfeeding.

Dr. Mike: Absolutely.

Megan Harrison: One of the good resources, which I know you’re going to put on there, is La Leche League. That’s a really good resource for moms to go because there’s usually a lot of mothers that have been there and done that breastfeeding and pumping.

00:51:04

Dr. Mike: Sure. Let’s a little bit, you had mentioned fathers along the way. What is a dad’s role in breastfeeding?

Megan Harrison: Dads and/or any other support person that mom identifies with is really just to be that support and that advocate of understanding that this is really important for that mother and standing up and, saying, you know, this is a really a choice that she’s made. And I’m very proud of her and I’m, you know, going to support her anyway.

But things that typically help moms is, you know, change the diaper of the baby. In the middle of the night and the baby starting to wake up and the diaper needs change, if the baby is not in the same room, maybe get up, change the diaper and bring the baby to the mom so that she can breastfeed, then you put them back to sleep, you know, afterwards.

If it’s pumping related, you know, helping assisting with cleaning the parts, things like that, because that can be very time consuming. Helping put the breast milk away, you know, if it’s needs going to refrigerator, frozen, things like that.

00:51:59

Dr. Mike: As a dad, I would encourage fathers also to really be a cheerleader in this because it gets to the point where a lot of times moms are discouraged that things aren’t going well and, you know, they’re worried. And it seems easy to make a decision to stop doing it.

But if dad would, kind of, step up to the plate and say, “No, let’s work through this. I mean, breastfeeding is important to us. We talked about this before the baby came. Let’s not give up so easily.” So they could really be kind of a coach and cheerleader in this too.

Megan Harrison: And the other thing I’ve mentioned earlier was that kangaroo time with the breastfeeding. It’s also important for dads to have kangaroo, skin to skin, time because it’s also another bonding thing. And it helps with growth and development. So it’s something that’s really important for moms to do but it’s also equally as important for fathers to do.

00:52:44

Dr. Mike: And then the siblings, especially toddlers, you know, can get pretty jealous when mom spending so much time with the baby. Do you have any advice for dealing with toddlers?

Megan Harrison: When you come, you need to look at where they are developmentally, but making sure you’re setting aside some time each day that’s just time with them. The other thing to think about is if there is something they really like, whether it’s the computer time, a TV show or a certain toy is they get that as a reward during the time that you’re breastfeeding. They only have access to it while you’re breastfeeding.

Dr. Mike: Great idea.

Megan Harrison: So that it’s kind of something that is rewarding to them and, you know, it’s something that they get especially for them.

Dr. Mike: Toddlers always like to help too. So, you know, go get this rag or do this. Get them to work

Megan Harrison: Yeah. And, you know, and the other thing is, with education, is having them, you know, mimic. Have them change the diaper on a baby doll. You know, teach them to feed the bottle so that they can also feel like they’re in this as a family.

00:53:48

Dr. Mike: Sure. And, of course, grandparents and others love to give advice. And sometimes it’s great advice. And sometimes it’s not so good advice. So how should nursing mothers respond? I mean, I think this is actually more difficult. I mean, when you have the pressure of family and they’re giving you the wrong advice and you know it’s the wrong advice because you’ve researched it yourself or you’ve gotten the information on a show like this or from a lactation consultant. How do you deal with bad advice from people you love?

[Laughter]

Megan Harrison: I always would encourage to say thank you and respect that person’s viewpoints, because where they received their education, whether it was 40, 50 years ago or it’s today, not there’s very conflicting information just like I’ve explained with the water. You know, I’ve had several people say, “Oh, just put water in the bottle. It’s OK. It’s good for the baby.” Well, that was a belief that was 40, 60 years ago.

But we know today that there is no nutritional value in water for it actually dehydrates them. So just to say thank you, sometimes not, you know, obviously. And if you feel like it’s an educational point, then say, you know, respect the father or the mother and use that as a learning time and say, “You know, actually this is what I was taught by X, Y and Z.”

00:55:00

Dr. Mike: Yeah. And maybe point them to the resource. You know, this is coming from the American Academy of Pediatrics or this is from literature that my lactation consultant gave me. So there’s a way to do it respectfully.

Megan Harrison: Exactly. Yes.

Dr. Mike: What about the needs of single breastfeeding moms? I suppose that that’s more difficult.

Megan Harrison: I think breastfeeding in general is, just in America, is the challenge just because of the way that our society doesn’t. I think the biggest key factor is whether you have supportive father or not is to just find support people. It doesn’t have to be the father. It may be your mother. It may be your friend. It may be a coworker. But always just having that person that you know you can call at two in the morning when you’re sobbing because the baby won’t quiet down and won’t latch, things like that. Just to know that you’ve got that place, the safe place, to vents.

Dr. Mike: Where are we with regard to public breastfeeding?

Megan Harrison: It’s actually a national thing. The U.S. Department labor and wages — actually we are protected by law that you are allowed to breastfeed in public and that you are to be able to pump at work, specifically…

00:56:15

Dr. Mike: And this is a part of Obama Care, right?

Megan Harrison: Yes. The Labor and Employment Alert that came out in 2010 states that if the employer has greater than 50 employees through the section 247 Patient Protection and Affordable Care Act that they have to provide reasonable break time for this mother to pump. Now you don’t have to be paid for this time but you have to have the time for them.

Dr. Mike: And that’s for companies over 50. But I would say small business owners, come one. I mean get on the bandwagon and really support your employees and help them be successful.

Megan Harrison: Yes. And the biggest thing I can tell mothers is when you find out you’re pregnant, start planning before you have the baby. Start talking to your employer and say, “This is actually my plan.” And these acts, it provides mothers to protect their milks of life for the first year of life, which is what the American Academy of Pediatrics suggests that a baby receives breast milk for the first year of life.

00:57:15

Dr. Nehal Parikh: This is economically beneficial for the employers as well. This has been well shown now.

Megan Harrison: Yeah. The babies, as they grow, get less sick so there’s less chances of having ill time.

Dr. Mike: Great. Great. Great information. In a perfect world, when is the ideal time to stop breastfeeding?

Dr. Nehal Parikh: There is no perfect answer to this. However, according to the AAP again, there’s no upper limit to the duration of breastfeeding and no evidence of physiologic or developmental harm from breastfeeding into even the third year of life or longer. They recommend moms nurse for at least one year and beyond, if mutually agreeable to mom and baby.

And the World Health Organization, their view is actually that you should go up to two years of age and beyond, again, if they wish. We know in primitive society, the average time was three to four years. And I think, in our society, often because of public social pressures, moms choose to stop nursing much sooner.

00:58:18

Dr. Mike: What’s a good, winning strategy, Megan? What’s the good way to go about stopping once you decide when you’re going to do it?

Megan Harrison: I would say the first thing is to call lactation consultant or someone that you know that has expertise in this to kind of talk through your plan because depending on what’s stage the baby is at with breastfeeding depends on how long the duration and how long mom wants to take it. Because some women want to stop very quickly and other women want to naturally take longer.

But the thing with breastfeeding, typically, if it’s going to be a natural cessation of mom and baby decide we’re done, the last two feeding sessions that disappear are usually the night time feeding and the morning feeding. So the baby or the infant or toddler usually can go throughout the day doing some cup feeding, bottle feeding and things like that, but usually that morning and night ones are the last ones that are given up. And if you think about it, a child that’s already a year, they’re typically getting their meal times and then maybe nursing in morning and night.

Dr. Mike: Sure. So there’s no real cookie cutter answer for this. It really depends on the situation.

Megan Harrison: No. Unfortunately, there isn’t. We really need to look at where the mom’s milk supply is and how that baby is interacting with this. And just naturally supporting this mom throughout the process is really important.

00:59:36

Dr. Mike: Great. Dr. Parikh, earlier in the show, you’ve mentioned that we’re going to talk about breast milk jaundice a little bit or maybe it was Megan. Someone mentioned it. And actually I did not put that in the original, sort of, topics that I wanted to discuss which shame on me because it is a big issue.

Dr. Nehal Parikh: Yeah. So it’s a big issue only in the fact that people aren’t well educated about it then. And now I think if you know about it, then you can work with that problem. So many babies, because of both the lower intake sometimes when breastfeeding is being established and certain enzymes in the breast milk will have prolonged jaundice or high levels of bilirubin that results in the visible yellowing of the skin and the whites of the eyes. And this can be address with frequent pediatrician checks as well as sometimes hospitalization to get phototherapy.

Dr. Mike: And the issue here is, and correct me if I’m wrong, when babies are born, they have increased red blood cell load because of the fetal maternal circulation that’s there. And as the body breaks down these extra red blood cells, the hemoglobin in the red blood cells gets converted to bilirubin, which the liver has to process. And with breastfed jaundice, what we think happens is that there are certain elements in the breast milk that make the liver not quite as good at doing that. And so, you get to build up the bilirubin and that’s what causes the jaundice.

01:01:08

But there are disease processes that can do it as well. So it’s important that you see your doctor and see how high the bilirubin is because it could cause brain problems if it’s from a different reason or the levels go too high.

Dr. Nehal Parikh: That’s right. But it’s important to recognize that if it’s related to breastfeeding or breast milk jaundice, that it’s usually benign and it doesn’t cause any problems with the bilirubin entering into the brain and causing long-term developmental problems. But it is extremely important that they’d be seen by their pediatrician.

And this be worked up sometimes just in an outpatient setting. But if it’s presenting late, then you might have to hospitalize the infant and do some testing and treatment with phototherapy for the jaundice.

Dr. Mike: Sure.

Megan Harrison: And the biggest thing for moms to remember is to just continue breastfeeding. And getting the support they need if they’re inpatient, usually at least here at Nationwide Children’s, lactation is available to continue to help, because usually it’s a combination of things babies are getting sleepier, you know, that because of the jaundice that they’re not breastfeeding as well.

01:02:10

But the biggest thing is just to keep moms breastfeeding throughout the session and/or if they aren’t able to breastfeed for the medical reason that the — if they’re inpatient that doctors are saying that we need to not breastfeed at this moment then pumping to protect their milk supply.

Dr. Nehal Parikh: But that’s rare, so thank you for pointing that out. I think there are still some pediatrician and family practitioners that may feel that you need to stop breastfeeding or giving the baby human milk, expressed human milk. But there’s very little evidence to support that.

Dr. Mike: Doing that may help the jaundice go away faster, but then the question becomes do you need the jaundice to go away faster at the expense of disrupting breastfeeding.

Dr. Nehal Parikh: Yeah. And then in some cases it may not do it at all.

01:02:51

Dr. Mike: May not do it at all. We’re at the one hour mark. And I knew this one is going to be a long show because there’s just so much great stuff to cover. But there are a couple quick questions that I’ve seen out there on the Internet. One is it is possible for mothers to restart breastfeeding after a period of not doing it? So let’s see, we have a mom who quit and now they are regretting it. It’s, you know, six weeks, two months later, can you restart?

Dr. Nehal Parikh: Absolutely. Not just six weeks or two months, but sometimes even six months later. Indeed it’s possible either naturally by just re-initiating the process of breastfeeding or with aids devices such as lactate or drugs that are out there, although the evidence with drugs is less robust. And I would say that should be a last resort. More often than not, just naturally restarting the process of breastfeeding oftentimes does it. And there are studies to support that. Even if you wait as long as six months, you can still resume breastfeeding.

Dr. Mike: Sure. You mentioned lactate. But I want to point out that’s not the same thing as like lactose intolerance, because it’s just like a lactate milk, you know?

Dr. Nehal Parikh: No. It’s a device to help. And certainly, you will have a help from a lactation consultant and a pediatrician or an OB to help you do this.

01:04:05

Megan Harrison: And there’s actually an induced lactation protocol. And that’s where the lactation consultant can see is that because moms stop breastfeeding for a week or two. The biggest thing to remember is like if you stop for a week it could take us up to two weeks to kind of rebuild you to potentially where you are with pumping and breastfeeding. But this is also something that can be utilized for people that are actually adapting that the mother wishes to breastfeed that infant.

Dr. Mike: And that was going to be my next question. So breastfeeding is possible for moms who weren’t pregnant and they’re adopting a young infant and they wanted to breastfeed, that something that can be induced?

Dr. Nehal Parikh: Yeah. Absolutely. And again, it can be done naturally or again with the aids of devices or drugs. However, I think in this population it may be hard to get a full note supply and maybe necessary to supplement with other nutrients or with formula. However it’s important to keep in mind that this provides more than just nutrition, it’s a bonding thing for the mother. So by all means, even if their supply is low they should be encouraged to do this if this is what they choose.

01:05:10

Dr. Mike: Sure. And these kind of things — and I don’t want to berate smaller communities because certainly there are people who are on top of the latest, you know, everywhere. But if you’re not associated with a teaching hospital or you’re not really have your nose in the research and sort of what’s out there. I mean, this is the kind of thing it’s easy for a mom to have this question, hey this is something I can do, can I restart breastfeeding or can I start when it’s not my baby.

And you ask someone who you looked to to be a professional. And they say, “No there’s no way you can do that.” I mean this is just out there to say “Moms, no there is a way to do it.” And if you have questions then, you know, maybe you do need to get in touch with a lactation consultant at a bigger tertiary care institution that maybe up on the latest evidence-based research.

Megan Harrison: Yes.

Dr. Mike: OK. I really appreciate both of you stopping by and taking time out of your busy schedules to get this information out to our listeners. We do have some resources for you at the website. So if you’re going to go to pediacast.org and click on show notes for episode 195. We’ll have a link to the La Leche League. They have lots and lots of information. It can actually get you in touch with lactation consultants in your local area, so lots of information in there. Megan?

Megan Harrison: And also every state has a lactation counsel. So if you type that info your state, so we have OCLA here in Ohio, which is O-C-L-A. So you can also look for that resources because all of the people that are a part of that association are listed in the region.

01:06:41

Dr. Mike: Sure. And one of the things I wanted to bring up. There are sort of becoming in vogue people to get human milk from other people. And I just wanted to point out that the best place to do that is through a certified breast milk bank. And I also put some resources for that in the show notes as well. You don’t want to buy human milk on Craigslist.

Megan Harrison:  Yeah. It’s discouraged to use shared milk.

Dr. Mike:  Right. Unless it’s through…

Megan Harrison: Unless it’s through an approved like Ohio milk bank.

Dr. Nehal Parikh: Yes. And although, I think it’s generally reserved for the pre-term infants. And I think they would probably have a hard time if you have a full-time infant and you’d like to get breast milk.

Dr. Mike: So if you’re going for a refutable source, you may not be able to get it that way anyway.

Megan Harrison: It’s all based on supply and demand. So if they have the supply, they definitely will be willing to let anyone purchase it.

01:07:32

Dr. Mike: And the other population that maybe interested in that kind of information are moms who want to donate to a refutable breast milk bank to help premature babies and others who, you know, maybe available for it.

Megan Harrison: Yes.

Dr. Mike: OK. So we’ll put some links to those kinds of resources. And we also have links to neonatal medicine here in Nationwide Children’s Hospital and clinical nutrition and lactation here. Our lactation consultants are available by phone. If you have any questions, we do — I mean it’s, really, you guys, we don’t want you to be inundated with thousands and thousands of phone calls but if you’re here in Central Ohio, absolutely call you. If you are outside of Central Ohio and you have a great resource in your community, we encourage you to use that. But if you don’t, you can still call us.

Megan Harrison: Please call us and we’ll find a connection for you to give you the best resource that you can need.

01:08:20

Dr. Mike: Great. All right. Well, before we go, there’s one more order of business. Here on PediaCast, one of the questions we ask all of our guests is just to give your input on a great board game. We like families to do fun things together that don’t always involve screens.
And so, you know, getting outside and being active is good, but on rainy days, you know, it’s always fun together around the table and play a game. So just, Dr. Parikh, what’s one of your favorite board games you can remember from or that you play now?

Dr. Nehal Parikh: Yeah. I have two little ones. And we play Forbidden Island. It’s a great game. And we really enjoy playing that. And then Parcheesi is another one, so I’ll give you two.

Dr. Mike: Sure. And Forbidden Island, I've got to look that one. That sounds interesting. I’ve never heard of it before.

Dr. Nehal Parikh: Yeah. Yeah. Even our six year old is able to play. Basically, you don’t play as individuals. You play as teams. And the goal is to beat the game. And it’s so much fun. You’re basically needing to get off the island and get all the treasures before the island sinks. It’s kind of like the lost kind of thing too.

[Laughter]

01:09:24

Dr. Mike: That sounds fun. It’s funny because we got several games for Christmas this year based on interviews that I’ve done, Settlers of Catan. I don’t know if you heard that one?

Dr. Nehal Parikh: I heard that one, yeah.

Dr. Mike: That is a lot of fun. That one is great. Megan, what about you?

Megan Harrison: We played a lot of cards. So for me, it was learning how to play Euchre and Rummy. But for the younger ones, I think my favorite one was probably Monopoly. And I mean that’s a big game. And then other thing is, coming from my educational side, is make up a game.

Dr. Mike: Absolutely. Yeah.

01:10:03

Megan Harrison: It’s very easy to do a board game. I mean it could be a search and find board game, you know? You can make it interactive. Just kind of look at where your child’s developmental, their interest, I mean, if it’s dinosaurs, just pick up some dinosaurs instead of playing, you know, checkers with those things, play him with the dinosaurs.

Dr. Mike: Speaking of card games, we got Five Crowns for Christmas. That was another one we did. And that is really a fun card game. And young kids played that easy too. That’s a fun one.

Dr. Nehal Parikh: Yes. We played that. Ticket to Ride is another great one.

Dr. Mike: Yeah. And that one is kind of like the Settlers of Catan, where you’re trying to build something. Great. Well, we appreciate that. We’ll add all of those to our list. We’re going to, once we hit the one anniversary here at Nationwide Children’s, which is going to be in February, we’re going to compile a list of all the interviews that we’ve done and different board games and so, you know, folks can see what the doctors are playing.

[Laughter]

01:10:57

Dr. Mike: All right. Well, thanks again to both of you for stopping by. Dr. Nehal Parikh and Megan Harrison, I appreciate both of you. And, of course, thank you to all of our listeners out there. I want to remind you that we do have the ability for community participation here at PediaCast.

So if you have some thoughts on breastfeeding or some helpful hints that you think other listeners would like to hear or resources you think that others could use that you want to pass along, if you go to pediacast.org and go to the show notes page and under episode 195, it’s basically like a blog post so you’re able to enter comments there that you may think that might be helpful to other PediaCast community.

I also want to remind you, once again, that you can get a hold of us, if there’s a topic you’d like us to talk about or you have a comment or suggestion for the show, just go to pediacast.org and click on the contact link. And you can also email: pediacast@gmail.com, or call the voice line at 347-404-KIDS. Again, that’s 347-404-K-I-D-S. And until next time. This is Dr. Mike, saying stay safe, stay healthy and stay involved with your kids. So long everybody.

[Music]

Announcer: This program is a production of Nationwide Children’s. Thanks for listening. We’ll see you next time on PediaCast.

 

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