Colic in the Breastfed Baby

Source: Canadian Breastfeeding Foundation

Colic is one of the mysteries of nature. Nobody knows what it really is, but everyone has an opinion. In the typical situation, the baby starts to have crying periods about two to three weeks after birth. These occur mainly in the evening, and finally stop when the baby is about three months of age (occasionally older). When the baby cries, he is often inconsolable, though if he is walked, rocked or taken for a drive, he may settle temporarily. For a baby to be called colicky, it is necessary that he be gaining weight well and be otherwise healthy.

The notion of colic has been extended to include almost any fussiness or crying in the baby, and this may be valid since we do not really know what colic is. There is no treatment for colic, though many medications and behaviour strategies have been tried, without any proven benefit. It is admitted that everyone knows someone whose baby was cured of colic by a particular treatment. It is also admitted that almost every treatment seems to work-for a short time, anyhow.

The breastfeeding baby with colic

Aside from the colic that any baby may have, there are three known situations in the breastfed baby that may result in fussiness or colic. Once again, it is assumed that the baby is gaining adequately and that the baby is healthy.

1. Feeding both breasts at each feeding
   Human milk changes during a feeding. One of the ways in which it changes is that the amount of fat increases as the baby drains more milk from the breast. If the mother automatically switches the baby from one breast to the other during the feed, before the baby has “finished” the first side, the baby may get a relatively low amount of fat during the feeding. This may result in the baby getting fewer calories, and thus feeding more frequently. If the baby takes in a lot of milk (to make up for the reduced concentration of calories), he may spit up. Because of the relatively low fat content of the milk, the stomach empties quickly, and a large load of milk sugar (lactose) arrives in the intestine all at once. The protein which digests the sugar (lactase) may not be able to handle so much milk sugar at one time and the baby will have the symptoms of lactose intolerance-crying, gas, and explosive, watery, green bowel movements. This may occur even during the feeding. These babies are not lactose intolerant. They have problems with lactose because of the sort of information women get about breastfeeding. This is not a reason to switch to lactose free formula.

   1. Do not time feedings. Mothers all over the world have breastfed babies successfully without being able to tell time. Breastfeeding problems are greatest in societies where everyone has a watch and least where no one has a watch.
   2. The mother should feed the baby on one breast, as long as the baby actually gets milk from the breast (see videos at our Index of Breastfeeding Movies) until the baby comes off himself, or is asleep at the breast. If the baby feeds for a short time only, the mother can compress the breast to keep the baby feeding, not just sucking. Please note that a baby may be on the breast for two hours, but may actually feed for only a few minutes. In that case the milk taken by the baby may still be relatively low in fat. This is the rationale for compressing the breast. If, after “finishing” on the first side, the baby still wants to feed, offer the other side. Do not prevent the baby from taking the other side if he is still hungry.
   3. The next feeding, the mother should start the baby on the other breast in the same way.
   4. The mother’s body will adjust quickly to the new method, and she will not become engorged or lop-sided.
   5. Just as there should be no “rule” for feeding both breasts at each feeding, there should be no rule for one breast per feeding. Let the baby finish on one breast (use compression to keep him feeding longer) but if he wants more, then offer the other side.
   6. In some cases, it may be helpful to feed the baby two or more feedings on one side before switching over to the other side for two or more feedings.
   7. This problem is made worse if the baby is not well latched on to the breast. A good latch is the key to easy breastfeeding.

2. Overactive letdown reflex
   A baby who gets too much milk too quickly, may become very fussy, very irritable at the breast and may be considered “colicky”. Typically, the baby is gaining very well. Typically, also, the baby starts nursing, and after a few seconds or minutes, starts to cough, choke or struggle at the breast. He may come off, and often, the mother’s milk will spray. After this, the baby frequently returns to the breast, but may be fussy and repeat the performance. He may be unhappy with the rapid flow, and impatient when the flow slows. This can be a very trying time for everyone. On rare occasions, a baby may even start refusing to take the breast after several weeks, typically around three months of age.

   1. If you have not already done so, try feeding the baby one breast per feed. In some situations, feeding even two or three times on one breast before changing to the other breast may be helpful. If you experience engorgement on the unused breast, express just enough to feel comfortable.
   2. Feed the baby before he is ravenous. Do not hold off the feeding by giving water (a breastfed baby does not need water even in very hot weather) or a pacifier. A ravenous baby will “attack” the breast and may cause a very active letdown reflex. Feed the baby as soon as he shows any sign of hunger. If he is still half asleep, all the better.
   3. Feed the baby in a calm, relaxed atmosphere, if possible. Loud music or bright lights are not conducive to a good feeding.
   4. Lying down to nurse sometimes works very well. If lying sideways to feed does not help, try lying flat, or almost flat, on your back, with the baby lying on top of you to nurse. Gravity helps decrease the flow rate.
   5. If you have time, express some milk (an ounce or so) before you feed the baby. This is not the first thing to try.
   6. The baby may dislike the rapid flow, but also become fussy when the flow slows too much. If you think the baby is fussy because the flow is too slow, it will help to compress the breast to keep up the flow.
   7. This problem is made worse if the baby is not well latched on to the breast. A good latch is the key to easy breastfeeding.
   8. On occasion, giving the baby commercial lactase (the enzyme that metabolizes lactose), 2-4 drops before each feeding, relieves the symptoms. It is available without prescription, but fairly expensive, and works only occasionally.
   9. A nipple shield may help, but use this only if nothing else has helped and only if you have got good help without any relief. This is a second-last resort.
   10. As a last resort, rather than switching to formula, give the baby your expressed milk by bottle.

3. Foreign proteins in the mother’s milk
   Sometimes, proteins present in the mother’s diet may appear in her milk and may affect the baby. The most common of these is cow’s milk protein. Other proteins have also been shown to be excreted into some mothers’ milk. The fact that these proteins and other substances appear in the mother’s milk is not usually a bad thing. Indeed, it is usually good, helping to desensitize your baby to these proteins. Ask about this if you have any questions.Thus, in the treatment of the colicky breastfed baby, one step would be for the mother to stop taking dairy products or other foods, but only one type of food at a time. Dairy products include milk, cheese, yoghurt, ice cream and anything else that may contain milk. When the milk protein has been changed (denatured), as in cooking for example, there should be no problem. Ask if you have any questions.

   If eliminating certain foods from the mother’s diet does not work, the mother can take pancreatic enzymes, starting with 1 capsule at each meal, to break down proteins in her intestines so that they cannot be absorbed into her body and appear in the milk.

   Please note: Intolerance to milk protein has nothing to do with lactose intolerance, a completely different issue. Also, a mother who is lactose intolerant herself should still breastfeed her baby.

   Suggested method:

   1. The mother should eliminate all milk products for 7-10 days.
   2. If there has been no change, the mother can reintroduce milk products.
   3. If there has been a change for the better, the mother can then slowly reintroduce milk products into her diet, if these are normally part of her diet. (There is no need to drink milk in order to make milk). Some babies tolerate absolutely no milk products in the mother’s diet. Most tolerate some. The mother will learn what amount of dairy products she can take without the baby reacting.
   4. If there is concern about your calcium intake, calcium can be obtained without taking dairy products. However, 7-10 days off milk products will not cause any nutritional problems. Actually, evidence suggests that breastfeeding may protect the woman against the development of osteoporosis even if she does not take extra calcium. The baby will get all he needs.
   5. The mother should be careful about eliminating too many things from her diet. Everyone will know someone whose baby got better when the mother stopped broccoli, beef, bananas, bread, etc. The mother may find that she is eating white rice only. Our diets are too complex to be sure exactly what, if anything, is affecting the baby.

   Be patient; the problem usually gets better no matter what. Formula is not the answer, but, because of the more regular flow, some babies do improve on it. But formula is not breastmilk. In fact, the baby would also improve on breastmilk from the bottle because of the regularity of the flow. Even if nothing works, time usually helps. The days and nights may seem eternal, but the weeks will fly by.

See the videos of how to latch a baby on, how to know a baby is getting milk, and how to use compression

.

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Handout #2. Colic in the Breastfed Baby. January 2005.
Written by Jack Newman, MD, FRCPC © 2005.

This handout may be copied and distributed without further permission, on the condition that it is not used in any context in which the WHO code on the marketing of breastmilk substitutes is violated.

Is my baby getting enough milk?

Source: Canadian Breastfeeding Foundation

Breastfeeding mothers frequently ask how to know if their babies are getting enough milk. The breast is not the bottle, and it is not possible to hold the breast up to the light to see how many ounces or millilitres of milk the baby drank. Our number obsessed society makes it difficult for some mothers to accept not seeing exactly how much milk the baby receives. However, there are ways of knowing whether the baby is getting enough. In the long run, weight gain is the best indication that the baby is getting enough, but rules about weight gain appropriate for bottle fed babies may not be appropriate for breastfed babies.

Ways of Knowing

1. Baby’s nursing is characteristic.
   A baby who is obtaining good amounts of milk at the breast sucks in a very characteristic way. When a baby is getting milk (he is not getting milk just because he has the breast in his mouth and is making sucking movements), you will see a pause at the point of his chin after he opens to the maximum and before he closes his mouth, so that one suck is (open mouth wide–>pause–>close mouth). If you wish to demonstrate this to yourself, put your index or other finger in your mouth and suck as if you were sucking on a straw. As you draw in, your chin drops and stays down as long as you are drawing in. When you stop drawing in, your chin comes back up. This same pause that is visible at the baby’s chin represents a mouthful of milk when the baby does it at the breast. The longer the pause, the more the baby got. Once you know about the pause you can cut through so much of the nonsense breastfeeding mothers are being told-like feed the baby twenty minutes on each side. A baby who does this type of sucking (with the pauses) for twenty minutes straight might not even take the second side. A baby who nibbles (doesn’t drink) for 20 hours will come off the breast hungry. asklenore.info’s Index of Breastfeeding Movies has videos that show this pause in the baby’s chin.
2. Baby’s bowel movements.
   For the first few days after delivery, the baby passes meconium, a dark green, almost black, substance. Meconium accumulates in the baby’s gut during pregnancy. It is passed during the first few days, and by the third day, the bowel movements start becoming lighter, as more breastmilk is taken. Usually by the fifth day, the bowel movements have taken on the appearance of the normal breastmilk stool. The normal breastmilk stool is pasty to watery, mustard coloured, and usually has little odour. However, bowel movements may vary considerably from this description. They may be green or orange, may contain curds or mucus, or may resemble shaving cream in consistency (from air bubbles). The variations in colour do not mean something is wrong. A baby who is breastfeeding only, and is starting to have bowel movements that are becoming lighter by day 3 of life, is doing well.Without becoming obsessive about it, monitoring the frequency and quantity of bowel motions is one of the best ways, next to observing the baby’s drinking, (see above, and videos) of knowing if the baby is getting enough milk. After the first three to four days, the baby should have increasing bowel movements so that by the end of the first week he should be passing at least two to three substantial yellow stools each day. In addition, many infants have a stained diaper with almost each feeding. A baby who is still passing meconium on the fourth or fifth day of life should be seen at the clinic the same day. A baby who is passing only brown bowel movements is probably not getting enough, but this is not very reliable.

   Some breastfed babies, after the first three to four weeks of life, may suddenly change their stool pattern from many each day, to one every three days or even less. Some babies have gone as long as 15 days or more without a bowel movement. As long as the baby is otherwise well, and the stool is the usual pasty or soft, yellow movement, this is not constipation and is of no concern. No treatment is necessary or desirable, because no treatment is necessary or desirable for something that is normal.

   Any baby between five and 21 days of age who does not pass at least one substantial bowel movement within a 24 hour period should be seen at the breastfeeding clinic the same day. Generally, small, infrequent bowel movements during this time period mean insufficient intake. There are definitely some exceptions and everything may be fine, but it is better to check.

3. Urination.
   With six soaking wet (not just wet) diapers in a 24-hour period, after about 4-5 days of life, you can be reasonably sure that the baby is getting a lot of milk (if he is breastfeeding only). Unfortunately, the new super dry “disposable” diapers often do indeed feel dry even when full of urine, but when soaked with urine they are heavy. It should be obvious that this indication of milk intake does not apply if you are giving the baby extra water (which, in any case, is unnecessary for breastfed babies, and if given by bottle, may interfere with breastfeeding). The baby’s urine should be almost colourless after the first few days, though occasional darker urine is not of concern.During the first two to three days of life, some babies pass pink or red urine. This is not a reason to panic and does not mean the baby is dehydrated. No one knows what it means, or even if it is abnormal. It is undoubtedly associated with the lesser intake of the breastfed baby compared with the bottle fed baby during this time, but the bottle feeding baby is not the standard on which to judge breastfeeding. However, the appearance of this colour urine should result in attention to getting the baby well latched on and making sure the baby is drinking at the breast. During the first few days of life, only if the baby is well latched on can he get his mother’s milk. Giving water by bottle or cup or finger feeding at this point does not fix the problem. It only gets the baby out of hospital with urine that is not red. Fixing the latch and using compression will usually fix the problem. If relatching and breast compression do not result in better intake, there are ways of giving extra fluid without giving a bottle directly. Limiting the duration or frequency of feedings can also contribute to decreased intake of milk.

The following are NOT good ways of judging

1. Your breasts do not feel full. After the first few days or weeks, it is usual for most mothers not to feel full. Your body adjusts to your baby’s requirements. This change may occur quite suddenly. Some mothers breastfeeding perfectly well never feel engorged or full.
2. The baby sleeps through the night. Not necessarily. A baby who is sleeping through the night at 10 days of age, for example, may, in fact, not be getting enough milk. A baby who is too sleepy and has to be awakened for feeds or who is “too good” may not be getting enough milk. There are many exceptions, but get help quickly.
3. The baby cries after feeding. Although the baby may cry after feeding because of hunger, there are also many other reasons for crying. Do not limit feeding times. “Finish” the first side before offering the other.
4. The baby feeds often and/or for a long time. For one mother feedings every 3 hours or so may be often; for another, 3 hours or so may be a long period between feeds. For one, a feeding that lasts for 30 minutes is a long feeding; for another, it is a short one. There are no rules on how often or for how long a baby should nurse. It is not true that the baby gets 90% of the feed in the first 10 minutes. Let the baby determine his own feeding schedule and things usually come right, if the baby is suckling and drinking at the breast and having at least 2-3 substantial yellow bowel movements each day. Remember, a baby may be on the breast for 2 hours, but if he is actually feeding or drinking (open wide-pause-close mouth type of sucking) for only 2 minutes, he will come off the breast hungry. If the baby falls asleep quickly at the breast, you can compress the breast to continue the flow of milk. Contact your physician or certified lactation consultant with any concerns, but wait to start supplementing. If supplementation is truly necessary, there are ways of supplementing which do not use an artificial nipple.
5. “I can express only half an ounce of milk”. This means nothing and should not influence you. Therefore, you should not pump your breasts “just to know”. Most mothers have plenty of milk. The problem usually is that the baby is not getting the milk that is available, either because he is latched on poorly, or the suckle is ineffective or both. These problems can often be fixed easily.
6. The baby will take a bottle after feeding. This does not necessarily mean that the baby is still hungry. This is not a good test, as bottles may interfere with breastfeeding.
7. The 5 week old is suddenly pulling away from the breast but still seems hungry. This does not mean your milk has “dried up” or decreased. During the first few weeks of life, babies often fall asleep at the breast when the flow of milk slows down even if they have not had their fill. When they are older (4-6 weeks of age), they no longer are content to fall asleep, but rather start to pull away or get upset. The milk supply has not changed; the baby has. Compress the breast to increase flow.

Notes on scales and weights

1. Scales are all different. We have documented significant differences from one scale to another. Weights have often been written down wrong. A soaked cloth diaper may weigh 250 grams (half a pound) or more, so babies should be weighed naked or with a brand new dry diaper.
2. Many rules about weight gain are taken from observations of growth of formula feeding babies. They do not necessarily apply to breastfeeding babies. A slow start may be compensated for later, by fixing the breastfeeding. Growth charts are guidelines only.

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Handout #4 Is My Baby Getting Enough?. Revised January 2005.
Written by Jack Newman, MD, FRCPC ©2005
This handout may be copied and distributed without further permission, on the condition that it is not used in any context in which the WHO code on the marketing of breastmilk substitutes is violated.

When the baby refuses to latch on

Source: Canadian Breastfeeding Foundation

Why would a baby refuse to take the breast?

There are many reasons a baby might refuse to latch on. Often there is a combination of reasons. For example, a baby might latch on even with a tight frenulum if no other factors come into play, but if, for example, he is also given bottles early on, this may very well change the situation from “good enough”, to “not working at all”.

1. If the mother’s nipples are particularly large, or inverted, or flat, these nipple variations make Starting Out Right more difficult, not usually impossible.
2. Some babies are unwilling to nurse, or suck poorly as a result of medication they received during the labour. Narcotics are responsible for many such situations, and meperidine (Demerol) is particularly bad as it stays in the baby’s blood for a long time and affects the way he sucks for several days. Even morphine given in an epidural may cause the baby to be unwilling to nurse or latch on, since medication from an epidural definitely does get into the mother’s blood, and thus into the baby before he is born.
3. Vigorous suctioning at birth may result in babies not sucking properly and not wanting to latch on. There is no need to suction a healthy, full term baby at birth.
4. Abnormalities of the baby’s mouth may result in the baby’s not Starting Out Right. Cleft palate, but not cleft lip, causes severe difficulties in Starting Out Right. Sometimes the cleft palate is not obvious, affecting only the part inside the baby’s mouth.
5. A tight frenulum (the whitish tissue under the tongue) may result in a baby having difficulty Starting Out Right. This is not, strictly speaking, considered an abnormality, and thus, many physicians do not believe that it can interfere with breastfeeding, but they are misinformed.
6. A baby learns to breastfeed by breastfeeding. Artificial nipples interfere with how the baby takes the breast. Babies are not stupid. If they get slow flow from the breast (as is expected in the first few days of life) and rapid flow from the bottle, they will not be confused-many will figure it out quite quickly.

However, one of the most common causes of babies’ refusing to latch on arises from the misguided belief that babies in the first few days must breastfeed every 3 hours, or on some sort of schedule. This results in anxiety on the part of the staff when a baby has not fed, for example, for three hours after birth, which results, frequently, in babies being forced to the breast when they are not ready yet to feed. When the baby is forced into the breast, and kept there by force, when the baby is not interested or ready, we should not be surprised that some babies develop an aversion to the breast. If this misguided approach then results in panic, and “the baby must be fed”, alternative feeding methods (the worst of which is the bottle) are then used, resulting in worsening of the situation and the beginning of a vicious circle.

There is no evidence that a healthy full term newborn must feed every three hours during the first few days. There is no evidence that they will develop low blood sugars if they don’t feed every three hours (the whole issue of low blood sugars has become a mass hysteria in newborn nurseries which, like all hysterias, has a legitimate basis for developing, perhaps, but actually causes more problems than it prevents, including the problem of many babies getting formula when they don’t need it, and being separated from their mothers when they don’t need to be, and not Starting Out Right). Babies should be together, skin to skin with their mothers, 24 hours a day. When they are ready, most will start looking for the breast. Having the baby with the mother skin to skin immediately after birth, and allowing the baby and the mother the time to “find” each other, will prevent most situations of the baby not Starting Out Right. Mother and baby skin to skin will also keep the baby as warm as being under a heating lamp. Having the baby and mother together for 5 minutes though, is not the answer. The mother and baby should be together until the baby latches on, without pressure, without time limits (“we’ve got to weigh the baby”, “we’ve got to give the baby vitamin K” etc – these procedures can wait!). This might take 2 hours or more.

But the baby is not Starting Out Right!

Okay, so how long can we wait? There is no obvious answer to that. Certainly, if the baby has shown no interest in nursing or feeding by 12 to 24 hours after birth, it may be worthwhile to do something, mostly because hospital policies usually require the mother to be discharged by 24 to 48 hours. What?

1. The mother should start expressing her milk, and that milk (colostrum), either alone, or mixed with sugar water, should be fed to the baby, preferably by finger feeding. If it is difficult to get colostrum (often hand expression works better than a pump in the first few days), then sugar water alone is fine for the first few days. Most babies will start sucking, and many will wake up enough to attempt going to the breast. As soon as the baby is sucking well, finger feeding should be stopped and the baby tried at the breast. Finger feeding is essentially a procedure to prepare the baby to take the breast, not primarily a method to avoid the bottle, though it will do that too.
2. Before discharge, early, competent help needs to be arranged so that the mother and baby are getting help by day four or five at the latest. Many babies not able to latch on in the first few days will latch on beautifully once the mother’s milk supply has increased substantially as it does around day 3 or 4. Getting help at this time avoids the negative associations with the breast that many babies develop as time goes on.
3. A nipple shield started before the mother’s milk becomes abundant (day 4 to 5) is bad practice. Starting a nipple shield before the mother’s milk “comes in” is not giving time a chance.

I’m home from hospital. The baby won’t latch on. What do I do?

The single most important factor influencing whether or not the baby latches on is the mother’s developing a good milk supply. If the mother’s supply is abundant, the baby will latch on by 4 to 8 weeks of life no matter what. What we try to do at the clinic is get the baby Starting Out Right earlier, so that you won’t have to wait that long. So, it is more important you keep up your supply, than avoid a bottle. The bottle interferes, and it is better you use other methods (such as a cup) if you can, but if you feel you have no choice, you should do what you need to do.

• Learn how to get the best position and latch from an experienced lactation specialist. As the baby comes onto the breast, compress the breast so that the baby gets a gush of milk. Try the baby on the breast he seems to prefer, not the one he resists more.
• If the baby latches on, he will start sucking and start drinking (get information on how to know a baby is actually getting milk at the breast).
• If the baby doesn’t latch on, don’t try to keep him on the breast; it won’t work. He will either get hysterical or “go limp”. Move him away from the breast and start again. It is better to go on-off, on-off several times than to push him into the breast when he hasn’t latched on.
• If the baby goes to the breast and sucks once or twice, he hasn’t latched on a little; he hasn’t latched on at all.
• If the baby refuses the breast, don’t keep at it until he’s angry. Try finger feeding a few seconds to a minute or two, and try again, perhaps on the other side. Finger feeding is to prepare the baby to take the breast, not primarily to avoid a bottle.
• If the baby doesn’t latch on, finish the feeding with whatever method you find easiest.
• Using a lactation aid at the breast may be helpful, but often requires an extra hand.
• At about two weeks after birth, a change in what you have been doing often seems to send a message to the baby that “there’s more than one way to do this”. If you have been finger feeding only, a change to a cup or bottle will sometimes work, or using a nipple shield will often work. If you have been bottle feeding only, switching to finger feeding may work (only before attempting the baby at the breast is good enough if finger feeding is too slow, and finishing the feeding with cup or bottle).

How to maintain and increase milk supply

• Express your milk as often as is practical, at least 8 times a day, using a reliable pump that expresses both breasts at the same time. Using compression while pumping increases the efficiency of pumping and increases the milk supply (another hand is helpful, but mothers have rigged up the pump so that they don’t have to hold onto the tubing or flanges while pumping and thus can compress without help).
• If the baby hasn’t latched on by day 4 or 5, start fenugreek and blessed thistle to increase milk flow. Domperidone may also be useful.
• Do not use a nipple shield until the milk supply is well established (at least 2 weeks after the baby is born).

Do not get discouraged. Even if your milk supply is not up to the needs of your baby, many babies will still latch on. Get good help. Do not do this on your own.

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When the baby refuses to latch on. January 2003.
Written by Jack Newman, MD, FRCPC ©2003
This handout may be copied and distributed without further permission, on the condition that it is not used in any context in which the WHO code on the marketing of breastmilk substitutes is violated.

Breastfeeding & Infant Nutrition

Source: Public Health Agency of Canada

http://www.phac-aspc.gc.ca/dca-dea/prenatal/nutrition-eng.php

Breastfeeding & Infant Nutrition

For the best possible start in life, the Public Health Agency of Canada supports and promotes breastfeeding as the unequalled way to provide optimal nutritional, immunological and emotional nurturing of infants.

Additional resources and links are provided below.

What should I know about feeding my newborn baby?

Today, most women are breastfeeding their babies. Breast milk is the best food you can offer your baby. Health Canada and the World Health Organization recommend that it should be the only food or drink for the first 6 months of life and after that breastfeeding should continue – with the gradual introduction of solid foods – for 2 years and more.

Breast milk is the best food for your baby to grow and develop. It is naturally and uniquely produced by each mother for her own baby. As your baby grows your milk will change to meet your baby’s needs and is the easiest milk of all for your baby to digest. Breast milk has just the right amount of protein carbohydrate, fat, vitamins and minerals, and, contains antibodies and other immune factors that help protect against infections and disease – benefits that last a lifetime. Breastfeeding has many benefits for the mother too and nurtures a special relationship between mother and baby.

Babies who are breastfed should receive a Vitamin D Supplement . This will prevent vitamin D deficiency, which can lead to a bone disease called rickets. When your baby starts getting vitamin D from other foods, you can stop giving the supplement.

There are rarely reasons not to breastfeed. If you smoke, you can still breastfeed, but you should consider cutting back or quitting smoking altogether. You should also avoid drinking alcohol. If you are sick or taking prescription medication, talk to your doctor.

Breastfeeding is natural, but it may take time for you and your baby to learn to breastfeed. It can take up to six weeks to establish breastfeeding so continue to breastfeed – it is important for your baby. If you need some advice or support there are many groups and individuals available to help you, including:

• local breastfeeding support groups
• lactation consultants
• La Leche League
• midwife/doctor
• public health clinic or CLSC

They have experience with the problems you might have, and understand how you feel.

Whether or not you are breastfeeding, feeding a baby is an opportunity to bond. Mothers and fathers can make the most of the feeding experience by holding the baby close, talking softly and looking into the baby’s eyes.

What other liquids are appropriate for babies?

For the first six months breast milk is all the food and drink your baby needs for optimal growth and development. Exclusively breastfed babies don’t need any other liquids (except their vitamin D supplements). If your doctor recommends you give water to an infant under six months, it should be boiled for at least 2 minutes. Babies should not be given herbal teas or other drinks.

When should I introduce solids?

By six months of age, although breast milk or formula is still your baby’s primary food, it’s time to begin adding solid foods. These foods help babies meet their growing nutritional needs. By about 6 months, most babies cannot get everything they need from breast milk alone.

There are many ways to introduce solid food. The first foods usually vary from culture to culture and from family to family. Start with foods that contain iron, which babies need for many different aspects of their development. It’s common to start with a single grain, iron-fortified infant cereal such as rice or barley. Meat, poultry, cooked egg yolk and well cooked legumes (beans, lentils, chick peas) are also good sources of iron. Introduce new foods one at a time, waiting about 3 to 5 days before trying another. That way, if your baby develops a reaction, you’ll have a better idea of what food might have caused it.

Healthy foods that your family eats are good to start with as long as they are plain, with no added salt, sugar, or spices. You can also use commercial baby foods, as long as you check the label to ensure there is no added salt or sugar. By the time your baby is one year old, her diet should contain a variety of foods from the different food groups. You can learn more about food groups from the Eating Well with Canada’s Food Guide .

Related Breastfeeding & Infant Feeding Resources:

• La Leche League Canada
• Canadian Lactation Consultants Association
• B.C. Association of Pregnancy Outreach Programs Breastfeeding Resources
• Alberta Health & Wellness: Breastfeeding Your Baby : Includes detailed information about breastfeeding positions, potential problems, expressing milk, etc.
• Breastfeeding Committee for Canada
• Canadian Paediatric Society
• Dietitians of Canada