Colic in the Breastfed Baby

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 spells about two to three weeks after birth. These occur mainly in the evening, and finally stop when the baby is about three months old (occasionally older). When the baby cries, he is often inconsolable, though if he is walked, rocked or taken for a walk, he may settle temporarily. For a baby to be called colicky, it is necessary that he be gaining weight well and be otherwise healthy. However, even if the baby is gaining weight well, sometimes the baby is crying because he is still hungry. See below.

The notion of colic has been extended to include almost any fussiness or crying in the baby, and this is not surprising 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. Of course, everyone knows someone whose baby was “cured” of colic by a particular treatment. Also, almost every treatment seems to work, at least 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.

Feeding both breasts at each feeding or feeding only one breast at each feeding

Human milk changes during a feeding. One of the ways in which it changes is that, in general, 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 amount of milk sugar (lactose) arrives in the intestine all at once. The enzyme 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, 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.

It is also very important that you realize that a baby is not drinking milk from the breast just because the baby is making sucking movements on the breast. He may be “nibbling” not drinking and therefore the baby is not getting higher fat milk just because he is on the breast and sucking.

1. Do not time feedings. Mothers all over the world have successfully breastfed babies 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) until the baby comes off himself, or is asleep at the breast from being full or is nibbling even with compression. Use breast compression (see the information sheet Breast compression) to keep baby drinking and not just sucking. Follow the Increase intake of breastmilk (the Protocol is found on the website as well as the video clips at the website ibconline.org to help use the Protocol). Please note that a baby may be on the breast for two hours, but may actually be drinking milk 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 using compression. If, after “finishing” 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. This is not a suggestion to feed only one breast at a feeding. You might be able to do it, and that’s fine, but not all mothers can manage it. You might find it possible in the morning when you have more milk (as most mothers do) but not in the evening when you have less milk (as most mothers do). If you insist on feeding on just one side, you may find your baby is “colicky” in the evening when he is, in fact, hungry.
4. At the next feeding, start the baby on the other breast and proceed in the same way.
5. Your body will adjust quickly to the new method and you will not become engorged or lop sided after a short while. But remember this: feeding on one side at a feeding, if you can manage it, will reduce the milk supply so that what may work now (breastfeeding on one breast at a feeding) may not work as the milk supply decreases. Therefore do not keep the baby to one breast, but “finish” one side and if the baby wants more, offer the other side. See Section ‘F’.
6. It is not a good idea to feed the baby on just one side, to follow a rule. Yes, making sure the baby “finishes” the first side before offering the second can help treat poor weight gain or colic in the baby, but rules and breastfeeding do not go together well. If the baby is not drinking, actually getting milk, there is no point in just keeping the baby sucking without getting any milk for long periods of time. You should “finish” one side and if the baby wants more, offer the other.

How do you know the baby is “finished” the first side?

• The baby is no longer drinking, even with compression (see the video clip and Breast compression) This does not mean you must take the baby off the breast as soon as the baby doesn’t drink at all for a minute or two (you may get another milk ejection reflex or letdown reflex, so give it a little time), but if it is obvious the baby is not drinking, take the baby off the breast and if the baby wants more, offer the other side. How do you know the baby is drinking or not? See the video clips.
• If the baby lets go of the breast on his own, does it mean that the baby has “finished” that side? Not necessarily. Babies often let go of the breast when the flow of milk slows, or sometimes when the mother gets a milk ejection reflex and the baby, surprised by the sudden rapid flow, pulls off. Try him again on that side if he wants more, but if the baby is obviously not drinking even with compression, switch sides.
• 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, as long as baby has come of the breast from drinking. Putting a baby back on a breast that was just “emptied” may cause baby to fuss or pull at the breast or fall asleep but not be full.
• 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.

Overactive Letdown Reflex

A baby who gets too much milk very quickly, may become very fussy and irritable at the breast and may be considered “colicky”. Typically, the baby is gaining very well. Typically, also, the baby starts breastfeeding, 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. What can you do?

• Get the best latch possible. 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. No matter what you are told about how good the latch looks, try to improve on it. Think of it this way: if your chin is tucked into your chest while you are trying to drink you would become overwhelmed by the fast flow very easily. If you want to drink quickly you will throw your head back, chin in the air, and be able to handle the fast flow. This is the kind of position baby’s head should be in while breastfeeding—his chin deep into your breast, his head in a slightly tipped-back position, his nose away from your breast, and his chin far from his own chest. This position will help him to handle the faster flow of the let down. see the information sheet Latching On and the video clips.
• If you have not already done so, try feeding the baby one breast per feed. In some situations, feeding even two or three feedings 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. Remember, if the baby wants the second breast, the mother should offer it.
• 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 when you put him to the breast, all the better.
• Feed the baby in a calm, relaxed atmosphere, if possible. Loud music, bright lights are not conducive to a good feeding. Older babies tend to become very distracted as the flow slows down. Using information sheet Breast compression gently at first, and then more firmly as necessary to keep the speed of flow consistent, will often keep baby interested in staying on the breast longer, because he is drinking better.
• Lying down to breastfeed 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 breastfeed, or try leaning back in a chair. Gravity helps decrease the flow rate. Remember, the baby may be frustrated at the inconsistent flow, so it may be necessary to lie down at the beginning when the flow is fast, and sit back up as the milk slows. Babies like the lying down position; they tend not to fuss with slower flow but tend to sleep.
• 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, see section ‘e’. (See the information sheet Breast Compression).

If all else has not made things better:

• On occasion giving the baby commercial lactase (the enzyme that metabolizes lactose), 2-4 drops after each feeding or between breasts if you give both, relieves the symptoms. It is available without prescription, but fairly expensive, and works only occasionally. It is difficult to understand why it would work, since the enzyme is broken down in the baby’s stomach but sometimes it does seem to work.
• A nipple shield may help, but use this only if nothing else has helped and only if you have had access to good help without any change. This is the second-last resort. Please not that a nipple shield is only very rarely the answer to any breastfeeding problem and in most situations it makes the situation worse, not better.
• As a last resort, rather than switching to formula, give the baby your expressed milk by cup or by bottle if baby won’t take a cup. Adding lactase to the expressed milk may help as well.

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, such as salad dressings with whey protein or casein. Check labels on prepared foods to see if they include milk or milk solids. 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 (Cotazyme, Pancrease 4, for example), starting with 1 capsule at each meal, to break down proteins in her intestines so that they are less likely to be absorbed into her body as whole protein and appear in the milk. Of course, your chances of not being able to produce enough of your own enzymes from your pancreas are very low (unless you have cystic fibrosis, for example), but it has been shown that whole protein does get absorbed into the breastfeeding mother’s body and into her milk and adding the enzymes may decrease the amounts of whole protein entering your body and getting into 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:

• Eliminate all milk products for 7-10 days.
• If there has been no change for the better in the baby, the mother can reintroduce milk products.
• If there has been a change for the better, you can then slowly reintroduce milk products into her diet, if these are normally part of your diet. (There is no need to drink milk in order to make milk, for example, so if you don’t drink milk normally, don’t while you are breastfeeding). Some babies will tolerate absolutely no milk products in the mother’s diet. Most tolerate some. You will learn what amount of dairy products you can take without the baby reacting.
• If you are concerned about your calcium intake, calcium can be obtained without taking dairy products. Speak with your doctor or a dietician. But, 7-10 days off milk products will not cause you 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.
• Be careful about eliminating too many things from your diet all at once. Everyone will know someone whose baby got better when the mother stopped broccoli, beef, bananas, bread, etc. You may find that you are eating white rice only. Our diets are too complex to be sure exactly what, if anything, is affecting the baby.

One more piece of information

Some babies are hungry even if they are gaining weight really well. This may occur for several reasons, some mentioned earlier in this information sheet. One more way a baby can be hungry and nevertheless gain weight well is that you are limiting the feedings; for example, you feed the baby 10 or 20 minutes a side. If you have a lot of milk, the baby may gain weight well and still be hungry. So don’t limit feedings.

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 and breastfeeding is much more than 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.

Written and revised (under other names) by Jack Newman, MD, FRCPC, 1995-2005 
Revised by Jack Newman MD, FRCPC and Edith Kernerman, IBCLC, 2008, 2009

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.

Candida or thrush of the nipple and breast

Herzl Family Practice Centre, Goldfarb Breastfeeding Clinic Patient handout

Definition:

Candida albicans is a type of fungus that can cause infections in various warm and humid places, such as the nipples, breasts, skin, vagina, mouth, and baby’s bum → these infections are commonly called “thrush” or “yeast infections”.

Risk factors for developing thrush:

For mother:

• Recent use of certain medications like: antibiotics, birth control pills, or anything with cortisone or steroids.
• Cracked or damaged nipples.
• Vaginal infections.
• Diabetes.
• A weak immune system.
• Diet → very high in sugar and yeast, or low in vitamins and minerals.

For baby:

• Use of a bottle nipple or pacifier.
• Use of artificial infant formula.

If you have thrush, you may notice the following:

In the mother:

• Redness, shininess, irritation and/or peeling skin on the areola or nipple.
• Nipple and/or breast pain:
  • Often at the end of a feed, or anytime during or in between feeds.
  • Burning and/or itchiness of the areola or nipple.
  • Deeper pain, either burning, throbbing, or shooting.
  • Pain that does not get better even with a good latch.

In the baby:

• White plaques in the mouth or on the tongue that you cannot remove.
• A red rash on the bum and diaper area.
• A fussiness or refusal to take the breast, or general irritability.

Even if the baby has no signs of infection, the mother may still be infected, and needs to seek treatment from a health professional or lactation specialist.

How to treat a candida infection?

First of all, make sure your baby has a good latch and that you have no pain while nursing.

Home remedy:

It is important to seek professional help if you think you might have thrush. However, you can try this home remedy in the meantime.

Rince your nipples with 1 tablespoon (15 ml) vinegar in 1 cup water (250 ml), every hour for a 24-hour period.

Treatments that may be suggested by your health professional:

• The use of Advil™ or Motrin™ (ibuprofen) and/or Tylenol™ (acetaminophen) may be very useful to treat the pain of thrush. These medications are safe during breastfeeding.
• Gentian violet, in a 1% aqueous (water-based) solution:
  • Use a cotton-tipped Q-tip to apply the solution in the baby’s mouth (swab inside baby`s cheeks, gums, tongue, roof of the mouth and under the tongue) so that all areas are covered violet. Once that is done, let the baby feed on both breasts. Make sure you use a fresh Q-tip with every application.
  • Otherwise, you can paint both nipples and areola with a Q-tip of gentian violet, and let the baby feed afterwards. The baby`s inner mouth will also turn violet.
  • Note: You do not have to apply Gentian violet in the baby`s mouth AND on your breasts, one of the above is enough.
  • Apply once a day, before a feed, for a period of 4 to 7 days. Whether things are better or not, the treatment should be stopped in 7 days, and you should return to see your health professional.
  • Gentian violet is safe for breastfeeding mothers and babies. However, in rare cases, it can cause some irritation in baby’s mouth. If you suspect this, stop the treatment immediately and contact your health professional. ** Be careful, as Gentian violet can stain clothes.
• Grapefruit seed extract (GSE):
  • There are 2 ways of using GSE:
    1. Mix 2-5 drops of GSE in 30 ml (1 oz) of distilled water. Use a Q-tip to apply this diluted solution on the nipple/areola after every feed. If also using APNO (see below), you can apply it to the nipple/areola after the GSE. Remember to change the Q-tip with every new application.
    2. GSE can also be taken orally by the mother. The dose is 250 mg 3 times in a day in pill form, or 5 drops in water 3 times a day.
    3. GSE can be added to the laundry, in a dose of 15-20 drops in the rinse cycle.
  • Remember that certain medications do not mix with GSE, such as domperidone (used to increase breastmilk supply) and fluconazole (a medication for thrush, discussed below).
  • Grapefruit seed extract is safe in breastfeeding mothers and babies.
    • These treatments can be done together, and can continue for 2-4 weeks or more, depending on instructions from your health professional.
    • Probiotics can be useful to treat and prevent thrush. You can take them in the form of Bio-K in yoghurt or pill form, acidophilus pills, or yoghurt pills. You may take probiotics for weeks, based on instructions from your health professional. They are safe for breastfeeding mothers and babies.
• APNO (all-purpose nipple ointment):
  • APNO is available by prescription only, and is made of 3 ingredients, an anti-fungal, anti-bacterial, and anti-inflammatory.
  • A thin later of APNO should be applied on the nipple and areola after every feed.
  • Make sure to check with your health professional for long you can use APNO.
  • APNO is safe for breastfeeding mother and babies, but if you feel any burning, irritation or pain while using it, stop right away and contact your health professional.
• Fluconazole (DiflucanTM):
  • This is a pill to treat thrush which is usually reserved for severe, long-standing or repetitive cases of thrush.
  • The dose is 400 mg the first day, followed by 100 mg twice a day for 2-4 weeks or longer if instructed by your health professional.
  • Fluconazole cannot be taken with grapefruit or grapefruit seed extract, and is safe for breastfeeding mothers and babies.

Home hygiene:

For cases of severe or repetitive thrush, certain things can be done in the home to prevent the growth of fungus in general. Note that these things are not essential if your thrush is easily treated, only if it keeps on coming back, or does not go away easily:

• Wash your hands and baby’s hands often.
• Wash your breasts and nipples in the shower/bath daily with water and soap.
• Wear a fresh clean bra everyday.
• If you are using breast/nursing pads, use disposable ones, and change them after every feed.
• Wash all clothes and towels that come into contact with your breasts or baby in hot water.
• Any object which is put in baby’s mouth can come into contact with candida:
  • Boil pacifiers, bottle nipples, teething rings, baby’s tooth brush, and medication droppers for about 20 minutes, once a day.
  • After a week of treatment for thrush, throw out the above objects and buy new ones.
• If you are using a breast pump, boil all the pieces that come into contact with your milk, for 20 minutes every day.

More home hygiene:

If the above don’t work, and you are still dealing with recurrent thrush, you may want to try the following:

• Start using paper towels to wipe your hands, instead of the same towel.
• For laundry, you can add 1 cup (250 ml) of bleach in the wash cycle, and 1 cup (250 ml) of vinegar in the rince cycle to boost washing power.
• Clothes can be dried in the dryer or on a clothesline exposed to the sun (if possible). Ironing clothes can also kill candida.
• All family members should be checked and treated for any candidal infections.
• Pets can also get candida infections.

Normally, you should feel better with the treatment prescribed by your health professional. If you are not better, it is important that you return to see your health professional.

The information contained in this patient handout is a suggestion only, and is not a substitute for consultation with a health professional or lactation specialist. This handout is the property of the author(s) and the Goldfarb Breastfeeding Clinic. No part of this handout can be changed or modified without permission from the author and the Goldfarb Breastfeeding Clinic. This handout may be copied and distributed without further permission on the condition that it is not used in any context in which the International Code for the Marketing of Breastmilk Substitutes is violated. For more information, please contact the Goldfarb Breastfeeding Clinic, Herzl Family Practice Centre, SMBD Jewish General Hospital, Montreal, Quebec, Canada. © 2009

Toddler Breastfeeding - Why on Earth?

Because more and more women are now breastfeeding their babies, more and more are also finding that they enjoy breastfeeding enough to want to continue longer than the usual few months they initially thought they would. UNICEF has long encouraged breastfeeding for two years and longer, and the American Academy of Pediatrics is now on record as encouraging mothers to breastfeed at least one year and as long after as both mother and baby desire. Even the Canadian Paediatric Society, in its latest feeding statement acknowledges that women may want to breastfeed for two years or longer and Health Canada has put out a statement similar to UNICEF’s. Breastfeeding to 3 and 4 years of age has been common in much of the world until recently in human history, and it is still common in many societies for toddlers to breastfeed.

Why should breastfeeding continue past six months?

Because mothers and babies often enjoy breastfeeding a lot. Why stop an enjoyable relationship? And continued breastfeeding is good for the health and welfare of both the mother and child.

But it is said that breastmilk has no value after six months.

Perhaps this is said, but it is patently wrong. That anyone (including paediatricians) can say such a thing only shows how ill-informed so many people in our society are about breastfeeding. Breastmilk is, after all, milk. Even after six months, it still contains protein, fat, and other nutritionally important and appropriate elements which babies and children need. Breastmilk still contains immunologic factors that help protect the baby. In fact, some immune factors in breastmilk that protect the baby against infection are present in greater amounts in the second year of life than in the first. This is, of course as it should be, since children older than a year are generally exposed to more sources of infection. Breastmilk still contains special growth factors that help the immune system to mature, and which help the brain, gut, and other organs to develop and mature.

It has been well shown that children in daycare who are still breastfeeding have far fewer and less severe infections than the children who are not breastfeeding. The mother thus loses less work time if she continues breastfeeding her baby once she is back at her paid work.

It is interesting that formula company marketing pushes the use of formula (a very poor copy of the real thing) for a year, yet implies that breastmilk (from which the poor copy is made) is only worthwhile for 6 months or even less (“the best nutrition for newborns”). Too many health professionals have taken up the refrain.

I have heard that the immunologic factors in breastmilk prevent the baby from developing his own immunity if I breastfeed past six months.

This is untrue; in fact, this is absurd. It is unbelievable how so many people in our society twist around the advantages of breastfeeding and turn them into disadvantages. We give babies immunizations so that they are able to defend themselves against the real infection. Breastmilk also helps the baby to fight off infections. When the baby fights off these infections, he becomes immune. Naturally.

But I want my baby to become independent

And breastfeeding makes the toddler dependent? Don’t believe it. The child who breastfeeds until he weans himself (usually from 2 to 4 years), is generally more independent, and, perhaps, more importantly, more secure in his independence. He has received comfort and security from the breast, until he is ready to make the step himself to stop. And when he makes that step himself, he knows he has achieved something, he knows he has moved ahead. It is a milestone in his life. Often we push children to become "independent" too quickly. To sleep alone too soon, to wean from the breast too soon, to do without their parents too soon, to do everything too soon. Don’t push and the child will become independent soon enough. What’s the rush? Soon they will be leaving home. You want them to leave home at 14? If a need is met, it goes away. If a need is unmet (such as the need to breastfeed and be close to mom), it remains a need well into childhood and even the teenage years.

Of course, breastfeeding can, in some situations, be used to foster an over-dependent relationship. But so can food and toilet training. The problem is not the breastfeeding. This is another issue.

What else?

Possibly the most important aspect of breastfeeding a toddler is not the nutritional or immunologic benefits, important as they are. I believe the most important aspect of breastfeeding a toddler is the special relationship between child and mother. Breastfeeding is a life-affirming act of love. This continues when the baby becomes a toddler. Anyone without prejudices, who has ever observed an older baby or toddler breastfeeding can testify that there is something almost magical, something special, something far beyond food going on. A toddler will sometimes spontaneously, for no obvious reason, break into laughter while he is breastfeeding. His delight in the breast goes far beyond a source of food. And if the mother allows herself, breastfeeding becomes a source of delight for her as well, far beyond the pleasure of providing food. Of course, it’s not always great, but what is? And when it is, it makes it all so worthwhile.

And if the child does become ill or does get hurt (and they do as they meet other children and become more daring), what easier way to comfort the child than breastfeeding? I remember nights in the emergency department when mothers would walk their ill, non-breastfeeding babies or toddlers up and down the halls trying, often unsuccessfully, to console them, while the breastfeeding mothers were sitting quietly with their comforted, if not necessarily happy, babies at the breast. The mother comforts the sick child with breastfeeding, and the child comforts the mother by breastfeeding.

Written and Revised by Jack Newman, MD, FRCPC 1995-2005 Revised May 2008