Breastfeeding

I don’t know of any pediatrician who will not extol the benefits of breastfeeding. I also don’t know of any pediatrician who will look down on any family who chooses not to breastfeed. I always tell families that breastfeeding a newborn is at the same time, the most natural and unnatural thing you will ever do. Once baby is born, it is super awesome to have access to a licensed lactation consultant. Back in the day, when it was more of a village mentality on raising a kiddo, families had tons of “lactation consultants'' to aid in helping to figure out latches and holds to help baby feed well. Now we have the luxury of these qualified specialists who have seen so many babies feed successfully and unsuccessfully that they can give excellent guidance for new families wishing to breastfeed. But it’s a bit of a double-edged sword with the legitimacy of lactation consultants and their extensive training, it puts a very scientific edge to an otherwise very instinctive and natural reflex for babies and parents. All the science behind breastfeeding can often make families feel more overwhelmed than assured. I try to find a balance between the natural process of learning to breastfeed and the science behind the reflex and physics of breastfeeding to act more like an understanding coach than a military drill sergeant. 

When baby is first born, they have a lot going on and sometimes feeding is not their biggest priority.  When helping at deliveries, I will often see the delivery team try to immediately put baby at the breast right after they come out. Let’s let baby get used to the fact they have just gone through the crazy experience of being born.  Also, it takes a bit of time before mom’s body even realizes baby is out and starts making colostrum (the before-breastmilk liquid to help hydrate baby and stimulate the gut). So get some good skin-to-skin time, take some awesome newborn pictures, and then if baby is acting like they want to try feeding, gently put baby to the breast in a way that you find comfortable because no matter what anyone tells you, the first week or two are going to be uncomfortable. I mean, nipple tissue is sensitive; you don’t just attach a Dyson vacuum to it every day. It takes 1-2 weeks for the tissue to get thicker and stronger so it can stand up to feeds. 

Let’s not try to time or schedule how baby is feeding for the first couple of days. Most of the feeding in the first few days is due to reflex and/or comfort rather than nutrition or hunger. Their stomach is as big as a marble initially, and they are born with a lot of extra fluid in their system to help with the transition from getting food from the umbilical cord to getting food from the breast or bottle. This is why pediatricians usually expect a baby to lose 5-10% of their birthweight in the first few days of life, especially if it is a firstborn kiddo because it takes first-time parents longer to start producing actual breastmilk than moms whose bodies have been there, done that. 

Well if they are not necessarily feeding for hunger, is it OK to use a pacifier? Of course. Babies are super smart and are primarily sucking soothers (60-80% of babies). They know nothing is coming out of a pacifier, and mom you do not need to be a pacifier. I know it can be rewarding thinking that your kiddo is breastfeeding for an hour straight, but you went from breastfeeding to being the pacifier about 45 minutes ago. All that extra pacification sucking is just going to injure the areola skin and make it more painful for ya, mom. If baby tuckers out after only one breast, that is okay, too. Don’t feel like you have to do both sides, just start on the other breast next time for those first days. 

After 3-5ish days, milk starts to come in for first-time parents, maybe a bit sooner for seasoned parents. At this time, we should start seeing more poop and pee. For pediatricians needing to know if baby is getting enough, we are lucky in that all of baby’s nutrition is liquid. So if by Day 3-5 baby is not peeing or pooping a whole bunch, then we know baby is not getting enough. Another key checkpoint for breastfeeding and milk supply is the back-to-birthweight milestone. We expect babies to lose up to 10% of their birthweight in the first few days to a week of life and then start gaining weight once milk and feeding have clicked in. We expect babies to return to or surpass their birthweight in 10-14 days. If we are not hitting that trajectory, then we may need to do a little more investigation to see if it is a feeding mechanics issue or a supply issue, which leads us into our discussion of supplementing. 

Yes, we are always going to promote breastfeeding, but not everyone will be able to or choose to. That is perfectly fine, acceptable, and applaudable. I don’t think enough parents who choose to or need to supplement with formula hear this. There have always been families who could not or choose not to breastfeed. Way back when, every village/family group had wet nurses for this very reason! Nowadays, there are not too many wet nurses around, as you may have noticed, so the next best thing is formula: our modern version of the wet nurse. Formula does a great job at getting kids to grow and develop just like their friends who are mainly fed with breast milk. Formula does not have the same type of hormonally developed proteins/immunofactors that breast milk may have initially, but that’s OK. Kids on formula grow well and become doctors and lawyers or whatever else they want to become. I always tell my families, I don’t care where or what form the milk is coming from for the most part; as your kiddos pediatrician, I will make sure they grow and develop. I refuse to take care of kids who shrink. The biggest thing for me is making sure a kiddo tolerates certain types and brands of formula. Some kiddos will have sensitivities to certain dairy or milk-based factors, and sometimes it takes some trial and error with different formula brands and types before getting the best fit. Signs that a kiddo on a formula may not be tolerating their formula are continued painful poops after 2 months of age or worsening body rashes after 6 weeks of age when on a formula. But to be honest, kiddos on breast milk can have the same sensitivities and demonstrations of these sensitivities from what mom is eating. 

Now when to introduce a bottle? I like to introduce a bottle as soon as the family feels like breastfeeding is going well and most things have clicked. Offering one bottle a day or every other day can usually allow baby to get used to, but not reliant on, bottle feeds. If families don’t feel comfortable introducing the bottle that soon, then I will ask them to try to introduce it before 6 weeks of age as after that, we lose that sucking reflex with baby, and they are much more set in their ways and picky about where they will and won’t get milk from. Sometimes we even need baby to be away from the breast source (I know that is a weird way of saying it as I was typing it) for a day or a weekend before they finally think, Fine! I’ll try the bottle. I’m starving! So if baby is not accepting the bottle, send mom/primary breastfeeder away for the weekend so baby can’t see or smell them. At first baby will think, OK, if I just hold out a little bit longer and cry a bit louder these chumps will cave in and just feed me like before. But eventually they get really hungry and will try the bottle. Now having said that, there are just some babies that no matter what bottle or nipple or position or distraction we do, they will not take a bottle. This can be super frustrating for families as having the option of the bottle can be helpful especially when starting day care or if parents want to get away for a weekend and let the grandparents watch the kiddos. The good news is there is no written law that says babies can only take milk from a breast or bottle. I checked, no law. There are great cups with spout options or even fancy spoons that we can use to get milk into that baby’s gullet.