Wednesday, September 24, 2008

Breastfeeding, Solids, and Sleeping Babies

Following is a copy of a letter I sent to a friend about ten years ago, in response to her query about whether she needed to start solid foods for her exclusively-breastfed son because she was concerned about something she'd read about declining iron levels at his age. He was her first child, and she knew that I had exclusively breastfed for a year with my own children. (At the time I was breastfeeding my third child.)

Interestingly, this copy was sent to me by another friend, to whom I'd forwarded the original letter when she was facing the same questions several years later. She mentioned it to me in an email, because she herself had been forwarding it to a friend of hers who was at that same stage of life now. Although I was humbled by her dubbing of it as "a very helpful read," I figured if it could be useful to anyone, I may as well post it here.

My copy has been long lost in a computer crash, and this is one of the subjects I am still asked about often. The details are getting hazy now that it has been several years since I have been actively breastfeeding, so I'm happy to have my own words back after all these years! Thank you, Michele, for having a copy and sending it on...

[As a side note, if anyone has an old saved copy of the letter that I first wrote to my friend Tiffany years ago about "Homeschool Kindergarten," I would really love a copy of that, too. It was also lost in the crash, and I usually have several folks a year asking about that subject. Again, the details are now hazy about how I handled homeschool kindergarten when I only had one child "doing school." Things look very different - and not necessarily better, I might add - when your kindergartener has older siblings in high school, middle school, and elementary school!]

So, anyway, here's the copy of the letter, if this topic is of any interest or usefulness to you.

Yes, I did exclusively breastfeed PT for his first year of life. It was wonderful. With EV, I started solids in response to great familial pressure from both sides of the family at Christmas, when she was just about 8 months old. I had successfully withstood the pressure at Thanksgiving, but to do it all over again at Christmas was just too much.

So, she began to eat some ground oatmeal, prepared very soft, or mashed banana, or plain yogurt, or things of that nature. This kept my folks and in-laws appeased, and I was sporadic about the feeding. Mostly we did it for “show” when they were around - every few days or so - and didn’t do any regular feeding for a couple more months. Anyway, they were "encouraging" me to start solids because (1) they'd never known anyone who went past six months starting food, and most folks they knew started baby food at two months, and (2) they, too, had heard about the iron thing, and they were worried that she was too small and that it must be because my milk wasn’t adequate for her. Ironically, I never fed her iron-fortified baby cereal, but feeding her regular food seemed to satisfy their fear about the iron thing and about the “you're starving your baby” thing.

When PT came along, I was more adamant, and they were less so. My mother got a little concerned when nine, ten, eleven months went by with no food for PT. “He’s a very big baby, Laurie, and you couldn’t possibly have enough milk for that to be all he needs.” After I pointed out to her that he had gotten that big on my milk alone, and that clearly it was enough for him, by virtue of his continued growth, she let up a little. It wasn’t until after I said, “Mom, you were worried that EV was too small, and that I must not have enough milk. Now you’re worried that PT is too big, and I must not have enough milk. You can’t have it both ways. Which is it?!?!” that she’s never said another word about any of it.
I started giving PT bits of bread or such, or let him gnaw on a raw carrot, at about 11 1/2 months, sporadically, to occupy him when we had guests at dinner or were in a restaurant or whatever.

It was so nice to skip the entire “baby food” thing! With EV, I had made all my own baby food, for both financial and health reasons, and so had to cook big batches, puree it and freeze it in ice cube trays, and pull it out to feed her later. There is the whole messy and time-consuming “feed them with a spoon as they spit it out all over you because their tongue still thrusts forward as if nursing on a nipple” thing, and the preparation of two separate meals, for the family and for baby. When you start that early, you have to cook baby’s food bland and plain, and feed him something different from the rest of the family, to avoid allergic reactions and digestive problems. When you wait until they’re a year old, they can feed themselves bits of whatever you prepare them, so you can skip the whole baby food stage. It is wonderful!! By a year, they have a few teeth in the front, and they can really “gum” the stuff well in the back, provided you fix it soft enough. Sweet potatoes, bananas, etc., are great to start with until they get the hang of it.

Anyway, I know that isn’t really what you asked, but it is the logical start of the discussion. On to the next thing you didn’t ask, but which I’ll talk about anyway.
In order to "pull off" exclusive breastfeeding of a larger, many-month-old child, you have to be willing to allow him opportunities to increase your milk supply as his needs increase. This can be accomplished without nursing in the middle of the night, and without just ‘demand feeding’ them all day. It really can’t be accomplished with only four very rigid feed times over the span of a day. So, how did I accomplish this?

I have the general policy pretty much from birth that I nurse the baby both when it wakes up (this is the “real” feeding) and before it goes down to sleep (this is a 'snacky, non-nutritive, settle down' feeding, usually), whether nighttime or naptimes are in view. By the time the child is five or six months old (when most people start itching to start solids), this tends to work itself into a schedule something like this:

- early morning nursing (real feeding) somewhere around 5 am, after which the baby goes back to sleep. I do this nursing lying down in bed.

- morning nursing (real feeding) somewhere between 7 and 9, whenever the baby wakes up in the morning for good.

[This "schedule" allows for two really good feedings early in the day, when my milk supply is very good from having been resting all night, and before the urgency of the rest of life has kicked in full-force. Notice that it is set by the child and centers feeding around sleep, not sleep around feedings. I very rarely wake a sleeping baby.]

- I nurse the baby before he goes down for a morning nap (usually around 10 or so, or a couple of hours after he woke up in the morning), even though this is usually only a little “snacky” feeding. He’ll suck until I have "let down," take a few swallows, and then pull off and fuss and want to be put down to sleep.
However, this opportunity allows for the baby to take more milk, and really use it as a real feeding, if he’s needing to increase my milk supply. Because this feeding occurs only a couple of hours (at the most) since the last one, his nursing more at this time will successfully increase the supply at the previous “real” nursing, so that he won’t need to keep “really” feeding at the snacky time once he’s upped my milk supply. Make sense?

Anyway, then morning nap of 2—3 hours (usually, although I don’t wake the baby from his naps).

- real feeding upon awakening (4-5 hours from the last “real” feeding, but only 2-3 hours from the “snacky” feeding that the baby didn’t really take but had opportunity for if he needed it).

- same thing a couple of hours later, or when the baby gets fussy again. I offer him a non-nutritive feeding to take if he wants or needs it. Generally, he only sucks until "let down," drinks a few gulps, and wants nothing more to do with it. If he “chows down” vigorously again, I know he’s hit a growth spurt, and I can pay attention to increasing my milk supply to meet his needs (i.e. nurse well at the “non-nutritive” times, take Brewer’s yeast, get good rest, drink lots of water, etc.)

Then he takes the afternoon nap for 2—3 hours or so.

I nurse him upon his awakening (real feeding) and again before he goes back to bed (“snacky" feeding) a couple of hours later.

This type of “schedule” (and again it is loose, based on the sleep schedule more than based on an eating schedule) allows for four “big, real, meal” type nursings, and for three “snacky but be a meal if you are needing more milk” type nursings in a given day.

Again, there is no nursing from bed time (usually between 6:30 and 8) until the early morning feeding at 5 am or so (and after which the child goes back to sleep for 2-4 more hours).

[Side note about sleep: On this "system," three of my children slept through the night, on their own, by six weeks; one took a little longer and did it by eight weeks. I never had to wake them up. I never had to schedule their feedings at certain times. I just followed this loose "work around their sleep, and let them sleep as much as possible" system I've outlined above. Not much makes me as sad as seeing a poor little fussy, tired guy whose mother is constantly waking him up to try and feed him when he's not hungry, in the name of helping him sleep! But I digress...]

Following this routine, you can pretty much expect (like clockwork) the child to hit a major growth spurt around four months, and again at around six months, at which point he’ll awaken again in the night. You will be tempted to think he now needs more than your milk can provide, and start wanting to add solids. This isn’t the case, and you don’t have to give him anything more than your milk, but just ensure that he gets more of your milk by attending to his need to increase your milk supply by more frequent and vigorous nursing during the day, as outlined above.

If you “cave” and nurse in the middle of the night when he awakens, he will develop a habit of eating in the middle of the night. It you allow this one middle-of-the-night feeding to continue, it will invariably turn into two (or more), and you’ll end up having to break him of a terrible habit by enduring hours and hours of crying in the middle of the night. This is NOT because he has to eat in the middle of the night to get enough milk!! (See above.) This is because once the long (around ten hours in a row without waking) sleep has been interrupted, they are back into the "I awaken every 3-4 hours or so" pattern again. I have “caved” with both of my first two, each time because they were sick with their first cold at the time, and I thought things like, "Oh, they might really need the extra milk, and they’re so snotty anyway, that if I let them cry they’ll get even more snotty" or, "They just don’t feel good and need the comfort, and ..."

At any rate, they did want to keep up the nursing after the illness passed, and I had to let them cry to break them of the habit. So far I haven’t “caved” with OG, although I haven’t had much opportunity yet, as she hasn’t awakened in the middle of the night since she gave up that midnight feeding at two months of age. I’ll let you know how I do when she does!

NOW, for the answer to the question you asked. (How’s that for offering advice no one asked for?!?!)

The "need iron" concern stems from the very true and real medical fact that the baby has had iron stores in its body (from the mother, stored up during gestation) that last him from 4-6 months without his needing to get any iron from any external source. After this time, it becomes necessary for him to get his iron from outside his own body stores, and he must have a good source of it. This does NOT mean he needs supplementation to get it (whether from baby cereal or baby vitamins), for iron passes freely and in adequate amounts, through the milk of the mother who is getting enough iron herself. SO, if you're worried about it, you should be taking an iron supplement yourself. (I take "Blood Builer" from Mega-Food, a food-source vitamin that is exorbitantly expensive if you buy it retail but which a friend gets for us at cost. This is what my midwife and others recommend, along with the "Baby and Me" natural prenatal formula and "Bone Builder" calcium supplement, for nursing mothers.)

To end, I will quote you some stuff from on of the books I read on the subject, written by pediatrician George Wootan, M.D., in his book Take Charge of Your Child's Health. If, between my letter and his quoted stuff, we didn't answer your questions, please feel free to write back and ask more. If I've had the same questions, and therefore sought for and found an answer, I'll be happy to pass it on. Happy reading!)

“Although most doctors do concede that breast-fed babies are generally healthier, many still persist in thinking that they need iron and vitamin D supplements, considering breast milk to be a less than adequate source of these nutrients. Supplements are not necessary, however. The idea that breast-fed babies need supplementary iron stems mainly from two misconceptions. The first of these is based on the fact that many bottle-fed babies who receive cow’s-milk-based formulas become anemic, usually around the age of six months. Since cow’s milk actually contains slightly more iron than breast milk, doctors assume that breast-fed babies must also be iron-deficient. However, the reason a bottle-fed baby becomes anemic is that the child's body is able to absorb only about thirty percent of the iron in cow’s milk. In contrast, the iron in breast milk is virtually one hundred percent absorbable, so that the breast-fed baby is actually less likely to become anemic.

A doctor may also conclude that a breast-fed baby is anemic after doing a hematocrit that shows a low ratio of red blood cells. If the child has just had a growth spurt, a low red blood count may simply indicate that his blood production is lagging slightly behind his weight gain. Given a little time, his blood production will catch up to his weight, and he will no longer show a deficiency of red blood cells.

I also believe that a baby may appear to be anemic simply because babies and toddlers do not need the same iron count as older children and adults. This may be because of the immune mechanism lactoferrin, which is dependent on a low level of iron in the baby. If the baby is saturated with iron, lactoferrin may be hampered.

Unless a breast-fed infant is severely anemic (and this is rare), I do not believe there is any reason to use iron supplements. However, if the baby’s red blood cell count is unusually low, the mother's should also be checked. If she is anemic, her body may be unable to provide enough iron in her breast milk to keep her baby adequately supplied. In this situation, the mother should be given supplements, not the baby. Once she is receiving enough iron, there will be enough in her breast milk to provide for her baby.

Like the presence of white blood cells in human milk, the presumed lack of vitamin D in breast milk has sometimes been considered another of nature’s little "mistakes." In reality, however, there is plenty of vitamin D in breast milk - if you know where to look for it. Because most sources of vitamin D are fat-based, researchers have separated the fat from the aqueous portion of breast milk, examined the fat, and found no vitamin D. Some scientists have looked for vitamin D in the aqueous portion of the milk - the part they had previously tossed into the sink - and found as much as a baby needs. One large study showed no deficiency of the vitamin in breast-fed infants who did not receive supplements.15

There has been a tendency in the medical community to compare the composition of breast milk against that of formula as if formula were the model that must be lived up to as a baby’s perfect food. Consider, for example, this quote from a medical journal: "Although breast milk contains less protein and energy than formula, this does not constitute a problem because breast milk is so well suited to the infant."16 It would make more sense to turn this statement around, to say that the composition of formula may present problems because it contains more protein and energy than breast milk. This same backward thinking is applied to expectations concerning infant growth patterns. At around the age of six months, bottle-fed infants tend to start getting larger than babies who are breast-fed. As a result, doctors will often conclude that breast-fed infants need supplemental feedings in order to take care of this “lag” in growth. However, they are comparing the growth of the breast-fed babies against reference standards for bottle-fed babies, who grow at a faster rate. To date, there has been no large study to chart the normal growth patterns for babies who are exclusively breast-fed. A doctor who tells you that your breast-fed baby “needs” solid food or formula is working under the faulty assumption that breast-fed and bottle-fed babies should have the same growth patterns. In fact, studies have been done in Japan of children who were highly allergic and so received nothing but breast milk for the first two years of life. These children showed no nutritional or growth problems whatsoever. As one researcher in the field has suggested, "As long as the infant is growing, there is no need to add supplemental foods."17

As you may have guessed by now, I am of the opinion that infants should not be started on solid foods between the ages of four and six months, as is often recommended by doctors. (Even La Leche League suggests beginning solids at six months.) There are some very good reasons to delay the introduction of solid foods into your child’s diet. One important reason is that the introduction of either solid foods or supplemental formula seems to reduce the effectiveness of breast milk’s immune properties. One study conducted in India observed three groups of children: one group was exclusively breast-fed, one was fed both breast milk and supplemental formula or solid foods, and one was fed only formula and/or solid foods. The breast-fed children had the lowest incidence of disease and mortality. The babies who had mixed feedings had slightly fewer gastrointestinal problems than those who were artificially fed, but their rates of respiratory diseases, middle ear infections, and skin diseases were essentially the same.18 Two more interesting studies were done in Guatemala, where the children are typically breast-fed for the first two to three years, with solid foods being added to the diet around five to six months. While the purpose of these studies was to illustrate how disease and diet work together in causing malnutrition, one of the findings was that the incidence of overt disease increased substantially after complementary foods were started.19
Another good reason to keep your baby on a diet of breast milk alone is that a baby’s intestinal tract is not fully developed until several months after birth, perhaps as late as eighteen to twenty-four months.20 Digestion is a complicated breakdown process that begins in the mouth when food is mixed with saliva, and continues throughout the digestive tract, with the stomach, pancreas, liver, and intestines all playing a unique role. Various enzymes are involved in each stage of digestion, speeding up the breakdown of food and converting it into a form that can be utilized by the body. Some of these enzymes are present only in very low levels or are entirely missing from the infant digestive system.

One of these enzymes is amylase, which plays a key role in the digestion of carbohydrates. The common suggestion for a baby’s first food is cereal or fruit, both carbohydrates. However, amylase is present at just ten percent of adult levels in an infant’s small intestines, and is virtually nonexistent in the pancreas until at least six months of age.21 Ptyalin, an enzyme in saliva that breaks down carbohydrates, does not appear until around twelve months of age. When carbohydrates are introduced into a baby’s diet too early, he is unable to digest them completely. The result can be poor nutrition due to failure to absorb the nutrients in the food, and possibly diarrhea.
This lack of enzymes presents no problem to the breast-fed baby, since human milk contains more than twenty enzymes that become active in the stomach so that the milk is easily digested. One of the most important enzymes contained in breast milk is lipase, which helps to break down fats, from which forty to fifty percent of the energy in both human milk and formula is derived. Not only is formula completely lacking in lipase, but at least one researcher has suggested that "these compensatory, or complementary, mechanisms for fat utilization... are less effective when cow’s milk fat or other fats are introduced into [the] diet," 22 so that the baby who is fed supplementary formula may have more trouble digesting even breast milk than if he were on a diet of breast milk alone.
Some lipase is produced at the back of an infant’s tongue as he nurses. You may have noticed the “milking” action that’s made with the back of the tongue as an infant sucks. It seems probable that this action helps to stimulate lipase secretion and to mix the lipase with the milk to begin digestion. Since drawing milk from a bottle involves just sucking, this effect is eliminated if a baby is bottle-fed.

Because formula contains no enzymes, the bottle-fed baby is more prone to digestive problems. Protein molecules, which may cross the underdeveloped intestinal lining before they have been completely broken down, can be particularly troublesome. These molecules can then act as antigens, causing an allergic reaction. Digestive problems are often compounded when modified food starch, a common ingredient in commercial baby foods, is added to the diet. Modified food starch, usually derived from corn or tapioca, has an even lower level of digestibility than other carbohydrates. In order for modified food starch to be effective, it must make up approximately five percent of the product. While this may not sound like much, at this level it contributes about thirty-two percent of the food’s total calories.

My recommendation regarding solid foods before one year is to start with proteins rather than carbohydrates and to introduce them no earlier than eight months of age, but preferably not until one year. Hydrochloric acid, which helps digest protein, begins to appear in the stomach around the seventh or eighth month of life. It would seem, therefore, that the body would first be ready to digest proteins (at eight months) and then carbohydrates (at one year). By holding off on introducing any solid foods (or formula) until the age of one year, you can be certain that the digestive tract is sufficiently developed to be able to handle the foods that you put into it. Remember, too, that breast milk contains everything your baby needs to thrive and be healthy for at least the first year of life, probably for the first two. There’s really no reason to feed him anything else, and there are several good reasons not to [emphasis his]."

- from Take Charge of Your Child's Health by George Wootan, M.D. and Sarah Verney. (New York: Crown Publishers, Inc., 1992) pps. 116-120.

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