 Introduction
Breastmilk is the only food your baby needs until about 6 months
of age. There is no advantage to adding other sorts of foods or milks
to breastmilk before about 6 months, except under unusual
circumstances. Many of the situations in which breastmilk seems to
require addition of other foods arise from misunderstandings about how
breastfeeding works and/or originate from a poor start at establishing
breastfeeding. In other words, if your baby is breastfeeding well and
gaining weight well, then add solids only when the baby shows signs of
being ready to eat solids. See the information sheet Protocol to Manage Breastmilk Intake.
Supplementing during the first few days
It is thought by many that there is “no milk” during the first few days
after the baby is born, and that until the milk “comes in” some sort of
supplementation is necessary. This idea seems to be born out by the
fact that babies, during the first few days, will often seem to feed
for long periods and yet, not be satisfied. However, the key phrase is
that “babies seem to feed” for hours when in fact, they are not really
feeding much at all (see the video clips of young babies, younger than
2 days, breastfeeding very well and getting milk well, at the website
nbci.ca). A baby cannot get milk efficiently when he is not
latched on properly to the breast, particularly when the supply is not yet abundant.
Note, it is not supposed to be abundant in these early days. But during
the first few days, if the baby is not latched on properly, he cannot
get milk easily and thus may “seem to feed” for very long periods.
There is a difference between being “on the breast” and drinking milk
at the breast. The baby must latch on well so he can get the mother’s
milk that is available in sufficient quantity for his needs, as nature intended.
In the first few days, the mother does have the appropriate amount of
milk that baby requires. She is not supposed to have a large amount and
nobody has proved that the large amount of formula a baby will take in
the first few days is good for him or safe! Yes, the milk is there even
if someone has proved to you with the big pump that there isn’t any.
How much does or does not come out in the pump proves nothing—it is
irrelevant. Also note, no one who squeezes a mother’s breast can tell
whether there is enough milk in there or not.
A good latch is important to help the baby get that milk that is
available. If the baby does not latch on well, the mother may be sore,
and if the baby does not get milk well, the baby may want to be on the
breast for long periods of time worsening the soreness. Or the baby may
fall asleep at the breast and seem to have fed well; but babies tend to
fall asleep at the breast when the flow of milk is slow.
-
A baby who drinks well (see video clips at the website nbci.ca)
and falls asleep at the breast > that’s the way it should be.
- A baby who drinks poorly and then falls asleep at the breast
> that’s not the way it should be. The mother and baby need help
with the breastfeeding.
When the mother's milk becomes more plentiful, after 3-4
days, the baby may do well even if he is not well latched on (the
mother may be sore, but even this is not necessarily so—many mothers
just put the baby to the breast any old way and both she and the baby
do fine). If a better latch, and compression (see the information sheet Breast Compression) do not get the baby breastfeeding, then supplementation, if medically needed, can be given by lactation aid (see the information sheet Lactation Aid).
The lactation aid is a far better way to supplement than finger feeding
or cup feeding, if the baby is taking the breast. And it is much, much
better than using a bottle. But remember, getting the baby well latched
on first and using compressions will work most of the time and no
supplements will be needed. Using a lactation aid before helping the
mother and baby with the breastfeeding is not appropriate just because
a bottle is not being used to supplement.
Water
Breastmilk is over 90% water. Babies breastfeeding well do not
require extra water, even in summer, even in the hottest weather. If
they are not breastfeeding well, they also do not need extra water, but
rather, the mother and baby need help so that breastfeeding works
better.
Vitamin D
It seems that breastmilk does not contain much vitamin D, but it does
have a little. We must assume this is as nature intended not a mistake
of evolution. In fact, breastmilk is one of the few natural foods that
does contain some vitamin D. We were obviously meant to get our vitamin
D from being exposed to sunlight. The baby stores up vitamin D during
the pregnancy and he will remain healthy without vitamin D
supplementation for at least a couple of months, unless the mother
herself is vitamin D deficient during the pregnancy. Vitamin D
deficiency in pregnant women in Canada and the USA is uncommon, but it
does exist. Outside exposure also gives your baby vitamin D even in
winter, even when the sky is cloudy. A few minutes of exposure very
late on a summer’s day is ample. Thirty minutes during a summer week,
and an hour or so in winter, gives your baby more than enough vitamin D
even if only his face is exposed.
Under unusual circumstances, it may be prudent to give the baby vitamin
D. For example, in situations where exposure of the baby to ultraviolet
rays of the sun is not possible (Northern Canada in winter or if the
baby is never taken outside), giving the baby vitamin D drops would be
advised. If you have had very little outside exposure yourself (women
who are veiled are particularly at risk, especially if they are dark
skinned), make sure your intake of vitamin D during the pregnancy is
higher than usually recommended. Your baby may need vitamin D
supplementation as well. Recent studies suggest that high intake of
vitamin D while breastfeeding (4000 IU a day—10 times the usual
recommended dose) does in fact increase the amount of vitamin D in the
milk to levels that will protect the baby from rickets.
Iron
Breastmilk contains much less iron than formulas, especially the
iron-enriched formulas, and this is as it should be. Actually, the low
levels of iron in breastmilk are thought to give the baby extra
protection against infection, as many bacteria require iron in order to
multiply. The iron in breastmilk is very well utilized by the baby
(about 50% is absorbed), while being unavailable to bacteria and the
breastfed full term baby does not need any additional iron before about
6 months of age. However, introduction of iron containing foods should
not be delayed much beyond 6 months of age.
Solid Foods (see also the information sheet Starting Solid Foods)
Exclusively breastfed babies do not usually require solid foods
before about 6 months of age. Indeed, many do not require solid foods
until 9 months or more of age, if we can judge by their weight gain and
iron status. However, there are some babies who will have great
difficulty learning to accept solid food if not started before 7-9
months of age. Because the six-month-old baby will also soon need to
have an additional source of iron, it is generally recommended and
convenient that solids be introduced around 6 months of age. Some
babies show great interest in grabbing food off your plate by 5 months,
and there is no reason not to allow them to start taking the food and
playing with it and putting it in their mouths and eating it.
It has been the habit of physicians to suggest that babies be
started first on cereals and then other foods be added. There is
nothing magic about cereal and babies do fine without it. In fact,
other than calories and added iron there is not much of nutritional
value in cereals. The easiest way for the baby to get additional iron
is by eating meat, not by cereals from which the iron is poorly
absorbed and the vast majority comes out with the baby’s bowel
movements. Furthermore, cereals tend to be constipating. Real food that
you eat is best for baby.
There is no good reason why a baby needs to eat or be introduced to
only one food per week or why vegetables should be started before
fruits. Anyone worried about the sweetness of fruit has not tasted
breastmilk. The six-month-old can be given almost anything off his
parents’ plate that can be mashed with a fork. If you eat healthy, then
baby will eat healthy. Far fewer feeding problems will occur if a
relaxed approach to feeding is taken.
Breastmilk, cow’s milk, formula, outside work and bottles. (See also the information sheet What to Feed the Baby When the Mother is Working Outside the Home).
In modern industrial societies we have so long fed babies with bottles
that we cannot imagine that a baby can be fed without one. The “need”
for baby to take a bottle is purely a manufactured one and marketing
continues to emphasize this need. No baby needs to take a bottle as an
entrance requirement for kindergarten—instead all children will
eventually learn to drink from a cup (not a “sippy” cup which is,
essentially, a bottle). It is true that an older baby will often not
take a bottle if not used to it. This is no great loss. So, why not
teach baby to use a cup? Babies can learn to take a cup at birth,
though there is not usually a reason to for them to do so. See the
video clip of a 2 or 3 week old baby drinking from a cup at the website
nbci.ca. In this case the baby is being cup fed to avoid a
bottle. He is not yet able to latch on to the breast.
However, if mother needs to be separated from her baby for any reason,
the baby can drink her milk by cup. This is best learned when baby is
not ravenous (see the information sheet Finger and Cup Feeding).
At about 6 months or even younger, the baby can start learning to use a
cup, even if he has never done this before and usually will be quite
good at drinking from a cup by about 7-8 months of age, if not sooner.
If the mother is returning to paid work at about 6 months or before,
there is also no need to start bottles or formula. In this situation,
solids may be started somewhat earlier than 6 months of age (say 4 or 5
months of age), so that by the time the mother is working outside the
home, the baby can be getting most of his food and liquid, when the
mother is not with him, off a spoon. As he gets older, the cup may be
used more and more for liquids. You and the baby can manage without his
taking bottles. Do not try to starve the baby into taking a bottle if he refuses to accept one.
Your baby is not being stubborn; rather, he does not know how to use an
artificial nipple. He also may not like the taste of formula, which is
understandable.
Note that too many workers in daycares do not realize any of
this and are surprised or dismayed or unhappy that the baby of 6 months
of age, say, does not take a bottle. Educate them, nicely, of course.
There has been a lot of publicity recently about not giving babies
cow’s milk until at least 9 months. The breastfeeding baby can take
some of his milk as cow’s milk after about 6 months of age, especially
if he is starting to take substantial amounts of a wide variety of
solids as well. The breastfed baby, who has been supplemented with
formula as mentioned above, can get that formula mixed with solids or
that formula can be replaced with cow’s milk. Certainly, cow’s milk is
less expensive. Goat’s milk is an alternative. Many breastfeeding
babies will not drink formula because they do not like the taste.
Actually, the breastfeeding baby can get all the milk he needs from the
breast without his requiring other sorts of milk, even if he is
breastfeeding only a few times a day. See the information sheet What to feed the baby when the mother works outside the home.
My 4 month old is hungry on breast only. Solids or Formula?
There is no advantage in this situation of giving formula,
especially by bottle and there may be some important disadvantages.
Even at this age a baby may start to prefer the bottle if he seems not
to be getting enough from the breast (if, in fact, he will accept a
bottle). On the other hand, if the baby does accept the bottle and if
your milk supply has decreased, as it might have, giving the baby a
bottle may almost guarantee that the baby will soon refuse the breast.
See the information sheet Slow Weight Gain After Early Good Weight Gain for
reasons your milk supply may have decreased. It would be preferable in
this circumstance to give solids off a spoon rather than to give
formula in a bottle. (Frequently, however, this situation can be
remedied differently by improving the breastfeeding—get help!). If you
wish to mix formula with solids, that does not cause the same sort of
problem as giving formula or even expressed milk in a bottle. If the
baby seems hungry after breastfeeding, feed him solids off a spoon. However,
it may be possible with a few simple techniques, to get the baby
gaining well, and/or to be satisfied with breastfeeding alone. Check with the clinic.
Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond.
To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002.
Breastfeeding and Other Foods, 2009©
Written and revised (under other names) by Jack Newman, MD, FRCPC, 1995-2005©
Revised Jack Newman MD, FRCPC, IBCLC and Edith Kernerman, IBCLC, 2008, 2009©
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