>>HOW TO BREASTFEED?
ESTABLISHING BREASTFEEDING : STARTING OFF
RIGHT- by Jack Newman, MD, FRCPC
Breastfeeding is the
natural, physiologic way of feeding infants and young children
milk, and human milk
is the milk made specifically for human infants. Formulas made
from cow’s milk or soy beans (most of them) are only superficially
similar, and advertising which states otherwise is misleading.
Breastfeeding should be easy and trouble
free for most mothers. A good start helps to assure breastfeeding
is a happy experience
for both mother and baby.
The vast majority of mothers are perfectly capable of breastfeeding
their babies exclusively for four to six months. In fact, most
mothers produce more than enough milk. Unfortunately, outdated
hospital routines based on bottle feeding still predominate in
many health care institutions and make breastfeeding difficult,
even impossible, for some mothers and babies. For breastfeeding
to be well and properly established, a good early few days can
be crucial. Admittedly, even with a terrible start, many mothers
and babies manage.
The trick to breastfeeding
is getting the baby to latch on well. A baby who latches on well, gets milk well.
A baby who latches
on poorly has difficulty getting milk, especially if the supply
is low. A poor latch is similar to giving a baby a bottle with
a nipple hole which is too small—the bottle is full of milk,
but the baby will not get much. When a baby is latching on poorly,
he may also cause the mother nipple pain. And if he does not get
milk well, he will usually stay on the breast for long periods,
thus aggravating the pain.
Here are a few ways breastfeeding can be made easy:
1. The baby
should be at the breast immediately after birth.
The vast majority of newborns can be put to breast
within minutes of birth. Indeed, research has shown that, given
the chance, babies only minutes old will often crawl up to the
breast from the mother’s abdomen, and start breastfeeding
all by themselves. This process may take up to an hour or longer,
but the mother and baby should be given this time together to start
learning about each other. Babies who "self-attach" run
into far fewer breastfeeding problems. This process does not take
any effort on the mother’s part, and the excuse that it cannot
be done because the mother is tired after labour is nonsense, pure
and simple. Incidentally, studies have also shown that skin to
skin contact between mothers and babies keeps the baby as warm
as an incubator.
2. The mother and baby
should room in together. There is absolutely
no medial reason for healthy mothers
and babies to be separated from each other, even for short periods.
Health facilities which have routine separations of mothers and
babies after birth are years behind the times, and the reasons
for the separation often have to do with letting parents know who
is in control (the hospital) and who is not (the parents). Often
bogus reasons are given for separations. One example is the baby
passed meconium before birth. A baby who passes meconium and is
fine a few minutes after birth will be fine and does not need to
be in an incubator for several hours’ "observation".
There is no evidence
that mothers who are separated from their babies are better rested. On the contrary, they are more rested
and less stressed when they are with their babies. Mothers and
babies learn how to sleep in the same rhythm. Thus, when the baby
starts waking for a feed, the mother is also starting to wake up
naturally. This is not as tiring for the mother as being awakened
from deep sleep, as she often is if the baby is elsewhere when
he wakes up.
The baby shows long before he starts crying that he is ready to
feed. His breathing may change, for example. Or he may start to
stretch. The mother, being in light sleep, will awaken, her milk
will start to flow and the calm baby will be content to nurse.
A baby who has been crying for some time before being tried on
the breast may refuse to take the breast even if he is ravenous.
Mothers and babies should be encouraged to sleep
side by side in hospital. This is a great way for mothers to rest while the baby
nurses. Breastfeeding should be relaxing, not
tiring.
3. Artificial nipples
should not be given to the baby. There seems
to be some controversy about whether "nipple
confusion" exists. Babies will take whatever method gives
them a rapid flow of fluid and may refuse others that do not. Thus,
in the first few days, when the mother is producing only a little
milk (as nature intended), and the baby gets a bottle (as nature
intended?) from which he gets rapid flow, he will tend to prefer
the rapid flow method. You don’t have to be a rocket scientist
to figure that one out, though many health professionals, who are
supposed to be helping you, don’t seem to be able to manage
it. Nipple confusion includes not just the baby refusing the breast,
but also the baby not taking the breast as well as he could and
thus not getting milk well and /or the mother getting sore
nipples. Just because a baby will "take both" does
not mean that the bottle is not having a negative effect. Since
there are now alternatives available if the baby needs to be supplemented
(see handout #5 Using a Lactation Aid, and handout #8 Finger Feeding)
why use an artificial nipple?
4. No restriction on
length or frequency of breastfeedings. A baby
who drinks well will not be on the breast
for hours at a time. Thus, if he is, it is usually because he is
not latching on well and not getting the milk which is available.
Get help to fix the baby’s latch, and use compression to
get the baby more milk (handout #15 Breast Compression). This,
not a pacifier, not a bottle, not taking the baby to the nursery,
will help.
5. Supplements of water,
sugar water, or formula are rarely needed. Most supplements
could be avoided
by getting the baby to take the breast properly and get the milk
that is available. If you are being told you
need to supplement without someone having observed you breastfeeding,
ask for someone
to help who knows what they are doing. There are rare indications
for supplementation, but usually supplements are suggested for
the convenience of the hospital staff. If supplements are required,
they should be given by lactation aid (see handout #5), not cup,
finger feeding, syringe or bottle. The best supplement is your
own colostrum.
It can be mixed with sugar water if you are not able to express
much at first. Formula is hardly ever necessary in the first few
days.
6. A proper
latch is crucial to success. This is the key to
successful breastfeeding. Unfortunately,
too many mothers are being "helped" by people who don’t know what
a proper latch is. If you are being told your two day old’s
latch is good despite your having very sore nipples, be skeptical,
and ask for help from someone who knows.
Before you leave the
hospital,
you should be shown that your baby is latched on properly, and
that he is actually getting milk from
the breast and that you know how to know he is getting milk from
the breast (open—pause—close type of suck). If you
and the baby are leaving hospital not knowing this, get help quickly.
7. Free
formula samples and formula company literature are not gifts.
There is only one purpose for these "gifts" and
that is to get you to use formula. It is very effective, and very
unethical, marketing. If you get any from any health professional,
you should be wondering about his/her knowledge of breastfeeding
and his/her commitment to breastfeeding. "But I need formula
because the baby is not getting enough!". Maybe, but, more
likely, you weren’t given good help and the baby is simply
not getting your milk well. Get good help. Formula samples are
not help.
Under some circumstances, it may be impossible to start breastfeeding
early. However, most medical reasons (maternal medication, for
example) are not true reasons for stopping or delaying breastfeeding,
and you are getting misinformation. Get good help. Premature
babies can start breastfeeding much, much earlier than they do
in many
health facilities. In fact, studies are now quite definite that
it is easier for a premature baby to breastfeed than to bottle
feed. Unfortunately, too many health professionals dealing with
premature babies do not seem to be aware of this.
Questions? (416) 813-5757
Handout #1. Breastfeeding—Starting
Out Right. Revised January 1998 - article by Dr. Jack
Newman
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>>COLIC IN THE BREASTFED BABY - by Jack Newman MD, FRCPC
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 3 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 proved 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 which 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
Human milk changes during a feeding. One of the ways in which it changes is that the amount of fat increases as the baby nurses longer at 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, greenish 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.
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.
The mother should feed the baby on one breast, as long as the baby breastfeeds, until the baby comes off himself, or is asleep at the breast. If the baby feeds for only a short time only, the mother can compress the breast (handout #15 Breast Compression) to keep the baby nursing. 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.
The next feeding, the mother should start the baby on the other breast in the same way.
The mother's body will adjust quickly to the new method, and she will not become engorged or lop sided.
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 (compress milk into his mouth if necessary to keep him swallowing longer) but if he wants more, then offer the other side.
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.
This problem is made worse if the baby is not well latched on to the breast. A proper latch is the key to easy breastfeeding.
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.
What can be done?
If you have not already done so, try feeding the baby one breast/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.
Feed the baby before he is ravenous. Do not hold off the feeding by giving water (a breastfeeding baby does not need water even in very hot weather) or a pacifier. A ravenous baby will "attack" the breast and 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.
Feed the baby in a calm, relaxed atmosphere, if possible. Loud music, bright lights and lots of action are not conducive to a successful feeding.
Lying down to nurse sometimes works very well. If lying sideways to feed does not help, try lying flat on your back with the baby lying on top of you to nurse. Gravity helps decrease the flow rate.
If you have time, express some milk (an ounce or so) before you feed the baby.
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 (handout #15 Breast Compression).
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.
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.
A nipple shield may help, but use this only if nothing else has helped and only if you have gotten good help without any relief.
As a last resort, rather than switching to formula, give the baby your expressed milk by bottle.
Foreign Proteins in the mother's milk
It has been shown that some proteins present in the mother's diet may be excreted into her milk and may affect the baby. It would seem that 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 necessarily a bad thing. Indeed, it should be considered a good thing. 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. These includes milk, cheese, yogurt, ice cream and anything else which 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.
Please note: Intolerance to milk protein has nothing to do with lactose intolerance. A mother who is herself lactose intolerant should also still breastfeed her baby.
Suggested Method:
The mother should eliminate all milk products for 7-10 days.
If there has been no change, the mother can reintroduce milk products.
If there has been a change for the better, the mother should 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.
If there is concern about your calcium intake, calcium can be had without taking dairy products. Ask if you have any questions. One week off milk products will not cause any problems. Actually, evidence suggests that breastfeeding may protect the woman against the development of osteoporosis even if she does not take extra calcium. And the baby will get all he needs.
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, though, 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.
This article may be copied and distributed without further permission
Handout #2 Colic in the breastfed baby. Revised January 1998
>>HOW DO I KNOW IF MY BABY
IS GETTING ENOUGH MILK?- by the La Leche Leaders?
HOW DO I KNOW IF MY BABY IS GETTING ENOUGH MILK?-
by the La Leche Leaders
This may be the most asked question for La Leche
League Leaders. It is understandable, since breasts are neither
see-through nor marked off in ounces. Thank goodness there are
other signs that indicate baby is getting enough milk.
Typically during the first few
days, while the baby is receiving mother’s thick, immunity-boosting
colostrum, he will wet only one or two diapers per day.
Once mother's milk comes in, usually on the third or fourth day,
the baby should begin to have 6-8 wet cloth diapers (5-6 wet disposable
diapers) per day. (An easy way to feel the weight of a wet disposable
diaper is to pour 2-4 tablespoons of water in a dry diaper.)
In addition, most young babies will have at least two to five
bowel movements every 24 hours for the first several months, although
some babies will switch to less frequent but large bowel movements
at about 6 weeks.
A baby that is sleeping rather than feeding every 2-3 hours or
is generally lethargic may need to be assessed by a health care
provider to make sure that he is adequately hydrated.
These are additional important signs that indicate your
baby is receiving enough milk:
- The baby nurses frequently averaging at least 8-12 feedings
per 24-hour period.
- The baby is allowed to determine the length of the feeding,
which may be 10 to 20 minutes per breast or longer.
- Baby’s swallowing sounds are audible
as he is breastfeeding.
- The baby should gain at least 4-7 ounces per week after the
fourth day of life.
- The baby will be alert and active, appear healthy, have good
color, firm skin, and will be growing in length and head circumference.
The physical act of breastfeeding is more than the quantity of milk that is supplied, as you will
find once you hold
your baby
in your arms. Breastfeeding is warmth, nutrition,
and mother's love all rolled into one. Understanding and
appreciating the signs of knowing when your baby is getting enough
to eat is the one of the most important things a new mother can
learn. If you have any concerns regarding your
baby, they should be addressed with your health care practitioner.
You can find a LLL Leader and Group by going to our Web
page on finding a local Leader.
For more information, read the article by Dr. Jack Newman. READ: Handout
#4. Is My Baby Getting Enough? Revised January 1998
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>>HOW CAN I INCREASE MY BREASTMILK?-
(Herbs for increasing milk supply
- by Dr. Jack Newman)
It is quite possible that herbal
remedies help increase milk supply. There are several drugs that obviously do increase
milk supply, and of course it is reasonable to assume that some
plants and herbs might contain similar pharmacological agents.
Almost every culture has some sort of herb or plant or potion to
increase milk supply. Some may work as placebos, which is fine;
some may not work at all; some may have one or more active ingredients.
Some will have active ingredients that will not increase the milk
supply but have other effects, not necessarily desirable. Note
that even herbs can have side effects, even serious ones. Natural
source drugs are still drugs, and there is no such thing as a 100%
safe drug. Luckily, as with most drugs, the baby will get only
a tiny percentage of the mother's dose. The baby is thus extremely
unlikely to have any side effects at all from the herbs.
Two herbal treatments that seem to increase the milk supply are
fenugreek and blessed thistle, in the following dosages:
Fenugreek: 3
capsules 3 times a day
Blessed thistle: 3
capsules 3 times a day, or 20 drops of the tincture 3 times a
day
The tincture container states
that blessed thistle should not be taken by nursing mothers,
presumably because of the tiny amount
of alcohol the mother would get. There are some preparations of
both herbs that are labelled "not for use by nursing mothers." Don't
worry about this; these herbs are safe for the mother to take because
so little gets into the milk. *Teas also seem
to work, but to take enough to make a difference, you will be drinking
tea all day and night, since the amount of the herbs you get is
much less. (See
the Oasis Lactation Tea difference)
- Fenugreek and blessed thistle seem to work better if you take
both, not just one or the other.
- Fenugreek and blessed thistle work quickly. If they do work,
you will usually notice a difference within 3 to 4 days of starting
taking them. If not, they probably won't work.
- Fenugreek is often sold as a combination with thyme. Do not
buy this combination, but try to get the capsules with fenugreek
alone.
- Herbal remedies are not standardized, so though the bottle
of fenugreek, for example, may say that it contains 405, 505,
605 or 705 mg/capsule, we do not really know how much of the
active ingredient you are taking. Fenugreek has a distinct smell.
If you cannot smell it on your skin, you are not taking enough,
even if you are taking three capsules three times a day.
- Fenugreek and blessed thistle seem also to work better in
the first few weeks than later. In fact they tend to work best
in the first week. Domperidone works better after the first few
weeks. (See Handout #19: Domperidone for more information.)
- You can take fenugreek and
blessed thistle together with domperidone if
you feel they are helping. If you take the herbs and domperidone,
take domperidone at the same time, 3 tablets three times a day.
If you are ready to stop fenugreek and blessed thistle, you can probably
stop suddenly, or wean off over a week or so.
- Fenugreek does not cause low blood sugar. Where this rumour
came from is unknown.
Other herbal treatments
that have been used to increase milk supply are: raspberry leaf,
fennel,
goat's rue, brewer's yeast, alfalfa
and many others. The effectiveness of none of these treatments,
including blessed thistle and fenugreek, has been proved. Remember!
Herbal treatments are only part of the solution to "not enough
milk" (see protocol to increase breastmilk intake by the baby).
Lecithin
Lecithin is a food supplement that seems to help some mothers prevent blocked
ducts. It may do this by decreasing the viscosity (stickiness) of the milk,
by increasing the percentage of polyunsaturated fatty acids in the milk.
It is safe, inexpensive, and seems to work in some cases. The dose is 1200
mg four times a day. There is more to preventing blocked ducts than taking
lecithin. See Handout #22: Blocked Ducts and Mastitis.
Handout #24. Miscellaneous Treatments. January 2003
Written by Jack Newman, MD,
FRCPC. © 2003
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>>COMMON LACTATION PROBLEMS?-
by the aAP
Minor problems can develop while breast-feeding, and are most
common during the first few weeks. Because you likely are physically,
mentally, and emotionally exhausted, minor problems can seem overwhelming.
Home treatment measures can be used for:
Breast engorgement
Feeding on demand not only ensures that your baby’s hunger is satisfied,
but it also helps prevent engorgement. Engorgement occurs when your breasts
become too full with milk. A little engorgement is normal, but excessive engorgement
can be uncomfortable or painful. If your breasts do become engorged, try the
following:
- Express some milk before you breastfeed, either manually or
with a breast pump.
- Soak a cloth in warm water and put it on your breasts. Or take
a warm shower before feeding your baby. For severe engorgement,
warmth may not help. In this case, you may want to use cold compresses
as you express milk. Ice packs used between feedings can relieve
your discomfort and reduce swelling.
- Feed your baby in more than one position. Try sitting up, then
lying down.
Gently massage your breasts from under the arm and down toward the nipple.
This will help reduce soreness and ease milk flow.
- Do not take any medications without approval from your doctor.
Acetaminophen (eg, Tylenol) may relieve pain and is safe to take
occasionally during breastfeeding.
It is important to keep breastfeeding. Engorgement is a temporary
condition and will be most quickly relieved by effective milk removal.
Once the engorgement passes, your breasts will become soft again.
This is normal and is exactly what should happen.
Let-Down
The let-down reflex occurs every time you breastfeed. The first few times you
breastfeed this let-down reflex may take a few minutes. Afterward, let-down
will occur much more quickly, usually within a few seconds.
The signs of let-down are different
for each woman. Sometimes when your baby starts to nurse, you
may feel a brief prickle, tingle,
or even slight pain in your breast. Or, milk may start dripping
from the breast that’s not being used. These feelings and
milk flow are signs of the let-down reflex. This means your body
is making it easier for your baby to nurse.
You may feel strong cramping in your uterus when your milk lets-down.
The hormone oxytocin, which stimulates milk flow, also causes the
muscles of the uterus to contract. Nursing helps your uterus go
back to its original size. This cramping is totally normal and
is actually a sign of successful nursing. The cramping should go
away in a week or so.
To help the let-down process along, try these tips:
- Sit in a comfortable chair with good support for your arms
and back. Many nursing mothers find that rocking chairs work
well.
- Make sure your baby is in the proper position on your breast.
Correct positioning is one of the most important factors in successful
breastfeeding.
- Listen to soothing music and sip a nutritious drink during
feedings.
- Do not smoke, drink alcohol,
or use illegal drugs. These all contain substances that can interfere
with let-down and affect the content of breast milk. They
are
not good for you and not good for your baby.
- Wear nursing bras and clothes that are easy to undo. Nursing
bras have front closing flaps that come down to expose your nipple
and part of your breast.
- If your household is very busy, set aside a quiet place ahead
of time where you will not be disturbed during feedings.
- Sometimes just thinking about your baby helps let-down take
place.
Food sensitivities
Sometimes breastfeeding babies react to certain foods that their mothers eat.
You might notice that after eating spicy or "gassy" foods, your
baby cries, fusses, or even nurses more often. Since babies with colic often
have similar symptoms, the best way to tell the difference between a food
reaction and colic is by how long symptoms last. With food reactions, symptoms
are usually short-lived, lasting less than 24 hours. Symptoms caused by colic
occur daily and often last for days or weeks at a time. If your baby gets
symptoms every time you eat a certain type of food, stop eating that particular
item.
Mastitis is an infection of the
breast. It causes swelling, burning, redness, and pain. This
usually occurs
in just one breast and may also cause a nursing mother to feel
feverish and ill. If you have any of these symptoms, let your doctor
know at once so that you can start treatment. Lots of rest, warm
compresses, antibiotics, breast support, and continued breastfeeding
are all that are usually needed.
Mastitis occurs when a milk duct gets blocked and bacteria infect
a portion of the breast. Rest and good nutrition will help you
get back your energy. Also, frequent nursing will help drain your
breasts and prevent the infection from spreading.
You should not stop
breastfeeding while you have mastitis since
the infection will not spread to your milk. It is important to
keep the milk flowing in the infected breast. If it is too painful
to have your baby nurse on the infected breast, open up both sides
of your bra and let the milk flow from that breast onto a towel
or absorbent cloth. This relieves the pressure as you feed the
baby on the opposite side. Pumping the affected side may also be
necessary.
Sore
or cracked nipples. If your baby is not positioned properly
or does not latch-on well when you start breastfeeding, you might
end up with cracked or sore nipples. To prevent cracked nipples,
position the baby better and be sure the baby’s lips and
gums are on the areola and not on the nipple. Also, try to vary
your baby’s position at each feeding. Get help from your
pediatrician or a lactation consultant.
The best treatments
for cracked nipples are dryness, light, and warmth. Do not wear plastic breast shields or plastic-lined nursing
pads that hold in moisture. Instead, gently pat your nipples dry
then apply human milk or medical grade modified lanolin. Wash your
breasts only with water, not soap. Many creams and lotions, which
must be removed before nursing, will not help and may actually
make the problem worse. If these steps do not solve the problem,
consult your doctor for further advice.
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>>BREASTFEEDING & JAUNDICE -
By Jack Newman, MD, FRCPC
Introduction
Jaundice is due to a buildup in the blood of bilirubin, a yellow pigment which comes from the breakdown of old red blood cells. It is normal for red blood cells to break down, but the bilirubin formed does not usually cause jaundice because the liver metabolizes it and gets rid of it into the gut. The newborn baby, however, often becomes jaundiced during the first few days because the liver enzyme which metabolizes bilirubin is relatively immature. Furthermore, newborn babies have more red blood cells than adults, and thus more are breaking down at any one time. If the baby is premature, or stressed from a difficult birth, or the infant of a diabetic mother, or more than the usual number of red blood cells are breaking down (as happens in blood incompatibility), the level of bilirubin in the blood may rise higher than what is usual.
Two Types of Jaundice
The liver changes bilirubin so that it can be eliminated from the body. If, however, the liver is functioning poorly, as occurs during some infections, or the tubes which transport the bilirubin to the gut are blocked, this changed bilirubin may accumulate in the blood and also cause jaundice. When this occurs, the changed bilirubin (called conjugated bilirubin), appears in the urine and turns the urine brown. This brown urine is an important clue that the jaundice is not "ordinary". Jaundice due to conjugated bilirubin is always abnormal, frequently serious and needs to be investigated thoroughly and immediately. Except in the case of a few extremely rare metabolic diseases, breastfeeding can and should continue.
Accumulation of bilirubin before it has been changed by the enzyme of the liver may be normal—"physiologic jaundice". Physiologic jaundice begins on the 2nd or 3rd day, peaks on the 3rd or 4th day and then begins to disappear. However, there may be other conditions which cause an exaggeration of this type of jaundice, such as a more rapid than normal breakdown of red blood cells. Because these conditions have no association with breastfeeding, breastfeeding should continue. If, for example, the baby has severe jaundice due to rapid breakdown of red blood cells, this is not a reason to take the baby off the breast. Breastfeeding should continue.
Breastmilk Jaundice
There is a condition commonly called breastmilk jaundice. No one knows what the cause of breastmilk jaundice is. In order to make this diagnosis, the baby should be at least a week old, though interestingly, many of the babies with breastmilk jaundice also have had physiologic jaundice, sometimes to levels higher than usual. The baby should be gaining well, with breastfeeding alone, having lots of bowel movements, passing plentiful, clear urine and be generally well (handout #4 Is my baby getting enough milk?). In such a setting, the baby has what some call breastmilk jaundice, though, on occasion, infections of the urine or an under functioning of the baby's thyroid gland may cause the same picture. Breastmilk jaundice peaks at 10-21 days, but may last for 2-3 months. Breastmilk jaundice is normal. Rarely, if ever, does breastfeeding need to be discontinued even for a short time. There is not one bit of evidence that this jaundice causes any problem at all for the baby. Breastfeeding should not be discontinued "in order to make a diagnosis". If, however, your doctor feels that discontinuing breastfeeding is appropriate, it would be worth trying a lactation aid with formula (handout #5 Using a Lactation Device) rather than taking the baby off the breast altogether, since this may result in difficulties with breastfeeding afterwards. If the baby is truly doing well on breast only, there is no reason, none, to stop breastfeeding or supplement with a lactation aid, for that matter. The notion that there is something wrong with the baby being jaundiced comes from the assumption that the formula feeding baby is the standard by which we should determine how the breastfed baby should be. This manner of thinking, almost universal amongst health professionals, truly turns logic upside down. Thus, the formula feeding baby is rarely jaundiced after the first week of life, and when he is, there is usually something wrong. Therefore, the baby with breastmilk jaundice is a concern and "something must be done". However, in our experience, most exclusively breastfed babies who are perfectly healthy and gaining weight well are still jaundiced at 5-6 weeks of life and even later. The question, in fact, should be whether it is normal not to be jaundiced and is this absence of jaundice something we should worry about? Do not stop breastfeeding for jaundice.
Not-enough-breastmilk Jaundice
Higher than usual levels of bilirubin or longer than usual jaundice may occur because the baby is not getting enough milk. This may be due to the fact that the mother's milk takes a longer than average time to "come in", or because hospital routines limit breastfeeding or because, most importantly, the baby is poorly latched on and thus not getting the milk which is available (handout #4 Is my baby getting enough milk?). When the baby is getting little milk, bowel movements tend to be scanty and infrequent so that the bilirubin that was in the baby's gut gets reabsorbed into the blood instead of leaving the body with the bowel movements. Obviously, the best way to avoid "not-enough-breastmilk jaundice" is to get breastfeeding started properly (handout #1 Breastfeeding—Starting Out Right). However, the answer to not-enough-breastmilk jaundice, is not to take the baby off the breast or to give bottles. If the baby is nursing well, more frequent feedings may be enough to bring the bilirubin down more quickly, though, in fact, nothing needs be done. If the baby is nursing poorly, helping the baby latch on better may allow him to nurse more effectively and thus receive more milk. Compressing the breast to get more milk into the baby may help (handout #15 Breast Compression). If latching and breast compression alone do not work, a lactation aid would be appropriate to supplement feedings (handout #5 Using a Lactation Aid).
Phototherapy (Bilirubin Lights)
Phototherapy increases the fluid requirements of the baby. If the baby is nursing well, more frequent feeding can usually make up this increased requirement. However, if it is felt that the baby needs more fluids, use a lactation aid to supplement, preferably expressed breastmilk, expressed milk with sugar water or sugar water alone rather than formula.
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Handout #7. Jaundice Revised January 1998
>>BLOCKED DUCTS AND MASTITIS - By Jack Newman, MD, FRCPC
Mastitis is a bacterial infection of the breast which usually occurs in breastfeeding mothers. However, it can occur even in women who are not breastfeeding or pregnant, and can even occur in small babies. Nobody knows exactly why some women get mastitis and others do not. Bacteria may gain access to the breast through a crack or sore in the nipple, but women without sore nipples also get mastitis.
Mastitis needs to be differentiated from a plugged or blocked duct, because the latter does not need to be treated with antibiotics, whereas mastitis often, but not always, does require treatment with antibiotics. A plugged duct presents as a painful, swollen, firm mass in the breast, often with overlying reddening of the skin, similar to mastitis, though not usually as intense. Mastitis, though, is usually associated with fever and more intense pain and redness of the breast. As you can imagine, it is not always easy to differentiate a mild mastitis from a severe blocked duct. A blocked duct can lead to mastitis.
In order to make a diagnosis of mastitis, there must be an area of hardness, pain, redness and swelling in the breast. The absence of such an area in the breast means that the mother does not have mastitis. Flu-like symptoms or fever alone are not enough to make the diagnosis of mastitis. Shooting pains in the breast without an area of hardness are not mastitis. These are more likely caused by a yeast infection and thus should not be treated with antibiotics.
As with almost all breastfeeding problems, a poor latch, and thus, poor draining of the breast sets up the situation where mastitis can occur.
Blocked Ducts
Blocked ducts will almost always resolve spontaneously within 24 to 48 hours after onset. During the time the block is present, the baby may be fussy when nursing on that side, as milk flow may be slower than usual. Blocked ducts can be made to resolve more quickly by:
Continuing breastfeeding on the affected side.
Draining the affected area better. One way of doing this is to position the baby so his chin "points" to the area of hardness. Thus, if the blocked duct is in the outside, lower area of your breast (about 4 o’clock), the football position would be best.
Using breast compression while the baby is feeding (Handout #15 Breast Compression).
Heat on the affected area (hot water bottle) also helps.
The mother trying to rest. (Not always easy, but take the baby into bed with you).
Sometimes a blocked duct is associated with a small blister on the end of the nipple. If you have this, you can open the blister with a sterile needle and squeezing out the toothpaste material in the duct (not always possible). This gives relief of nipple pain and may result in the blocked duct immediately resolving. Come to the clinic if you cannot open the blister yourself.
If a blocked duct has not settled within 48 hours (unusual), therapeutic ultrasound often works. This can be arranged at a neighbourhood physiotherapy office or sports medicine clinic. Many ultrasound therapists are not aware of this use of ultrasound. The dose of ultrasound is:
2 watts/cm2, continuous, for five minutes to the affected area, once daily for up to two doses.
If two treatments on two days do not work, there is no point in continuing with ultrasound. Get the blocked duct evaluated at the clinic or by your physician. Usually, however, if ultrasound is going to work, one treatment does the trick. Ultrasound also seems to prevent recurrent blocked duct which always occurs in the same place. Lecithin, one capsule (1200 mg) three or four times a day also seems to help prevent recurrent blocked ducts, at least for some mothers.
Mastitis: The following is my approach to dealing with mastitis.
If the mother has symptoms for more than 24 hours, she should start antibiotics. If the mother has symptoms for less than 24 hours, I will prescribe an antibiotic, but suggest the mother wait before starting the medicine. If, over the next 8-12 hours, her symptoms are worsening (more pain, spreading of the redness, enlargement of the hardened area), then the mother should start the antibiotics. If, 24 hours later, the mother has not worsened, but not improved, she should start the antibiotics. However, if symptoms are starting to decrease, there is no need to start the antibiotics. The symptoms usually continue to resolve and will have disappeared over the next 2 to 5 days. Fever will usually be gone within 24 hours, the pain within 24-48 hours, the breast hardness within the next couple of day. The redness may remain for a week or longer.
Once improvement begins, on or off antibiotics, it should continue. If you get worse, or symptoms do not continue to improve over 24 or 48 hours, call the clinic.
Remember:
Continue breastfeeding, unless it is just too painful to do so. If you cannot continue breastfeeding, express your milk as best you can in the meantime, and restart breastfeeding as soon as you can. Continuing breastfeeding helps mastitis to resolve more rapidly. There is no danger to the baby.
Heat (hot water bottle) applied to the affected area helps fight off the infection.
Rest helps fight off infection.
Fever helps fight off infection. Treat fever if you feel bad, not just because you have it.
Take acetaminophen, ibuprofen or other medication for pain as you need it. You will feel better and there is no danger to the baby, who gets only a tiny amount.
Note: Amoxycillin, plain penicillin and other antibiotics are often ineffective for mastitis. If you need an antibiotic, you need one which is effective against Staphylococcus aureus. Effective for this bug are: cephalexin, cefaclor, cloxacillin, flucloxacillin, amoxycillin-clavulinic acid, clindamycin and ciprofloxacin. The last two are effective for mothers allergic to penicillin. You can and should continue breastfeeding with all these medications.
Abscess: Abscess occasionally complicates mastitis. You do not have to stop breastfeeding, not even on the affected side. Usually, the abscess needs to be drained surgically, but you should continue breastfeeding. Contact the clinic.
Handout #22 Blocked Ducts and Mastitis. January 1998
BREAST COMPRESSION
by Jack Newman, MD, FRCPC
The purpose of breast compression is to continue the flow of milk to the baby once the baby no longer drinks (open - pause - close type of suck) on his own. Breast compression simulates a letdown reflex and often stimulates a natural letdown reflex to occur. The technique may be useful for:
1. Poor weight gain in the baby
2. Colic in the breastfed baby
3. Frequent feedings and/or long feedings
4. Sore nipples in the mother
5. Recurrent blocked ducts and/or mastitis
6. Encouraging the baby who falls asleep quickly to continue drinking
Breast compression is not necessary if everything is going well. When all is going well, the mother should allow the baby to "finish" feeding on
the first side and, if the baby wants more, should offer the other side. How do you know the baby is finished? When he no longer drinks at the
breast (open - pause - close type of suck).
It may be useful to know that:
1. A baby who is well latched on gets milk more easily than one who is not. A baby who is poorly latched on can get milk only when the flow of milk is rapid. Thus, many mothers and babies do well with breastfeeding in spite of a poor latch, because most mothers produce an abundance of milk.
2. In the first 3-6 weeks of life, babies fall asleep at the breast when the flow of milk is slow, not necessarily when they have had enough to eat. After this age, they may start to pull away at the breast when the flow of milk slows down.
3. Unfortunately many babies are latching on poorly. If the mother’s supply is abundant the baby often does well as far as weight gain is concerned, but the mother may pay a price - sore nipples, a "colicky" baby, a baby who is constantly on the breast (but feeding only a small part of the time).
Breast compression continues the flow of milk once the baby starts falling asleep at the breast and results in the baby:
1. Getting more milk.
2. Getting more milk that is high in fat.
Breast Compression: How to do it
1. Hold the baby with one arm.
2. Hold the breast with the other, thumb on one side of the breast, your other fingers on the other, fairly far back from the nipple.
3. Watch for the baby’s drinking, though there is no need to be obsessive about catching every suck. The baby gets substantial amounts of milk when he is drinking with an open - pause - close type of suck. (open - pause - close is one suck, the pause is not a pause between sucks).
4. When the baby is nibbling or no longer drinking with the open - pause - close type of suck, compress the breast. Not so hard that it hurts and try not to change the shape of the areola (the part of the breast near the baby’s mouth). With the compression, the baby should start drinking again with the open - pause - close type of suck.
5. Keep the pressure up until the baby no longer drinks even with the compression, then release the pressure. Often the baby will stop sucking altogether when the pressure is released, but will start again shortly as milk starts to flow again. If the baby does not stop sucking with the release of pressure, wait a short time before compressing again.
6. The reason to release the pressure is to allow your hand to rest, and to allow milk to start flowing to the baby again. The baby, if he stops sucking when you release the pressure, will start again when he starts to taste milk.
7. When the baby starts sucking again, he may drink (open - pause - close). If not, compress again as above.
8. Continue on the first side until the baby does not drink even with the compression. You should allow the baby to stay on the side for a short time longer, as you may occasionally get another letdown reflex and the baby will start drinking again, on his own. If the baby no longer drinks, however, allow him to come off or take him off the breast.
9. If the baby wants more, offer the other side and repeat the process.
10. You may wish, unless you have sore nipples, to switch sides back and forth in this way several times.
11. Work on improving the baby’s latch.
The above works best, in our experience in the clinic, but if you find a way which works better at keeping the baby sucking with an open - pause - close type of suck, use whatever works best for you and your baby. As long as it does not hurt your breast to compress, and as long as the baby is "drinking" (open - pause - close type of suck), breast compression is working.
You will not always need to do this. As breastfeeding improves, you will able to let things happen naturally.
>>BREASTFEED A TODDLER- by the Jack Newman
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 do it. UNICEF has long encouraged breastfeeding for two years and longer, and the American Academy of Pediatrics is now on record as encouraging mothers to nurse at least one year and as long after as both mother and baby desire. Breastfeeding to 3 and 4 years of age has been common in much of the world until recently, and breastfeeding toddlers is still common in many societies.
Why should breastfeeding continue past six months?
Because mothers and babies often enjoy breastfeeding a lot. Why stop an enjoyable relationship?
But it is said that breastmilk has no value after six months.
Perhaps this is said, but it is wrong. That anyone can say such a thing only shows how ignorant 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 which help protect the baby. In fact, some immune factors in breastmilk which 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 infection. Breastmilk still contains factors which 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 nursing her baby once she is back at her paid work.
It is interesting that formula company marketing pushes the use of formula (a rather imperfect copy of the real thing) for a year, yet implies that breastmilk (from which the imperfect copy is copied) is only worthwhile for 6 months. Too many health professionals have taken up the refrain.
I have heard that the immunologic factors 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 allows the baby to be 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?
Of course, breastfeeding can, in some situations, be used to foster an overdependent 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 nursing a toddler is not the nutritional or immunologic benefits, important as they are. I believe the most important aspect of nursing 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 nursing can testify that there is something almost magical, something special, something far beyond food going on. A nursing toddler will sometimes spontaneously break into laughter for no obvious reason. 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? But 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 nursing babies or toddlers up and down the halls trying, often unsuccessfully, to console them, while the nursing 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.
Handout #21. Toddler nursing. January 1998
BREASTFEEDING & OTHER FOODS - by Jack Newman, MD, FRCPC
Introduction
Breastmilk is the only food your baby needs until at least 4 months of age, and most babies do very well on breastmilk alone for 6 months or more. There is no advantage to adding other sorts of foods or milks to breastmilk before 4 to 6 months, except under unusual or extraordinary 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.
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. A baby cannot get milk efficiently when he is not latched on properly to the breast. When the mother's milk becomes more plentiful, after 3-7 days, the baby may do well even if he is not well latched on. 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 breastfeeding. The baby must latch on well so he can get the mother's milk which is there in sufficient quantity for his needs, as nature intended. If a better latch, and compression (see Breast Compression) do not get the baby breastfeeding, then supplementation, if medically needed, can be given by lactation aid (see Using a 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 works most of the time and no supplements will be needed.
Water
Breastmilk is over 90% water. Babies breastfeeding well do not require extra water, even in summer. If they are not breastfeeding well, they also do not need extra water, but require that the breastfeeding be fixed. Babies do not need extra water even in hot weather.
Vitamin D
It seems that breastmilk does not contain much vitamin D. We must assume this is as nature intended, not a mistake of evolution. The baby stores up vitamin D during the pregnancy and he will remain healthy without vitamin D supplementation, unless you yourself were vitamin D deficient during the pregnancy. Vitamin D deficiency in pregnant women in Canada is rare. Outside exposure also gives your baby vitamin D even in winter, even when the sky is covered. An hour or so of outside exposure during a week gives your baby more than enough vitamin D even if only his face is exposed, even in winter.
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 extra vitamin D would be advised. Vitamin D drops are expensive.
Iron
Breastmilk contains much less iron than formulas, especially the iron enriched formulas. Actually, this seems to give the baby extra protection against infection, as many bacteria require available 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 Starting Solid Foods)
Breastfed babies normally do not require solid foods before 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 6-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 the table 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. However, the 6 month old is far different from the 4 month old. Many 6-month-old babies do not seem to like cereal if it is introduced at this time. Do not push the baby to take it, but offer other foods, and perhaps try again when your baby is a little older. But if he refuses, do not worry he will be missing something. There is nothing magic about cereal, and babies do fine without it. Anyhow, your baby may soon be eating bread. The best way for the baby of getting additional iron is by eating meat.
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 6 month old can be given almost anything off his parents' plate that can be mashed with a fork. 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 What to feed the baby when the mother is working outside the home).
A breastfeeding baby who is older than about 4 months will not likely take a bottle if he has not already gotten used to one. This is no loss or disadvantage. At about 6 months or even younger, the baby can start learning to use a cup, 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, 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 off a spoon when the mother is not with him. 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, but does not know how to use an artificial nipple. He also may not like the taste of formula, which is understandable.
Though there has been a lot of publicity recently about not giving babies cow's milk until at least 9 months, this does not really apply to breastfeeding babies. 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. 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 nursing only a few times a day.
My 4 month old is hungry on breast only. Solids or Formula?
There is no advantage in this situation of giving formula by bottle and there may be some disadvantage. Even at this age a baby may start to prefer the bottle if he seems to not be getting enough from the breast (if, in fact, he will accept a bottle). 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 it in a bottle. If the baby seems hungry after breastfeeding, feed him solids off a spoon. However, it may be possible with simple techniques, to get the baby gaining well and/or to be satisfied with breastfeeding alone. Check with the clinic.
WARNINGS
Lupas: Alfalfa has been known to aggravate
lupus and other auto-immune disorders. Avoid alfalfa is you have
an auto-immune problem.
Pregnancy: Fenugreek
and Blessed Thistle are contraindicated during pregnancy.
Diabetics: Fenugreek may lower blood
sugar levels.
Allergies: If you are allergic to other
members of the Compositae (daisy, ragwort) family of plants,
you may be allergic to Blessed Thistle. and or Chamomile.
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