The pediatricians, nurse practitioners, and staff at Child and Adolescent Clinic are committed to helping you and your infant succeed as a breastfeeding team. We offer consultations with an Internationally Certified Lactation Consultant routinely. In fact, we believe that each breastfeeding mother should meet with our Lactation Consultant once around the time of the baby's first clinic vist, to help prevent problems before they occur. If you choose to breastfeed your infant, we will be there to help you!
Dr. Sue has had opportunity to answer a few common breastfeeding questions, below.
BREASTFEEDING AND ALLERGIES
Dear Dr. Sue,
My wife is expecting our first baby, and we have a huge amount of allergies and asthma on both sides of the family, including both of us. I read your article about peanut allergy, and she is not having anymore peanut butter sandwiches until the baby gets here! But I would like to know if breastfeeding makes a big difference in allergies (other than food allergies) and asthma.
You are not alone in wondering just how much of a protective role breastfeeding may play in respiratory allergies and asthma; there is much controversy about this subject and a large number of conflicting studies about how much impact it has.
You are also right to be concerned about your child's risk of developing these problems. If both parents are allergic, their child has a 40-60 percent chance of having allergies as well. (If only one parent is allergic the risk drops to 25 to 30 percent, and even if neither parent show signs of allergies there is still a 10-15 percent chance any given child will develop allergies.)
There are several different factors that may contribute to whether a child does develop allergies. The first of these, genetics, you have no control over. The second is early exposure to "antigens," which are substances that the baby's body thinks are foreign invaders that it has to fight off. Some people believe that even early exposure to food antigens may help turn on the baby's immune system in such a way that other allergies are more likely later. We know for certain that exposure to food antigens increases the risk of FOOD allergies, though, and with an allergic family like yours, that is reason enough to give the baby nothing but breast milk for her first four to six months.
Early exposure to indoor antigens, like dog or cat dander, dust mites, and mold can make your child more likely to show signs of allergies. I would definitely take some preventative steps in this regard. If you have a dog or cat, try to make it an outdoor pet if it can't find a new home. Get a dehumidifier and use it. Get rid of dust catchers like heavy curtains and buy a good vacuum cleaner with a filtration system designed to remove allergens. Use wood or vinyl flooring in the baby's room with washable throw rugs. Remember to wash his bedding once a week, and once he is out of a crib, buy a good mattress cover that zips around his entire mattress.
Early exposure to irritants such as cigarette smoke are well-proven to increase the risk of asthma. Don't do it!
Early respiratory infections probably play a role in the development of asthma, as well. Breastfeeding has definitely been proven to decrease the number and severity of these infections, another reason it should be a priority.
Whether breastfeeding prevents allergies and asthma in other ways as well is still open to debate. I will list some opinions for you, all based on recent, large and apparently well-designed studies:
- Breastfeeding for just the first month of life protects against food allergies, while breastfeeding for more than six months also decreases the risk of eczema and asthma. This may be because breasfeeding stimulates the maturation of the infant's intestinal wall and of the immune system. Also IgE (the antibody most involved in allergic responses) has been found to be suppressed by IgE suppressor factors in colostrum.
- Breastfeeding does not protect against asthma and eczema (35,000 Austrian children studied). This same survey DID show that breastfed children were less likely to develop hay fever. (Year 2000 study).
- Breastfeeding exclusively can significantly protect babies from developing asthma and allergies (2187 Australian children). In this study, children who received only breast milk in their first four months were 25% less likely to be diagnosed as asthmatic by age six. (Year 2000 study).
- Breastfeeding is protective against food allergies and respiratory allergies, even up to 17 years of age. Six months of breastfeeding exclusively also prevents eczema during a child's first three years. (Finland study, 1995).
- Children with allergies who were breastfed by mothers with asthma are MORE likely to develop asthma themselves, but they are protected during their first two years of life. (This one, done by the University of Arizona Respiratory Services Center in 2001, surprised the researchers. All of their previous research has consistently demonstrated the health benefits of breastfeeding.)
So the bottom line is this. Exclusive breastfeeding may provide a longer allergy/asthma-free period in your child's life. There is no definite proof that it will make her less likely to develop these problems later, but it might! It will definitely decrease her likelihood of developing food allergies (if your wife continues to stay away from risky foods like peanuts; and I would advise no cow's milk, also). Breastfeeding will definitely decrease your child's risk of respiratory and other infections. All this, plus:
- Beneficial effects on brain growth and development
- Protection against peptic ulcer disease, even into adulthood
- Protection against certain childhood cancers, and even breast cancer in adulthood, if your child is a girl
- Fewer inguinal hernias
- Better jaw development (fewer need braces)
- Better speech development (fewer need speech therapy)
- Earlier development of good binocular vision (using both eyes together)
- More rapid development of good hand-eye coordination
- Decreased susceptibility to certain immune-type diseases, including Juvenile Diabetes, Juvenile Rheumatoid Arthritis and Multiple Sclerosis
- An improved response to childhood vaccines
- A significantly lower rate of SIDS
- Breastfeeding is the most economical and the most environmentally friendly form of nutrition.
BREASTFEEDING AND ARTIFICIAL SWEETENERS, COLD AND ALLERGY MEDS
Dear Dr. Sue
I’m a breastfeeding mom, and I have wondered very often about whether certain things are OK with breastfeeding. Is it safe for my baby for me to drink diet drinks or have tea or coffee sweetened with Equal or with Splenda? Can I use cold medications when I have a cold? Can I take Tylenol or ibuprofen when I have a headache, and which of the two is the better choice with breastfeeding? I also have spring-time allergies, and have usually used Claritin, but have been afraid to use it while nursing.
To answer your questions, I used my favorite reference regarding breastfeeding and maternal medications. This excellent book is Medications and Mother’s Milk, Twelfth Edition, by Thomas W. Hale, R.Ph., Ph.D. Other sources are often less than helpful, as few drug trials have been done using infants and breastfeeding moms. Dr. Hale has compiled information from various published sources regarding medications and nursing mothers (and during pregnancy as well), and has categorized each substance according to expected risk level. I’ll review what he says about the substances you asked about in your letter.
1. Aspartame (Equal). The levels that end up in breastmilk are too low to produce any significant side effects in normal babies. However, babies with a disorder called phenylketonuria must not be exposed to aspartame in their mother’s milk, because one of its breakdown byproducts is the substance which they cannot tolerate. (Remember the “PKU test” your baby had as a newborn? This is one of the disorders that panel tests for.) Dr. Hale assigns aspartame the lowest risk category, L1, meaning that it has been used by many breastfeeding women with no observed bad effects on the baby.
2. Sucralose (Splenda). Even Dr Hale, who is always the most up to date source for new substances and mother’s milk, has no information on this substance. Its manufacturer states that it is safe to use during breastfeeding, and very little is actually absorbed into the mother’s bloodstream, so this is likely to be true. No studies have been done looking at concentrations in human milk, however.
3. Saccharine. Saccharine, which has recently come back on the market due to re-evaluation of its safety, is assigned the risk category L3, or moderately safe. There was one small study that suggested the saccharin levels could accumulate in breastmilk over time, though still only reaching very small levels. It is believed that moderate use during breastfeeding is safe.
Cold medications are often combination medications, containing substances directed at helping with cough, stuffy nose and runny nose, sometimes even with a pain or fever controller added. I don’t recommend cold medications because I don’t believe that they work, and I am especially reluctant to expose an infant to medications that don’t have a clear benefit. I will give you Dr. Hale’s risk assessment for several of the medications most likely to be used for cold symptoms, though, in case you decide to use them. I would certainly stick with single ingredient medications and just target the symptoms that bother you the most, if you must use them.
4. Pseudoephedrine. Pseudoephedrine is a decongestant (sold as Sudafed and many other names). In addition to it use for cold symptoms, pseudoephedrine is sometimes taken on a more regular basis for congestion associated with allergies. This medication received an L3 rating for occasional use, as with a cold. Regular use of pseudoephedrine while breastfeeding was felt to be less safe (L4). There was one case of irritability of the breastfeeding infant published in the literature. There were also reports of decreased milk production in some mothers who used this medication more regularly. (A rating of L4 means that there is evidence of some risk to the baby or some risk to milk production but the medication may be considered if the benefits outweigh the risks, “if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective.” Allergies can’t be said to fall into either category!)
5. Brompheniramine. Brompheniramine is one of the more common antihistamines found in cold preparations (including Dimetapp, Bromfed). It appears that only a small amount of brompheniramine ends up in breastmilk, but there have still been cases reported of significant irritability, increased crying and decreased sleep in breastfed infants whose mothers were taking this medication. This medication also received an L3 rating.
6. Dextromethorphan. Dextromethorphan is the safest of the available cough suppressants, according to Dr. Hale. Although no studies have been done regarding how much of it passes from the bloodstream to a mother’s milk, it received an L1 rating for safety during breastfeeding.
7. Diphenhydramine. Diphenhydramine is sold as Benadryl. This is one of the sedating antihistamines than many people still keep in the house to use for allergy symptoms. Because it is known to pass into the brain to cause drowsiness, it is preferred that nursing mothers avoid it and choose a non-sedating antihistamine like the one that you say you are using. It received an L2 rating.
8.Loratadine. Loratadine is another antihistamine, which is very useful for allergy symptoms. It is sold as Claritin, Alavert and other brands. Loratadine received an L1 rating. Only a very small proportion of the mother’s dose appears to end up in breastmilk, and there have been no reported concerns in breastfed infants. If you are prescribed certain other medications, including some antibiotics and an antifungal, your blood level of loratadine may increase, and so would the level in your milk. Ask your doctor or pharmacist whether you should hold off on the loratadine until you finish the second prescription.
9. Acetaminophen. Acetaminophen is sold as Tylenol and many generics. Only very small amounts end up in your milk, and those amounts are felt to be very safe. The baby would receive far less than a normal dose you would give her directly. (L1)
10. Ibuprofen. Ibuprofen is sold as Advil, Motrin and many generics. Only very tiny (often unmeasurably tiny) amounts are found in mother’s milk. This is felt to be a very safe medication for breastfeeding mothers to use for pain or fever. (L1)
The best advice I can give regarding medications or food additives like artificial sweeteners during breastfeeding is to avoid them when possible. When avoidance is not possible, or not practical, take substances that have a long history of use rather than newer compounds, take the smallest and most infrequent doses that are effective, and take them for as brief a period as possible. If you are taking (or considering) an herbal or other alternative medicine while breastfeeding, ask your pediatrician about its possible effects on your baby first.
BREASTFEEDING AND WEANING
Dear Dr. Sue,
I've been breastfeeding my baby for 10 months now, and I'm trying to go for a full year. Since she's getting close to that, I need to know how to wean her when the time comes. I don't have any idea how to start.
Dear Breastfeeding Mom,
There are several different ways to wean, some that are easy and some that can be painful for both you and the baby, so I'm glad you asked first. Some people decide to wean and just refuse to nurse from that time forward. This is the painful method! The baby is confused and may feel rejected, and mother has painfully engorged breasts that can more easily become infected. The abrupt hormonal changes, as well as the distress your baby is going through, can also leave you feeling sad and depressed. Don't wean this way unless an emergency makes it unavoidable.
Another option is to wean only partially, gradually eliminating most nursing sessions but continuing to nurse once or twice a day as long as baby shows any interest. This is a very viable option, but one that few American mothers are interested in continuing for many months beyond a year of age. Closely related to this method is the natural wean, which means letting the baby decide when he is done nursing. The mother is still involved in helping to direct her baby toward independence, however, by offering a cup, offering other foods or interesting activities in place of nursing, or asking the baby to wait longer periods from when he first shows interest in nursing to when he actually does. (Some children will continue to nurse until four or five years of age if this method is chosen.)
When the goal is actually to move from breastfeeding to not-breastfeeding within a more limited time frame, the best method for both mother and baby is gradual weaning. Choose the feeding that your baby is least interested in to eliminate first. Offer milk (if your baby is a year old) or formula (if less than a year) in a cup at this time, as well as finger foods. Plan to spend lots of time nurturing your baby in other ways during this period, by reading to him, rocking, or playing on the floor with your attention fully on him; this way you will be changing only the manner of feeding, not the degree of closeness your baby has gotten used to. When the baby and your breasts have both adapted to this change, choose the remaining feeding that he is least interested in to replace. Continue in this way until all feedings are replaced, leaving several days to a couple of weeks between each change.
The feedings that your baby will resist giving up the most are usually the last feeding before bed and the first one on awakening. You can continue those feedings indefinitely, or substitute other methods of being intensely close to your baby at these times. A bedtime ritual, including reading books, rocking, soft music, low lights, and a certain soft toy to snuggle will help to ease the loss of the bedtime nursing session.
Remember that as you are decreasing the number of times you breastfeed you are also taking away your child's most important source of excellent nutrition. If you have not started feeding meat products to your baby, please start them at this time. Other foods including fruits, vegetables and cereals are important, but may not replace the protein, zinc, iron and B vitamins that your baby was getting from nursing. If you give her formula because she is less than a year old, these nutrients will be supplied, but after a year of age cow's milk from a cup (not a bottle) is appropriate. If you feel your baby does not get enough fluids, offer water frequently from a cup. She can also be offered up to six ounces of juice per day, but more than this may interfere with her appetite for other foods, in addition to being harmful to her teeth.