Am I not producing enough milk?
	Will formula cause allergies later in life?
	What antidepressants are safe for nursing moms?
	Is 3 1/2 months too early to stop breastfeeding?

Am I not producing enough milk?

I am a registered nurse and work three 12-hour shifts rotating each week.  I pump while at work, and usually it seems to be enough to get him through while I am gone.  My problem is when I am home it seems like he never gets enough from me.  When I pump it is only 3-4 oz a session (over 15 minutes) and I pump 2 to 3 times.  Is this all I am producing when he nurses from me, and is this why he seems constantly hungry when I am at home and he is nursing and not getting a bottle from dad?  Sometimes I am so sore after nursing him for what seems like hours, I finally give him a bottle of breastmilk and sometimes formula.  He is eating one meal of cereal, and a fruit and veggie each day.  Please help...this is the longest I have nursed any of my kids and I want to continue for at least one year. I love it.  Oh by the way...the birth weight is a little misleading...he weighed 8 lb even at discharge (4 days later) he had complications APGAR 3 and 8. Nuchal cord X 2 and was an emergency c-section. I didn't nurse until six hours after delivery due to grunting and other respiratory complications.  He was 39 weeks gestation. 

Thanks for any input you may have for me.





Dear Renee,

Congratulations for salvaging breastfeeding against all odds!  A depressed baby, a c-section delivery, delayed initiation of nursing were all hurdles you needed to overcome.  Most likely, you had what we call "delayed lactogenesis," with your milk coming in later than usual.  That must have contributed to Connor's 13.5% weight loss by day four.  Most babies will drop about 8% below birthweight.  If there is a 10% drop in weight, I would certainly be suspicious of breastfeeding problems.  In your case, I am quite amazed and delighted that you were able to eventually produce enough milk to feed Connor.  But having said that, the average baby will have doubled their birthweight by 4.8 months.  Not uncommonly, a mother with delayed lactogenesis may have problems later on producing generous volumes, particularly for a baby who is large for gestational age, such as Connor.   I would respect Connor's cues that he needs more calories that he seems to get from breast alone, but there are some things that you could try to improve your production.

Consider pumping a bit more frequently, maybe even after he nurses on occasion.  Predictably, you won't get much, but this may boost your production.  There are products which might possibly help, although the literature is more anecdotal for the over-the-counter remedies.  I think that it is worth trying fenugreek, and herb you can find at your health food store. Possibly it also would be helpful to try a couple of weeks of Reglan (Metaclopromide) 10 mg 3 times per day to see if this would help.

I would not beat yourself up too much, however, if your production does not respond to these efforts.  You should really pat yourself on the back for succeeding in such a very difficult situation.  Make sure that Connor is getting the calories that he needs, and see if you can make breastfeeding a more comfortable, fun part of your life without volume being the key issue.

One way to know if Connor is getting enough to eat is simply to liberalize his bottle or solid food supplementation.  Babies, if given the chance, will usually consume the number of calories they need. Ask his pediatrician to show you his growth curve and explain to you what normal growth means in Connor's situation.

Will formula cause allergies later in life?

Hi. I have a very desperate question.  I am currently breastfeeding my son. Because of allergies (eczema) I would like to give him breastmilk only until he is 6 months old, but since about 1 month he is becoming more hungry - asking for food about every two hours, also at night.  Needles to say, I am exhausted!  I have asked for help and it was suggested that I pump the milk and try to get him back on feeding every four hours.  Now here is my problem, I pumped milk and only got 50 ml. total out of my breasts, so probably he is really hungry!  So now it was suggested that I give him some formula next to the breastmilk, but I am so worried about doing this!  I am in desperate need of some rest, but I would also want to do what is right for him.  Could giving him some formula cause him to have allergic problems later in life?  Or is it really OK to give him this right now, so we can both get some rest and so that I can get my supply back up?  I hope you can help me!  Thank you.





Dear Sylvia,

I understand your concern and I would take all of the reasonable measures to augment your production.  But, the most important thing is to make sure that Tom is getting the calories that he needs.  If you are concerned about allergies, this might be helpful.  The most allergenic formulas are the cow's protein formulas - namely Enfamil, Similac, and SMA.  One step less allergenic would be the soy-based formulas, such as Isomil, Soyalac, Prosoybe, etc.  Then, still one step less allergenic would be Good Start formula.  Finally, the least allergenic formulas are Nutramigen, Alimentum, and Pregestamil.  These last three are expensive, not easy to find, and smell like wallpaper glue.  Most babies older than three months don't like the taste.  But, you could try.  (Goats milk is not a safe option as it contains too little folate).  Another possibility is to begin low allergenic foods, such as rice cereal.  In Tom's case, I would definitely defer introducing the most allergenic foods until he is 12 months or older.  These would include dairy product such as yogurt, chocolate, peanuts (peanut butter), citrus (including tomatoes), fish (particularly shell fish), egg whites, and berries. The older the baby the more capable he will be of handling large allergenic proteins.  Usually, by one year even babies with parents with allergies will be more likely to handle these allergenic foods without difficulty. But you are absolutely right, eczema can be a sign of intolerance to a food and can be worsened by early introduction of allergenic foods.  Hope this is helpful.

What antidepressants are safe for nursing moms?

I have a mother that has been diagnosed with depression and would like medical treatment.  She is exclusively nursing a healthy baby that is thriving with height and weight at the 95%.  My first response to her question regarding antidepressants and nursing was that Prozac would probably be a good choice. Unfortunately, she was unable to tolerate Prozac in the past.  She would like to try St. Johns' Wort, and I wonder if there is any data available on safety profile for nursing babies whose moms are taking this, or if you recommend any other antidepressants that are safe for nursing mothers to take. I feel that this mother is doing such an excellent job at nursing her baby it would worsen her outlook if she had to stop because she needed to be on an antidepressant. 

Thank you for your time.





Dear Dr. Hasell,

This has been a difficult question for many of us.  I believe that the consensus is now that the benefits of the mother taking Prozac or other like antidepressents, outweigh the potential theoretical risks to the infant and the risk of not breastfeeding at all.

There are a few interesting articles looking at Prozac, which crosses the placenta, and the effect of the neurodevelopment of the offspring preschooler. There was no significant impairment in global IQ scores, language scores, temperament, mood, or behavior problems in the children of mothers who took Fluoxetime (Prozac) during pregnancy compared to mothers who did not (N Eng Jnl Med, 336:258-62, 1997).

For the depressed mother, many times breastfeeding is one of the most important positive experiences of her day.  For her baby, we need to remember the short and long-term benefits of breastfeeding that formula surely does not come close to providing.  I have read that some pharmocologists believe that Zoloft, for theoretical reasons, would be a better choice than Prozac.  But I think we have enough experience over the past several years to know that there at least no major risks to the baby whose mother uses either drug.

I would suggest for more information you call the following resources: Dr. Tom Hale (fax: 806-354-5536); Dr. Ruth Lawrence (phone: 716-275-4354); or Dr. Audrey Naylor at the Wellstart Clinic (phone: 619-295-5192).  You might also read the article on Breastfeeding.com by Dr. Ruth Lawrence that discusses herbal remedies for breastfeeding mothers, including St. John's Wort.

Is 3 1/2 months too early to stop breastfeeding?

Is 3 1/2 months too early to stop breastfeeding my baby.  I wonder if nursing her is going to make any difference if I quit now.





Dear Carol,

From a strictly medical point-of-view, the younger the baby the more important it is for he or she to receive breastmilk. For the premature, the benefits of breastmilk may be even more important than to the term baby. The more immature the baby, the greater the need for the protective features of breastmilk. The American Academy of Pediatrics recommends that for ideal nutrition, the baby be exclusively breastfed for the first six month, and that nursing continue after the introduction of solids up until at least six months.

The ideal age to wean a child is a commonly asked question. Although I consider myself a strong advocate of breastfeeding, I also feel strongly that, even more important than breastfeeding, is having a mother feel privileged and thrilled to take care of her baby.  For some mothers, breastfeeding is not as emotionally rewarding. Frequently, it is difficult for these mothers to feel comfortable expressing their feelings about the without feeling somewhat guilty.  In my own practice, I want my mothers to be able to open their photograph album, look at the pictures of their little one, and be able to feel in their heart of hearts, "Oh wasn't that fun… wasn't it such a lovely experience for me to take care of my baby at that age."  If breastfeeding interferes with that feeling, I think it is a shame.

I don't know why you are considering weaning your baby at this age.  If it is for work reasons, I think it is not difficult finding time to express milk to leave for your child.  I also know that for the working mother, breastfeeding before you leave for work and as soon as you come home can be a wonderful, intimate, and relaxing beginning and end of your workday.  So, I would encourage you to at least try this if you are considering weaning only because of work.

Ideally, weaning is a mutual decision between mother and baby, and most women find their children are quite different.  One seems to enjoy nursing for a longer time than another.  If weaning is a unilateral decision, ideally it is the baby's decision.  In a situation in which the mother unilaterally decides to wean, hopefully she can feel positive about her wonderful contribution to her baby, knowing that she did the best she could.






 

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