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Let's talk about infant feeding decisions.
Let's start with an overview of lactation
and the requirements in terms of nutrition
and some benefits and some prohibitions.
So in order for lactation to be as successful as it possibly
can, one of the considerations is nutrition.
We want people to maintain a really good diet
and also to continue taking prenatal vitamins.
The average woman produces about 25 ounces of milk per day.
Now, this is going to vary fairly widely depending
on the needs of the infant.
And maybe they are twins.
In that case, she's going to be producing a lot more milk.
So it's a supply-and-demand operation here.
We also know that it's contingent to some extent
on the woman's hydration status, but it
isn't a direct correlation between how much fluid
she takes on board or the type of fluid and the amount of milk
produced.
The recommendation we have is about 13 cups
of fluid each day.
The average recommendation for a non-lactating woman
is eight to nine cups so we see that there's an increase there.
So we're trying to make sure that women
maintain good hydration status.
It's going to prevent headaches and feeling
logey and all those things that happen
when we're a little dehydrated.
In terms of the energy required for nursing,
sometimes maybe you've talked to someone who's had a baby
and they said, oh I nursed the baby
and I lost the weight very, very quickly.
And some women do experience that.
And the reason is that it's about 500 calories a day that's
used during lactation.
So if you want to get back to pre-pregnancy weight
this can be a really helpful mechanism.
Now, that doesn't mean that we want
her to consume 500 calories.
What we're going to do here is that we're
going to use some of the maternal fat stores
and that varies a little bit, maybe 170 calories, maybe 200,
depends.
And then the rest is going to come from extra food
that she's consuming.
And again, that's not ice cream and chocolate chip cookies.
That's more of the good, healthy foods that she's normally
consuming as part of her diet.
OK, so keep in mind the amount of energy
needed for breast milk and lactation.
When the mother's diet maybe isn't optimal.
And you can think about women who maybe are nursing children,
but they've resided in developing countries
so they don't have access to adequate food or even people
who live in a food desert who don't have access
to fresh fruits and vegetables and things like this.
They say, well, what happens to the quality of that milk?
The answer to that question is actually fairly simple.
What we see happening is that there's
a fluctuation in the quantity, but not
the quality of the milk.
And this goes counter to what we might assume here.
So she's going to have adequate nutritious milk, but maybe not
as much of it as you normally would
have to meet the demands of the infant.
So this is where supplementation with formula
can sometimes be an important mechanism
to make sure that the infant is getting enough calories.
There are all kinds of benefits to breastfeeding.
And we see them for not only the infant,
but also for mother and for society in general.
So if we look at the benefits that we see from infants,
you can look at this chart in the book.
It's the right balance of nutrients, the right type
of macronutrients and the right amount.
It's actually really protective against allergies,
boosts immunity.
It creates stronger muscles in the mouth
because if you think about a baby bottle, you turn it up
and it just leaks.
Well, you can turn a woman upside down
and she's not going to leak.
It actually takes quite a bit of muscle strength for babies.
It's also good for dental health.
Babies who are breast fed are smarter, they have higher IQs.
You can reduce risk of chronic disease.
You can reduce risk of obesity, and it goes on and on and on.
So there are lots of benefits.
And then, well, what's in it for mom?
We know that it's going to help her uterus get back
to its normal pre-pregnancy size and shape.
It delays the return of regular ovulation.
And now, it is completely possible to get pregnant
while you're breastfeeding, but we actually
see that women don't get their period on a normal basis
as quickly as if they were bottle feeding or not
breastfeeding.
So we want to be kind of careful about that.
Also, conserves iron stores.
And this, again, is very, very important for women
because we know that they're at risk for low-iron intake,
and it can be protective against breast cancer and ovarian
cancer.
Now, what this slide doesn't tell
you is that it also is important for that bond between mother
and baby, and that can be really critical
in those first couple of days and weeks.
We want them to have this good strong bond.
And it doesn't tell also about weight loss.
So there are plenty of things here.
It also can provide some confidence for moms,
especially if they're unsure of this new role they've just
taken on.
But I've also talked to women who say the opposite is true.
That if they couldn't establish breastfeeding it
was really, really *** them psychologically.
So one quick thing I'll say there
is that breastfeeding is an art.
You would think because women have ***
they know how to do this and it's simple
and it's easy to establish.
That's not really true for most women.
It takes work.
Not for everyone.
Some people it's no big deal and they just
get this established and it's fine, but for a lot of women,
a lactation consultant or a patient doctor, midwife,
or an experienced other mom can be
really helpful in getting this started and feeling confident.
Some other things in terms of society,
lower medical costs because these kids
tend to have fewer sick days.
They tend to be healthier in general, better immune
function, better immune system.
Also, if you think about formula,
I always think about all the garbage from that.
And also the fact that I would have to heat up that formula,
I would have to sterilize bottles.
If you're breastfeeding there's nothing to sterilize really.
It's very, very simple.
It's an on-demand thing.
I don't have to carry a baby bag with all these cans of formula.
It's just right there when the kid needs it.
So there are a lot of savings to society as well.
Now, there are reasons why we wouldn't want people
to breastfeed, and I want to talk about these as well.
And I'll just talk about them very quickly
because I think they'll make a lot of sense to you.
When people are using alcohol, that alcohol
is going to peak in the breast milk about one hour after.
And this is somewhat controversial.
You'll hear midwives talk about having a glass of beer
or a little bit of wine or something to help mom relax,
and there's some evidence that that can be helpful.
There's also some evidence that maybe we
shouldn't be doing that.
So I think it's somewhat a personal choice.
But one thing that women can do if they
want to have maybe two glasses of wine or whatever's happening
is pump and dump so that they're actually getting rid
of that milk that might have the highest
concentration of alcohol in it because the alcohol will
go on to the baby through the breast milk.
We also want to look at cigarette smoking.
And we know that there is a relationship between cigarette
smoking and the amount of milk being produced.
There are some conflicts, I would say, here about
whether or not women should be breastfeeding
when they're smoking.
And you'll talk to some physicians who
advocate that women not breastfeed,
but then you'll also talk to others that say it's OK.
One of the things we absolutely do not want women doing
is smoking over the infant.
And again, this might be a head scratcher.
Why would I even have to bring this up,
but you will see women sometimes or talk
to women who are actually smoking
a cigarette while they're breastfeeding.
Or even if they leave the house and they go outside to smoke
and they come back in and then breastfeed,
they can have that cigarette smoke
residue on their clothing, and this environmental smoke
exposure.
And again, infant's lungs are so tender
we just don't want them exposed to this.
There are so many risks when there's smoking in the house
and there's a newborn or anyone living
in the house for that matter.
I also want to talk about a couple of other effects
from cigarette smoking on children and infants
in particular.
And there are a whole host of potential problems here.
So poor growth, hearing impairment,
also gastrointestinal problems, breathing difficulties,
unexplained death.
So when we look at something like sudden infant death
syndrome, SIDS, this is what we're talking about.
And we know that there's a relationship between smoking
in the home and SIDS.
Again, this is something that we may be able to avoid.
Caffeine.
Now, this one's a little bit controversial.
Again, there are purists who say when you're breastfeeding
absolutely no alcohol ever and no caffeine.
That's kind of a personal call.
There is no set safe amount or unsafe amount.
We do know that the effects that you experience when you're
having some caffeine are the same kinds of effects
that the infant will be experiencing.
So jittery.
I can't imagine a jittery little infant,
but I do know that they can be sleepless,
and there's nothing worse than a crying, sleepless baby.
So you want to make sure that timing is really appropriate.
And again, moderate consumption should not really be a problem.
Outside of moderation that would really
necessitate a conversation with a pediatrician and the OB/GYN
potentially.
There are some medications that are considered safe
during pregnancy and lactation, and there
are some that are not.
One common medication that women might be on
are oral contraceptives, so birth control pills.
So they wonder how this is going to affect lactation.
And we do know that there is a little bit
of a decrease in milk production.
And then there are a couple of other things.
And women who are taking these medications
tend to shorten the duration of breastfeeding.
So maybe they had intended to breastfeed
for the first year of life and then
maybe they do a little bit less.
And our goal, really, for all women
is to initiate breastfeeding at least, and then to try and get
most women to six months, and after that
to get them to at least a year.
There's a lot of people who could breastfeed, but maybe
need a little bit more information
or need the confidence to try this.
And again, breast milk is considered
the best choice for infant feeding.
Bottled formulas and things like that are also nutritive,
but they don't confer some of the advantages
that we've already talked about.
We also have concerns about environmental contaminants.
And here I'm talking about polluted water potentially
and other kinds of things that mothers
might be eating that then would get passed on to the infant.
So it could be a lot of fish in the diet that contains mercury,
other kinds of heavy metals.
It could be really anything that's
unsafe in the environment.
So *** contamination, anything found
in the water at really high levels is considered unsafe.
So when we look at formula, we want
to be very careful the water we're
using to reconstitute that formula.
In the developing world, this can be a huge problem
because clean water is often not available.
About 2/3 of the world population
does not have access to clean water.
So when you put it in those particular statistics,
you understand some of the barriers
that people are facing in other areas of the world.
With maternal illness, most short-term illnesses
don't cause a problem in terms of breastfeeding, a common cold
or something like that.
And usually, that infant because of all the immunity
that they're getting from mom is really
going to have decreased susceptibility
and so they're going to stay healthy.
But there are concerns with some illnesses.
So *** is one that we'd be very concerned about.
This can be transmitted vertically
during pregnancy and during the birth process because
of the exchange of blood.
So there are antiretrovirals that
are given in that situation, and then also C-sections
are very often encouraged.
In terms of breastfeeding, that ***, the virus,
actually is in breast milk, and so there
is transmission concern.
So it's best off that that infant born
to an ***-positive mom be put on formulas of some kind.
Now, formula is an acceptable alternative.
If our goal is to feed infants, we're
certainly going to be able to do that with formula.
And it's for all those reasons that we talked about.
Maybe mom's on a certain kind of medication
that isn't appropriate for lactation
or all kinds of other things that happen.
Maybe she's had a C-section and by the time she recovered,
the baby had already been given a bottle.
It can be very, very difficult to establish breastfeeding
sometimes if the baby has already
been given bottled formula.
So they get very confused sometimes
these little critters.
So formula is a great option for some moms.
And there are some caveats here we want to talk about.
So when you go to buy formula, if the physician has not
discuss this with you, you need to bring it up with the doctor.
I strongly encourage that.
Low-iron formulas should not be purchased.
We want to make sure that we're getting formulas that
contain iron unless we're directed by a physician not to.
Most standard formulas available are
perfectly fine for most infants.
There are some children, some infants,
that actually need a different kind of formula.
So they may need a hypoallergenic
or an elemental formula or they might need a soy-based formula
or a not soy-based formula.
It gets a little tricky.
That conversation is one that you have with the pediatrician
because there are all kinds of allergies that can develop.
We know that we don't want infants put on cow's milk.
Cow's milk under the age of six months
or even under the age of a year can be particularly disastrous.
It can actually be a wrong kind of food for that really
tender, immature gut of the infant.
So again, we don't want foods given
to the infant early or cow's milk.
Now, one of the advantages here for bottle feeding-- and we
could certainly express breast milk and put it in a bottle
and get the same advantage-- is that other family members
can take part.
And who doesn't want to feed the baby, right?
That's really fun.
So the husband or the father can get involved, the partner,
anyone can get involved at that point.
And that can be particularly gratifying,
especially if somebody's feeling a little left out.
Now, the first foods.
Now, I often think about-- this is
my take on it-- the first food should
be the formula or the breast milk.
But very often what we're talking about here
are solid foods.
So there's a lot of recent information, a new study I just
looked at, talking about how people are feed
their infants real food too early.
Pediatricians may be recommending it
before it's appropriate or parents are just
excited to see what the child thinks of food
and start giving them inappropriate foods early.
So really not before six months.
We want that baby to be on formula
or to be on breast milk.
So there are indications that the infant might
be ready to have something more than the milk.
So they can swallow foods, that they can also move foods around
in their mouth, and that they can really control their head.
So if you've been around an infant,
they have this big, floppy neck, right?
And one of the developmental stages
is actually to be able to sit up and to be
able to hold up your head.
For most, like I said, it's around six months
where we're seeing these indications that the infant is
ready for more food, more diversity in their diet.
So in terms of feeding skills, you
can look at this chart from the book.
We have the age in months here.
And then we have all of the different kinds
of skills that are going to be important.
And as this infant ages and becomes
a little bit older, six months, nine months,
they're going to be able to learn and do
all kinds of new things.
They're going to be able to use their fingers to pick up
Cheerios or peas or whatever it is you put on the tray.
They're going to be able to use a cup.
And now, we really want to get infants using a cup
and get them away from that baby bottle.
This can be a crutch sometimes and parents will say,
oh, I don't want them to spill or whatever.
Hey, that's part of parenting.
There are going to be spills.
There are going to be messy things.
Sippy cups are OK, but again, you
want to be careful about how you use this.
Talk to the pediatrician, Google it,
look for some more information.
See what's appropriate for you and your child
and your parenting style.
So as we go-- the child is going to be able to use a spoon,
but some spills are still going to happen.
So again, this is a messy thing.
You want to be very careful about how you're introducing
foods and the type that you use first.
So one quick comment about iron again.
I've told you that we want it to be iron-fortified formulas,
but we also want to look for cereals
that are fortified with iron.
So if you are interested in making your own baby food--
and a lot of moms are interested in this or dads--
just take this into consideration
that it might be something to examine a little more fully.
Most of the infant cereals, dedicated infant cereals,
like rice and things like this, are iron fortified.
Their needs for iron are really very, very high at this age,
and we want to make sure there's adequate supply in the diet.
In breast milk, it's a completely appropriate amount
of iron.
And we actually see that as breastfeeding continues,
if it goes on past a year, maybe into a year and a half, two
years, we may need to encourage iron in the woman's diet.
But really for the vast majority of women,
they have plenty of iron, especially if they're
continuing to take that prenatal vitamin.
We also want to make sure that that infant is getting
enough vitamin C. So with those fruits and vegetables
that we're providing, whether it's
strained peas or some applesauce or something like this,
we're going to be getting that vitamin C. A lot of foods
are also fortified.
And vitamin C, believe it or not,
is actually in0 pretty good supply in breast milk.
It's completely appropriate.
Formulas are also appropriate.
Cow's milk is not.
Cow's milk contains virtually no vitamin C. So again,
that's a reason we want to be very cautious about that.
So there are some recommended intakes for juice.
Be very, very aware of juice.
We tend to give our children way too much of it.
We tend to consume way too much of it as adults.
So four to six ounces a day is really the upper limit.
Now, there's nothing saying you can't water that down
and I actually really encourage it.
So if you have a really thirsty little tyke at home,
there's no problem with reducing it by half
and filling the rest of the cup with water.
That's actually considered a pretty good idea.
And we want to look at some choking hazards
because this is really a significant danger
for little babies because they can't move things
around their mouth and their swallowing
isn't completely developed.
And there are foods that we want to be just very, very
aware of when we put them in front of a child.
So carrots diced in very, very small pieces.
And they can still pick them up with their fingers.
It's still going to improve those fine motor skills.
Cherries.
Anything that's round and can block that airway.
And we have a story in my household
about the time my husband gave my daughter an olive.
If a child chokes, even if they bring that food up,
it can be very, very important to get them
in front of the pediatrician.
You want to treat this with a lot of seriousness.
Things like grapes, you want to cut them.
Even things that are squishy, like a marshmallow.
That can also block that airway because it's really sticky.
Popcorn.
There are all kinds of other things.
So food is one thing.
And then keep all those little objects away because children,
really at this age, explore the world with their mouth.
And you see this.
They're putting everything in their mouth,
including Barbie shoes.
I've been there personally where my young daughter joked
on a Barbie shoe.
So coins, pen tops, all of these little things here.
Anything that's small, we want to make sure
that that child doesn't have access to it because they're
going to put it into their mouth.
I mentioned earlier that one of the advantages of breastfeeding
was around oral development.
So strong teeth, strong muscles in the mouth.
I want to look at a few problems that sometimes come up
around dental health.
And we have something called baby bottle rot
that we want to look at.
One of the concerns about juice-- and I
had mentioned our recommendation is four to six ounces a day--
and it could be none.
You could choose to give the child none
and that would be completely fine.
We want to make sure that that juice is served in a cup
and not in a baby bottle, and not before six months.
So we have a lot of rules right there,
but we know that if a child, for instance, is put down in a crib
or to sleep with some kind of a sugary beverage--
it could be juice and it could be milk
even-- that is going to sit in their mouth
and it potentially rots their teeth.
So you can see in this example, I mean, this poor kid's teeth.
These are deciduous teeth, they're baby teeth
so they're not the permanent ones,
but it still can cause a tremendous amount of pain
for that little guy or girl.
And about five or six when they start actually
getting in their permanent teeth you
can even see where that bottle rot has been so extensive
that it goes up into the permanent teeth.
So again, we really want to be careful about this.
If you need to put the baby down with a bottle
because a lot of babies like to self-soothe with a bottle,
I would consider putting a bottle with just water in it
in the crib if you're going to.
Or if you want to give it to the baby in a car seat
or something like that.
Just water in the bottle is a fine choice.
Let's talk about food allergies.
This is a big issue right now.
It seems like you can't throw a stone without talking
to someone who has a problem with peanuts or eggs or soy
or wheat or whatever it is.
One of the advantages, again, of breastfeeding
is lower incidence of food allergies
and also allergies in general.
Whether it's hay fever or any other kind of allergy.
So when we look at how we introduce foods
they need to be one at a time.
So you're going to introduce that food.
You're going to wait a few days and see how the baby reacts.
Because if I were to introduce five new foods and the baby
reacts, I don't know which one is causing the problem.
So you want to be very, very careful about this.
You also want to be very, very careful
about the foods you're introducing
at a particular time.
So I put down a few foods that tend to be problematic.
And wheat is one of them.
You want to introduce that one last when the baby's gut is
a little bit more mature, a little bit older.
Because this, again, can be a somewhat common problem
in our population.
Also, egg whites and soy products I've mentioned that.
Cow's milk.
That's one that we see as well, fairly common.
And then citrus fruit.
You want to keep that until much later.
Also, strawberries.
That's another one that we see people sometimes
introducing early and save that one for a little bit later.
It's fine.
Now, again, one of the things that I mentioned
is you want to introduce those new foods one at a time.
You very often won't see symptoms of a food allergy
until about five days after the child
has been exposed to the food.
You can wait a couple of months and then introduce that food
again because people's body as they age-- and here we're
talking about little guys-- their body
is changing pretty rapidly.
So just because they've had a reaction
doesn't mean that they will in the future.
But you want to wait a little bit of time,
but I would also say there's a caveat there, a real caution.
If you're introducing a food that you yourself
have an allergy to or someone in your family
and you see a reaction, I think I would probably
talk to the pediatrician before I reintroduce that food,
especially if it's a high-allergen food,
such as some kind of a nut-exposed food or the wheat
or soy or one of these other ones we've already
talked about.
A lot of these sensitivities will disappear over time,
but there are some that are going to be lifelong
and we want to be really cautious about that.
And we also want to be able to recognize an allergic reaction.
Like one of the really common ones
that you might see for a milk sensitivity
is a rash around the elbows and then behind the knees.
And so that's a telltale milk response or milk allergy.
So you could talk to your pediatrician about this.
I would, actually, keep a little diary
of the food that's administered, how much I
gave, and then any reaction.
And I know busy moms don't have time to do these things,
but if there is a reaction you're
going to be able to provide a really nice bit of information
to the pediatrician.
So after one year, really we see some dramatic changes
in infant nutrition.
So that infant can go to whole milk.
Now, we don't want low-fat or fat-free milk.
Whole milk is completely appropriate for that infant.
And they need to have that little bit of fat.
It's completely fine and it's OK that it's saturated fat.
Now, if the child is not going on cow's milk,
goat's milk would be a good choice
or some kind of a soy formula.
Again, if you have some dairy issues
or you're raising the child as a vegan,
those might be conversations to have with the pediatrician.
So we have some recommendations about the amount of milk
that we want infants to have.
And then also a variety of other foods,
which are going to meet macronutrient, micronutrient,
and energy needs.
So you see all of those here.
Again, we want them to be in forms
that are easily eaten by children.
I'm not going to give my one-year-old a whole corn
on the cob, but also allow children to explore things.
And again, they're going to do that orally, which is great.
I think that's one of the most fun
parts of going through that one-year status with kids.
One of the things I just want to stress
is that when you have nutrition issues if you're
feeding an infant or someone in your family is,
talking to the pediatrician can be really, really important.
There's a lot of information available on the internet
and I wouldn't believe even half, probably not even
a tenth of it.
Facebook, iVillage, all of these non-medical sites,
it's probably not your first line of defense.
Get a good reference book, show it to the pediatrician,
say what do you think, get a yea or nay on it,
and then go from there.