Mom and Baby Articles

Infant Potty Training

2007-11-23T21:18:00.000+07:00

by Laurie Boucke

Infant potty training is about a gentle, natural and loving method of communication and toilet learning. In most societies where Attachment Parenting has been practiced for centuries, this method of infant toileting is used. Because of this, I consider it to be another element of AP and refer to it as the sixth Baby B - after Dr. Sears' 5 Baby B's:

Breastfeeding (Sears)
Bonding (Sears)
Babywearing (Sears)
Bed-sharing (Sears)
Belief in Baby’s Cries (Sears)
Bladder/Bowel Communication & Learning (Boucke)

In many parts of Asia and Africa, mothers start pottying babies around 1-3 months old and finish before their babies walk. At that time, babies still need some assistance since they can't dress or walk. Mothers read and respond to their baby's signals - such as elimination body language, timing, patterns (in relation to feeding and waking) and vocalizations - and in this way, their babies stay clean and dry. Many mothers also rely on intuition. The reason this is possible is that there is a window of learning (sensitive period) open from birth until the age of 5-6 months.

On the medical front, recent European research has found that the current Western views on bladder and bowel control are flawed and that it is often better to start earlier than to delay. Unfortunately, the Western world has been indoctrinated to reject any form of early toilet learning. Even when our own parents or grandparents tell us that they had all of their children potty trained by 12-18 months, we assume they are mistaken. Our doubts stem from "medlore" - maturational readiness theories which are based on opinion and commercialism rather than scientific proof. By changing our attitude from skepticism to recognizing our babies' amazing abilities, we open new doors.

I refer to this method as "infant potty training" (IPT) or "infant pottying." Other terms include "elimination communication," "trickle treat" (the title of my first book on this topic, now out of print) and "natural infant hygiene."

A normal, healthy infant is aware of the bodily function of elimination and can learn to respond to it from infancy. By using diapers, we condition and thereby train baby to go in them. Later the child must unlearn this training. This can be confusing and a traumatic experience for the child.

An infant does his best to communicate his awareness to you, but if you don't listen, he will stop communicating and gradually lose touch with the elimination functions. He will be conditioned not to care and learn that you want him to use his diaper as a toilet.

One of the most common questions I'm asked is, "Is it too late to start if my baby is older than 5-6 months?" In one sense, it is never too late to start, but you will probably need to used a modified version of IPT for babies over 6 months. Many parents have started at 6, 9, even 12 months and have done okay by making some modifications. It is usually harder to start with a mobile baby who has been "trained" to go in a diaper or who wears disposables and does not associate the feeling of wetness with elimination. If this method resonates, if you feel it is right for you and your baby, and if your healthy baby takes to it, it is certainly worth an honest try! As long as there are no major upsets in your family life or health, you are likely to be open and receptive to your baby's elimination communication.

Another factor to consider is that there is not a fixed cutoff age at which babies lose their connection with the elimination functions. Each child is unique and develops in his own manner. There are parents who have learned about IPT or who have started other methods of toilet learning when their babies were 6-18 months, 2 years or even older, and who have been delighted to find that their little ones were ready, receptive and communicative about toileting at these ages. In short, the window of learning seems to remain open or accessible for some older babies. No matter what age your baby is when you first learn about IPT, I usually recommend that parents give this gentle and nurturing method a try for a few weeks, then assess whether you want to continue.

Tips for juggling a newborn and toddler

2007-11-23T21:16:00.000+07:00

By Kelly Bonyata, BS, IBCLC

First off, per a wise friend of mine who is a mom of five:
Be creative, patient, and hold tight to your sense of humor!

What can I do to prepare my older child for a new baby?

Before baby is born, it can help to talk with your older child about what newborns are like - what they look like, that they mainly nurse and sleep and cry, and how they need to be held much of the time.
Tell stories about what your older child was like as a newborn and how you took care of him.
Discuss things that your older child can do to help with baby: talk and sing to baby, get diapers and wipes, get mom her water bottle.
Make opportunities for your children to see young babies and nursing babies (a La Leche League meeting can be a great place for this, especially if you don't know any nursing moms), and read books that show newborns and nursing babies.
If your child has weaned or was never breastfed: Explain that mom makes milk for baby, that nursing is how baby eats, and that nursing also helps baby feel better when he's sad or scared or feeling bad.
If your child is still nursing and you expect to tandem nurse: Talk to your child about how he and baby will both nurse after the baby is born. Point out that since baby can't eat other foods like your toddler can, he will need to nurse a lot. Look at pictures of tandem nursing siblings with your child. Here's more on tandem nursing.

Should breastfeeding be "hidden" from your older child or other children?

Absolutely not! Modeling nurturing behavior and breastfeeding to your children is one of the best things you can do for them.

By seeing you nurse, your child is learning that breastfeeding is the normal, healthy way to feed a child rather than a "shameful" thing that needs to be hidden away. Breastfeeding is not something that should be hidden from children (or anyone else).

Since most everyone in our culture equates babies with bottles, it's not unusual for other children to be curious when you are breastfeeding your baby. If other children are curious when you are breastfeeding, simply tell them that you are nursing the baby and that nursing is how we feed babies. Again, you are teaching them by example that breastfeeding is the way to feed and nurture babies.

General tips

Could you use a free hand when you're nursing? While you're nursing, a pillow can help bring baby to breast level so you have a hand or two free (sometimes it takes weeks or even months to get that free hand... keep trying). If you need to support your breast with your other hand, try using a small rolled-up towel.

A sling will also free up a hand or two. Are you comfortable with using a sling and nursing baby in it? In addition to nursing while you're lying down, this is another lifesaver for many moms. It frees at least one hand and allows you to keep nursing or holding your baby while tending to and playing with another child. Also, as someone I know once mentioned, when baby is in the sling your toddler can't be pulling baby's toes, or trying to get baby out of the crib, or trying to brush baby's "teeth", or dropping toys on baby.

It can be handy to have your toddler around, as many times you can ask them to fetch things for you (a diaper, a wipe, the remote, the phone, a water bottle). I don't know how many times I got settled on the couch with my first baby, then realized I was going to have to get up again to get something I forgot - the second time around I had a helper all day long, instead of only when Dad was home from work. She couldn't hold baby while I took a shower, but it sure did help with the little things.

Activities to do with your older child while baby is nursing

Read books and snuggle and talk with your toddler while you're nursing. If you don't have a free hand, get your toddler to hold a book and turn the pages while you read.
Play games - "I Spy" and "Simon Says" are often a big hit with toddlers.
Play with your food - try counting (and eating) cheerios or raisins with your toddler.
Some toddlers like to pretend-nurse their dolls or stuffed animals (or trucks!) while mom is nursing baby.
Look at your toddler's baby book or baby pictures. Tell stories about when your toddler was a little baby. Tell stories about what your toddler can do now that he/she is bigger.

You can also set your toddler up with other activities to do while you're nursing. Drawing, coloring, puzzles, blocks or big legos, cars/trains, etc. Some moms keep a box of toys that is out only when baby is nursing. We have a play kitchen that keeps my kids interested for a long time - they bring me food to eat and fix food for their dolls and stuffed animals and plastic dinosaurs, and have tea parties. Things like playdough and painting and water play can keep kids interested for a long time, but depending upon where you can set it up and your child, this may or may not be something that works when you're nursing.

If you need a nap and your toddler doesn't

Childproof a room of the house that has:

a door or a baby gate (so your toddler can't "escape" and play in the toilet while you're resting)
a bed or comfortable spot on the floor where you can lie down and nurse
interesting toys that your toddler is likely play with without much interaction - some moms also put on a favorite video
a snack and a drink for toddler

When you want to nap (or at least rest) while baby naps, close off the door so you can lie down with baby without worrying about what your toddler is getting into. A friend says she would lie on the floor with baby and let her toddlers use mom as a "road" for their matchbox cars - rest and a massage all "rolled" into one!

What if your older child asks to nurse?

It's pretty common for a toddler, or even an older child, to ask to nurse at some point after the new baby arrives. Many just want to know whether mom will say yes - they may also want to be held like a baby or "babied" in other ways. If given the opportunity to nurse, most children will simply touch or kiss the breast, giggle, and go play. Some moms prefer not to offer, but might offer breastmilk in a cup to taste, or simply distract the child with another activity. See What if a "weaned" child asks to nurse again? for more on the subject.

What should I know about giving my breastfed baby a pacifier?

2007-11-23T21:15:00.001+07:00

By Kelly Bonyata, BS, IBCLC

When can I begin using a pacifier?

It is recommended that pacifiers and other types of artificial nipples be avoided for at least the first 3-4 weeks. I'd personally suggest that most breastfed babies - if they get a pacifier at all - would be better off without a pacifier until mom's milk supply is well established (6-8 weeks, usually) and the 6 week growth spurt is over. That way you've established a good milk supply and don't lose any much-needed breast stimulation to a pacifier.

What should I consider before using a pacifier?

After the early weeks, pacifier use is less likely to cause problems as long as you are aware of the following:

Never substitute a pacifier for a feeding at the breast or try to hold the baby off longer between feedings with one. (See Should baby be on a schedule?)
There are studies that indicate that babies who take a pacifier tend to wean earlier than those who do not. This is most likely because as a baby gets older - once he's established on solid food - it is often his desire to suck that ensures he continues to seek out the breast often. Babies who use pacifiers are getting that need to suck met with something other than the breast, and therefore may decide to give up breastfeeding sooner than if they did not take a pacifier.
Some babies who take pacifiers are more prone to oral yeast (thrush) which can be transferred to mom's nipples.
A number of studies have shown a link between pacifier use and an increased incidence of ear infections.
Pacifiers can result in choking or strangulation if the pacifier breaks or if it is tied around the neck (which it never should be). Follow all safety guidelines and keep an eye out for the many pacifier safety recalls. Also, keep in mind that latex allergy is becoming an increasing problem - consider using a silicone pacifier rather than latex.
Prolonged pacifier use can result in teeth misalignment, and can also occasionally lead to shaping of the soft palate or speech problems.
Giving baby a pacifier will increase mom's chances of ovulating and getting pregnant. Exclusive breastfeeding, depending upon your breastfeeding frequency and other factors, is a method of birth control that can be more than 98% effective during the first 6 months and 94% effective during the second six months. Ensuring that all of baby's sucking needs are met at the breast increases the effectiveness of this method of contraception.

When to avoid the pacifier

If you observe any of the following problems, it would be a good idea to discontinue pacifier use, at least until the problem is resolved:

Pacifier use reduces your baby's frequency or duration of feeds (newborns should be nursing at least 8 to 12 times a day).
Baby is having difficulties nursing well (this may be due to nipple confusion).
Baby is having problems with weight gain (in which case baby needs to nurse as often as possible).
Mom is having problems with sore nipples (baby may be causing this due to nipple confusion)
Mom is having milk supply problems (in which case she needs to put baby to breast, not pacifier, at every opportunity in order to increase milk supply).
Mom and/or baby have thrush, particularly if it's hard to get rid of or repeated.
Baby is having repeated ear infections (an increased incidence of ear infections has been linked to pacifier use).

Can pacifiers help prevent SIDS?

Have you heard in the news that pacifier use might help to prevent SIDS? Here's what the American Academy of Pediatrics says about this in their March 2000 Policy Statement Changing Concepts of Sudden Infant Death Syndrome: Implications for Infant Sleeping Environment and Sleep Position:

Four recent studies have reported a substantially lower SIDS incidence among infants who used pacifiers than among infants who do not. Although this association has been strong and consistent, it does not prove that pacifier use prevents SIDS. Mechanisms by which pacifiers might protect against SIDS have been proposed, such as stinting of the upper airway, but data are lacking to demonstrate that any of them are relevant to SIDS. Conversely, other studies have demonstrated that pacifier use can be linked to a shortened duration of breastfeeding, increased susceptibility to otitis media, and increased dental malocclusion. The Task Force believes that additional outcome studies are required before a specific recommendation about pacifiers can be made.

In conclusion...

As long as you keep the above in mind and only use a pacifier sparingly, it is up to you whether and when you wish to comfort baby yourself or with a pacifier. However, keep in mind that there is no scientific evidence that suggests that babies have a need to suck independant of the need for food. When a baby is indicating a sucking need, it's generally best that baby be encouraged to nurse, especially if there is a weight gain concern. The breast was the first pacifier and in most cases remains the best.

My baby is fussy! Is something wrong?

2007-11-23T21:13:00.000+07:00

What is normal baby fussiness?

Whether breastfed or formula fed, during their first few months, many babies have a regular fussy period, which usually occurs in the late afternoon or evening. Some babies' fussy periods come so regularly that parents can set their clocks by it! The standard infant fussiness usually starts at about 2 to 3 weeks, peaks at 6 weeks and is gone by 3 to 4 months. It lasts on "average" 2 to 4 hours per day. Of course, there is a wide variety of normal.

To distinguish between "normal" and a problem, normal usually occurs around the same time of day, with approximately the same intensity (with some variation); responds to some of the same things each time, such as motion, holding, frequent breastfeeding, etc.; and occurs in a baby who has other times of the day that he is contentedly awake or asleep. Normal fussiness tends to occur during the time of the day that the baby usually stays awake more, the most common time is in the evening right before the time that the baby takes his longest stretch of sleep.

What causes babies to be fussy?

If you feel that your baby's fussiness is not normal, it's never a bad idea to get baby checked by the doctor to rule out any illness. A common cause of fussy, colic-like symptoms in babies is foremilk-hindmilk imbalance (also called oversupply syndrome, too much milk, etc.) and/or forceful let-down. Other causes of fussiness in babies include diaper rash, thrush, food sensitivities, nipple confusion, low milk supply, etc.

Babies normally fuss for many reasons: overtiredness, overstimulation, loneliness, discomfort, etc. Babies are often very fussy when they are going through growth spurts. Do know that it is normal for you to be "beside yourself" when your baby cries: you actually have a hormonal response that makes you feel uncomfortable when your baby cries.

Comfort measures for fussy babies (many fit into several different categories)

Basic needs	Nurse Burp baby Change his diaper Undress baby completely to make sure no clothing is "sticking" him
Comforting Touch	Hold baby Carry baby in a sling Give baby a back rub Carry baby in the "colic hold" (lying across your forearm, tummy down, with your hand supporting his chest) Lay baby across your lap & gently rub his back while slowly lifting & lowering your heels Lay baby tummy-down on the bed or floor and gently pat his back Massage your baby
Reduce stimulation	Swaddle baby Dim lights and reduce noise
Comforting Sounds	Play some music (try different styles and types of voices to see which baby prefers) Sing to baby Turn on some "white noise" (fan, vacuum cleaner, dishwasher)
Rhythmic motion / change of pace	Nurse baby in motion (while walking around or rocking) Give baby a bath Rock baby Hold baby and gently bounce, sway back and forth or dance Put baby in a sling or baby carrier and walk around inside or outside Put baby in a baby swing (if he's old enough) Take baby outside to look at the trees Take baby for a walk in the stroller Go for a car ride Set baby in a baby carrier (or car seat) on the dryer with the dryer turned on (stand by him, as the vibration can bounce the seat right off the dryer onto the floor)

One of the most interesting things I've seen in the research regarding infant fussiness is that almost anything a parent tries to reduce fussiness will work, but only for a short time (a few days), and then other strategies need to be used.

If you nurse and it doesn't seem to help, then try other comfort measures. If you pick him up or nurse him, and baby is content, then that was what he needed. If it works, use it!

I'm worried about spoiling my baby

Your baby will not be spoiled if you hold him and nurse him often - quite the opposite, in fact. Studies have shown that when babies are held often and responded to quickly, the babies cry less, and the parents learn to read baby's cues more quickly. A young child's need for his mother is very intense - as intense as his need for food. Know that your child really needs you. It is not about manipulation or something you can "fix" with the right discipline. Often a baby who is perceived as fussy is simply a baby who needs more contact with mom (and is smart enough to express this need) and is content once his needs are met. See the links below to read more about spoiling.

Conclusion

Caring for a fussy baby can be very stressful! Give both yourself and baby some extra TLC. Surround yourself with supportive people, de-stress in other areas if possible (for example, minimize housework), and tell yourself you are doing a great job. It is very difficult to feel good about yourself as a parent when you have a fussy baby. Don't be too alarmed if your efforts seem to have no positive effect - they are. When you stay with your baby to try to provide comfort you are beginning to teach your baby that he can count on you and that he is loved.

Breastfeeding and Vaccines

2007-11-23T21:09:00.000+07:00

Breastfeeding and Vaccines

Vaccines in general

Breastfeeding does not affect the safety of vaccinations for mom or baby.

Although breastfeeding passes many immune factors to baby, breastfeeding should not be considered a substitute for immunization. Research indicates that when breastfed babies are vaccinated, they will produce higher levels of antibodies in comparison to formula fed babies.

According to the US Centers for Disease Control document General Recommendations on Immunization (February 8, 2002) [PDF version for printing]:

"Neither inactivated nor live vaccines administered to a lactating woman affect the safety of breast-feeding for mothers or infants. Breast-feeding does not adversely affect immunization and is not a contraindication for any vaccine. Limited data indicate that breast-feeding can enhance the response to certain vaccine antigens. Breast-fed infants should be vaccinated according to routine recommended schedules.

"Although live vaccines multiply within the mother's body, the majority have not been demonstrated to be excreted in human milk. Although rubella vaccine virus might be excreted in human milk, the virus usually does not infect the infant. If infection does occur, it is well-tolerated because the viruses are attenuated. Inactivated, recombinant, subunit, polysaccharide, conjugate vaccines and toxoids pose no risk for mothers who are breast-feeding or for their infants."

Information on specific vaccines

Anthrax Vaccine

Per the US Centers for Disease Control document Use of Anthrax Vaccine in the United States (December 15, 2000):

"No data suggest increased risk for side effects or temporally related adverse events associated with receipt of anthrax vaccine by breast-feeding women or breast-fed children. Administration of nonlive vaccines (e.g., anthrax vaccine) during breast-feeding is not medically contraindicated."

CDC Update: Interim Recommendations for Antimicrobial Prophylaxis for Children and Breastfeeding Mothers and Treatment of Children with Anthrax (November 16, 2001) discusses the use of antibiotics for prevention of anthrax in breastfeeding mothers and children.

Chicken Pox Vaccine

“Whether attenuated vaccine VZV is excreted in human milk and, if so, whether the infant could be infected are not known. Most live vaccines have not been demonstrated to be secreted in breast milk. Attenuated rubella vaccine virus has been detected in breast milk but has produced only asymptomatic infection in the nursing infant. Therefore, varicella vaccine may be considered for a nursing mother.” ACIP, Prevention of Varicella, pp. 19-20.

Is it necessary to wean before getting the chicken pox vaccine? by Debbi Donovan, IBCLC

Flu Vaccine

Many moms wonder specifically about the flu vaccine. This, like other vaccines, can be administered to nursing mothers. According to Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP), from the US Centers for Disease Control:

"Influenza vaccine does not affect the safety of mothers who are breastfeeding or their infants. Breastfeeding does not adversely affect the immune response and is not a contraindication for vaccination."

There are currently two forms of the flu vaccine:

The intranasal (nasal mist) form of the influenza vaccine (trade-name FluMist™) is an attenuated (weakened) live vaccine. It is approved for use only in healthy people between the ages of 5 and 49 years. Per the CDC, "The current estimated risk of getting infected with vaccine virus after close contact with a person vaccinated with the nasal-spray flu vaccine is low (0.6%-2.4%)."
The standard, injectable form of the flu vaccine is an inactivated (killed) vaccine.

The CDC indicates that either form of the vaccine is acceptable for a breastfeeding mother, as long as she otherwise meets requirements for receiving the vaccine.

US Centers for Disease Control has general information on the current Flu Season and the CDC maintains a Weekly Flu Map for the US.

Pre-Menstrual Syndrome Medications & Breastfeeding

2007-11-23T21:07:00.000+07:00

Following is a list of active ingredients for various PMS medications:

	Acetaminophen	Caffeine	Ibuprofen	Pamabrom	Pyrilamine maleate
	AAP- Approved*	AAP-Approved*	AAP-Approved*
Midol Menstrual Complete	500 mg	60 mg	-	-	15 mg
Midol Pre-Menstrual Syndrome	500 mg	-	-	25 mg	15 mg
Midol Cramp & Body Aches	-	-	200 mg	-	-
Midol Teen Formula	500 mg	-	-	25 mg	-
Pamprin Multi-Symptom	500 mg	-	-	25 mg	15 mg
Premsyn PMS	500 mg	-	-	25 mg	15 mg
* Per the AAP Policy Statement The Transfer of Drugs and Other Chemicals Into Human Milk, revised September 2001. Sources: midol.com (12/22/03) drugstore.com (12/22/03)

Acetaminophen and ibuprofen (pain relievers) and caffeine (a stimulant) are all approved by the AAP for use in breastfeeding mothers.

The other two drugs - pamabrom and pyrilamine maleate - are diuretics.

I have been unable to locate specific information regarding pyrilamine with regards to breastfeeding, but this medication is an antihistamine used directly in pediatrics (in some pediatric cold medications).

Pamabrom is a very mild diuretic - many pharmacists and lactation professionals consider small amounts of this drug to be safe for nursing mothers.

Pain Medications and Breastfeeding

2007-11-23T21:05:00.000+07:00

Info on selected pain medications

The information summarized below is only a general overview of selected pain medications. For detailed information on the specific drugs or for information on drugs not listed here, please review the references listed below with your health care provider.

Info on selected medications used for pain relief

Name of medication

AAP approved?*

Pregnancy Risk Category**

Lactation Risk Category**

Notes

Acetaminophen
(Tylenol)

Approved

Aspirin

Caution

C (1st, 2nd trim.)
D (3rd trim.)

Azapropazone
(Rheumox)

Approved

Butalbital
(Fioricet, Fiorinal, Bancap, Two-dyne)

Butorphanol
(Stadol)

Approved

B (1st, 2nd trim.)
D (3rd trim.)

Celecoxib
(Celebrex) (FDA safety info)

Codeine
(in Tylenol #3, #4)

Approved

Colchicine

Approved

Diclofenac
(Cataflam, Voltaren)

Fentanyl
(Sublimaze)

Approved

Flurbiprofen
(Ansaid, Froben, Ocufen)

B (1st, 2nd trim.)
C (3rd trim.)

Hydrocodone
(Lortab, Vicodin)

Hydromorphone
(Dilaudid)

Ibuprofen
(Advil, Nuprin, Motrin, Pediaprofen)

Approved

B (1st, 2nd trim.)
D (3rd trim.)

Indomethacin
(Indocin)

Approved

B (1st, 2nd trim.)
D (3rd trim.)

Ketorolac
(Toradol, Acular)

Approved

B (1st, 2nd trim.)
D (3rd trim.)

Meperidine
(Demerol)

Approved

L2;
L3 early postpartum

Methadone
(Dolophine)

Approved

Morphine
(Duramorph, Infumorph, Epimorph, MS Contin)

Approved

Nalbuphine
(Nubain)

Naproxen
(Anaprox, Naprosyn, Naproxen, Aleve)

Approved

L3;
L4 for chronic use

Nefopam
(Acupan)

Approved

Oxycodone
(Tylox, Percodan,Oxycontin, Roxicet, Endocet, Roxiprin, Percocet)

Pentosan polysulfate
(Elmiron)

Piroxicam
(Feldene)

Approved

Propoxyphene
(Darvocet N, Propacet, Darvon)

Approved

Rofecoxib
(Vioxx)

Withdrawn from the market

Secobarbital
(Seconal)

Approved

Tolmetin
(Tolectin)

Approved

Tramadol HCL
(Ultram, Ultracet)

Valdecoxib
(Bextra) (FDA safety info)

Withdrawn from the market

* Per the AAP Policy Statement The Transfer of Drugs and Other Chemicals Into Human Milk, revised September 2001.

Approved: (Table 6) Maternal Medication Usually Compatible With Breastfeeding
Caution: (Table 5) Drugs That Have Been Associated With Significant Effects on Some Nursing Infants and Should Be Given to Nursing Mothers With Caution
NR: Not Reviewed. This drug has not yet been reviewed by the AAP.

** Per Medications' and Mothers' Milk by Thomas Hale, PhD (2004 edition).

Lactation Risk Categories	Pregnancy Risk Categories
L1 (safest) L2 (safer) L3 (moderately safe) L4 (possibly hazardous) L5 (contraindicated)	A (controlled studies show no risk) B (no evidence of risk in humans) C (risk cannot be ruled out) D (positive evidence of risk) X (contraindicated in pregnancy)
NR: Not Reviewed. This drug has not yet been reviewed by Hale.

Aspirin use is discouraged in children and nursing mothers due to the risk of Reye's syndrome and internal bleeding.
Fioricet (Fiorinal, Bancap, Two-dyne) contains acetaminaphen or asprin, caffeine, and butalbital. Per Hale, baby should be observed for sedation.
Hale suggests weakened or premature infants be observed for sedation and apnea.
Hale suggests newborns be observed for sedation, apnea, constipation.
Per Hale, use of frequent, higher dose may result in infant sedation.
Per Hale, Meperidine use during labor or early postpartum has been associated with sedation, poor sucking reflex, and neurobehavioral delay in infants.
Per Hale, observe infant for sedation, respiratory depression, addiction, withdrawal syndrome.
Per Hale, higher doses may result in infant sedation.
Per Hale, should be used with caution due to its long half-life and its effect on baby's cardiovascular system, kidneys and GI tract; short-term, infrequent or occasional use is not necessarily incompatible with breastfeeding.
Roxicet, Endocet, Roxiprin, Percocet also contain acetaminophen. Per Hale, observe infant for sedation.
Per Hale, observe infant for sedation.
Per Hale, observe infant for GI cramping, distress, diarrhea.
Per Hale, observe infant for sedation.
Per Hale, observe infant for sedation.

Migraine Medications and Breastfeeding

2007-11-23T21:04:00.000+07:00

Info on selected migraine meds

The information summarized below is only a general overview. For detailed information on the specific drugs, please review the references listed below with your health care provider.

Info on selected meds used for migraine prevention and/or pain relief
Name of medication	AAP approved?*	Lactation Risk Category**	Notes
Acetaminophen (Tylenol)	yes	L1 (safest)
Almotriptan malate (Axert)	not reviewed	not reviewed	1
Amitriptylline (Elavil, Endep)	no	L2 (safer)	2
Asprin	no	L3 (moderately safe)	3
Butalbital (Fioricet, Fiorinal, Bancap, Two-dyne)	not reviewed	L3 (moderately safe)	4
Caffeine	yes	L2 (safer)	more
Codeine	yes	L3 (moderately safe)	5
Ergot alkaloids (DHE 45, Cafergot, Wigraine, Ergostat, Ergomar)	no	L4 (possibly hazardous)	6
Frovatriptan (Frova, Migard)	not reviewed	not reviewed	13
Ibuprofen (Advil, Motrin)	yes	L1 (safest)
Isometheptene Mucate (Midrin)	not reviewed	L3 (moderately safe)	7
Ketorolac (Toradol, Acular)	yes	L2 (safer)
Metoprolol (Toprol-XL, Lopressor)	yes	L3 (moderately safe)	8
Naproxen (Anaprox, Naprosyn, Aleve)	yes	L3 (moderately safe); L4 (possibly hazardous) for chronic use	9
Naratriptan (Amerge)	not reviewed	L3 (moderately safe)
Nifedipine (Adalat, Procardia)	yes	L2 (safer)
Propranolol (Inderal)	yes	L3 (moderately safe)
Rizatriptan (Maxalt)	not reviewed	L3 (moderately safe)	14
Sumatriptan (Imitrex)	yes	L3 (moderately safe)
Valproic Acid (Depakene, Depakote)	yes	L2 (safer)	10
Verapamil (Calan, Isoptin, Covera-HS)	yes	L2 (safer)	11
Zolmitriptan (Zomig, Zomig-ZMT)	not reviewed	L3 (moderately safe)	12
* Per the AAP Policy Statement The Transfer of Drugs and Other Chemicals Into Human Milk, revised September 2001. ** Per Medications' and Mothers' Milk by Thomas Hale, PhD (2002 edition).

1. Almotriptan malate (Axert) is a new drug in the same category as Sumatriptan (Imitrex). It has a relatively short half-life (3-4 hours) and reaches peak plasma level 2-4 hours after administration (see pharmacologic info). No data is currently available regarding its transfer into human milk.

2. Amitriptylline (Elavil, Endep) is listed by the AAP as a "drug whose effect on nursing infants is unknown but may be of concern." However, several studies have shown that this drug is secreted into breastmilk in very small amounts and per Hale, "no untoward effects have been reported in several studies" of breastfed babies whose mothers took this med.

3. Aspirin use is discouraged in children and nursing mothers due to the risk of Reye's syndrome and internal bleeding. The AAP lists it as a "drug associated with significant side effects and should be given with caution."

4. Fioricet (Fiorinal, Bancap, Two-dyne) contains acetaminaphen or asprin, caffeine, and butalbital. Per Hale, baby should be observed for sedation.

5. Codeine (in Tylenol #3 and #4) is AAP approved for nursing mothers but, per Hale, is probably not a good choice for mothers of premature or weakened infants. Hale suggests weakened or premature infants be observed for sedation and apnea .

6. Per Hale, use of ergot alkaloids during lactation should be strongly discouraged. The AAP lists them as "drugs associated with significant side effects and should be given with caution." Excessive dosing and prolonged use may inhibit lactation. Long term exposure is contraindicated.

7. Because better drugs exist for migraine therapy, Hale suggests that Isometheptene Mucate (Midrin) is probably not a good choice for breastfeeding mothers.

8. Per Hale, although the levels of this drug transferred to the infant are probably too low to be clinically relevant, close supervision should be used. No pediatric concerns have been reported in several studies, but observe infant for hypotension, weakness, bradycardia.

9.Aleve (Naproxen) is AAP-approved for nursing mothers, but (per Hale) should be used with caution due to its long half-life and its effect on baby's cardiovascular system, kidneys and GI tract; short-term, infrequent or occasional use is not necessarily incompatible with breastfeeding.

10. Per Hale, no pediatric concerns reported via milk, but observe infant closely for changes in liver enzymes, clinical status and platelet levels.

11. Per Hale, no pediatric concerns reported via milk, but observe infant for hypotension, bradycardia, weakness.

12. Per Hale, zolmitriptan is structurally similar to sumatriptan. It is currently unknown how much of this drug is secreted into human milk.

13. More info on frovatriptan:

Thoughts from Dr. Hale
Manufacturer information from Elan.com
Frovatriptan: Pharmacological Differences and Clinical Results by Alan M. Rapoport
Frovatriptan (Frova®): A new Triptan by Trinh Kieu

14. It is currently unknown how much of this drug is secreted into human milk. It is concentrated in rodent milk, so caution is recommended.

Cold and Allergy Remedies Compatible with Breastfeeding

2007-11-23T20:59:00.001+07:00

he common cold will usually run its course within 7 to 14 days. There are many natural remedies and over the counter products that are compatible with breastfeeding.

Natural Remedies

Medications generally regarded as safe

Disclaimer

Natural Remedies

General

Rest. Drink lots of water and take hot baths. Run a humidifier.
Take in extra vitamin C from foods, juices or in supplement form.
Echinacea is generally recognized to be safe for nursing moms.
Garlic eaten raw, cooked, or taken as a supplement can help. Raw is always best, though it's hardest to get down.
Homeopathic remedies, are considered safe for nursing moms.
OMT is a very gentle form of osteopathic manipulation, which can enhance the immune system, and help keep the fluids draining from the head and neck so bacteria and viruses are less likely to be able to grow. This can help to reduce or even prevent chronic ear and respiratory infections. OMT has been shown to have a dramatic effect on fluid in the ears, and works well on any type of upper respiratory infection.

Head congestion

Use a saline nasal spray
Steam treatments:
- Boil a pot of water, remove from the stove and (optional) add a few drops of essential oils (for example: eucalyptus, sage and balsam). Drape a bath towel over your head and breathe deeply for 5 minutes. Do this 2 or 3x a day until symptoms subside.
- Put two inches of apple cider vinegar in a pan and heat until it begins to steam. Inhale the vapor. If the vapor is too strong, add a little water. Repeat as needed.
Essential Oils: Place a drop or two of either eucalyptus or peppermint essential oil on a cotton ball or handkerchief and hold near the nose while breathing deeply.
- A couple of cautions: Do not use the oil in the nose - it can cause swelling. Do not use peppermint oil or menthol (one of the main components in peppermint oil) or camphor on or near the breast where baby might ingest it, and do not apply directly on the skin of a baby or young child. There have been cases where the direct application of menthol or camphor products (for example, Vicks VapoRub™) to baby's skin resulted in severe breathing difficulties or liver problems (see info on colds and congestion in baby).
Cayenne pepper: Sprinkle it on your food, or put a quarter teaspoon in a glass of water and drink.
Drink fenugreek tea to relieve head and chest congestion and cough.
Massage can help with sinus problems
What To Do When You Have Sinus Pain by Allison Ishman

Chest congestion

Anise steam treatment: Boil a pot of water, remove from the stove and add about 3 teaspoons of dried anise. Drape a bath towel over your head and breathe deeply for 5 minutes. Do this 3x a day to help keep the chest clear.
Drink fenugreek tea to relieve head and chest congestion and cough.

Sore, itchy throat and/or cough

Drink strong black tea (use 2 tea bags per cup).
Drink hot lemonade with honey. Or make a mixture of one part lemon juice and two parts honey. Sip throughout the day.
Drink fenugreek tea to relieve head and chest congestion and cough.
Use Zinc gluconate lozenges, but avoid taking large amounts of zinc for more than seven days, because it can interfere with other minerals in the body.
Salt water gargle:
Mix a 1 tablespoon of salt in eight ounces of warm water. Gargle the whole mixture (don't swallow) several times a day.
Apple-cider vinegar and water gargle.
Mix 1-6 teaspoons (1/3 - 2 tablespoons) vinegar in a glass of water; you can mix it as strong as you can stand it. Gargle one mouthful (swallow afterward or spit it out). Repeat twice. Do this every hour, or as needed.
Slippery elm bark can help with sore throat and cough. It comes in herbal cough drops and throat lozenges (check the other ingredients!), or you can make a tea. For tea, use 1 to 3 teaspoons of powdered bark per cup, boil and simmer 15 minutes. Up to 3 cups per day.
Chamomile tea gargle (you can also drink the tea)
Goldenseal tea gargle (use every 2 hours or as needed)

Medications generally regarded as safe

General guidelines

Treat only the symptoms you have: avoid a combination medicine when a single one will do the job.
Short-acting forms of drugs (6 hours or less) are generally better than the long-acting varieties (but see the info below on the nonsedating antihistamines).
Use nasal spray instead of oral medications when possible (see below).
Take any medication right AFTER you nurse and only as needed.

The 2004 edition of Medications and Mothers' Milk by Thomas Hale, PhD has information on many cold medications (including specific guidance on combination products) in the Appendix (p. 874-889). Many of the active ingredients in cold and allergy medications are listed below.

Cough & sore throat meds

Sore throat sprays or lozenges are generally considered safe, as are cough drops. Avoid eating excessive amounts of cough drops containing menthol. Large amounts of menthol can reduce milk supply.
Many forms of Robitussin, Delsym and Benylin are considered compatible with breastfeeding. Always check the active ingredients, as there are many versions.

Cough Medicines
Name of medication	AAP approved?*	Lactation Risk Category**
Codeine	yes	L3 (moderately safe)
Dextromethorphan	not reviewed	L1 (safest)
Guaifenesin	not reviewed	L2 (safer)
* Per the AAP Policy Statement The Transfer of Drugs and Other Chemicals Into Human Milk, revised September 2001. ** Per Medications' and Mothers' Milk by Thomas Hale, PhD (2002 edition)

Pain meds

Both Advil/Motrin (Ibuprofen) and Tylenol (Acetaminophen) are considered compatible with breastfeeding and are approved by the AAP for use in nursing moms.

Aleve (Naproxen) is also AAP-approved for nursing mothers, but (per Hale) should be used with caution due to its long half-life and its effect on baby's cardiovascular system, kidneys and GI tract; short-term, infrequent or occasional use is not necessarily incompatible with breastfeeding.

Aspirin use is discouraged in children and nursing mothers due to the risk of Reye's syndrome and internal bleeding.

See Pain medications and breastfeeding for more information.

Eye drops

Eye drops designed for cold/allergy symptom relief are considered compatible with breastfeeding.

Nasal sprays or gels

Nasal sprays are generally considered compatible with breastfeeding.

Of the preparations available for treatment of allergic symptoms, the nasal steroids (e.g., Flonase, NasalCrom) are considered to be, by far, some of the most effective and safest to use in breastfeeding moms. Although there is so far no data specifically on these intranasal steroids, it is known that the plasma levels of the drug are extremely low, and thus milk levels would be even lower.

Nasal sprays containing oxymetazoline are probably not a problem, but oxymetazoline is long-acting and thus not the first choice for nursing mothers. A shorter acting alternative is phenylephrine.

Zicam, a homeopathic nasal gel containing ionic zinc gluconate, is generally considered to be compatible with breastfeeding. Zicam contains small amounts of zinc (Zincum Gluconicum) - 266 micrograms per squirt; in one study (Mossad 2003) the daily dosage used was 2.1 mg per day. Zinc is considered compatible with breastfeeding, particularly in small amounts (excessive amounts are not a good idea, for mom's sake rather than baby's). In addition, nasal sprays/gels are generally a better choice for nursing moms as compared to oral medicines. The amount of systemic absorption of nasal sprays/gels is minimal compared to oral ingestion. Although not related to lactation, it should be noted that there are reports of loss of smell resulting from the use of intranasal zinc gluconate (see Jafek BW, Linschoten MR, Murrow BW. Anosmia after intranasal zinc gluconate use. Am J Rhinol. 2004 May-Jun;18(3):137-41).

Nasal Sprays
Name of medication	AAP approved?*	Lactation Risk Category**
Beclomethasone (Vanceril, Beclovent, Beconase, Vancenase)	not reviewed	L2 (safer)
Cromlyn sodium (Nasalcrom)	not reviewed	L1 (safest)
Fluticasone (Flonase)	not reviewed	L3 (moderately safe)
Mometasone (Nasonex)	not reviewed	L3 (moderately safe)
Phenylephrine (in some forms of Sinex and Neo-Synephrine)	not reviewed	L3 (moderately safe)
Triamcinolone Acetonide (Nasacort)	not reviewed	L3 (moderately safe)
* Per the AAP Policy Statement The Transfer of Drugs and Other Chemicals Into Human Milk, revised September 2001. ** Per Medications' and Mothers' Milk by Thomas Hale, PhD (2002 edition)

Decongestants

Both pseudoephedrine and phenylephrine are generally considered to be safe for the breastfed baby, but pseudoephedrine may reduce milk supply.

Pseudoephedrine & milk supply: Thomas Hale Ph. D., a renowned breastfeeding pharmacologist (Breastfeeding Pharmacology), notes that "breastfeeding mothers with poor or marginal milk production should be exceedingly cautious in using pseudoephedrine" and that "it is apparent that mothers in late-stage lactation may be more sensitive to pseudoephedrine and have greater loss in milk production" (Medications and Mother's Milk, 2006 edition).

Dr. Hale is referring to this study: Aljazaf K, et. al. Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk. Br J Clin Pharmacol. 2003 Jul;56(1):18-24.

If you do take pseudoephedrine and notice a drop in milk supply (many moms do not, but research shows that it can decrease milk supply by as much as 24%), simply stop the medication and take measures to increase milk supply - the problem should resolve fairly quickly.

Be very cautious about taking pseudoephedrine on a regular basis, as it has the potential to permanently decrease your milk supply. Regular use of pseudoephedrine (120 mg/day) has occasionally been used to decrease milk production in moms with overproduction, where the usual methods to regulate milk production were not working.

Many meds have been reformulated so they no longer contain pseudoephedrine -- they're using phenylephrine instead. Per Hale, "Because of pseudoephedrine's effect on milk production, many have concerns that phenylephrine may suppress milk production as well. There is no evidence that this occurs at all."

Decongestants
Name of medication	AAP approved?*	Lactation Risk Category**
Phenylephrine	not reviewed	L3 (moderately safe)
Pseudoephedrine (Sudafed, Actifed)	yes	L3 (moderately safe) for acute use L4 (possibly hazardous) for chronic use due to potential for decreasing milk supply
* Per the AAP Policy Statement The Transfer of Drugs and Other Chemicals Into Human Milk, revised September 2001. ** Per Medications' and Mothers' Milk by Thomas Hale, PhD (2006 edition)

Antihistamines

Mom's use of Benadryl and Chlor-Trimeton are generally regarded to be compatible with breastfeeding, but always double-check the active ingredients. Monitor your infant for possible drowsiness if you use an antihistamine. The non-sedating antihistamines (below) are generally preferred and are less likely to sedate baby.

The ingredients of Claritin, Claritin-D, Allegra, Allegra-D, Actifed (the decongestant pseudoephedrine plus triprolidine) and Seldane have been approved by the AAP for use by nursing moms. Loratadine (Claritin) has been studied and the amount of loratadine that passes into breastmilk is extremely low. Claritin-D and Allegra-D have pseudoephedrine added (which is AAP approved, but see above about possible effect on milk supply). Dr. Hale has said that he prefers the nonsedating antihistamines (even though they are long-acting) over the sedating allergy medications.

Zyrtec is also generally considered to be compatible with breastfeeding. It is commonly used by nursing moms, although its levels in milk are not known. Hale rates Zyrtec in the lactation risk catagory L2 (safer).

Clarinex (desloratadine): Desloratadine is another name for descarboethoxyloratadine, which is the main metabolite (breakdown product) of Claritin (loratadine). Per one study (Hilbert J, Radwanski E, Affrime MB et al. Excretion of loratadine in human breast milk. J Clin Pharmacol.1988:28:234-9), 0.019% of the descarboethoxyloratadine was transferred into breastmilk. Since Claritin (and thus its active metabolites, too) is considered safe for nursing moms (it's AAP approved, in fact), Clarinex should not be a problem either.

Milk supply: A common concern is that antihistamines might lower milk supply but, per Dr. Thomas Hale, there is no current research supporting this belief. If you feel that your supply has decreased, it could simply be a byproduct of decreased nursing frequency or dehydration due to your illness.

If you feel that a medication is the cause of a sudden drop in milk supply, then stop taking (or decrease your use of) the medication - if the med is indeed the cause, then supply should increase again soon after you stop taking it. When using an antihistamine, it can be helpful to step up your fluid intake quite a bit. As with any medication, take it only as needed, and discontinue use as soon as you can.

Antihistamines
Name of medication	AAP approved?*	Lactation Risk Category**
Brompheniramine	not reviewed	L3 (moderately safe)
Chlorpheniramine (Chlor-Trimeton)	not reviewed	L3 (moderately safe)
Cetirizine (Zyrtec)	not reviewed	L2 (safer)
Dexbrompheniramine maleate with d-isoephedrine	yes	not reviewed
Diphenhydramine (Benadryl)	not reviewed	L2 (safer)
Doxylamine	not reviewed	L4 (possibly hazardous)
Fexofenadine (Allegra)	yes	L3 (moderately safe)
Loratadine (Claritin)	yes	L2 (safer)
Terfenadine (Seldane)	yes	not reviewed
Triprolidine (Actidil, Actifed)	yes	L1 (safest)
* Per the AAP Policy Statement The Transfer of Drugs and Other Chemicals Into Human Milk, revised September 2001. ** Per Medications' and Mothers' Milk by Thomas Hale, PhD (2002 edition)

Milkmen: Fathers Who Breastfeed

2007-11-23T20:50:00.000+07:00

by Laura Shanley

I first became interested in male lactation in 1978 after reading Dana Raphael's book, The Tender Gift: Breastfeeding. Although Raphael only dealt with the subject briefly, she did say that men can and have produced milk after stimulating their nipples.

While my husband David had no interest in nursing our son, we both were intrigued with the idea. We had just had our first unassisted homebirth and were excited about applying our positive thinking techniques to other aspects of our lives. Although Raphael had written about milk production through nipple stimulation, perhaps, we thought, David could do it simply through suggestion. He began telling himself that he would lactate, and within a week, one of his breasts swelled up and milk began dripping out. When we excitedly showed my father (a physician) David's breast he said, "Obviously there's something physiologically wrong with David." The fact that David had willed himself to do this, did not impress him. We knew, however, that this was yet another example of the power of the mind.

Still, we were not ready for David to actually breastfeed our baby. First of all, there was no need for it. I was doing just fine on my own. But more importantly, he simply had no desire to do it. After he discovered that his body had indeed been responsive to his thoughts, he suggested to himself that the lactation would stop, and within a week his breast returned to normal. The experiment had been a success.

We didn't give it much thought after that until years later when I came across a short article called "Male Lactation" by Professor Patty Stuart Macadam of the Department of Anthropology at the University of Toronto (Compleat Mother, Fall, 1996, Volume 43).

It is possible, and has been observed in animals and humans. In 1992, 18 Dayak fruit bats were captured from a rainforest in the Krau Game Reserve, Pahang, Malaysia. Of the 10 mature males captured, each had functional mammary glands from which small amounts of milk were expressed. A breast is a breast. Male lactation is physiologically possible and, according to Dr. Robert Greenblatt, production in males can be stimulated by letting a baby suckle for several weeks. Indeed some human males secrete milk at birth and at puberty.Historically, male lactation was noted by the German explorer Alexander Freiherr von Humboldt prior to 1859, who wrote of a 32-year-old man who breastfed his child for five months. It was also observed in a 55-year-old Baltimore man who had been the wetnurse of the children of his mistress.

My interest in male lactation was piqued again when I recently received the following letter from a friend of mine.

I knew these two wonderful guys, very dear friends of mine for years. A mutual acquaintance of ours was pregnant, unplanned, and did not want to do the whole "adoption thing" so when the guys approached her about taking the baby, they just proceeded as if it had been a planned surrogate pregnancy. The guys were adamant that the baby should get breastmilk. So when she was in her 7th month we bought a really good quality breastpump and Ian started pumping, every 2 hours during the day and once during the night. He was wonderful about it! He used an SNS (supplimental nursing system) after she was born, with donated milk from several friends who were nursing. He was making milk but not a full supply. By the time the baby was 12 weeks old he was making a full milk supply! He stayed at home with the baby (he was a massage therapist) and nursed her exclusively until she was 8 months old!! I don't think many people outside their intimate circle knew about it, I'm sure folks would have had a fit if they'd known...but I thought it was wonderful!

While reading my friend's letter, I suddenly remembered my mother telling me years ago that as an infant I once tried to nurse on my father. I laughed about it at the time, yet I'm sure it is a fairly common occurrence. Babies want to be loved, nursed, and nurtured. The gender of the person doing it is not important.

On the other hand, I think it is safe to say that women are better suited to breastfeeding than men are. They generally produce milk soon after birth, with little or no nipple stimulation. If a mother is completely out of the picture, however, as in the case of adoption, or a mother goes back to work and a baby is left in the care of its father, for some families male breastfeeding might be an acceptable alternative to formula bottles and pacifiers.

For those who claim male lactation is "unnatural," I would have to ask: how natural is canned formula from Nestle' or pacifiers made from petrolium byproducts? If milk production in men were truly unnatural, it wouldn't exist. The fact that it does, leads me to believe that perhaps male lactation is simply nature's back-up system. In any case, it's an interesting phenomenon.

Prescription Drugs Used for Increasing Milk Supply

2007-11-23T20:48:00.000+07:00

By Kelly Bonyata, IBCLC

There are several prescription drugs that have been used to increase milk supply: Metoclopramide (Reglan), Domperidone (Motilium), and sulpiride (Eglonyl, Dolmatil, Sulpitil, Sulparex, Equemote).

The presence of an appropriate level of the hormone prolactin permits lactation to proceed normally. When a mother has low prolactin levels, milk supply may be affected. Prolactin levels are primarily regulated by inhibition: the presence of prolactin-inhibiting factors (dopamine is the principal one) keep prolactin levels in check. The drugs used for increasing milk supply work by blocking dopamine, which results in an increase in prolactin levels. These drugs do not work in all women and would not be expected to increase milk production in a woman who already has normal (high) prolactin levels.

Reglan has often been used in the U.S.. One major side-effect of Reglan is severe depression; it is contraindicated in moms with a history of depression, and all moms who take this should keep an eye out for signs of depression. One of my sources advises all adoptive mothers to stay away from Reglan, since it has caused serious depression/anxiety in moms regardless of previous history. This depression side effect usually develops over 3-4 weeks, and goes away if mom discontinues the Reglan. Other side effects include diarrhea, sedation, gastric upset, nausea, seizures and extrapyramidal effects (twitching, etc.)

Domperidone has been used successfully in Canada and other areas of the world, and has significantly fewer side effects than Reglan. It has been approved by the American Academy of Pediatrics for use in breastfeeding mothers, and has been given Lactation Risk Category L1 ("safest") in the 2004 edition of Medications and Mothers' Milk. It is not widely available in the U.S. - you may be able to get a compounding pharmacy to make it for you if your doctor prescribes it, or may also be able to order it from Canada or other countries). See the links below for more info.

Sulpiride is commonly used in various countries including Zimbabwe, South Africa and Chile. The primary use for sulpiride is for schizophrenia (it is an antipsychotic and antidepressant), but it also increases serum prolactin levels and thus can enhance breast milk yield.

Prescription drugs that stimulate lactation
Name of medication	AAP approved?*	Lactation Risk Category**
Domperidone (Motilium, Motilidone)	yes	L1 (safest)
Metoclopramide (Reglan)^†	no	L2 (safer)
Sulpiride (Dolmatil, Sulparex, Sulpitil, Eglonyl, Equemote)	not reviewed	L2 (safer)
* Per the AAP Policy Statement The Transfer of Drugs and Other Chemicals Into Human Milk, revised September 2001. ** Per Medications' and Mothers' Milk by Thomas Hale, PhD (2004 edition) † Per the AAP, classified as "Drug whose effect on nursing infants is unknown but may be of concern." AAP notes on this drug: "reported or possible effect: none described; dopaminergic blocking agent"; "Drug is concentrated in human milk relative to simultaneous maternal plasma concentrations." Hale reports results of a number of studies and indicates that domperidone is preferred but not available in the US. He notes that no pediatric concerns have been reported via milk, and that this drug is commonly used in pediatrics.

Oatmeal for Increasing Milk Supply

2007-11-23T20:46:00.000+07:00

By Kelly Bonyata, BS, IBCLC

Eating a bowl of oatmeal, if nothing else, is healthy for mom. At best, it may be a simple way to increase milk supply.

Eating a bowl of oatmeal for breakfast each morning is a frequently heard recommendation for increasing milk supply. Although there is no scientific evidence regarding oatmeal and milk supply, oatmeal does seem to work for some. Many working moms have noticed that on the days they eat oatmeal for breakfast, they can pump more milk than on the days they eat something else. In some countries, "traditional wisdom" recommends eating oatmeal as a way to increase milk supply. A number of lactation consultants recommend eating oatmeal as a way to increase supply.

Some possible explanations:

Oatmeal is is a good source of iron. It is known that maternal anemia/low iron levels can result in a decreased milk supply, so it makes sense that eating something high in iron might increase milk supply in some women.
Oatmeal is a comfort food for many women. Anything that increases relaxation in mom can encourage let-down, and hence also influence milk supply.
A use that some of the milk-increasing herbs share is that of decreasing cholesterol levels. Herbs used for both increasing milk production and decreasing cholesterol levels include fenugreek and alfalfa. Oat bran, which is in oatmeal, is also known to help lower cholesterol.

Suggested dosage:	One bowl of hot oatmeal (any type) every day. Some moms say that they see an increase in supply when they eat anything made with oats, including instant oatmeal and oatmeal cookies.
Side effects:	Oats are not associated with any adverse effects Those with gluten sensitivity (celiac disease) should eat oats with caution

Increasing Low Milk Supply

2007-11-23T20:45:00.000+07:00

By Kelly Bonyata, BS, IBCLC

Is your milk supply really low?

First of all, is your milk supply really low? Often, mothers think that their milk supply is low when it really isn't. If your baby is gaining weight well on breastmilk alone, then you do not have a problem with milk supply.

It's important to note that the feel of the breast, the behavior of your baby, the frequency of nursing, the sensation of let-down, or the amount you pump are not valid ways to determine if you have enough milk for your baby.

What if you're not quite sure about baby's current weight gain (perhaps baby hasn't had a weight check lately)? If baby is having an adequate number of wet and dirty diapers then the following things do NOT mean that you have a low milk supply:

Your baby nurses frequently. Breastmilk is digested quickly (usually in 1.5-2 hours), so breastfed babies need to eat more often than formula-fed babies. Many babies have a strong need to suck. Also, babies often need continuous contact with mom in order to feel secure. All these things are normal, and you cannot spoil your baby by meeting these needs.
Your baby suddenly increases the frequency and/or length of nursings. This is often a growth spurt. The baby nurses more (this usually lasts a few days to a week), which increases your milk supply. Don't offer baby supplements when this happens: supplementing will inform your body that the baby doesn't need the extra milk, and your supply will drop.
Your baby nurses more often and is fussy in the evening.
Your baby doesn't nurse as long as she did previously. As babies get older and better at nursing, they become more efficient at extracting milk.
Your baby is fussy. Many babies have a fussy time of day - often in the evening. Some babies are fussy much of the time. This can have many reasons, and sometimes the fussiness goes away before you find the reason.
Your baby guzzles down a bottle of formula or expressed milk after nursing. Many babies will willingly take a bottle even after they have a full feeding at the breast. Read more here from board-certified lactation consultant Kathy Kuhn about why baby may do this and how this can affect milk supply. Of course, if you regularly supplement baby after nursing, your milk supply will drop (see below).
Your breasts don't leak milk, or only leak a little, or stop leaking. Leaking has nothing to do with your milk supply. It often stops after your milk supply has adjusted to your baby's needs.
Your breasts suddenly seem softer. Again, this normally happens after your milk supply has adjusted to your baby's needs.
You never feel a let-down sensation, or it doesn't seem as strong as before. Some women never feel a let-down. This has nothing to do with milk supply.
You get very little or no milk when you pump. The amount of milk that you can pump is not an accurate measure of your milk supply. A baby with a healthy suck milks your breast much more efficiently than any pump. Also, pumping is an acquired skill (different than nursing), and can be very dependent on the type of pump. Some women who have abundant milk supplies are unable to get any milk when they pump. In addition, it is very common and normal for pumping output to decrease over time.

Who to contact if you suspect low milk supply

If you're concerned about your milk supply, it will be very helpful to get in touch with a La Leche League Leader or a board certified lactation consultant. If your baby is not gaining weight or is losing weight, you need to keep in close contact with her doctor, since it's possible that a medical condition can cause this. Supplementing may be medically necessary for babies who are losing weight until your milk supply increases. If supplementing is medically necessary, the best thing to supplement your baby with is your own pumped milk.

Potential causes of low milk supply

These things can cause or contribute to a low milk supply:

Supplementing. Nursing is a supply & demand process. Milk is produced as your baby nurses, and the amount that she nurses lets your body know how much milk is required. Every bottle (of formula, juice or water) that your baby gets means that your body gets the signal to produce that much less milk.
Nipple confusion. A bottle requires a different type of sucking than nursing, and it is easier for your baby to extract milk from a bottle. As a result, giving a bottle can either cause your baby to have problems sucking properly at the breast, or can result in baby preferring the constant faster flow of the bottle.
Pacifiers. Pacifiers can cause nipple confusion. They can also significantly reduce the amount of time your baby spends at the breast, which may cause your milk supply to drop.
Nipple shields can lead to nipple confusion. They can also reduce the stimulation to your nipple or interfere with milk transfer, which can interfere with the supply-demand cycle.
Scheduled feedings interfere with the supply & demand cycle of milk production and can lead to a reduced supply, sometimes several months later rather than immediately. Nurse your baby whenever she is hungry.
Sleepy baby. For the first few weeks, some babies are very sleepy and only demand to nurse infrequently and for short periods. Until baby wakes up and begins to demand regular nursing, nurse baby at least every two hours during the day and at least every 4 hours at night to establish your milk supply.
Cutting short the length of nursings. Stopping a feeding before your baby ends the feeding herself can interfere with the supply-demand cycle. Also, your milk increases in fat content later into a feeding, which helps baby gain weight and last longer between feedings.
Offering only one breast per feeding. This is fine if your milk supply is well-established and your baby is gaining weight well. If you're trying to increase your milk supply, let baby finish the first side, then offer the second side.
Health or anatomical problems with baby can prevent baby from removing milk adequately from the breast, thus decreasing milk supply.

See Reasons for Low Milk Supply and Hidden Hindrances to a Healthy Milk Supply from more information on things that can decrease milk supply.

Increasing your milk supply

Milk production is a demand & supply process. If you need to increase milk supply, it's important to understand how milk is made - understanding this will help you to do the right things to increase production.

To speed milk production and increase overall milk supply, the key is to remove more milk from the breast and to do this frequently, so that less milk accumulates in the breast between feedings.

OK, now on to things that can help increase your milk supply:

Make sure that baby is nursing efficiently. This is the "remove more milk" part of increasing milk production. If milk is not effectively removed from the breast, then mom's milk supply decreases. If positioning and latch are "off" then baby is probably not transferring milk efficiently. A sleepy baby, use of nipple shields or various health or anatomical problems in baby can also interfere with baby's ability to transfer milk. For a baby who is not nursing efficiently, trying to adequately empty milk from the breast is like trying to empty a swimming pool through a drinking straw - it can take forever. Inefficient milk transfer can lead to baby not getting enough milk or needing to nurse almost constantly to get enough milk. If baby is not transferring milk well, then it is important for mom to express milk after and/or between nursings to maintain milk supply while the breastfeeding problems are being addressed.
Nurse frequently, and for as long as your baby is actively nursing. Remember - you want to remove more milk from the breasts and do this frequently. If baby is having weight gain problems, aim to nurse at least every 1.5-2 hours during the day and at least every 3 hours at night.
Take a nursing vacation. Take baby to bed with you for 2-3 days, and do nothing but nurse (frequently!) and rest (well, you can eat too!).
Offer both sides at each feeding. Let baby finish the first side, then offer the second side.
Switch nurse. Switch sides 3 or more times during each feeding, every time that baby falls asleep, switches to "comfort" sucking, or loses interest. Use each side at least twice per feeding. Use breast compression to keep baby feeding longer. For good instructions on how to do this, see Dr. Jack Newman's Protocol to increase intake of breastmilk by the baby. This can be particularly helpful for sleepy or distractible babies.
Avoid pacifiers and bottles. All of baby's sucking needs should be met at the breast (see above). If a temporary supplement is medically required, it can be given with a nursing supplementer or by spoon, cup or dropper (see Alternative Feeding Methods).
Give baby only breastmilk. Avoid all solids, water, and formula if baby is younger than six months, and consider decreasing solids if baby is older. If you are using more than a few ounces of formula per day, wean from the supplements gradually to "challenge" your breasts to produce more milk.
Take care of mom. Rest. Sleep when baby sleeps. Relax. Drink liquids to thirst (don't force liquids - drinking extra water does not increase supply), and eat a reasonably well-balanced diet.
Consider pumping. Adding pumping sessions after or between nursing sessions can be very helpful - pumping is very important when baby is not nursing efficiently or frequently enough, and can speed things up in all situations. Your aim in pumping is to remove more milk from the breasts and/or to increase frequency of breast emptying. When pumping to increase milk supply, to ensure that the pump removes an optimum amount of milk from the breast, keep pumping for 2-5 minutes after the last drops of milk. However, adding even a short pumping session (increasing frequency but perhaps not removing milk thoroughly) is helpful.
Consider a galactagogue. A substance (herb, prescription medication, etc.) that increases milk supply is called a galactagogue. See What is a galactagogue? Do I need one? for more information.

Herbs to avoid while Breastfeeding

2007-11-23T20:42:00.000+07:00

By Kelly Bonyata, IBCLC

Herbs that may decrease milk supply

Using large amounts of the following herbs and other natural remedies should be avoided while nursing because they have been known to decrease milk supply. The amounts of these herbs normally used in cooking are unlikely to be of concern; it's mainly the larger amounts that might be used therapeutically that could pose a problem. However, some moms have noticed a decrease in supply after eating things like dressing with lots of sage, sage tea (often recommended when moms are weaning), lots of strong peppermint candies or menthol cough drops, or other foods/teas with large amounts of the particular herb. These herbs are sometimes used by nursing mothers to treat oversupply, or when weaning.

Black Walnut
Chickweed
Herb Robert (Geranium robertianum)
Lemon Balm
Oregano
Parsley (Petroselinum crispum)
Peppermint (Mentha piperita)/Menthol

Periwinkle Herb (Vinca minor)
Sage (Salvia officinalis)
Sorrel (Rumex acetosa)
Spearmint
Thyme
Yarrow

Herbs that may be harmful to mom and/or baby

Other herbs should be avoided while nursing due to their potential for harming mom and/or baby. Check the index of herbs for more specific information. Here are a few herbs that are generally considered to be contraindicated for nursing mothers. This is by no means a complete list.

Bladderwrack
Buckthorn
Chaparral
Coltsfoot (Farfarae folium)
Dong Quai (Angelica Root)
Elecampane
Ephedra / Ephedra sinica / Ma Huang
Ginseng (Panax ginseng)

Indian Snakeroot
Kava-kava (piper methysticum)
Petasites root
Phen-fen, herbal
Rhubarb
Star anise
Tiratricol (TRIAC)
Uva Ursi
Wormwood

Additional Information

Hidden Hindrances to a Healthy Milk Supply by Becky Flora, IBCLC

Too much milk: Sage and other Herbs (this website)

Birth control pills are also well known for decreasing milk supply, particularly the ones that contain estrogen.

Sudafed (a decongestant) can also decrease milk supply, particularly with regular use.

Individual herb listings (this website)

Disclaimer: Most herbal treatments have not been thoroughly researched, particularly in regard to lactation. Herbs are drugs, and some caution is necessary. I am presenting this data as is, without any warranty of any kind, express or implied, and am not liable for its accuracy nor for any loss or damage caused by a user's reliance on this information.

Is Baby Getting Enough Milk?

2007-11-23T20:40:00.000+07:00

By Kelly Bonyata, BS, IBCLC

IS BABY GETTING ENOUGH? -- QUICK REFERENCE CARD

~~~ BIRTH to 6 WEEKS ~~~

WEIGHT GAIN:
If baby is gaining well on mom’s milk alone, then baby is getting enough. A 5-7% weight loss during the first 3-4 days after birth is normal. Baby should regain birth weight by 2 weeks. Once mom’s milk comes in, average weight gain is 6 oz/week. If these goals are not met, call your lactation consultant. More on weight gain.

WET DIAPERS: 5 - 6+ sopping wet diapers per day (after 1st week).
Expect one wet diaper on day one, increasing to 5-6 by one week. To feel what a sufficiently wet diaper is like, pour 3 tablespoons (45 mL) of water into a clean diaper (if baby wets more often, then the amount of urine per diaper may be less). Urine should be pale and mild smelling.

DIRTY DIAPERS: 3 – 4+ dirty diapers per day (after day 4).
Stools should be yellow (no meconium) by day 5 and the size of a US quarter (2.5 cm) or larger. The normal stool of a breastfed baby is usually yellow and is loose (soft to watery, may be seedy or curdy). More on infant stooling.

OTHER POSITIVE SIGNS: After a feeding, mom’s breast feels softer and baby seems reasonably content. Baby is alert, active and meeting developmental milestones.

My breasts feel empty! Has my milk supply decreased?

2007-11-23T15:13:00.000+07:00

By Kelly Bonyata, BS, IBCLC

It is normal for a mother's breasts to begin to feel less full, soft, even empty, after the first 6-12 weeks.

Many mothers have concerns about milk supply after the early weeks because they notice a drop in pumped amounts or they notice that their breasts feel "soft" or "empty". It is normal for your breasts to feel mostly soft after the first weeks, although if there has been a long stretch without nursing or pumping they might feel a little full and heavy.

The feeling of fullness (sometimes even engorgement) that nursing mothers notice during the early weeks of breastfeeding is really not the norm at all, but means that mom's breasts haven't yet adjusted to the amount of milk that baby needs. At some point, typically around 6-12 weeks (if a mom has oversupply it may take longer), your milk supply will begin to regulate and your breasts will begin to feel less full, soft, or even empty. You may stop leaking, you may stop feeling let-down (or feel it less), and if you pump you may notice that you're not getting as much milk. This doesn't mean that milk supply has dropped, but that your body has figured out how much milk is being removed from the breast and is no longer making too much. This change may come about gradually or seem rather sudden. Many people are not aware that these breast changes are normal because so many mothers stop breastfeeding early on and never see this change (or mistakenly interpret this change as a sign that milk supply has dried up and wean because of this change).

Why the change? Although milk synthesis has already switched over to autocrine control (driven by breast emptying) after mom's milk comes in, the extra hormonal influence of the early weeks and months frequently causes moms to have more milk than their baby needs. Early postpartum hormonal levels tend to "turn up the volume" on milk synthesis so that extra milk can be produced if it is needed (most moms can produce enough milk for twins or even triplets). Over the first few months, this high baseline prolactin level that is the norm in the early weeks gradually decreases to the lower baseline that is the norm for later lactation. After this point it may be easier for mom's body to adjust milk production down to baby's needs.

I'm confused about foremilk and hindmilk - how does this work?

2007-11-23T14:46:00.000+07:00

By Kelly Bonyata, BS, IBCLC

Foremilk is the milk (typically lower in fat) available at the beginning of a feeding; hindmilk is milk at the end of a feeding, which has a higher fat content than the foremilk at that feeding. There is no sharp distinction between foremilk and hindmilk – the change is very gradual. Research from Peter Hartmann's group tells us that fat content of the milk is primarily determined by the emptiness of the breast -- the less milk in the breast, the higher the fat content.

A woman's breast really only makes one type of milk, the higher-fat milk that we typically think of as hindmilk. As milk is produced in the breast, the fat globules in the milk tend to stick to each other and to the walls of the alveoli (where the milk is made). Between feedings, milk collects in mom's breasts and gradually moves out toward the nipple, leaving more and more of the fat "stuck" further back in the milk ducts. The more time between feedings, the lower the fat content of the foremilk available to baby at the beginning of the feeding.

Once the let-down (or Milk Ejection Reflex/MER) is triggered (by baby's nursing, pumping, etc.), the milk is squeezed down the ducts until it becomes accessible to the baby. Milk production is not faster during letdown - the flow is simply faster. There are several let-downs per feed, although most mothers only sense the first one.

As the breast starts to empty, the fat globules begin to dislodge and move down the ducts (let-down facilitates this process). So the further into the feed, the higher the fat content of the milk, as more and more fat globules are forced out. The end result is that the milk gradually increases in fat as the feeding progresses.

Your breasts don't "flip a switch" at some arbitrary point and start producing hindmilk instead of foremilk. Instead, think of the beginning of a nursing session as being like turning on a hot water faucet.

The first water you get out of the tap isn't usually hot, but cold. As the water runs, it gradually gets warmer and warmer and warmer. This is what happens with the fat content in mom's milk - moms's milk gradually increases in fat content until the end of the feeding.

Since fat content is is directly related to the degree of emptiness of the breast, it is possible, depending upon nursing pattern, for fat content to be higher at the beginning of a particular feeding than it is at the end of some other feeding.

Now think about the hot water faucet again. If there is a long period of time before the faucet is used again, then you go through the "cold to hot" process once more, but if you turn the water on fairly soon after it was used then the water is either pretty warm or still hot, depending upon how long it's been since the faucet was last on.

This is how it works with mother's milk too - the longer the time between feedings, the lower the fat content at the beginning of the next feeding. If feedings are closer together, you're starting off with a higher fat content.

As a particular feeding progresses, fat content increases, milk volume and flow decrease, and milk synthesis speeds up. Because every baby varies in the amount of time it takes him to receive his fill of the higher-fat milk at the end of the feeding, it is important not to switch breasts while baby is actively nursing.

How does Milk Production Work?

2007-11-23T14:42:00.000+07:00

By Kelly Bonyata, BS, IBCLC

To understand how to effectively increase (or decrease) milk supply, we need to look at how milk production works...

For the most part, milk production is a "use it or lose it" process.
The more often and effectively your baby nurses, the more milk you will make.

In the Beginning...

Endocrine (Hormonal) Control of Milk Synthesis -- Lactogenesis I & II

Milk production doesn’t start out as a supply and demand process. During pregnancy and the first few days postpartum, milk supply is hormonally driven – this is called the endocrine control system. Essentially, as long as the proper hormones are in place, mom will start making colostrum about halfway through pregnancy (Lactogenesis I) and her milk will increase in volume (Lactogenesis II) around 30-40 hours after birth.

During the latter part of pregnancy, the breasts are making colostrum, but high levels of progesterone inhibit milk secretion and keep the volume “turned down”. At birth, the delivery of the placenta results in a sudden drop in progesterone/estrogen/HPL levels. This abrupt withdrawal of progesterone in the presence of high prolactin levels cues Lactogenesis II (copious milk production). Other hormones (insulin, thyroxine, cortisol) are also involved, but their roles are not yet well understood. Although biochemical markers indicate that Lactogenesis II commences approximately 30-40 hours after birth, mothers do not typically begin feeling increased breast fullness (the sensation of milk "coming in") until 50-73 hours (2-3 days) after birth.

These first two stages of lactation are hormonally driven – they occur whether or not a mother is breastfeeding her baby.

Established Lactation...

Autocrine (Local) Control of Milk Synthesis -- Lactogenesis III

After Lactogenesis II, there is a switch to the autocrine (or local) control system. This maintenance stage of milk production is also called Lactogenesis III. In the maintenance stage, milk synthesis is controlled at the breast -- milk removal is the primary control mechanism for supply. Milk removal is driven by baby’s appetite. Although hormonal problems can still interfere with milk supply, hormonal levels play a much lesser role in established lactation. Under normal circumstances, the breasts will continue to make milk indefinitely as long as milk removal continues.

By understanding how local/autocrine control of milk synthesis works, we can gain an understanding of how to effectively increase (or decrease) milk supply.

What does current research tell us about milk production?

Current research suggests that there are two factors that control milk synthesis:

Milk contains a small whey protein called Feedback Inhibitor of Lactation (FIL) – the role of FIL appears to be to slow milk synthesis when the breast is full. Thus milk production slows when milk accumulates in the breast (and more FIL is present), and speeds up when the breast is emptier (and less FIL is present).

The hormone prolactin must be present for milk synthesis to occur. On the walls of the lactocytes (milk-producing cells of the alveoli) are prolactin receptor sites that allow the prolactin in the blood stream to move into the lactocytes and stimulate the synthesis of breastmilk components. When the alveolus is full of milk, the walls expand/stretch and alter the shape of prolactin receptors so that prolactin cannot enter via those receptor sites – thus rate of milk synthesis decreases. As milk empties from the alveolus, increasing numbers of prolactin receptors return to their normal shape and allow prolactin to pass through - thus rate of milk synthesis increases. The prolactin receptor theory suggests that frequent milk removal in the early weeks will increase the number of receptor sites. More receptor sites means that more prolactin can pass into the lactocytes and thus milk production capability would be increased.

Both of the above factors support research findings that tell us:

FULL
Breast

SLOWER
Milk
Production

EMPTY
Breast

FASTER
Milk
Production

Research indicates that fat content of the milk is also determined by how empty the breast is (emptier breast = higher fat milk), rather than by the time of day or stage of the feed.

How does milk supply vary throughout the day?

Earlier researchers observed that milk volume is typically greater in the morning hours (a good time to pump if you need to store milk), and falls gradually as the day progresses. Fat content tends to increase as the day progresses (Hurgoiu V, 1985). These observations are consistent with current research if we assume the researchers were observing babies with a fairly typical nursing pattern, where baby has a longer sleep period at night and gradually decreases the amount of time between nursing as the day progresses.

Storage capacity: Another factor that affects milk production and breastfeeding management is mom’s milk storage capacity. Storage capacity is the amount of milk that the breast can store between feedings. This can vary widely from mom to mom and also between breasts for the same mom. Storage capacity is not determined by breast size, although breast size can certainly limit the amount of milk that can be stored. Moms with large or small storage capacities can produce plenty of milk for baby. A mother with a larger milk storage capacity may be able to go longer between feedings without impacting milk supply and baby's growth. A mother with a smaller storage capacity, however, will need to nurse baby more often to satisfy baby’s appetite and maintain milk supply since her breasts will become full (slowing production) more quickly.

Think of storage capacity as a cup - you can easily drink a large amount of water throughout the day using any size of cup - small, medium or large - but if you use a smaller cup it will be refilled more often.

What does the research tell us about increasing milk supply?

Milk is being produced at all times, with speed of production depending upon how empty the breast is. Milk collects in mom's breasts between feedings, so the amount of milk stored in the breast between feedings is greater when more time has passed since the last feed. The more milk in the breast, the slower the speed of milk production.

To speed milk synthesis and increase daily milk production, the key is to remove more milk from the breast and to do this quickly and frequently, so that less milk accumulates in the breast between feedings:

EMPTY
Breast

FASTER
Milk
Production

In practice, this means that a mother who wishes to increase milk supply should aim to keep the breasts as empty as possible throughout the day.

To accomplish this goal and increase milk production:

Empty the breasts more frequently (by nursing more often and/or adding pumping sessions between nursing sessions)
Empty the breasts as thoroughly as possible at each nursing/pumping session.

To better empty the breasts:

Make sure baby is nursing efficiently.
Use breast massage and compression.
Offer both sides at each nursing; wait until baby is finished with the first side before offering the second. Switch nursing may be helpful if baby is not draining the breast well.
Pump after nursing if baby does not adequately soften both breasts. If baby empties the breasts well, then pumping is more useful if done between nursing sessions (in light of our goal to keep the breasts as empty as possible).

Are you having problems with oversupply?

Mothers who are working to remedy oversupply usually need to decrease supply without decreasing overall nursing frequency or weaning baby. One way to accomplish this is by "block nursing" - mom nurses baby as frequently as usual but restricts baby to one breast for a set period of time (often 3-4 hours but sometimes longer) before switching sides. In this way, more milk accumulates in the breast before mom switches sides (thus slowing milk production) but baby's nursing frequency is not limited.

Average Weight Gain for Breastfed Babies

2007-11-23T14:31:00.000+07:00

Baby's Age	Average Weight Gain ¹	Average Weight Gain ^2,3
0-4 months	5.5 - 8.5 ounces per week	5 - 7 ounces per week †
4-6 months	3.25 - 4.5 ounces per week	4 - 5 ounces per week
6-12 months	1.75 - 2.75 ounces per week ‡	2 - 4 ounces per week
[click here to see tables in Metric Units] † It is acceptable for some babies to gain 4-5 ounces per week. ‡ The average breastfed baby doubles birth weight by 3-4 months. By one year, the typical breastfed baby will weigh about 2 1/2 - 3 times birth weight. ¹ Sources: World Health Organization Child Growth Standards, 2006. Available at: http://www.who.int/childgrowth/en/. To figure average weight gain, we used the weight-per-age percentile charts for birth - 5 years. The range is a combination of boys and girls 5% to 95%, rounded to the nearest quarter-ounce. Click here for more details on calculations [PDF file]. Riordan J. Breastfeeding and Human Lactation, 3rd ed. Boston: Jones and Bartlett, 2005, p. 103, 512-513. Mohrbacher N and Stock J. The Breastfeeding Answer Book, Third Revised ed. Schaumburg, Illinois: La Leche League International, 2003, p. 148-149.

Baby's Age	Avg. Length Increase	Avg. Head Circumference Increase
0-6 months	1 inch per month	1/2 inch per month
6-12 months †	1/2 inch per month	1/4 inch per month
[click here to see tables in Metric Units] † By one year, the typical breastfed baby will increase birth length by 50% and head circumference by 33%. Source: Mohrbacher N and Stock J. The Breastfeeding Answer Book, Third Revised ed. Schaumburg, Illinois: La Leche League International, 2003, p. 148-149.

A few things to keep in mind when evaluating weight gain

A 5-7% weight loss during the first 3-4 days after birth is normal. A 10% weight loss is sometimes considered normal, but this amount of weight loss is a sign that the breastfeeding needs to be evaluated. It's a good idea to have a routine weight check at 5 days (baby should be gaining rather than losing weight by day 5), so that any developing problems can be caught and remedied early.

Baby should regain birth weight by 10 days to 2 weeks. If your baby lost a good bit of weight in the early days, or if your baby is sick or premature, it may take longer to regain birth weight. If baby does not regain birth weight by two weeks, this is a sign that the breastfeeding needs to be evaluated.

Always figure weight gain from the lowest point rather than from baby's birth weight.

Baby needs to be weighed on the same scale with the same amount of clothing (preferably naked) each time to get an accurate picture of weight gain. Different scales can give very different readings (I've personally seen a difference of a pound in two different scales); clothing or diapers can vary in weight and throw the numbers off. The scale should be zeroed before weighing, and baby should be centered on the scale tray. It's never a bad idea to do a second measurement (it should be close to the first) and then use an average of the two measurements. If your baby is very active or distressed, don't expect to get an accurate measurement. Babies grow in spurts rather than at a steady rate - to keep from needless worrying, it's generally best to weigh baby no more often than once a week.

Frequent Nursing

2007-11-23T14:25:00.000+07:00

By Kelly Bonyata, BS, IBCLC

Tips for coping with frequent nursing

Both of my children seemed to spend the first 6 weeks or so in a constant growth spurt. If your child is doing the same, then hang in there... things almost always start to calm down somewhere between 6 and 8 weeks. With my second I figured that the early weeks would be easier since we already had one child, but I quickly found out that this just isn't the case. We were still adjusting to a change in family size (and the older child is having to adjust too - not just two adults), and our new baby was having to adjust to life outside of mom. After years of talking to mothers with new babies, I've discovered that the first 6-8 weeks with a new baby tends to be a combination of magic, exhaustion, and stress for any family - no matter how many children you have.

Tips for coping with frequent nursing

First of all, do know that frequent nursing is normal and expected in the early months - most newborns need to nurse at least 8 - 12 times per day. Frequent nursing is also needed -- to avoid/reduce engorgement in the early days, to nourish and grow a baby who has a stomach the size of his fist but who needs to double his weight within 5-6 months, to establish a good milk supply for mom, and to help a baby who has been cradled close and warm inside mom for 9 months adjust to life in the outside world. Frequent nursing may sometimes be a warning sign of inefficient milk transfer or low milk supply, but if baby has good diaper output, is gaining well and is generally happy and healthy, then the frequent nursing is unlikely to be a sign of a problem.

Remember that nursing is not just about food - it's also warmth, closeness, reassurance, comfort, healing, love... Nursing has been shown to reduce stress and pain in baby, too. If you're feeling that baby shouldn't be hungry again so soon - remember that it's sometimes Mom that baby needs just as much as the milk.

Fine-tune breastfeeding

If baby seems to be nursing all the time, you first want to make sure that breastfeeding is working well. Problems with latching can result in frequent nursing if baby is not transferring milk efficiently. If baby's latch is shallow, it can be like when you're drinking from a straw and pinch the straw mostly shut - baby is still getting milk but it takes a loooong time at the breast to get enough. Often, even minor changes in latch can help a lot. Here's more on latching. If you feel that breastfeeding is not working as well as it should, do your best to get some local help - evaluating and fixing latch problems over the phone or online is difficult. Using breast massage and breast compression can also be helpful at times for babies who are frequent nursers.

Adjust your expectations

In the early weeks of breastfeeding, it really helped me to plan my day with the expectation that I would be nursing most of the time. Once I considered frequent nursing to be the norm rather than a problem, it made my life much easier.

Many books, magazine articles, friends and other products of our modern culture suggest to us that we will be able to go on with "life as usual" after baby is born - that we can and should "train" baby to conform to an adult routine. But our lives do change greatly with the birth of a new baby, and urging baby to conform to our pre-baby routines can come at great cost to both baby and parents. Routinely delaying nursing when baby cues a need to eat can harm milk supply, affect baby's weight gain, and is very stressful to both mom and baby. It is developmentally appropriate for young babies to nurse frequently. By letting baby stretch out nursing frequency on his own (and it will happen with time) - you are preserving your nursing relationship and meeting baby's physical and emotional needs.

The first 6-8 weeks are a time when you are building your milk supply and you and baby are getting used to each other and learning about nursing. After the first 6-12 weeks, most babies are much more settled and move toward a more predictable routine. Nursing sessions do not take as much time, either, as baby becomes more efficient at nursing. Nursing will not always take this much time - soon nursing will be much quicker and easier, and you will have gotten past "boot camp" to the easy phase of nursing.

Set priorities

Will the dishes be unhappy and depressed if you neglect them for a few months? You're growing and building a relationship with your children - the dishes and housework can wait when your child needs time and attention.

Make a list of the things you'd like to get done each week, and prioritize them. For the things that absolutely need to get done, see if you can find shortcuts and/or someone else who can do the job. In the early weeks, if a friend or family member asks if they can help, take them up on it - see if someone can put a load of clothes on, or wash the dishes, or vacuum the floor while you nurse baby. Some families decide that it's worth the money to get a cleaning service to come in every couple of weeks to do the heavy cleaning. Can an older neighborhood child or a friend come over to entertain your older children while you nap with baby? Can Dad make sandwiches or cut up vegetables/fruit so you have food easily available when baby is nursing often? Be creative, and don't be afraid to let the smaller things slide. You'll have plenty of time for them later - the "in arms" phase of baby's life is so short, even though it might feel like forever when you're in the middle of it.

Be prepared

Put together a collection of items that you might need while you're nursing. If you usually nurse in one particular place, you might set up a nursing area there, or if you move around you can keep your collection in a basket or other container with a handle. Some things you might want:

a few diapers & wipes
extra cloth diapers or burp rags
water bottle
snacks
books
any remote controls you might want to use
cordless phone (or make sure your answering machine is turned on)

Do you have a sling? Are you comfortable with using it and nursing baby in it? A sling will give you an extra hand (sometimes two) and allow you to keep nursing or holding baby while walking around doing other things.

Maximize sleep

Nap when baby naps. You've probably heard it a million times, but we say it because it helps! When baby goes to sleep, don't jump up to do housework - lie down and rest and try to go to sleep. If you can't sleep, then read a book, listen to music, watch a movie... but don't run around the house. If you get some sleep now, you'll have more energy to do what you need to do later.

Consider sleeping with or nearby baby so you can get more sleep. Co-sleeping (for naps, and/or during the night) is a lifesaver for many nursing moms. The closer you are to your baby, the less your sleep will be interrupted for night waking. Here are some tips on side lying nursing, and information on safely sleeping with your baby. Getting more rest can make life with baby much easier.

Do you feel trapped at home?

Many new moms feel like they're trapped at home with a frequently nursing baby, but most young babies are incredibly easy to take out and about. It can really help to get out occasionally. Here are some tips for going out:

Get a sling. Other baby carriers can be nice, too, but with a sling (and a little practice) you can nurse your baby while you walk around the park or the mall.
Put baby in a sling or other baby carrier or a stroller, and go for a walk.
Go to a movie. Most young babies simply sleep and nurse through movies. And if you're nervous about nursing in public, a dark movie theater can be a good place to start. Go here for commentary and tips on nursing in public.
If you want to go out by yourself for a bit, you don't have to leave a bottle. If your baby normally goes an hour or two between nursing sessions, then nurse baby right before you leave and plan to be back before the next nursing session. If you have a cell phone, take it with you so Dad or another caregiver can call you if the going gets rough. Even if you can only expect 20-30 minutes between nursings, go for a walk by yourself while someone watches baby. Every little bit helps, when you're feeling "touched out.".

Nursing your newborn — what to expect in the early weeks

2007-11-23T14:22:00.000+07:00

The First Week

How often should baby be nursing?

Frequent nursing encourages good milk supply and reduces engorgement. Aim for nursing at least 10 - 12 times per day (24 hours). You CAN'T nurse too often--you CAN nurse too little.

Nurse at the first signs of hunger (stirring, rooting, hands in mouth)--don't wait until baby is crying. Allow baby unlimited time at the breast when sucking actively, then offer the second breast. Some newborns are excessively sleepy at first--wake baby to nurse if 2 hours (during the day) or 4 hours (at night) have passed without nursing.

Is baby getting enough milk?

Weight gain: Normal newborns may lose up to 7% of birth weight in the first few days. After mom's milk comes in, the average breastfed baby gains 6 oz/week (170 g/week). Take baby for a weight check at the end of the first week or beginning of the second week. Consult with baby's doctor and your lactation consultant if baby is not gaining as expected.

Dirty diapers: In the early days, baby typically has one dirty diaper for each day of life (1 on day one, 2 on day two...). After day 4, stools should be yellow and baby should have at least 3-4 stools daily that are the size of a US quarter (2.5 cm) or larger. Some babies stool every time they nurse, or even more often--this is normal, too. The normal stool of a breastfed baby is loose (soft to runny) and may be seedy or curdy.

Wet diapers: In the early days, baby typically has one wet diaper for each day of life (1 on day one, 2 on day two...). Once mom's milk comes in, expect 5-6+ wet diapers every 24 hours. To feel what a sufficiently wet diaper is like, pour 3 tablespoons (45 mL) of water into a clean diaper. A piece of tissue in a disposable diaper will help you determine if the diaper is wet.

Breast changes

Your milk should start to "come in" (increase in quantity and change from colostrum to mature milk) between days 2 and 5. To minimize engorgement: nurse often, don’t skip feedings (even at night), ensure good latch/positioning, and let baby finish the first breast before offering the other side. To decrease discomfort from engorgement, use cold and/or cabbage leaf compresses between feedings. If baby is having trouble latching due to engorgement, use reverse pressure softening or express milk until the nipple is soft, then try latching again.

Call your doctor, midwife and/or lactation consultant if:

Baby is having no wet or dirty diapers
Baby has dark colored urine after day 3
(should be pale yellow to clear)
Baby has dark colored stools after day 4
(should be mustard yellow, with no meconium)
Baby has fewer wet/soiled diapers or nurses less
frequently than the goals listed here
Mom has symptoms of mastitis
(sore breast with fever, chills, flu-like aching)

Weeks two through six

How often should baby be nursing?

Frequent nursing in the early weeks is important for establishing a good milk supply. Most newborns need to nurse 8 - 12+ times per day (24 hours). You CAN'T nurse too often—you CAN nurse too little.

Nurse at the first signs of hunger (stirring, rooting, hands in mouth)—don't wait until baby is crying. Allow baby unlimited time at the breast when sucking actively, then offer the second breast. Some newborns are excessively sleepy—wake baby to nurse if 2 hours (during the day) or 4 hours (at night) have passed without nursing. Once baby has established a good weight gain pattern, you can stop waking baby and nurse on baby's cues alone.

The following things are normal:

Frequent and/or long feedings.
Varying nursing pattern from day to day.
Cluster nursing (very frequent to constant nursing) for several hours—usually evenings—each day. This may coincide with the normal "fussy time" that most babies have in the early months.
Growth spurts, where baby nurses more often than usual for several days and may act very fussy. Common growth spurt times in the early weeks are the first few days at home, 7 - 10 days, 2 - 3 weeks and 4 - 6 weeks.

Is baby getting enough milk?

Weight gain: The average breastfed newborn gains 6 ounces/week (170 grams/week). Consult with baby's doctor and your lactation consultant if baby is not gaining as expected.

Dirty diapers: Expect 3-4+ stools daily that are the size of a US quarter (2.5 cm) or larger. Some babies stool every time they nurse, or even more often--this is normal, too. The normal stool of a breastfed baby is yellow and loose (soft to runny) and may be seedy or curdy. After 4 - 6 weeks, some babies stool less frequently, with stools as infrequent as one every 7-10 days. As long as baby is gaining well, this is normal.

Wet diapers: Expect 5-6+ wet diapers every 24 hours. To feel what a sufficiently wet diaper is like, pour 3 tablespoons (45 mL) of water into a clean diaper. A piece of tissue in a disposable diaper will help you determine if the diaper is wet. After 6 weeks, wet diapers may drop to 4-5/day but amount of urine will increase to 4-6+ tablespoons (60-90+ mL) as baby's bladder capacity grows.

Milk supply?

Some moms worry about milk supply. As long as baby is gaining well on mom's milk alone, then milk supply is good. Between weight checks, a sufficient number of wet and dirty diapers will indicate that baby is getting enough milk.

Hydrocephalus - From History to Treatment

2007-11-23T12:40:00.001+07:00

Hydrocephalus is a term derived from the Greek words "hydro" meaning water, and "cephalus" meaning head, and this condition is sometimes known as "water on the brain". People with this condition have abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles, or cavities, of the brain. This may cause increased intracranial pressure inside the skull and progressive enlargement of the head, convulsion, and mental disability.

Hydrocephalus is usually due to blockage of CSF outflow in the ventricles or in the subarachnoid space over the brain. In a normal healthy person, CSF continuously circulates through the brain and its ventricles and the spinal cord and is continuously drained away into the circulatory system. In a hydrocephalic situation, the fluid accumulates in the ventricles, and the skull may become enlarged because of the great volume of fluid pressing against the brain and skull. Alternatively, the condition may result from an overproduction of the CSF fluid, from a congenital malformation blocking normal drainage of the fluid, or from complications of head injuries or infections.^[1]

Infants and young children with hydrocephalus typically have abnormally large heads, because the pressure of the fluid causes the individual skull bones — which have not knitted with each other yet — to bulge outward at their juncture points. Compression of the brain by the accumulating fluid eventually may cause convulsions and mental retardation. Hydrocephalus occurs in about one out of every 500 live births^[2] and was routinely fatal until surgical techniques for shunting the excess fluid out of the central nervous system and into the blood or abdomen were developed.

Usually, hydrocephalus need not cause any intellectual impairment if recognized and properly treated. A massive degree of hydrocephalus rarely exists in normally functioning people, and such rarity may occur if onset is gradual rather than sudden.^[3]

History

Hydrocephalus was first described by the ancient Greek physician Hippocrates, but it remained an intractable condition until the 20th century, when shunts and other neurosurgical treatment modalities were developed. The condition has been often informally referred to as "water on the brain".

Epidemiology

Hydrocephalus affects one in every 500 live births, making it one of the most common birth defects, more common than Down syndrome or deafness.^[2] According to the NIH website, there are an estimated 700,000 children and adults living with hydrocephalus, and it is the leading cause of brain surgery for children in the United States. There are over 180 different causes of the condition, one of the most common being brain hemorrhage associated with premature birth.

One of the most performed treatments for hydrocephalus, the cerebral shunt, has not changed since it was developed in 1960. The shunt must be implanted through neurosurgery into the patient's brain, a procedure which itself may cause brain damage. An estimated 50% of all shunts fail within two years, requiring further surgery to replace the shunts. In the past 25 years, death rates associated with hydrocephalus have decreased from 54% to 5% and the occurrence of intellectual disability has decreased from 62% to 30%.

In the United States, the healthcare costs for hydrocephalus has exceeded $100 billion per year, but is still much less funded than research on other diseases including juvenile diabetes.^[4]

Pathology

The elevated intracranial pressure may cause compression of the brain, leading to brain damage and other complications. Conditions among affected individual vary widely. Children who have had hydrocephalus may have very small ventricles, and presented as the "normal case". This is the problem with this condition.

If the foramina (pl.) of the fourth ventricle or the cerebral aqueduct are blocked, cereobrospinal fluid (CSF) can accumulate within the ventricles. This condition is called internal hydrocephalus and it results in increased CSF pressure. The production of CSF continues, even when the passages that normally allow it to exit the brain are blocked. Consequently, fluid builds inside the brain causing pressure that compresses the nervous tissue and dilates the ventricles. Compression of the nervous tissue usually results in irreversible brain damage. If the skull bones are not completely ossified when the hydrocephalus occurs, the pressure may also severely enlarge the head. The cerebral aqueduct may be blocked at the time of birth or may become blocked later in life because of a tumor growing in the brainstem.

Internal hydrocephalus can be successfully treated by placing a drainage tube (shunt) between the brain ventricles and abdominal cavity to eliminate the high internal pressures. There is some risk of infection being introduced into the brain through these shunts, however, and the shunts must be replaced as the person grows. A subarachnoid hemorrhage may block the return of CSF to the circulation. If CSF accumulates in the subarachnoid space, the condition is called external hydrocephalus. In this condition, pressure is applied to the brain externally, compressing neural tissues and causing brain damage. Thus resulting to a much further damage of the brain tissue and leading to necrotization

Types of hydrocephalus and their aetiologies

Hydrocephalus can be caused by impaired cerebrospinal fluid (CSF) flow, reabsorption, or excessive CSF production.

The most common cause of hydrocephalus is CSF flow obstruction, hindering the free passage of cerebrospinal fluid through the ventricular system and subarachnoid space (e.g., stenosis of the cerebral aqueduct or obstruction of the interventricular foramina - foramina of Monro secondary to tumors, hemorrhages, infections or congenital malformations).
Hydrocephalus can also be caused by overproduction of cerebrospinal fluid (relative obstruction) (e.g., papilloma of choroid plexus).

Based on its underlying mechanisms, hydrocephalus can be classified into communicating, and non-communicating (obstructive). Both communicating and non-communicating forms can be either congenital, or acquired.

Communicating hydrocephalus

Communicating hydrocephalus, also known as non-obstructive hydrocephalus, is caused by impaired cerebrospinal fluid resorption in the absence of any CSF-flow obstruction. It has been theorized that this is due to functional impairment of the arachnoid granulations, which are located along the superior sagittal sinus and is the site of cerebrospinal fluid resorption back into the venous system. Various neurologic conditions may result in communicating hydrocephalus, including subarachnoid/intraventricular hemorrhage, meningitis, Chiari malformation, and congenital absence of arachnoidal granulations (Pacchioni's granulations).

Normal pressure hydrocephalus (NPH) is a particular form of communicating hydrocephalus, characterized by enlarged cerebral ventricles, with only intermittently elevated cerebrospinal fluid pressure. The diagnosis of NPH can be established only with the help of continuous intraventricular pressure recordings (over 24 hours or even longer), since more often than not, instant measurements yield normal pressure values. Dynamic compliance studies may be also helpful. Altered compliance (elasticity) of the ventricular walls, as well as increased viscosity of the cerebrospinal fluid, may play a role in the pathogenesis of normal pressure hydrocephalus.

Main article: normal pressure hydrocephalus

Hydrocephalus ex vacuo also refers to an enlargement of cerebral ventricles and subarachnoid spaces, and is usually due to brain atrophy (as it occurs in dementias), post-traumatic brain injuries and even in some psychiatric disorders, such as schizophrenia. As opposed to hydrocephalus, this is a compensatory enlargement of the CSF-spaces in response to brain parenchyma loss - it is not the result of increased CSF pressure.

Non-communicating hydrocephalus

Non-communicating hydrocephalus, or obstructive hydrocephalus, is caused by a CSF-flow obstruction (either due to external compression or intraventricular mass lesions).

Foramen of Monro obstruction may lead to dilation of one or, if large enough (e.g., in colloid cyst), both lateral ventricles.
The aqueduct of Sylvius, normally narrow to begin with, may be obstructed by a number of genetically or acquired lesions (e.g., atresia, ependymitis, hemorrhage, tumor) and lead to dilatation of both lateral ventricles as well as the third ventricle.
Fourth ventricle obstruction will lead to dilatation of the aqueduct as well as the lateral and third ventricles.
The foramina of Luschka and foramen of Magendie may be obstructed due to congenital failure of opening (e.g., Dandy-Walker malformation).
The subarachnoid space surrounding the brainstem may also be obstructed due to inflammatory or hemorrhagic fibrosing meningitis, leading to widespread dilatation, including the fourth ventricle.

Congenital hydrocephalus

The cranial bones fuse by the end of the third year of life. For head enlargement to occur, hydrocephalus must occur before then. The causes are usually genetic but can also be acquired and usually occur within the first few months of life, which include 1) intraventricular matrix hemorrhages in premature infants, 2) infections, 3) type II Arnold-Chiari malformation, 4) aqueduct atresia and stenosis, and 5) Dandy-Walker malformation.

Main articles: Arnold-Chiari malformation and Dandy-Walker malformation

In newborns and toddlers with hydrocephalus, the head circumference is enlarged rapidly and soon surpasses the 97th%. Since the skull bones have not yet firmly joined together, bulging, firm anterior and posterior fontanelles may be present even when the patient is in an upright position.

The infant exhibits fretfulness, poor feeding, and frequent vomiting. As the hydrocephalus progresses, torpor sets in, and the infant shows lack of interest in his surroundings. Later on, the upper eyelids become retracted and the eyes are turned downwards (due to hydrocephalic pressure on the mesencephalic tegmentum and paralysis of upward gaze). Movements become weak and the arms may become tremulous. Papilledema is absent but there may be reduction of vision. The head becomes so enlarged that the child may eventually be bedridden.

About 80-90% of fetuses or newborn infants with spina bifida - often associated with meningocele or myelomeningocele - develop hydrocephalus.

Acquired hydrocephalus

This condition is acquired as a consequence of CNS-infections, meningitis, brain tumors, head trauma, intracranial hemorrhage (subarachnoid or intraparenchymal) and is usually extremely painful for the patient.

Symptoms

Symptoms of increased intracranial pressure may include headaches, vomiting, nausea, papilledema, sleepiness, or coma, or death. Elevated intracranial pressure may result in uncal and/or cerebellar tonsill herniation, with resulting life threatening brain stem compression. For details on other manifestations of increased intracranial pressure:

Main article: intracranial pressure

The triad (Hakim triad) of gait instability, urinary incontinence and dementia is a relatively typical manifestation of the distinct entity normal pressure hydrocephalus (NPH). The triad can easily be remembered as "Wacky, Wet, and Wobbly!" Focal neurological deficits may also occur, such as abducens nerve palsy and vertical gaze palsy (Parinaud syndrome due to compression of the quadrigeminal plate, where the neural centers coordinating the conjugated vertical eye movement are located).

Main article: normal pressure hydrocephalus

Effects

Because hydrocephalus injures the brain, thought and behavior may be adversely affected. Learning disabilities are common among those with hydrocephalus, who tend to score better on verbal IQ than on performance IQ, which is thought to reflect the distribution of nerve damage to the brain. However, the severity of hydrocephalus differs considerably between individuals and some are of average or above average intelligence. Someone with hydrocephalus may have motivation and visual problems, problems with coordination, and may be clumsy. They may hit puberty earlier than the average child (see precocious puberty). About one in four develops epilepsy.

Because the problem resides inside the head, doctors rely heavily upon computer tomography scanning (CT scans), which may be used frequently to evaluate the condition of the disorder throughout the patient's life. Each CT scan exposes the patient to many times the level of x-ray radiation of a chest x-ray. See CT radiation exposure.

Treatment

Hydrocephalus treatment is surgical. It involves the placement of a ventricular catheter (a tube made of silastic), into the cerebral ventricles to bypass the flow obstruction/malfunctioning arachnoidal granulations and drain the excess fluid into other body cavities, from where it can be resorbed. Most shunts drain the fluid into the peritoneal cavity (ventriculo-peritoneal shunt), but alternative sites include the right atrium (ventriculo-atrial shunt), pleural cavity (ventriculo-pleural shunt), and gallbladder. A shunt system can also be placed in the lumbar space of the spine and have the CSF redirected to the peritoneal cavity (LP Shunt). An alternative treatment for obstructive hydrocephalus in selected patients is the endoscopic third ventriculostomy (ETV), whereby a surgically created opening in the floor of the third ventricle allows the CSF to flow directly to the basal cisterns, thereby shortcutting any obstruction, as in aqueductal stenosis. This may or may not be appropriate based on individual anatomy.

Shunt complications

Examples of possible complications include shunt malfunction, shunt failure, and shunt infection. Although a shunt generally works well, it may stop working if it disconnects, becomes blocked (clogged), infected, or it is outgrown. If this happens the cerebrospinal fluid will begin to accumulate again and a number of physical symptoms will develop (headaches, nausea, vomiting, photophobia/light sensitivity), some extremely serious, like seizures. The shunt failure rate is also relatively high (some sources site up to 45% chance of shunt failure in the first year following placement) and it is not uncommon for patients to have multiple shunt revisions within their lifetime.

The diagnosis of cerebrospinal fluid buildup is complex and requires specialist expertise.

Another complication can occur when CSF drains more rapidly than it is produced by the choroid plexus, causing symptoms - listlessness, severe headaches, irritability, light sensitivity, sound sensitivity, nausea, vomiting, dizziness, vertigo, migraines, seizures, a change in personality, weakness in the arms or legs, excessive head growth (seen infants, children under age 2), strabismus, and double vision - to appear when the patient is vertical. If the patient lies down, the symptoms usually vanish in a short amount of time. A CT scan may or may not show any change in ventricle size, particularly if the patient has a history of slit-like ventricles. Difficulty in diagnosing overdrainage can make treatment of this complication particularly frustrating for patients and their families.

Resistance to traditional analgesic pharmacological therapy may also be sign of shunt overdrainage or failure. Diagnosis of the particular complication usually depends on when the symptoms appear.

Exceptional case

One interesting case involving a person with past hydrocephalus was a 44-year old French man, whose brain had been reduced to little more than a thin sheet of actual brain tissue, due to the buildup of fluid in his skull. The man, who had a shunt inserted into his head to drain away fluid (which was removed when he was 14), went to a hospital after he had been experiencing mild weakness in his left leg.

DWS: All of the black in the middle is water and the brain matter is the rim of white along the outside of the skull. This is a screen shot from a Fox News report.

In July of 2007, Fox News quoted Dr. Lionel Feuillet of Hopital de la Timone in Marseille as saying: "The images were most unusual... the brain was virtually absent."^[5] When doctors learned of the man's medical history, they performed a computed tomography (CT) scan and magnetic resonance imaging (MRI) scan, and were astonished to see "massive enlargement" of the lateral ventricles in the skull. Intelligence tests showed the man had an IQ of 75, below the average score of 100 but not considered mentally retarded or disabled, either.

Remarkably, the man was a married father of two children, and worked as a civil servant, leading a normal life, despite having little brain tissue. "What I find amazing to this day is how the brain can deal with something which you think should not be compatible with life," commented Dr. Max Muenke, a pediatric brain defect specialist at the National Human Genome Research Institute. "If something happens very slowly over quite some time, maybe over decades, the different parts of the brain take up functions that would normally be done by the part that is pushed to the side."^[6]

Hydrocephalus - From History to Treatment

2007-11-23T12:40:00.000+07:00

History

Epidemiology

In the United States, the healthcare costs for hydrocephalus has exceeded $100 billion per year, but is still much less funded than research on other diseases including juvenile diabetes.^[4]

Pathology

Types of hydrocephalus and their aetiologies

Hydrocephalus can be caused by impaired cerebrospinal fluid (CSF) flow, reabsorption, or excessive CSF production.

The most common cause of hydrocephalus is CSF flow obstruction, hindering the free passage of cerebrospinal fluid through the ventricular system and subarachnoid space (e.g., stenosis of the cerebral aqueduct or obstruction of the interventricular foramina - foramina of Monro secondary to tumors, hemorrhages, infections or congenital malformations).
Hydrocephalus can also be caused by overproduction of cerebrospinal fluid (relative obstruction) (e.g., papilloma of choroid plexus).

Communicating hydrocephalus

Normal pressure hydrocephalus (NPH) is a particular form of communicating hydrocephalus, characterized by enlarged cerebral ventricles, with only intermittently elevated cerebrospinal fluid pressure. The diagnosis of NPH can be established only with the help of continuous intraventricular pressure recordings (over 24 hours or even longer), since more often than not, instant measurements yield normal pressure values. Dynamic compliance studies may be also helpful. Altered compliance (elasticity) of the ventricular walls, as well as increased viscosity of the cerebrospinal fluid, may play a role in the pathogenesis of normal pressure hydrocephalus.

Main article: normal pressure hydrocephalus

Hydrocephalus ex vacuo also refers to an enlargement of cerebral ventricles and subarachnoid spaces, and is usually due to brain atrophy (as it occurs in dementias), post-traumatic brain injuries and even in some psychiatric disorders, such as schizophrenia. As opposed to hydrocephalus, this is a compensatory enlargement of the CSF-spaces in response to brain parenchyma loss - it is not the result of increased CSF pressure.

Non-communicating hydrocephalus

Non-communicating hydrocephalus, or obstructive hydrocephalus, is caused by a CSF-flow obstruction (either due to external compression or intraventricular mass lesions).

Foramen of Monro obstruction may lead to dilation of one or, if large enough (e.g., in colloid cyst), both lateral ventricles.
The aqueduct of Sylvius, normally narrow to begin with, may be obstructed by a number of genetically or acquired lesions (e.g., atresia, ependymitis, hemorrhage, tumor) and lead to dilatation of both lateral ventricles as well as the third ventricle.
Fourth ventricle obstruction will lead to dilatation of the aqueduct as well as the lateral and third ventricles.
The foramina of Luschka and foramen of Magendie may be obstructed due to congenital failure of opening (e.g., Dandy-Walker malformation).
The subarachnoid space surrounding the brainstem may also be obstructed due to inflammatory or hemorrhagic fibrosing meningitis, leading to widespread dilatation, including the fourth ventricle.

Congenital hydrocephalus

Main articles: Arnold-Chiari malformation and Dandy-Walker malformation

About 80-90% of fetuses or newborn infants with spina bifida - often associated with meningocele or myelomeningocele - develop hydrocephalus.

Acquired hydrocephalus

Symptoms

Main article: intracranial pressure

Main article: normal pressure hydrocephalus

Effects

Treatment

Shunt complications

The diagnosis of cerebrospinal fluid buildup is complex and requires specialist expertise.

Resistance to traditional analgesic pharmacological therapy may also be sign of shunt overdrainage or failure. Diagnosis of the particular complication usually depends on when the symptoms appear.

Exceptional case

DWS: All of the black in the middle is water and the brain matter is the rim of white along the outside of the skull. This is a screen shot from a Fox News report.

Hydrocephalus Fact Sheets

2007-11-23T12:34:00.000+07:00

What is Hydrocephalus?

Hydrocephalus is a condition in which the primary characteristic is excessive accumulation of fluid in the brain. Although hydrocephalus was once known as "water on the brain," the "water" is actually cerebrospinal fluid (CSF) -- a clear fluid surrounding the brain and spinal cord. The excessive accumulation of CSF results in an abnormal dilation of the spaces in the brain called ventricles. This dilation causes potentially harmful pressure on the tissues of the brain. Hydrocephalus may be congenital or acquired. Congenital hydrocephalus is present at birth and may be caused by genetic abnormalities or developmental disorders such as spina bifida and encephalocele. Acquired hydrocephalus develops at the time of birth or at some point afterward and can affect individuals of all ages. For example, hydrocephalus ex-vacuo occurs when there is damage to the brain caused by stroke or traumatic injury. Normal pressure hydrocephalus occurs most often among the elderly. It may result from a subarachnoid hemorrhage, head trauma, infection, tumor, or complications of surgery, although many people develop normal pressure hydrocephalus without an obvious cause. Symptoms of hydrocephalus vary with age, disease progression, and individual differences in tolerance to CSF. In infancy, the most obvious indication of hydrocephalus is often the rapid increase in head circumstance or an unusually large head size. In older children and adults, symptoms may include headache followed by vomiting, nausea, papilledema (swelling of the optic disk, which is part of the optic nerve), downward deviation of the eyes (called "sunsetting"), problems with balance, poor coordination, gait disturbance, urinary incontinence, slowing or loss of development (in children), lethargy, drowsiness, irritability, or other changes in personality or cognition, including memory loss. Hydrocephalus is diagnosed through clinical neurological evaluation and by using cranial imaging techniques such as ultrasonography, computer tomography (CT), magnetic resonance imaging (MRI), or pressure-monitoring techniques.

Is there any treatment?

Hydrocephalus is most often treated with the surgical placement of a shunt system. This system diverts the flow of CSF from a site within the central nervous system to another area of the body where it can be absorbed as part of the circulatory process. A limited number of patients can be treated with an alternative procedure called third ventriculostomy. In this procedure, a small hole is made in the floor of the third ventricle, allowing the CSF to bypass the obstruction and flow toward the site of resorption around the surface of the brain.

What is the prognosis?

The prognosis for patients diagnosed with hydrocephalus is difficult to predict, although there is some correlation between the specific cause of hydrocephalus and the patient's outcome. Prognosis is further complicated by the presence of associated disorders, the timeliness of diagnosis, and the success of treatment. The symptoms of normal pressure hydrocephalus usually get worse over time if the condition is not treated, although some people may experience temporary improvements. If left untreated, progressive hydrocephalus is fatal, with rare exceptions. The parents of children with hydrocephalus should be aware that hydrocephalus poses risks to both cognitive and physical development. Treatment by an interdisciplinary team of medical professionals, rehabilitation specialists, and educational experts is critical to a positive outcome. Many children diagnosed with the disorder benefit from rehabilitation therapies and educational interventions, and go on to lead normal lives with few limitations.

What research is being done?

The NINDS conducts and supports a wide range of fundamental studies that explore the complex mechanisms of normal brain development. The knowledge gained from these studies provides the foundation for understanding how this process can go awry and, thus, offers hope for new means to treat and prevent developmental brain disorders such as congenital hydrocephalus.

Select this link to view a list of studies currently seeking patients.

Organizations

Guardians of Hydrocephalus Research Foundation 2618 Avenue Z Brooklyn, NY 11235-2023 GHRF2618@aol.com http://ghrf.Homestead.com/ghrf.html Tel: 718-743-GHRF (4473) Fax: 718-743-1171	Hydrocephalus Association 870 Market Street Suite 705 San Francisco, CA 94102 info@hydroassoc.org http://www.hydroassoc.org Tel: 415-732-7040 888-598-3789 Fax: 415-732-7044
Hydrocephalus Support Group, Inc. P.O. Box 4236 Chesterfield, MO 63006-4236 hydrodb@earthlink.net Tel: 636-532-8228 Fax: 314-251-5871	National Hydrocephalus Foundation 12413 Centralia Road Lakewood, CA 90715-1623 hydrobrat@earthlink.net http://nhfonline.org Tel: 562-924-6666 888-857-3434 Fax: 562-924-6666

Glucose Tolerance Test (GTT)

2007-11-20T10:06:00.000+07:00

Gestational glucose intolerance is detected during pregnancy with the glucose tolerance test (GTT). This test is usually recommended around 24-28 weeks, and may be repeated around 32-34 weeks in mothers with high-risk pregnancies.

By identifying gestational glucose intolerance during pregnancy, the mother can alter her diet to keep her blood sugar from getting too high. Gestational glucose intolerance is more common in overweight women, older women, those with a family history of diabetes, or women who have previously delivered a baby weighing more than nine pounds.

The GTT is done at your doctor's office. You drink a glass of sweet liquid called glucola (it tastes like sweetened Coke or Pepsi) on an empty stomach, and then your blood sugar is checked one hour later. (An alternative to drinking the sugar-loaded liquid is to measure the blood sugar 1-2 hours after a big meal.) The result of the GTT should be available within a few hours. After ingesting the test "meal," it's important to stay active (e.g. walking) so your body has a better chance of metabolizing the sugar load than if you just sit there waiting to have your blood drawn.

If this one-hour screening test turns out to show high blood sugar, the doctor may recommend a more accurate three-hour test. Only around 15 percent of women with abnormal one-hour GTT will have an abnormal three-hour GTT test. If the three-hour test is abnormal, the doctor may recommend a diabetic diet throughout the rest of pregnancy. New research questions the value of routine screening for gestational glucose intolerance. A 1990 study of 1,307 women (533 of whom were not screened and 774 who were screened) showed that screening resulted in more tests and worry during pregnancy and a significantly higher cesarean rate in the screened mothers, but it did not decrease the number of large infants. These researchers concluded that the routine use of GTT caused more worry than the benefits derived. Discuss with your practitioner whether or not the GTT is necessary in your particular pregnancy.

Mom and Baby Articles

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Should breastfeeding be "hidden" from your older child or other children?

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Breastfeeding and Vaccines

Breastfeeding and Vaccines

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Pain Medications and Breastfeeding

Migraine Medications and Breastfeeding

Cold and Allergy Remedies Compatible with Breastfeeding

Milkmen: Fathers Who Breastfeed

Prescription Drugs Used for Increasing Milk Supply

Oatmeal for Increasing Milk Supply

Eating a bowl of oatmeal, if nothing else, is healthy for mom. At best, it may be a simple way to increase milk supply.

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In the Beginning...

Endocrine (Hormonal) Control of Milk Synthesis -- Lactogenesis I & II

Established Lactation...

Autocrine (Local) Control of Milk Synthesis -- Lactogenesis III

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What does the research tell us about increasing milk supply?

To accomplish this goal and increase milk production:

To better empty the breasts:

Are you having problems with oversupply?

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A few things to keep in mind when evaluating weight gain

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Tips for coping with frequent nursing

Fine-tune breastfeeding

Adjust your expectations

Set priorities

Be prepared

Maximize sleep

Do you feel trapped at home?

Nursing your newborn — what to expect in the early weeks

Weeks two through six

How often should baby be nursing?

The following things are normal:

Is baby getting enough milk?

Milk supply?

Hydrocephalus - From History to Treatment

History

Epidemiology

Types of hydrocephalus and their aetiologies

Communicating hydrocephalus

Non-communicating hydrocephalus

Congenital hydrocephalus

Acquired hydrocephalus

Symptoms

Effects

Treatment

Exceptional case

Hydrocephalus - From History to Treatment

History

Epidemiology

Types of hydrocephalus and their aetiologies

Communicating hydrocephalus

Non-communicating hydrocephalus

Congenital hydrocephalus

Acquired hydrocephalus

Symptoms