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The Feeding episode: Helping your baby thrive

©MFMER

Breast is best. Or is formula fine? A bit of both? Co-hosts Angela Mattke, M.D., and Nipunie Rajapakse M.D., talk through all the issues and research, with help from special guest Jay Homme, M.D., pediatrician at Mayo Clinic and father of six children. Topics include:

*          Breastmilk vs. formula

*          The “dream feed” for breast-resistant babies

*          Pumping milk

*          The partner’s role

*          What to eat, drink and avoid for optimal baby health during breastfeeding

Listen: The Feeding episode: Helping your baby thrive

Read the transcript:

Dr. Angela Mattke:

Welcome to the Mayo Clinic Moms podcast. We’re having candid conversations and answering difficult questions about pregnancy, raising kids, and everything mom-related. I’m Dr. Angela Mattke, and I’m a mom of two and a pediatrician at Mayo Clinic Children’s Center in Rochester, Minnesota. My co-host is Dr. Nipunie Rajapakse, who’s a pediatric infectious disease doctor at Mayo Clinic and is also pregnant.

On today’s episode, we’re focusing on feeding your baby. You brought your baby home from the hospital, but there’s no instruction manual that came with this thing. You’re probably starting to think about long-term feeding plans for your baby. Are you going to choose breast milk versus formula? Sometimes you start to wonder, is my baby getting enough or are they getting too much? How do you know the difference? Some other questions that might come up include: how does what I eat affect my breast milk supply? Can I have a glass of wine once in a while, or is that not safe for my baby? Then most importantly, as a pediatrician, I start to wonder: does having vaccines transfer to my baby through the breast milk? We will be discussing all this and more on today’s episode.

So Nipunie, full disclosure, I think you know this already, and I’ve talked about it on previous episodes, but I breastfed both of my babies. First baby, so easy, breastfeeding went well. He probably would still be breastfeeding now if I let him, and I hadn’t weaned. I pumped while at work, and it was really challenging at times. I pumped for about the first 12 months, and then I stopped pumping and just breastfed him a little bit longer, but my second baby was a completely different experience, and not in a good way. I tell my patients when you breastfed one baby, you’ve breastfed one baby because they are completely different experiences. He stopped breastfeeding at six weeks. He went on a breastfeeding strike and never went back — it was horrible, and it was miserable. I didn’t get this bonding experience with him with breastfeeding, which can be really beautiful. Most importantly, for me, I had to pump. I felt like I had to pump. I’m a pediatrician, and I did feel a lot of pressure that I had to do breastfeeding for a whole year — but it was just miserable pumping for ten and a half months straight. Sometimes I would sneak in the middle of the night and do what we call a dream feed. I’d wake him up and quickly throw him on the breast so I wouldn’t have to pump in the middle of the night. That was the only breastfeeding I pretty much got for 11 months of his life. Breastfeeding can be really challenging. I had talked about how there’s a lot of pressure on moms to breastfeed. I think being in medicine — you’re a board certified pediatrician as well. Do you feel the pressure to breastfeed, or have you started to think about what you want to do for feeding for your baby?

Dr. Nipunie Rajapakse:

Yeah, I definitely feel the same way. I feel like I do want to breastfeed; obviously, I know about all the benefits of it. But I’ve also heard from a lot of friends and colleagues that it’s maybe not as easy as – or as natural as it’s made to come across when you look on social media or other places. I am trying make sure I go in with realistic expectations and as much knowledge as possible to hopefully set us up for success — knowing that each baby is different, each mom is different, and that there will probably be some challenges that come up as well. The other aspect I’ve been thinking about is I obviously want my partner, Thomas, to be involved. How does that work with breastfeeding? How do I incorporate pumping so he can do some feeds as well? So all these things, I think, are a bit hard to know. This is our first baby, so [we’re] not really sure what to expect as much as I’ve heard from everyone. How do we balance those things? Obviously, I want the baby to be healthy and growing well, and that’s the number one priority. Definitely also thinking about supplementation options and things, if we aren’t able to make the breastfeeding thing work, but yes, we do intend to try and breastfeed.

Dr. Angela Mattke:

You know, that’s one of the things I want to talk about more in today’s episode — what are people’s expectations going into breastfeeding and how people can really have appropriate expectations of what breastfeeding will be like? I think we should definitely talk more about that on today’s episode. I love how you just brought up Thomas and how he can be part of nourishing your baby and getting the experience of bonding through feeding. Because [babies] don’t do a lot in the beginning. They sleep, they eat, and they poop, and they don’t even smile right away—so you don’t get a lot of feedback. And so, if [your partner] doesn’t get to be involved in one of those three things, you know, it’s hard for dads sometimes to bond.

We have a guest today who is an incredibly experienced father of six. I want to bring him on because he can really help us understand a little bit more about the partner’s role with feeding as well. I want to welcome our guest, Dr. Jay Homme, who is a pediatrician and adolescent medicine physician at Mayo Clinic Children’s Center. A very experienced father, like I mentioned before, and he’s also been a mentor to me over the years. And I remember with my first baby, he was the person who we saw first right after leaving the hospital. Our first visit was less than 24 hours after leaving, and there we were in a Saturday clinic, and I got to see Jay, and it was great because I was like, “What do I do with this thing now? I know, I’m a pediatrician, but at this point — help. You’ve done this a lot of times.” So Jay, welcome. And I want you to introduce a little bit about yourself because, obviously, we need to establish a little bit of street credibility. Because you are a guy, and we’re going to be talking about breastfeeding.

Dr. Jay Homme:

Yeah. Well, thanks so much for inviting me. This is one of my favorite things to talk about, and, you know, street cred, of course I can, full disclosure, say I’ve never personally breastfed any child. I have had the good fortune of participating in the feeding of our children; my wife, Becky, and I are proud parents of six children: five biologic, and our youngest is adopted. And the first five, all were exclusively breastfed for the first year of life, with one ounce of formula exception. My wife, still to this day, kind of holds that…she didn’t have enough milk one day at daycare. I said, “Honey, you are doing awesome.” I’ve been practicing pediatric medicine for over 28 years and have really had the privilege of walking with many new parents and families through this process. That visit that you described, seeing you the first day out of the hospital, I can say, hands down, that is my absolute favorite thing to do in pediatrics is that very first visit with new parents, bringing a new baby in because there are so many questions. There’s so much uncertainty and it’s fun for me to really help provide reassurance and some guidance on breastfeeding. I have said it a thousand times — just because it’s natural, it doesn’t mean it’s easy, and there are lots of barriers that can be in place. I think our role [as doctors] is to really help eliminate some of those barriers. Maybe it’s knowledge, maybe it’s strategies. A lot of it comes around guilt, and we can get rid of a lot of that stuff. We want babies to grow and thrive.

Dr. Angela Mattke:

Well said. One thing that I’ll never forget in that first visit – besides what you just said about breastfeeding. I totally remember you saying that to me, even though it was nine and a half years ago. It was that you asked about our carbon monoxide and smoke detectors, and if our batteries were working. And I remember my husband and I, we turned to each other, and were like, “I don’t know, but we’ll check. So thanks for the reminder on that.” It was good because we hadn’t even thought about it, but anyway, back to feeding your baby. Nipunie and I have a lot of questions for you. Since this is Nipunie’s journey, I’m going to let her drive the ship for us.

Dr. Nipunie Rajapakse:

Yeah. I think we’ve seen the pendulum swing back and forth historically on breast versus formula. I know initially, breastfeeding was the really only option until formulas came around. Then for a while, especially amongst the wealthy, formula was seen to be superior. Then now we see the pendulum has swung back to where breastfeeding is becoming much more popular and certainly encouraged as well. I guess maybe we can start with talking a bit about what the benefits are that we see from breastfeeding? Why is it encouraged, especially in pediatrics, as a really good feeding choice for babies?

Dr. Jay Homme:

Wonderful question. I just want to start by saying congratulations, Nipunie. I haven’t had the opportunity to offer you my congratulations yet. These are exciting times, exciting days ahead, but breastfeeding really has been the mainstay of feeding babies since babies were there to be fed. We hear some of the platitudes like “breast is best”, but it’s not instructive. And you’re right, there are different ways to feed babies, whether it’s exclusively breast milk, exclusively formula, or a combination of those things. We even have donor breast milk available to a lot of families now. We’re privileged here where we’re taping this, and where we’re living, that we have safe options. There are other places where breastfeeding is the safest option because there aren’t safe water supplies to make formula with.

There are rare situations where breastfeeding is not recommended — if certain illnesses are within mothers or [other] certain situations — but breastfeeding is recommended as a preferred option if it is available or if there aren’t barriers to it because of some of the benefits when it comes to growth, development, prevention of certain types of illnesses; there are associations with a lot of benefits. And there are really very few downsides to it. That being said, I think of tools in the toolbox. There are different tools in your toolbox for helping feed and to help your baby to grow. Breast milk is definitely one of those important tools to know about and to explore for many, many families. I would say that not all moms, but many moms have some desire to at least give this a try. Many of them go on to continue it as long as they’re supported, as long as there aren’t significant barriers or discomforts, and that’s where we can kind of help out.

Dr. Nipunie Rajapakse:

Yeah, that makes total sense. I guess, regardless of what I choose to feed the baby, how do I know that they’re getting enough? What are some of the things that you look at to make sure that a baby’s getting fed enough? I guess we’ll start there first.

Dr. Jay Homme:

Well, start at the beginning. Babies are born, they’re handed to their moms, and some of them go straight to the breast. Are they getting much? Nope. They’re not getting much, but they’re learning a skill, and they’re working together. Whether they’re fed at the breast, whether they’re fed through formula, it’s normal for newborns to lose some weight in the first few days. We actually expect that; we expect weight loss. As long as it’s less than about 10% of their birth weight loss, that’s normal. And then they’ll start to regain weight. As food goes in, whatever it is, things are going to come out. One of the good ways for newborn parents to get a sense of “are they getting enough?” — particularly if they’re breastfeeding and not sure what’s going in — is what’s coming out. In the first week of life, we expect babies to have about one wet diaper for every day of life they’re as old. As the days go on, they should have more wet diapers. And by the end of the first week, 6–8 wet diapers a day, that’s a good sign. The initial poops are really dark and sticky, and they just sort of clean them out, but then there’s not much. Then they start to stool and poop more, and there are more and more dirty diapers. That’s a good sign. The other thing too is breast milk. It’s takes energy for the body and maybe they’ll sleep a lot, but as they’re getting more milk, they’re getting that reinforcement. They have to work for it if they’re breastfeeding; breastfeeding’s hard work. It’s kind of like exercising. I have to run to the grocery store to get my food. If I get to the grocery store, and they don’t have any food, I’m going not going to go to the grocery store anymore. So as they start to get more, you start to get that feedback loop; the feedings just seem more productive. They may be a little bit longer and then start – over time, to get shorter and more efficient. They’re getting good at this new job that they have.

Dr. Angela Mattke:

That’s such a good way to describe it, Jay. I love that. And the other way you can know that your baby’s getting milk transfer, especially with breastfeeding, is you’re hearing those gulps. Also, your breasts are full beforehand [and then not full afterward]. Or in the beginning if you’re engorged, and you have a lot of knots, and you can feel the milk ducts and bumps all over that you can massage while you’re breastfeeding, and feel those working their way out. Those are a couple other things to look for. And then, just the number of times you’re breastfeeding – babies in the beginning should breastfeed probably about 10 times a day, anywhere between eight and 12 is usually pretty good.

Most babies will breastfeed about every two to three hours, but sometimes they may breastfeed every hour in the beginning, and we call that cluster feeding. Sometimes after they cluster fed, it’s usually between 9:00 PM and 1:00 AM, and the parents say they were on the breast the whole time, and then they slept for four hours. So that sometimes will happen. But most of the time you don’t want to let your infant go too long, probably more than three hours in most cases, unless they just cluster fed a ton. And if they want to have a little bit longer snooze at that time, it’s usually okay.

Dr. Jay Homme:

I don’t think we give babies credit for how smart they are. A lot of parents get really frustrated with those initial cluster feeds because they just seem like they go on forever. They can be uncomfortable, but really, that’s one of the baby’s ways of helping bring milk in sooner — if moms are drinking enough, they’re resting, they’re putting the babies to breast frequently. The milk will come in sooner. And once the milk comes in sooner, you’ll get those cues. Like Angie was saying, breasts feel full, breasts feel less full. You hear babies sucking and swallowing, and then you start to get those slightly longer periods of babies that are content, and they sleep a little bit longer. And that’s a nice thing to see.

Dr. Angela Mattke:

Oh, it’s a wonderful feeling.

Dr. Jay Homme:

When you come into the office, we’ll weigh babies, and we can actually calculate out, and we can say in the first month or two of life, “We going to see 20 to 30 grams of weight per day.” But parents don’t need to do that at home. You don’t need to buy scales. You don’t need to weigh your baby. There are plenty of other cues and clues to show you that your baby’s getting what they need.

Dr. Angela Mattke:

Yeah. I love that you said that because I think sometimes our anxiety about if the baby’s getting weighed and bringing them back more frequently can give the parents anxiety, but your job is just to feed your baby and make sure that you’re getting rest too. And our job is to weigh them in the office and make sure that they’re gaining weight. It divides it up and doesn’t put as much pressure on families.

Dr. Nipunie Rajapakse:

Yeah, that makes a lot of sense and I think takes some of the pressure off for sure, to know that we will be having some follow-up in the days and weeks after the baby is born. And that will be an opportunity to make sure that she’s gaining weight well and doing all the things that she’s supposed to be doing. Are there certain red flags that should prompt us to bring the baby in when it comes to feeding? Are there certain things we should be keeping an eye out for? You mentioned stooling and diapers. I know as an infectious disease doctor, I get quite a few pictures of different things in diapers. Usually, they want to know from me, is this a worm or something? But I’m sure you guys get a lot of questions about, is this normal baby poop or should I be worried? What are some of the red flags or things to look out for?

Dr. Jay Homme:

Well, before the red flags, let me just mention a couple of the normal things. We’ve talked about frequency of diapers increasing, that initially stools are going to look one way, and then they’re going to transition. They’re going to go from the black, sticky, tarry-looking meconium stools to, as they get breast milk, transitional stools, where they’re kind of brownish-green. Then they transition to what’s sort of described as yellow and seedy. And I think when parents see changes, they’re wondering, is this a normal change or an abnormal change? All of that is totally normal. Red flags, when it comes to stooling, you shouldn’t see blood in the stool, or if the stools are getting less and less frequent, that’s not what we’d expect as they start to increase and get more. Same thing with wet diapers, decreasing frequency of wet diapers, babies that are getting sleepier over days, rather than having better periods of wakefulness — shorter, seemingly inefficient feeds — rather than feeds that are seeming to go a bit longer and better. Those early days, those are some of the signs that I would say are red flags. As you move a little later on, or even sometimes early, if it should go in this end and should come out that end. If there’s a lot coming out the top, every baby will spit up some, but babies really shouldn’t have a lot of forceful or frequent vomiting where you feel like, “Boy, most of what went in just came right back out.” That’s something we definitely want to hear from you about.

Dr. Nipunie Rajapakse:

Great, definitely good things to keep in mind. What are some of the things that you look for? Say a primarily breastfeeding mom may be struggling a bit. What do you look for to decide when it might be time to supplement or try an option, and what options are available now?

Dr. Jay Homme:

Well, first and foremost, if mom is just struggling emotionally, having a lot of difficulty with sleep and feeling like, “Man, I just don’t think I’m going to do this anymore, even though I wanted to do it before.” That’s sometimes a great time to supplement [and say], “Hey, let’s get you some breaks. Let’s get you some more sleep.” You mentioned your partner, Thomas, who can be helpful with this, whether it’s through pumping or some type of formula supplementation. Or there is the option of donor breast milk, too, that some people can access. Those are things that are options. I think supplementation can be really helpful if it helps people continue down the pathway that they’re going to continue down; they don’t feel like they have to take the off-ramp. Another reason to supplement is sometimes milk is delayed and it’s coming in slower than we’d hope — and rarely…sometimes there just truly isn’t enough milk production for the baby, or sometimes multiple babies’ needs. Most moms’ breasts will make enough milk for their babies or their single baby’s supply and demand. But once in a while, that’s not the case, and it’s nothing against the mom, but that’s a good time to help. If the weight gain just isn’t coming along, we say, “Let’s go to the breast first. Let’s use pumping to try and stimulate milk,” but maybe this is a good time for a little formula supplementation. That doesn’t undo any of the good of the breast milk; formula and breast milk don’t fight inside babies’ bodies and try and duke it out for supremacy. It doesn’t work like that.

Dr. Angela Mattke:

Yeah. I love that. I love that analogy. I love that. And you mentioned in the beginning — I love the phrase “fed is best.” We want to support moms’ journeys no matter what, and whatever their goals are, we’ll do anything we can to help them, as long as it’s beneficial for the mom and beneficial for the baby, but we need babies to grow, and we need moms to have good mental health because it’s not good for babies when moms are struggling.

Dr. Jay Homme:

There’s so much mom guilt out there, so much mom guilt. Anything we can do to sort of relieve some of that.

Dr. Angela Mattke:

Yeah, exactly. Some of the benefits that we see with breastfeeding — they’ve really mostly been early studies — two months and four months for some of the reduction of illnesses and other things. And so if you’ve gotten to two months or four months that’s where most of our data ends on how beneficial breast milk is and in decreasing recurrent infections or obesity and other things. Then you should give yourself a really good pat on the back, and if it’s just too much for you at that point, then pick another option. Exactly like Jay said.

Dr. Jay Homme:

I was too excited that my kids were breastfed for the entire year. One, because I knew there were benefits; two, my wife just really enjoyed those interactions. I got jealous once in a while, though. Like, when will you pump so I can feed the baby some? And we said, “Six weeks, six weeks. Like, come on, do I have to wait six weeks?”. But also, you know, I’m a little bit on the cheap side, and we never had to buy formula – it’s expensive! So we bought the cheap diapers and no formula, and saved a lot of money. Rather spend it on his tuition.

Dr. Nipunie Rajapakse:

Yeah, exactly. That’s awesome. I’ve heard that, obviously, certain things that I eat can impact the baby, and I’ve heard if your baby is fussy, that there may be things in your diet that might be contributing. Is there truth to that? Or is that a rumor? Or any tips around what I can do with my own diet?

Dr. Jay Homme:

Well, in medicine, we’re always looking for evidence of things, and this is something that, honestly, is really difficult to study. This is one of the things I have learned from mothers rather than I’ve taught to mothers through the years. They’ve told me what they’ve noticed. I’ve had several moms say, “Well, every time I eat broccoli, the next day, my baby is gassy.” I said, “Well, try to stop eating broccoli.” And they came back later, “Yep. It was the broccoli.” So I learned, yes, the answer to your question is what you eat may have an impact or will have an impact on what your baby gets because your body is processing your nutrients and creating nutrition for your baby. Some of those things can have an impact. There’s no straight correlation between “never eat this because it always causes this in babies.” But we do find associations sometimes. And once in a while, there are things that are reasonably serious. Some babies do develop intolerances or some form of an allergy to something. And then moms really do need to eliminate that so that we can prevent harm to babies. But that’s very rare. Those are the kind of things that you would want talk to your doctor or nurse practitioner or healthcare provider for and we’ll help you sort that out. If you want to use it as an excuse, like, if you don’t like broccoli, just don’t eat broccoli.

Dr. Angela Mattke:

Just don’t eat broccoli.

Dr. Nipunie Rajapakse:

Excellent. I’ll start making my list.

Dr. Angela Mattke:

In general, it’s just best to eat just a wide variety of foods and things like that. And like Jay said, if they find one food is really, really bothersome to them, then it seems reasonable. But if pretty soon, like, every food is a concern for them, then I’m not sure that that’s really what’s causing it. And it might be a bigger issue because we don’t want moms to have really, really limited diets because the nutritional value of their breast milk goes down. And so, to me, it’s got to be a really significant improvement sustained over a while and not just like, “Oh, they were better for two hours this one day, but then the next day it was back.” It’s probably not the broccoli at that point.

Dr. Jay Homme:

Yeah. We’re always looking for “this caused this,” but as Angie said, there should be some consistent differences, not just one-offs. And in the middle of a sleepless night, we’re always looking for “what’s causing this” more.

Dr. Angela Mattke:

Because then you can fix it. You know what it is. But you can’t sometimes!

Dr. Jay Homme:

That’s right. And breast milk does change over time. Initial breast milk — the colostrum — is very different than breast milk that comes a week or two later. And it’s different than what comes a few months later. It changes for the needs of your child.

Dr. Angela Mattke:

Yeah, exactly. Nipunie, I have a question for you. So in the beginning I mentioned about antibody transfer for breast milk. This is your area since you are a pediatric infectious disease doctor. Can you talk a little bit about that? And, you know, we’re in the time of the COVID vaccine and there’s influenza vaccines every year. Are these things that can be transferred through breast milk to help benefit the infant?

Dr. Nipunie Rajapakse:

Yeah. As we talked about a bit already, one of the benefits of breastfeeding is some of the immunologic or immune system impacts that it can have. And so, we do know that there is transfer of antibodies from the mom to the baby during breastfeeding, and that early breast milk — the colostrum — is especially rich in different antibodies. From experiences with other infections, respiratory tract infections, or viruses that cause stomach flus, for example, or ear infections, we do know that there’s benefit to breastfeeding for some of those. The type of antibodies that are transferred in breast milk…there’s a mix of them, but primarily they’re the ones that protect our mucus membrane lining. The lining of the nose, mouth, and digestive system, and especially a type of antibody called secretory IGA, that helps to protect those surfaces.

The content changes over the course of breastfeeding itself. If there’s something that the mom has some immunity to, some of that antibody can be transferred to the baby and give them protection. Whether it’s something the mom has gotten immunity from, from being infected with it herself in the past, or she’s gotten a vaccine for that infection. Now, we’re obviously learning a lot about the COVID vaccine and breastfeeding, and the studies that have been done so far do show that moms generate a good antibody response in their bloodstream so that antibody can get to the baby when they’re in utero through the cord blood, but also that they do transfer some of that antibody over in the course of breastfeeding as well in pretty good levels. We still need to do some studies to see what level of protection is derived from the baby themselves. But certainly, since the youngest age that we’re studying COVID vaccines for is babies up to six months, that period – first six months of life – if they can get any boost of antibodies through cord blood or breastfeeding, would definitely be of benefit to them. We know that there are benefits when it comes to the immune system and breastfeeding.

Dr. Jay Homme:

It’s great hearing that more detailed response because when I get asked that question, I just say, “Yes.”

INTERMISSION

Dr. Angela Mattke:

Are you thinking about getting pregnant, or maybe you’re a current mom-to-be, or you’re like myself, in the midst of raising kids, and you’re looking for practical, evidence-based advice from Mayo Clinic experts? Mayo Clinic Press has got you covered. We have a series of four books, starting from Fertility and Conception to Guide to a Healthy Pregnancy, Guide to Your Baby’s First Years, and the last book in this series, the one I was the medical editor of, Guide to Raising a Healthy Child. You can find these amazing books from Mayo Clinic Press wherever books are sold, or on the Mayo Clinic Press website.

BACK TO THE SHOW

Dr. Nipunie Rajapakse:

We talked a bit about dietary things; so I’ve given up glasses of wine during pregnancy, looking forward to post-pregnancy. And so I’m curious, Angie, maybe you can take this one. Is it safe to have a glass of wine here and there while breastfeeding? Is it going to cause any problems for the baby? What do you recommend there?

Dr. Angela Mattke:

Yeah, I would say, one. There are a lot of good resources, and I’m going to answer the question, and for people that want all the details, the La Leche League has a really great website that’s evidence-based, uses research and uses LactMed resources to really go into the details about how it affects the baby, and when to do it and whatnot. But the take-home message is, we don’t know the long-term effects of alcohol in breast milk or when women are drinking. But we do know some of the short-term effects. Whatever you are ingesting with your alcohol, which is in your blood, your alcohol blood level will be the same as it is in your breast milk. If you still have alcohol in your blood, you still have alcohol in your breast milk, is the best way to think about it.

The La Leche League gives overall recommendations about how it can affect a baby; it can affect sleep; it can affect what we call your milk ejection reflex — so kind your let-down, per se. It can decrease your supply as well. But if you’re going to do it, they give some guidance, I think some kind of guardrails — what are the best ways to reduce the risk on the infant. That would include breast feeding the infant right before you’re going to drink. You give them all the breast milk at that point, then you would have your glass of wine or your glass of alcohol, and they recommend really limiting it to about one per day. Then ideally you wait about two hours before you would breastfeed again, because that would give enough time for the alcohol to be metabolized out of your blood and therefore metabolized out of your milk.

If you’re drinking more than one glass or continuing to drink, it’s probably not a good idea to breastfeed your baby that milk because there is going to be alcohol in it. There’s thought that the alcohol in breast milk is probably more intensified, as for the effects on the infant. You’ll see effects on their sleep. They won’t have good quality sleep; they’ll have less REM sleep. There’s also some research that that will continue for about the next 24 hours after the infant has had it. Take-home message: if you’re going to have it, have one glass, breastfeed the baby first, wait two hours before you breastfeed. And if you have any concerns about whether maybe you still have some alcohol content in your breast milk, it’s okay to just pump that one and not give it to the baby and give them some previously expressed breast milk or formula — supplementing in that situation. Does that help answer your question?

Dr. Nipunie Rajapakse:

Yeah, for sure. I like it, very practical tips and things to think about. That’s great. I know there are some things that can come up for moms when it comes to breastfeeding, mastitis being one of them. Any experiences to share with that?

Dr. Angela Mattke:

Yes. I had some experiences. I’m curious to hear if Jay’s wife, Becky, had some experiences as well. I had mastitis a couple times, and it seemed like every time my in-laws were around, I got mastitis. I don’t know. I don’t know what it was, but I remember that.

Dr. Jay Homme:

That’s one of those associations that we’re talking about–

Dr. Angela Mattke:

That’s an association!

Dr. Jay Homme:

Probably not causative.

Dr. Angela Mattke:

Absolutely. I noticed the association because they were there, and I remember feeling incredibly miserable. Mastitis often feels like you have influenza. Your body’s interferon response, which is the thing that makes you feel crummy, is your body trying to fight it off. Your breasts are really tender. They’re warm, they’re hot, they’re uncomfortable, breastfeeding feels horrible, and it hurts. But you need to breastfeed, and you need to express your breast milk because that’s part of the problem—it’s usually some blocked ducts, and bacteria gets in there, replicates, and then continues to cause infection from that point. Breastfeeding through it is fine. Breastfeeding, even on usually the majority of the antibiotics that we use for mastitis, which you probably know more about, Nipunie, than I do, are typically safe for the infant.

But I would catch it early. And then, more importantly, do the things you can do to prevent mastitis. If you’re noticing that you’re getting clogged ducts — if you’re having big, almost like ropes in your breast — you need to get that breast milk out. You need to get the clogged ducts taken care of. So massage, massage, massage. Warm packs before breastfeeding are really, really helpful. Then massaging those ducts out when you’re breastfeeding is incredibly helpful. Sometimes, people would need to pump in that situation, but sometimes we see mastitis when we see an imbalance between the infant’s demand for breast milk and your supply. If you’re having a lot of oversupply, that does sometimes put you at risk for mastitis because you’re not going to be always expressing all of the breast milk, and it increases your risk of having blocked ducts and developing that kind of pathway that I just talked about. Jay, did Becky ever experience it?

Dr. Jay Homme:

Yeah, unfortunately, a couple…two or three times early on. She felt really sick. Usually, just one breast – a little bit further up the breast — tender, red, sore, and then fever. She felt crummy. Early identification, getting on the appropriate antibiotics and continuing to nurse to express that milk, to clear it out, was really helpful. You can turn around pretty quickly, but this is one of those things where you should get in touch with whoever helps provide your healthcare, if you feel like you’re getting mastitis. Now, this is different than sore or cracked or even bleeding nipples. That’s another issue, and that’s a challenge, but that’s usually fairly early on in the process and gets better, but mastitis can come at any time. It’s really something to get on pretty quickly.

Dr. Angela Mattke:

Absolutely. And a lot of places just have telephone protocols to treat it. I know at Mayo Clinic, we just call in and you can get your antibiotics right away. I happened to be in another state, and they still took care of me, which was fantastic. Right at my in-laws, I started my antibiotics.

Dr. Nipunie Rajapakse:

Great. I wanted to ask a bit about breastfeeding in public. We have this situation where sometimes society is so judgmental of how you’re feeding your baby. They want you to breastfeed, but they don’t want to see you doing it. They don’t want you to be doing it out in public. I’m curious if either of you had any experiences along those lines or how do you approach that situation?

Dr. Angela Mattke:

Yeah. Jay, do you want to go first on this one?

Dr. Jay Homme:

Yeah. I mean, I think this is one of those times that it’s a good time to put some blinders on; you are setting the priorities for you, your child, your family’s situation. All the societal pressures – I’m not going to say they’re not impactful. I mean, we’re all influenced in some way, shape, or form, but this is one of the times, if it’s time to feed the baby, and you’re out in public, you do what you need to do for your baby. You can find ways that you feel comfortable doing it – there are many ways to cover; there are a lot of sort of shawls or blankets, or the baby industry will sell you anything and everything at all sorts of different price points. But even just a choice of thinking ahead of what you’re going to wear when you go out into public, it may make it much easier for you to do that and feel less self-conscious. I think there are options to be in places for breastfeeding. If you need to be out in public, you just find a way to do it that you feel comfortable with. I just say we don’t need to worry so much about the people around us. Now, we’re not trying to intentionally make other people uncomfortable, but that’s more their issue than it should be your issue, I think.

Dr. Angela Mattke:

Yeah, well said, well said. You know, we started talking a little bit about formula earlier in our discussion, and I think we should kind of move a little bit more into that. I know that sometimes formula gets a bad name, and we’ve talked about, the guilt and the feelings of failure that moms feel when maybe their goal was to breastfeed, and they transition to formula. But with that being said, I think a lot of us were raised on formula and turned out okay. I was one of them. I think I turned out okay. My husband definitely turned out as an amazing human being, and he was a hundred percent formula-fed. So we do know that babies will thrive and grow and be intelligent and be incredible members of society on formula. Let’s talk a little bit more about that. Jay, I have a question for you. I get this all the time in the office: which formula should I feed my baby? Like, everyone asks me that. And I’m like, “I don’t know. There’s a gazillion formulas on the shelf.”

Dr. Jay Homme:

I’ve been asked that many, many times as well. And my answer is pretty much always the same: I want you to start with the standard infant formula with iron. If you want to buy the store brand or you want to buy the one that they gave you a sample of in the hospital – they give the samples for a reason. Do you know where they get those? From the formula makers. It’s the same thing with the diapers. The only time my kids ever wore Pampers was in the newborn nursery. I’m not paying for those things. You can if you want, but formula needs to meet certain safety standards. It’s kind of like car seats. There are a lot of bells and whistles, but they should all be safe — the same thing with formulas. I would say many times through the years, I’ve seen parents back, and they’ve gone through several different iterations of formulas looking for the best one. I’d rather they talk to us along the waypoints. Sure, you can try two or three, but if you’re on your fourth or fifth formula, there’s something else we should be talking about. Maybe there’s some advice we can give you, but a standard infant formula with iron. Now, there are special situations for some babies where they need higher-calorie formulas, or they need ones without certain nutrients or more of certain nutrients, but most term babies can use any standard infant formula with iron.

Dr. Angela Mattke:

I would say, one thing to add on that is that babies are kind of just fussy in general. We used to just call our kids the angry poopers; 5:00 PM to midnight was the witching hour. They were just fussy. And I think having some type of expectation that your baby’s going to be fussy. It’s not always because they’re gassy; everyone thinks it’s gas, and they need gas drops and things like that. But have some expectation that there’s going to be some fussing going on. I bet by now, Jay, you are the baby whisperer of all baby whisperers.

Dr. Jay Homme:

Ooh, I love babies. I tell many a parent, if your baby goes missing, I will have a rock solid alibi. Now that’s a little creepy, but we don’t have any more! I’m waiting for grandchildren someday. Nipunie, if you need a babysitter, you just let me know, I’m good.

Dr. Nipunie Rajapakse:

I will take you up on that.

Dr. Jay Homme:

But about fussiness, I want to mention…because babies, they just can’t communicate well. They really have only one way early on, and it’s crying. How do you interpret what those things mean? There are actual normal things to expect around about three weeks of life. It’s developmentally normal for babies to start having a fairly predictable, fussy time. It might be 15 minutes. It might be an hour, and it’s like, “Well, we just sort of got this stuff figured out. Now my baby’s getting fussy. I must be doing something wrong.” No, it’s just normal. And that’s a good time to give us a call or send a message, and we’ll help you decide whether this might actually be totally appropriate.

Dr. Angela Mattke:

My favorite line– maybe you taught me this, Jay – but the best treatment for a fussy baby is a babysitter or a grandparent, not a formula change, or a food change in your diet.

Dr. Jay Homme:

Some parents think, “Oh, is my kid colicky?”. There are different definitions of colic. My simple definition is a truly colicky baby is the one that grandparents don’t want to be around.

Dr. Angela Mattke:

Oh! I had one of those.

Dr. Jay Homme:

Yeah.

Dr. Angela Mattke:

I had one of those with my second.

Dr. Jay Homme:

One of the pediatricians that helped train me gave me a mental picture for how to soothe a lot of babies, other than just giving them to somebody else, and this idea of warmth, motion, and sounds – sort of the old movie where the nanny was holding and rocking and shushing in a darker, quiet room, but the warmth, motion, and sound. Try those sort of things. Sometimes what you do is you just lay them down in a safe place, and you go away for a short period of time. Sometimes it’s the best thing you can do.

Dr. Angela Mattke:

It is the best thing. Yeah. I have one of those truly colicky babies. He would cry for about five hours straight per night. I remember my husband having a meeting one night, and I’m texting him at progressively more frequent intervals. Like, “When are you getting home? Why aren’t you getting home? You need to leave now.” At that point, I was like, “I’m going to call my mom. We need some help. We can’t handle this.” And she walked him for like 30 minutes and said, “I can’t do this,” and gave him back to us, so that’s when I knew that I had a colicky baby, when the grandma didn’t want to hold this screaming infant in their ear.

Dr. Jay Homme:

Yeah, my kids, most of them had some degree of a fussy time, but none were truly colicky. My nephew and one of my nieces were. The niece — my sister-in-law looked like she was experiencing post-traumatic stress disorder. She was looking at me like, “What do you tell your patients about colic? Why would their babies cry all the time?”. And I told them, “It will stop. I just can’t tell you exactly when.” And she’s like, “That’s what you tell them?”. I said, “That’s all I can tell them. It will stop. But I just can’t tell you when.”

Dr. Angela Mattke:

Yep. My mom kept telling me, “This, too, shall pass.” And I felt like, “When? I want the date!”

Dr. Nipunie Rajapakse:

As soon as possible.

Dr. Jay Homme:

Well, it’s just a good example. Colic is an extreme example, but there are going to be things, Nipunie, that come up that you either expected but just aren’t sure how to handle, or you just don’t expect. That’s what Angie said at the beginning: they don’t come with manuals. I had one mom tell me once in a visit, a pretty educated woman, waited a little bit longer to start her family, and was really just wanting to do it right. She said, “This book says this on this, this book says this on this. And this book says this on this.” And it was all about the same thing. And they’re just little gradations that were different. And she says, “Which is right?”. And I said, “Well, I hate to tell you, but your baby didn’t read any of those books.” Sometimes, we make big deals over little things, and we’re trying to not make a big deal over a little thing. And it’s hard, but it’s fun. I can honestly tell you looking back, there are great things about every stage, and there are hard things about every stage. And when you have to take one and drop the first one off at college, you want that little baby back, even though there were a lot of sleepless nights.

Dr. Nipunie Rajapakse:

No, I love that advice guys. So practical and puts my mind at ease a bit about feeling like I have to know all of this going into this journey. I think there’s going to be a lot to learn along the way for sure.

Dr. Jay Homme:

It’s a lot to be excited about, and it’s fun. Feeding your baby is such an important transactional thing. Parents will ask me, “How far can my baby see?”. About that far, you know, at first. There’s a reason to all these things. They see a short distance, they look in your face, and it’s a really special time to be able to feed babies, and then getting partners involved as well. Remember them. Changing diapers is a good role for partners, too. Particularly with middle of the night breastfeeding, my wife and I had a routine. I would get our child and change them if they needed to be changed; then, I would bring them to my wife. She would feed them, and then I would put them back in the crib or the bassinet nearby. And if they poop during the feed, then I would change them again. That was what I could contribute early on. Later on, there were other things.

Dr. Angela Mattke:

That is a great way. You were definitely contributing, and there are lots of things the partners can do. So it’s a great reminder.

Dr. Nipunie Rajapakse:

Alright. I had some questions about vitamin D. Is this something that you need to give the baby if they’re getting formulas or enough in formula? Do I have to give it to the baby, or can I take it myself, and does enough get through the breast milk to them?

Dr. Jay Homme:

Yeah, what we said before, breast milk is generally the optimal feeding for babies. Maybe we will say with one exception: we have shown over time that, oftentimes, babies don’t get enough vitamin D. That’s led the American Academy of Pediatrics and other pediatric providing organizations to recommend supplementation in the first year of life. The standard recommendation is that babies get 400 international units of vitamin D daily. Now most parents, if they remember to do it a few days a week, they’re doing better or they’re going to be getting enough. And you say, “Well, doesn’t formula have vitamin D?”. It does, it does have vitamin D. But we still recommend vitamin D supplementation, even for formula-fed babies, unless they’re getting somewhere between like 30–35 ounces or so a day, and they will get that at some point, but not right away. It’s just simpler to recommend it for everybody. It’s safe; it’s effective. There are different ways to go about it. It’s available pretty readily now, and moms can take vitamin D supplementation, and there have been studies to show if you take a lot, the baby will get enough, and you can do that if you want. But I think it’s simpler to get some vitamin D drops and try and remember to give your baby one drop a day most days of the week, and they’ll be doing great.

Dr. Angela Mattke:

I like that pragmatic advice: most days of the week when you could remember, because that’s reality. That is reality. I can remember my son’s medications, but I felt like that vitamin D – sometimes, that was just easier to forget. I’m not quite sure how that happens. Thank you all for joining us today, and Dr. Homme, thank you so much for joining Nipunie and I; this was a fantastic discussion. I think I’ve laughed more than I have in a long time. Thank you to our listeners! We hope you can join us on the rest of our episodes of the pregnancy podcast series. The next one is the sleep episode, and we’ll help you understand the science of infant sleep and how to prevent the most common sleep issues in the first year of life. We’ll talk about what’s actually appropriate for infants, and if it’s a realistic goal that your infant should be sleeping through the night by 12 weeks? Or is it even healthy for them? We’ll delve into that a little bit further. We’ll go through bad habits that you can avoid. And Dr. Homme will be joining us on that episode and sharing all of his experience of raising his kids and trying to get them to sleep through the night.

Thanks everyone for joining today. Make sure you don’t miss any of our upcoming episodes by subscribing and falling along on either Apple Podcasts or Spotify. If you enjoyed this episode and you want other moms out there to hear this valuable information, make sure that you leave a review wherever you listen. Thanks for joining us. We’ll see you next time.

Angela Mattke

Angela C. Mattke, M.D.

Dr. Mattke is the medical editor of Mayo Clinic Guide to Raising a Healthy Child and  a pediatrician in the Division of Community Pediatrics and Adolescent Medicine at Mayo Clinic Children’s Center in Rochester, Minnesota.

Nipunie Rajapakse, M.D.

Dr. Rajapakse is a pediatric infectious diseases physician at Mayo Clinic in Rochester, Minnesota. Her clinical focus includes management of pediatric infections. Her primary research interests include studying ways of optimizing antibiotic use in children (antimicrobial stewardship) to decrease antibiotic resistance and other harmful effects. She has worked for the World Health Organization and has an interest in global health and outbreaks of emerging infectious diseases.

Jason (Jay) H. Homme, M.D.

Dr. Homme is a pediatrician at Mayo Clinic in Rochester, Minnesota. His clinical and research interests include diagnosis and treatment of the common condition of group A streptococcal (GAS) pharyngitis (strep throat). Additionally, as program director for the Pediatric and Adolescent Medicine Residency at Mayo Clinic, Dr. Homme aspires to provide the highest quality training experience possible for the pediatricians of tomorrow.

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