Qn of the Month: How Can I Tell My Baby Is Full?

A: An age old question is, “How can I tell my baby is full?” Just as important as the previous post (How Can I Tell My Baby is Hungry?) is being able to tell when your baby is full, so that baby gets just the amount of intake he/she needs for optimum growth and development.

Some signs to watch out for in the infant include:

  • Falling asleep after emptying or softening at least one breast
  • Infant pushing away from the breast or fussing with back arching
  • Reduced sucking
  • Infant drawing head away from the nipple
  • Infant’s body relaxes with extended and relaxed hands/arms

Young babies under 3 months of age may not give clear signs of hunger and fullness, but these cues are usually clear by 3 to 6 months of age. For optimal health and growth, parents should check to see if their baby is still hungry after a pause in feeding by looking for satiety cues. This is important before continuing forward in the feeding, especially in babies that are bottle fed. Parents are often eager to have a baby finish an entire bottle of expressed breast milk or formula, simply because they see the contents in the bottle, instead of letting the baby decide when or how much to take at a feeding.

Qn of the Month: What are Early and Mid Hunger Cues?

A: Instead of waiting till your baby starts bawling from hunger, look out for these signs (early and mid cues) that baby needs a feed…before he/she starts kicking and screaming in a fit of frenzy. Most people are not aware that crying is actually a late hunger cue. Early cues help signal that the baby is getting hungry, while mid cues signal that baby is REALLY hungry.

Early Cues:

  • Stirring in the sleep
  • Mouth opening as if he or she is nursing
  • Turning head from side to side
  • Seeking/Rooting

Mid Cues:

  • Stretching
  • Increased physical movement
  • Hand to mouth activity
  • Sucking on hands or clothing

Mothers Aware: Breastfeed for Your OWN Health!

We often hear of the myriad of benefits a baby gets from breastfeeding and breastmilk. These range from the antibodies and immune enhancing properties provided by colostrum, the changing but tailored macronutrient composition of breastmilk as an infant grows, to the reduction of infant mortality and a quicker recovery during illness for infants exclusively breastfed.

But what about for mothers? The list of benefits is just as impressive. Although more studies are needed, current research is showing that mothers with gestational diabetes who breastfeed tend to have better blood glucose control, and likely longer term benefits such as a reduced risk of type 2 diabetes, a reduced risk of metabolic syndrome and more long-term continued function of the pancreas in insulin production. The improved glucose control seems to come via many routes such as better glucose utilization for milk production and increased insulin secretion and pancreatic beta cell mass caused by the hormone prolactin which increases through lactation. Other benefits of breastfeeding for mothers include better cardiometabolic profiles, improved blood pressure levels, quicker contraction of the uterus postpartum and reduced ovarian and breast cancer risks.

From personal experience, this seems to be true. For my first pregnancy I had more severe gestational diabetes, requiring blood glucose checks 4 times a day, and relatively strict diet control to maintain good blood glucose levels. However,  I subsequently breastfed my firstborn for 15 months. When it came time for my oral glucose tolerance test (OGTT) during my second pregnancy, I was pleasantly surprised to see the results showing I had only borderline gestational diabetes. The doctor advised me that I only needed to check my glucose level once every day or so! As a result I had a much more relaxing second pregnancy and did not need to monitor everything I ate so closely, as my blood glucose levels staying mostly within range.  So mothers, breastfeed for your own health!

(Sources:

  1. Kalra B, Gupta Y, Kalra S. Breast feeding: preventive therapy for type 2 diabetes. J Pak Med Assoc. 2015; 65(10):1134-6. http://jpma.org.pk/PdfDownload/7505.pdf. Accessed May 15, 2016.
  1. Breastfeeding. World Health Organization. http://www.who.int/maternal_child_adolescent/topics/child/nutrition/breastfeeding/en/ . Accessed May 15, 2016.
  1. Gunderson EP. Impact of breastfeeding on maternal metabolism: implications for women with gestational diabetes. Curr Diab Rep. 2014; 14(2):460. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4146528/pdf/nihms558299.pdf. Accessed May 15, 2016.
  1. Rabin RC. Breast-Feeding Is Good for Mothers, Not Just Babies, Studies Suggest. The New York Times. http://well.blogs.nytimes.com/2015/11/23/breast-feeding-is-good-for-mothers-not-just-babies/. November 23, 2015. Accessed May 15, 2016.
  1. Much D, Beyerlein A, Roßbauer M, Hummel S, Ziegler AG. Beneficial effects of breastfeeding in women with gestational diabetes mellitus. Mol Metab. 2014; 3(3):284-292. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3986583/pdf/main.pdf. Accessed February 18, 2016.
  1. Ziegler AG, Wallner M, Kaiser I, Rossbauer M, Harsunen MH, Lachmann L, et al. Long-term protective effect of lactation on the development of type 2 diabetes in women with recent gestational diabetes mellitus. Diabetes.2012; 61:3167 – 3171. http://diabetes.diabetesjournals.org/content/61/12/3167.long. Accessed May 15, 2016.)

Qn of the Month: Does My Breastfeeding Baby Need Iron Supplements?

Infant Grasping Mother's FingerA: This is another ‘yes’ and ‘no’ answer. Whether a breastfeeding baby needs iron supplementation is dependent on many factors such as whether the child was born full term or premature, fully breastfed or not, amount of iron-fortified infant formula consumed, the age of introduction of solids, what those complementary solids are and also country specific recommendations.

In the United States, the American Academy of Pediatrics (AAP) revised its recommendations in 2010 to better meet the iron needs of infants to prevent iron deficiency. For infants who are exclusively breastfeeding, the AAP currently recommends an oral iron supplement of 1 milligram iron per kilogram per day (1mg/kg/day) starting when the baby is 4 months of age. This should be continued until the baby is well established on iron-containing complementary foods to provide the same level of iron. This also applies to partially breastfed infants, who receive more than half of their daily feedings as breast milk. Some examples of iron-containing complementary foods would be iron fortified infant cereals and puréed meats.

All preterm infants should have an iron intake of a minimum of 2 mg/kg/day up until 12 months of age. For preterm infants fed breast milk, the AAP recommends 2 milligrams of iron per kilogram per day to be started at one month of age. This supplementation should be continued until the infant is transitioned over to an iron fortified formula and/or the diet includes complementary foods supplying 2 mg/kg per day of iron.

What about babies who are not breastfed? Fully formula fed term infants would likely have their iron needs met during the first 12 months of life from standard infant formulas alongside iron-containing complementary foods introduced after 4-6 months of age. For premature fully formula fed infants, the standard preterm or term infant iron fortified formula would generally be a sufficient source of iron, though some formula fed preterm infants may need additional iron supplementation. The exception to the need for supplementation is if the preterm infant was provided blood transfusions and is at risk for iron overload.

(Source: Baker RD, Greer FR, Committee  on Nutrition. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children 0 through 3 years. Pediatrics. November 2010. 126(5):1-11. http://pediatrics.aappublications.org/content/early/2010/10/05/peds.2010-2576.abstract. Accessed October 27, 2014.)

Fresh Versus Frozen: The Taste of Thawed Breast Milk

Frozen thawed milk tastes different from fresh. How do I know? Because I was basically dared by my mother-in-law (MIL) to try my own breast milk (yes…). At the time, my baby was about 3 months of age and wasn’t taking breast milk well from the bottle. My MIL suggested it was the taste of the thawed breast milk, as her friend said her grandchildren had the same issue because the thawed breast milk did not taste good. I knew breast milk usually tasted slightly sweet because of the lactose content, but I didn’t really believe my MIL that there could be such a vast difference in taste between fresh and frozen to affect baby’s intake. Especially since I had learned as a dietitian that a baby doesn’t usually develop a strong taste preference until after 6 months of age. Before then it was often possible to get a baby established onto a more bitter tasting hydrolyzed formula even if the baby had been used to the sweet taste of breast milk. And after all, if the expressed breast milk had been quickly frozen, wouldn’t that slow down the lipase enzymatic action on the fats within the breast milk and so prevent the breast milk from going ‘off’ in taste? Well, my MIL then implied that if I didn’t believe her I should taste the breast milk myself. So I did. In front of her.

And okay… there IS a difference. Fresh breast milk tastes…fresh…a bit like cow’s milk but lighter, more watery and with a slightly sweet taste. The thawed breast milk tasted more bitter and metallic. I found it had to be heated more in temperature to make it more palatable tasting.

My little one still took the thawed frozen breast milk (sometimes with a bit of cajoling and distraction with a toy) from a bottle until about 4-5 months of age, then after that she seemed to get wise to the fact that it really didn’t taste very good, and so refused more adamantly to take it (even when she was really hungry). She would always drink fresh pumped breast milk though!

What I have found I needed to do was this: Give the frozen breast milk as soon as it has thawed. This means really within the first hour or two after it has been thawed out in the fridge. Doing so will keep the thawed frozen breast milk tasting as close as possible to freshly pumped milk. Any more than that, and the bitter, metallic and soapy taste starts to appear, especially the longer it sits (mainly because of the active components within the breast milk like the lipases which start to break down the fat within the milk).

Note that even if there are some taste changes in the thawed breast milk, you can still use it in the baby’s food, assuming the baby is eating at least a few tablespoons’ worth of solids in a sitting. This gets easier to do as baby gets bigger and eats more at a time. So don’t toss all your hard work of pumping away!

 

Breastfeeding Nutrition: Country Specific Recommendations

Here are a few specific nutrient recommendations for breastfeeding women in the United States (US) and United Kingdom (UK). As you’ll see, some of these differ, so choose which recommendations you want to follow!

UNITED STATES

Fish Intake & Mercury—
Fish is a good source of vitamins, minerals and essential omega 3 fatty acids. The American Academy of Pediatrics (AAP) recommends an average daily intake of 200-300mg of omega 3 long-chain polyunsaturated fatty acids (docosahexaenoic acid [DHA]). This can be met through the consumption of 1-2 portions of fish a week. The general guideline is to aim for 8-12 ounces of cooked fish a week, choosing lower mercury containing fish (examples are herring, canned light tuna, salmon, flounder, tilapia, trout, pollock, catfish) while avoiding intake of predatory fish (e.g., shark, pike, marlin, King mackerel, swordfish, tile fish) due to their likely higher mercury levels. For the same reason, choose light canned tuna instead of canned “white” tuna (albacore). If you consume canned “white” tuna (albacore), have less than 6 ounces a week. If you don’t include fish in your diet, then some non-fish sources of omega 3 fatty acids are canola oil, soybean oil, ground flaxseed and walnuts.

Calcium—
In the United States, the calcium recommendations are the same for adult breastfeeding and pregnant women (19-50 years of age) at 1000mg/day. Look for calcium rich sources like dairy products, calcium and vitamin D fortified drinks, breakfast cereals and breads fortified with calcium.

Vitamin D—
For a breastfeeding mother, 600 international units (IU) or 15 ug of vitamin D is recommended daily. It is generally easier to meet these recommended vitamin D intakes in the United States because more commercial products tend to be fortified with vitamin D. Examples are many cow’s milk, yogurts, and cheese dairy products, calcium and vitamin D fortified soy milk and juices, and breakfast cereals like General Mills Total® cereal.

Vitamin & Mineral Supplementation—
According to the AAP, there are currently no routine recommendations for maternal supplements during breastfeeding, though many doctors recommend continued use of prenatal vitamins. Poorly nourished mothers or those on selective vegan diets may need multivitamin and omega 3 supplements.

UNITED KINGDOM

Fish Intake & Mercury—
Breastfeeding women are recommended to have no more than 2 portions of an oily fish a week (examples of oily fish are fresh tuna, salmon, mackerel, sardines, herring, pilchards and trout). If predatory fish like shark, swordfish, marlin are consumed, it is recommended that no more than 1 portion of these fish are consumed a week. There is no restriction on the amount of canned tuna a breastfeeding woman can have. In the UK, however, canned tuna does not count as oily fish as they are low in the good fats and in vitamin D due to the processing methods used.

Calcium—
Calcium recommendations actually jump from 700mg a day for an adult pregnant woman to 1250mg a day for a breastfeeding mother! One cup of milk has about 300mg of calcium, so this would mean aiming for at least 3-4 servings of calcium rich products a day. Examples are dairy products like cow’s milk, yogurt, cheeses, fromage frais; calcium and vitamin D enriched oat milk, rice milk and soy milk (note that ‘organic’ versions mean these are not fortified with calcium or vitamin D); calcium fortified breads and cereals.

Vitamin D—
The UK Department of Health recommends that all pregnant and breastfeeding women have 400 international units (IU) or 10 ug of vitamin D daily. Some food sources of vitamin D include oily fish, fortified margarine and eggs. Here are also some foods on the market that are fortified with both calcium and vitamin D: certain breakfast cereals like Kellogg’s Corn Flakes®, Weetabix Crunchy Bran®, Ready Brek® porridge, and calcium and vitamin D fortified cow’s milk alternatives like soy milk, rice milk and oat milk.

Though food in the diet can contribute to vitamin D levels, it may be difficult to obtain enough vitamin D from diet alone (especially in the UK where many foods on the market like dairy products are not fortified with vitamin D). Our bodies can also manufacture vitamin D through modest exposure to direct UVB sunlight. However, factors like variable weather conditions, use of sunscreens, different skin types and cultural practices may all impact on vitamin D levels. So for those who find it hard to get enough vitamin D from the sun and their diet, a vitamin D supplement might be needed.

Breastfeeding Nutrition: Nourish Your Body!

Eating well is an important part of self-care, especially during breastfeeding. Nourishing your body can only help you in post-delivery healing, maintaining health, and in keeping up energy levels during this demanding period of life. Plus if you’re going to eat anyway, you might as well be smart about what you are having!

How much to eat?
It is estimated that a breastfeeding woman may need an extra of 450-500 calories a day, though the actual intake a woman needs also depends on other factors like body fat and physical activity levels.  How much is 450-500 calories? It’s roughly equivalent to a Starbucks’ white hot chocolate (16oz) with whipped cream, or a sandwich (made of 2 slices of bread, mayo, cheese and lunchmeat) plus a glass of milk, so not a huge amount more!

At the beginning you may not notice the need to increase your intake (this may be why breastfeeding women lose those pregnancy pounds much faster). However, as your baby’s intake at the breast increases, you may start to feel hungrier. If you’re like me, I felt like I was the cookie monster raiding the kitchen every few hours (especially after a full pumping session). I found I soon needed to add in 1-2 snacks or ‘mini-meals’ during the day to compensate and keep up my energy levels.

What to eat?
As in pregnancy, continue to aim for a varied and healthy diet, with plenty of whole grains, protein-rich foods (e.g., lean meat, chicken, turkey, fish, eggs, pulses like beans and lentils), vegetables and fruits. Continue to include at least 2-3 daily servings of good sources of calcium in your diet. These include milk, yogurt, cheese, tofu prepared with calcium sulphate, broccoli, okra, and calcium fortified drinks.

Keep meals simple so they will be easy to prepare.  If you are too tired or feel you don’t have the energy to fix yourself three proper meals in between trying to rest and breastfeed, then eat smaller ‘mini-meals’ throughout the day. Alternatively, have lots of healthful nutrient dense snacks available in the house which you can consume quickly and then rest. Examples are a quick handful of nuts, dried fruit or sunflower seeds (or combine these with cereal to make your own trail mix), bananas, granola bars, fresh fruits, tinned fruits (canned in its own juice), salads, yogurts, hummus with pitta bread or vegetable sticks, cheese and crackers, canned soup, tinned fish to make quick sandwiches, and cereal.

Hydration
Along with eating well, is drinking well too. Breastfeeding can make you feel quite thirsty so drink lots! Water is fine, but include other more nutritious options during the day as well. Examples are milk or calcium fortified alternatives (like calcium fortified soymilk, oatmilk, coconut milk, orange juice…the possibilities are endless!), frozen fruit banana yogurt smoothies, soups and broths. Sometimes it helps to have a glass ready near your breastfeeding chair so that every time your baby breastfeeds, you can have a drink too!