Priority Topic: Newborn & Priority Topic: Well-baby Care

Newborn

Key Feature 5: When a parent elects to bottle feed, support their decision in a non-judgemental manner.
Skill: Professionalism, Patient Centered
Phase: Treatment

Well-baby Care

Key Feature 3: Anticipate and advise on breast-feeding issues (ex: weaning, returning to work, sleep patterns) beyond the newborn period to promote breast-feeding for as long as it is desired.
Skill: Clinical Reasoning, Patient Centered
Phase: Hypothesis generation, Treatment

According to the Evidence Summary of my fave Rourke Baby Record (RBR), "Exclusive breastfeeding is recommended for the first six months of life for healthy term infants. Introduction of solids should be led by the infant’s signs of readiness – a few weeks before to just after 6 months. Breast milk is the optimal food for infants, and breastfeeding (with complementary foods) may continue for up to two years and beyond unless contraindicated. Breastfeeding reduces gastrointestinal and respiratory infections and helps to protect against SIDS." This Evidence Summary also provides a link to an article published by the Canadian Pediatric Society titled, "Weaning from the breast." The abstract for this article concurs with and elaborates on the above quote from the RBR, and includes the following text:

"Exclusive breastfeeding provides optimal nutrition for infants until they are six months old. After six months, infants require complementary foods to meet their nutritional needs. This is when weaning begins. Weaning is the gradual process of introducing complementary foods to an infant’s diet while continuing to breastfeed.

There is no universally accepted or scientifically proven time when all breastfeeding must stop. The timing and process of weaning need to be individualized by mother and child. Weaning might be abrupt or gradual, take weeks or several months, be child-led or mother-led. Physicians need to guide and support mothers through the weaning process."

I find the entire article a very useful read for any primary care provider who may find themselves in a position of counselling women on weaning. It certainly talks about the basics, and provides links to further sources of information. 

One particularly useful thing about this article is its section on recommendations for physicians, which includes the following suggestions:

• Support exclusive breastfeeding, with vitamin D supplementation, for the first six months of life
• Encourage continued breastfeeding for up to two years and beyond while providing appropriate nutritional guidance
• Advise mothers to introduce iron-fortified foods in the form of meat, fish or iron-fortified cereals as first foods, to avoid iron deficiency
• Advise slow, progressive, natural weaning whenever possible
• Inform and support breastfeeding mothers while ensuring adequate nutrition for their babies, regardless of the timing of weaning

For women who are returning to work, the articles suggests pumping as a method of promoting ongoing breastfeeding, as indicated: "Partial weaning is an option for the mother who wishes to continue breastfeeding. This can work well for the mother who is working or studying outside the home. Early morning, evening and night feedings can continue even if mother and baby are separated during the day. For times spent away from her baby, a mother can express milk. Pumping should allow her to maintain production of milk."

Another useful resource, of the many, linked through by the RBR is the Breastfeeding Handbook published by the Baby-Friendly Newfoundland and Labrador Perinatal Program. Breastfeeding moms will often want to know how often they should be feeding their babies, including throughout the night. The Breastfeeding Handbook provides an answer for this:

"All babies have their own feeding and sleeping habits. Breastfeed your baby as often as she is interested or 'on cue.' Many babies will need to breastfeed every 2–3 hours during the day and night, at least 8 or more feedings in 24 hours. Remember, breastfeeding at night boosts your milk production and prevents engorgement.

Your baby may breastfeed more often at certain times of the day (every hour for 2–6 hours) and then sleep for a longer period. This is called cluster feeding and it is normal. Some mothers worry that they do not have enough milk if their baby seems to want to be on the breast often. Follow your baby’s cues. Frequent breastfeeding in the early weeks helps to establish a plentiful milk supply at six weeks.

As your baby grows, she will set her own sleeping and feeding patterns. A breastfed baby may feed about every two hours during the day and sleep for longer stretches at night by the age of 2–3 months. There is no set age when a baby should sleep through the night. In fact, most healthy breastfed infants wake often for night feedings well into their first year of life."

Like most of the counselling provided to parents with concerns, it usually involves reassurance, as most parents have many concerns despite the fact that most children develop normally. That being said, providing effective reassurance requires health care providers to know what clues suggest a potential problem. The key here is knowing what the problems look like, and then being reassured when evidence of those problems is not found. Even without answers to the multitude of creative questions parents may have, simply knowing what the reasons to worry about are, and reassuring if those worries are not present, is the key to providing effective counselling, with the understanding that the trajectory of childhood development is not homogenous and variability in and of itself is not problematic.

One other issue to make mention of here is the fact that some women prefer not to breastfeed at all, for whatever reason. While breastfeeding is preferred by medical professionals in general, babies can receive sufficient nutrition using commercially available infant formulas. It is important for the sake of preserving the quality of the physician-patient relationship to be nonjudgmental when women choose to feed their infant using formula rather than breastmilk. There is an excellent guide put out by Alberta Health Services for medical professionals that gives an overview of the formula available and when different formulas may be recommended. You can reach it by the links through the Rourke Baby Record or here.