Breastfeeding and Introducing Other Foods

by Jack Newman, MD, FRCPC

Introduction

Here's What You'll Find Below:Supplementing during the first few days
Does my baby need water?
Vitamin D
Starting solid foods

Breastmilk is the only food your baby needs until about 6 months of age. There is no advantage to adding other sorts of foods or milks to breastmilk before about 6 months, except under unusual circumstances.

Many of the situations in which breastmilk seems to require addition of other foods arise from misunderstandings about how breastfeeding works and/or originate from a poor start at establishing breastfeeding.

In other words, if your baby is breastfeeding well and gaining weight well, then add solids only when the baby shows signs of being ready to eat solids. See the information sheet Protocol to Manage Breastmilk Intake.

Supplementing during the first few days

It is thought by many that there is "no milk" during the first few days after the baby is born, and that until the milk "comes in" some sort of supplementation is necessary. This idea seems to be born out by the fact that babies, during the first few days, will often seem to feed for long periods and yet, not be satisfied.

However, the key phrase is that "babies seem to feed" for hours when in fact, they are not really feeding much at all (see the video clips of young babies, younger than 2 days, breastfeeding very well and getting milk well, at the website nbci.ca). A baby cannot get milk efficiently when he is not latched on properly to the breast, particularly when the supply is not yet abundant.

Note, breastmilk is not supposed to be abundant in these early days. But during the first few days, if the baby is not latched on properly, he cannot get milk easily and thus may "seem to feed" for very long periods. There is a difference between being "on the breast" and drinking milk at the breast.

The baby must latch on well so he can get the mother's milk that is available in sufficient quantity for his needs, as nature intended. In the first few days, the mother does have the appropriate amount of milk that baby requires. She is not supposed to have a large amount and nobody has proved that the large amount of formula a baby will take in the first few days is good for him or safe!

Yes, the milk is there even if someone has proved to you with the big pump that there isn't any. How much does or does not come out in the pump proves nothing -- it is irrelevant. Also note, no one who squeezes a mother's breast can tell whether there is enough milk in there or not.

A good latch is important to help the baby get that milk that is available. If the baby does not latch on well, the mother may be sore, and if the baby does not get milk well, the baby may want to be on the breast for long periods of time worsening the soreness. Or the baby may fall asleep at the breast and seem to have fed well; but babies tend to fall asleep at the breast when the flow of milk is slow.

1. A baby who drinks well (see video clips at the website nbci.ca) and falls asleep at the breast > that's the way it should be.

2. A baby who drinks poorly and then falls asleep at the breast > that’s not the way it should be. The mother and baby need help with the breastfeeding.

When the mother's milk becomes more plentiful, after 3-4 days, the baby may do well even if he is not well latched on (the mother may be sore, but even this is not necessarily so -- many mothers just put the baby to the breast any old way and both she and the baby do fine). If a better latch, and compression (see the information sheet Breast Compression) do not get the baby breastfeeding, then supplementation, if medically needed, can be given by lactation aid (see the information sheet Lactation Aid).

The lactation aid is a far better way to supplement than finger feeding or cup feeding, if the baby is taking the breast. And it is much, much better than using a bottle. But remember, getting the baby well latched on first and using compressions will work most of the time and no supplements will be needed. Using a lactation aid before helping the mother and baby with the breastfeeding is not appropriate just because a bottle is not being used to supplement.

Water

Breastmilk is over 90% water. Babies breastfeeding well do not require extra water, even in summer, even in the hottest weather. If they are not breastfeeding well, they also do not need extra water, but rather, the mother and baby need help so that breastfeeding works better.

Vitamin D

It seems that breastmilk does not contain much vitamin D, but it does have a little. We must assume this is as nature intended not a mistake of evolution. In fact, breastmilk is one of the few natural foods that does contain some vitamin D. We were obviously meant to get our vitamin D from being exposed to sunlight.

The baby stores up vitamin D during the pregnancy and he will remain healthy without vitamin D supplementation for at least a couple of months, unless the mother herself is vitamin D deficient during the pregnancy. Vitamin D deficiency in pregnant women in Canada and the USA is uncommon, but it does exist.

Outside exposure also gives your baby vitamin D even in winter, even when the sky is cloudy. A few minutes of exposure very late on a summer's day is ample. Thirty minutes during a summer week, and an hour or so in winter, gives your baby more than enough vitamin D even if only his face is exposed.

Under unusual circumstances, it may be prudent to give the baby vitamin D. For example, in situations where exposure of the baby to ultraviolet rays of the sun is not possible (Northern Canada in winter or if the baby is never taken outside), giving the baby vitamin D drops would be advised.

If you have had very little outside exposure yourself (women who are veiled are particularly at risk, especially if they are dark skinned), make sure your intake of vitamin D during the pregnancy is higher than usually recommended. Your baby may need vitamin D supplementation as well. Recent studies suggest that high intake of vitamin D while breastfeeding (4000 IU a day—10 times the usual recommended dose) does in fact increase the amount of vitamin D in the milk to levels that will protect the baby from rickets.

Iron

Breastmilk contains much less iron than formulas, especially the iron-enriched formulas, and this is as it should be. Actually, the low levels of iron in breastmilk are thought to give the baby extra protection against infection, as many bacteria require iron in order to multiply. The iron in breastmilk is very well utilized by the baby (about 50% is absorbed), while being unavailable to bacteria and the breastfed full term baby does not need any additional iron before about 6 months of age. However, introduction of iron containing foods should not be delayed much beyond 6 months of age.

Solid Foods

Exclusively breastfed babies do not usually require solid foods before about 6 months of age (see also the information sheet Starting Solid Foods). Indeed, many do not require solid foods until 9 months or more of age, if we can judge by their weight gain and iron status.

However, there are some babies who will have great difficulty learning to accept solid food if not started before 7-9 months of age. Because the six-month-old baby will also soon need to have an additional source of iron, it is generally recommended and convenient that solids be introduced around 6 months of age. Some babies show great interest in grabbing food off your plate by 5 months, and there is no reason not to allow them to start taking the food and playing with it and putting it in their mouths and eating it.

It has been the habit of physicians to suggest that babies be started first on cereals and then other foods be added. There is nothing magic about cereal and babies do fine without it. In fact, other than calories and added iron there is not much of nutritional value in cereals. The easiest way for the baby to get additional iron is by eating meat, not by cereals from which the iron is poorly absorbed and the vast majority comes out with the baby's bowel movements. Furthermore, cereals tend to be constipating. Real food that you eat is best for baby.

There is no good reason why a baby needs to eat or be introduced to only one food per week or why vegetables should be started before fruits. Anyone worried about the sweetness of fruit has not tasted breastmilk. The six-month-old can be given almost anything off his parents' plate that can be mashed with a fork. If you eat healthy, then baby will eat healthy. Far fewer feeding problems will occur if a relaxed approach to feeding is taken.

Breastmilk, cow's milk, formula, outside work and bottles. (See also the information sheet What to Feed the Baby When the Mother is Working Outside the Home).

In modern industrial societies we have so long fed babies with bottles that we cannot imagine that a baby can be fed without one. The "need" for baby to take a bottle is purely a manufactured one and marketing continues to emphasize this need. No baby needs to take a bottle as an entrance requirement for kindergarten -- instead all children will eventually learn to drink from a cup (not a "sippy" cup which is, essentially, a bottle).

It is true that an older baby will often not take a bottle if not used to it. This is no great loss. So, why not teach baby to use a cup? Babies can learn to take a cup at birth, though there is not usually a reason to for them to do so. See the video clip of a 2- or 3-week-old baby drinking from a cup at the website nbci.ca. In this case the baby is being cup fed to avoid a bottle. He is not yet able to latch on to the breast.

However, if mother needs to be separated from her baby for any reason, the baby can drink her milk by cup. This is best learned when baby is not ravenous (see the information sheet Finger and Cup Feeding). At about 6 months or even younger, the baby can start learning to use a cup, even if he has never done this before and usually will be quite good at drinking from a cup by about 7-8 months of age, if not sooner.

If the mother is returning to paid work at about 6 months or before, there is also no need to start bottles or formula. In this situation, solids may be started somewhat earlier than 6 months of age (say 4 or 5 months of age), so that by the time the mother is working outside the home, the baby can be getting most of his food and liquid, when the mother is not with him, off a spoon. As he gets older, the cup may be used more and more for liquids. You and the baby can manage without his taking bottles.

Do not try to starve the baby into taking a bottle if he refuses to accept one. Your baby is not being stubborn; rather, he does not know how to use an artificial nipple. He also may not like the taste of formula, which is understandable.

Note that too many workers in daycares do not realize any of this and are surprised or dismayed or unhappy that the baby of 6 months of age, say, does not take a bottle. Educate them, nicely, of course.

There has been a lot of publicity recently about not giving babies cow's milk until at least 9 months. The breastfeeding baby can take some of his milk as cow's milk after about 6 months of age, especially if he is starting to take substantial amounts of a wide variety of solids as well. The breastfed baby, who has been supplemented with formula as mentioned above, can get that formula mixed with solids or that formula can be replaced with cow's milk. Certainly, cow's milk is less expensive. Goat's milk is an alternative.

Many breastfeeding babies will not drink formula because they do not like the taste. Actually, the breastfeeding baby can get all the milk he needs from the breast without his requiring other sorts of milk, even if he is breastfeeding only a few times a day. (See the information sheet What to feed the baby when the mother works outside the home.)

My 4 month old is hungry on breast only. Solids or Formula?

There is no advantage in this situation of giving formula, especially by bottle and there may be some important disadvantages. Even at this age a baby may start to prefer the bottle if he seems not to be getting enough from the breast (if, in fact, he will accept a bottle).

On the other hand, if the baby does accept the bottle and if your milk supply has decreased, as it might have, giving the baby a bottle may almost guarantee that the baby will soon refuse the breast. See the information sheet Slow Weight Gain After Early Good Weight Gain for reasons your milk supply may have decreased. It would be preferable in this circumstance to give solids off a spoon rather than to give formula in a bottle. (Frequently, however, this situation can be remedied differently by improving the breastfeeding -- get help!).

If you wish to mix formula with solids, that does not cause the same sort of problem as giving formula or even expressed milk in a bottle. If the baby seems hungry after breastfeeding, feed him solids off a spoon. However, it may be possible with a few simple techniques, to get the baby gaining well, and/or to be satisfied with breastfeeding alone. Check with the clinic.
Questions? Get Dr. Jack Newman's book The Ultimate Breastfeeding Book of Answers.

Jack NewmanJack Newman graduated from the University of Toronto medical school as a pediatrician in 1970. He started the first hospital-based breastfeeding clinic in Canada in 1984 at Toronto's Hospital for Sick Children. He has been a consultant with UNICEF for the Baby Friendly Hospital Initiative in Africa, and has published articles on the subject of breastfeeding in Scientific American and several medical journals. Dr. Newman has practiced as a physician in Canada, New Zealand, and South Africa.

Breastfeeding and Other Foods, 2009©
Written & revised (under other names) by Jack Newman, MD, FRCPC, 1995-2005©
Revised Jack Newman MD, FRCPC, IBCLC & Edith Kernerman, IBCLC, 2008, 2009©