Posted by: Diana Cassar-Uhl, IBCLC | January 8, 2012

So, what CAN I eat?


Let me begin this post by saying that many of my colleagues are hesitant to suggest that a mother consider eliminating one or more foods from her diet; they are worried that “one more thing” will make a mother not want to breastfeed her baby.  My perspective is a little different, because when my babies were suffering, I knew:

  1. If something is wrong with my baby, breastfeeding is definitely NOT to blame, because it is the biological norm.
  2. Galactosemia is an incredibly rare condition, so the likelihood that my baby is “allergic to my milk” is extremely small.
When I changed my diet 9 years ago and saw marked improvement in both my baby and in myself, I was discouraged by the dismissive attitude of my healthcare providers at the time, who refused to confirm any connection between maternal diet and sensitivities in an exclusively breastfed baby.  What I didn’t know in 2002 when my little one was showing signs of allergy was that my diet was not normal.  I have a broader understanding now of what the Standard American Diet is, what it is not, and what our bodies are biologically programmed to need in terms of nutrition.
Here’s a hint:  processed foods, genetically-modified organisms (GMO’s), milk/dairy products from another species, soy/corn derivatives, and the wheat that’s being grown and distributed in the U.S. today are not consistent with what’s biologically normal.  With that in mind, I present to you information that I have picked up over the years as a food-sensitive mother with three food-sensitive children.  I’m not a nutritionist or dietitian, just a mom who’s had to figure out how to feed my family and keep each member healthy and comfortable.
You may be at that point in your breastfeeding journey where you’ve tried everything to temper an oversupply of milk, or you’re discouraged because your baby is showing signs of food allergy or sensitivity and you’re exclusively breastfeeding – indicating that something in your diet is causing the trouble.  You’ll do anything to stop the pained crying and keep your baby happy, but a diet of salad and air isn’t sustainable!  What can you do?

First, keep in mind that green poop, a red ring around your baby’s anus, bloody poop, diaper rash, gas, skin rashes, and extreme fussiness may be common symptoms, but they are NOT normal!! (More about this here)  Many pediatricians dismiss these occurrences as “part of being a baby” (mine did), but you may be able to alleviate these symptoms by improving your own health.

Please note my last statement:  you can help your baby by helping yourself.  Many mothers consider elimination diets “sacrificial,” but in reality, they can be helpful and healing to both mother and baby if food allergies and sensitivities are what’s plaguing your little one.

Some important points to consider, and to discuss with your healthcare providers:

  • Remember that this change in your diet doesn’t have to be forever.  Many babies can tolerate small amounts of offending proteins that pass to them in breastmilk after the 6- or 9-month mark.  Take one day at a time, and know, without question, that if your baby is struggling with breastmilk, he will do far worse on regular baby milk preparations, which are made from the allergens you’re trying to avoid!  The available preparations for highly sensitive babies are very expensive and don’t offer the other protections from allergy and disease your milk provides.
  • It can take awhile for all allergenic proteins to leave your body and your baby’s body.  Be patient.  Allow at least a week of total elimination before deciding the particular food wasn’t your problem.  Even a tiny bit of the offender can cause symptoms.
  • Learn how to read labels.  The Food Allergy and Anaphylaxis Network offers an excellent guide for consumers about how to translate ingredient names so you know what you’re actually eating (click link to see guide).
  • Unsure your diet is causing the trouble?  Keep a log of what you’re eating and another log of how your baby behaves.  Watch sleeping, fussy periods, diaper content and frequency, rashes, and anything else that raises a question for you.  It may be that something you ate on Monday affects your baby on Thursday – so keep that in mind as you look for correlations.
  • Some practitioners recommend eliminating one allergen at a time, while others suggest you take a total elimination approach from the beginning.  I tell mothers to do what they feel like they can do, and if improvement doesn’t occur, to go a little further.  For many of the mothers I have worked with, eliminating dairy and soy brought significant, but not complete relief; eliminating eggs and gluten brought further improvement, and sometimes even allowed mothers to reintroduce dairy in small amounts again as long as they kept the gluten out of their diets … so it might not have to be “all or nothing.”  This link to the Academy of Breastfeeding Medicine’s clinical protocol, Allergic Proctocolitis in the Exclusively Breastfed Infant, asserts that cow’s milk allergy is the most common, and that many babies improve significantly after their mothers eliminate all dairy.
  • Look at the world according to what you CAN eat, rather than what you can’t!  This approach has been vital for me – the day before I gave up gluten, I felt like I was marching to the gallows … but opening my eyes to all the wonderful food possibilities out there has helped me so much (plus I feel better).
  • Consider whether “substitutes” for various allergens are really necessary long-term.  Keep in mind that many babies are as intolerant of soy as of dairy, so soy “milks” or other products may not be good choices (I’ve seen lots of mothers switch from dairy to soy, see no improvement, and mistakenly assume allergens were not the problem).
  • Likewise, gluten-free replacements for breads, baked goods, and pasta can be very expensive and may be disappointing in flavor and texture – while they might be valuable short-term to help you cross the bridge to a changed diet, consider whether they have a place in your diet long-term.
  • The fewer packaged, processed, “convenience foods” in your diet, the easier it will be to eliminate allergens.  Whole, real foods (think the perimeter of your grocery store) will be nutrient-dense and satisfying.
  • Have your baby evaluated by an IBCLC or pediatrician “in the know” for tongue-tie (ankyloglossia).  Not only does this condition cause some symptoms that look like food sensitivities (spitting up, reflux-like discomfort), it seems to appear more frequently in babies with food sensitivities and mothers with leaky gut.  See this link for an outstanding resource you can take with you to the pediatrician.
  • If you haven’t already, talk to your pediatrician and do some research on probiotics, for both you and your baby.  These beneficial bacteria are absolutely vital for keeping your gut healthy and crowding out “bad bugs.”  Many pediatricians are recommending powdered probiotics for babies, administered as a small amount on mother’s nipple before baby latches on to feed.  Here’s one link to start with: The claim: Probiotics can soothe a colicky baby.

I am by no means a nutritionist or dietitian – I speak only as a mother who has suffered with food intolerances all my life and eliminated allergens while breastfeeding my own three babies.  Here are my suggestions and resources for foods and meals that can be delicious, satisfying ingredients to a healthy, healing lifestyle for you and your family:

Avocadoes

  • Guacamole with garlic, lime juice, and chopped cilantro
  • Mashed avocado with black beans, lime juice, chopped cilantro, served warm over wild rice or cold over salad greens
  • Avocado slices with unrefined salt, or cubes on a salad
  • Not an avocado person?  Try making chocolate pudding with it!

Bananas

  • Bananas lend a silky, satisfying texture to fruit smoothies.  Try freezing them first!
  • Gluten-free baked goods with bananas tend to retain a moist, dense character better than options not banana-based.
  • Banana “ice cream,” anyone?

 Vegetables

I have seriously never met a roasted vegetable I didn’t like.  Even rutabagas and turnips get sweet and delicious after they’ve been roasted.  To roast a vegetable, peel and chop into uniform pieces, arrange in a single layer in a roasting pan, drizzle with a little extra-virgin olive oil and coarse sea salt, and roast in a 425-degree oven for 20-minute intervals, turning the veggies each time the timer beeps.  Most veggies are done in 40 minutes, but others like to be roasted a little bit longer.  Be prepared to be amazed at how delicious this makes even the least popular of vegetables!  My family’s favorites include:

  • Beets (cubed)
  • Broccoli
  • Brussels sprouts (trim stem end and cut each sprout in half)
  • Carrots
  • Cauliflower
  • Green beans
  • Parsnips
  • Sweet potatoes

Pickled veggies are also a favorite – not just cucumbers, but asparagus, green beans, or giardiniera mix are great snacks or side items for lunch.

Blended soups from summer vegetables are easy to make and can be served hot or cold.  Gazpacho, zucchini soup, or a puree made from potatoes and vegetables are easy and delicious.

Fruits

  • Fresh pineapple is an indulgence – even better if it’s sliced and broiled briefly, until slightly caramelized.  Add a touch of honey if it’s not sweet enough for you!
  • Smoothies are incredibly easy – choose frozen, organic, pre-sliced fruits (NO SYRUP or SWEETENERS), blend with canned coconut milk and a little water for a sweet, satisfying treat.  If you want to get a little crazy, pour the smoothie into ice pop molds and freeze until solid!
  • Strawberries dipped in dark chocolate?  Yes, please!
  • Make a quick and easy fruit salad with canned (in JUICE, not syrup) mandarin orange sections and pineapple tidbits.  Add sliced banana and chopped mint or basil for a special touch.
  • Unsulphured dried fruits (apricots, prunes, raisins) are portable and make a delicious, satisfying snack with a handful of almonds or cashews.  (If you’re watching calories, be aware that these are very calorie-dense.)
  • Add chopped apples or pears to chicken or cabbage salad – raisins are terrific, too.
  • Have you ever poached summer stone fruits, like plums and nectarines?  Or made balsamic macerated strawberries? (I’m not recommending non-dairy whipped topping as a healthy food, but if you don’t mind the occasional dose of chemicals, a little dollop is pretty yummy on these berries and shouldn’t cause a reaction in your baby.)
  • Gelatin desserts, with fruit or juice, aren’t difficult to make if you don’t want to eat commercially-prepared Jell-O.

Grains

  • If you eliminate gluten from your diet, you may find it was in nearly everything if you ate a lot of packaged or processed foods.  Be careful, because many gluten-free substitutes contain corn and oats, which also cause trouble for some highly sensitive individuals.  Even gluten-free oats might be difficult for some people to digest.  Eliminating these in the beginning, then carefully adding them back in as you figure out what affects your baby is a good strategy.
  • Quinoa is a complete-protein grain (it’s technically a seed) and can substitute for wheat in tabouli … it’s also delicious on its own or as a base for salads or stuffed peppers.
  • Rice is in many gluten-free items, as well.  I prefer wild rice or wild rice blends.  Be sure to choose brown rice over white if rice becomes a staple in your diet.  Coconut rice and beans can be made in a crock pot – exotic and delicious (I’ve done this recipe and used brown basmati instead of white – comes out fine).

Leafy Greens

  • I was not a fan of leafy green vegetables until I learned there’s more out there than lettuce and spinach!
  • Peppery greens like arugula and mustard greens are great accents to a green salad.
  • Napa cabbage is mild and a delicious base for a salad or slaw.
  • Round heads of cabbage are easily chopped and sautéed with coconut oil and seasonings of your choice for a quick, healthy lunch.  Add ready-to-eat sausage or some mushrooms for a little more oomph.
  • Kale chips!  Easy, delicious, and kid-friendly!
  • Add any kind of leafy green vegetable to soups during the last few minutes of cooking.  Favorites in our family are bok choy (my kids call it “chazel,” so it makes “chazel soup!”), mustard greens, and kale, chopped up small enough to just fit right in.  Lentil soup, chicken soup, or soups with garlic-based broths all welcome leafy greens!

Meats/fish

  • Whenever possible, choose locally-pastured meats and poultry.  These will have the best nutrition profile and flavor.  Too expensive?  Eat less of them – back down to once or twice a week and eat vegetarian the other days.
  • Be sure your store-bought chickens, turkeys, or hams are not injected with gluten-containing broths or fillers.  No ingredient list?  Call the 1-800 number on the label before you buy.
  • Avoid pre-seasoned fish – these spice mixes often contain hidden allergens.
  • A roast beef, pork, or chicken/turkey, roasted potatoes with herbs or roasted root vegetables, and a green vegetable or salad makes a satisfying meal that requires no substitutes – everyone in the family can eat it and it’s all in its original state!
  • Leftovers can be chopped and made into salads or put in soups or rice dishes.
  • Make a terrific gluten-free gravy by substituting rice flour, potato starch, or corn starch (if you’re not avoiding corn) for flour.
  • Miss your daily sandwich?  Choose gluten-free deli meats and make roll-ups – ham around a pineapple spear is a favorite, or turkey with hummus spread before rolling, or salami wrapped around a baby dill pickle or pickled asparagus spear — delicious!

Nuts/seeds

  • Look for baked goods recipes that use almond flour or almond meal.  Every one I’ve had has been a winner.
  • Avoid flavored nuts – many have hidden allergens.
  • Look online for things you can do with cashews!  We’ve enjoyed a “cheesecake” made from soaked cashews; cashew “cream” is another popular option.
  • Struggling for a breakfast option?  This granola is amazing … but extremely calorie-dense, so enjoy in moderation!

Potatoes

  • Roasted potatoes are delicious.  Enough said.  Sea salt and parsley put them over the edge!
  • Mashed potatoes are easily made dairy-free … add a little chicken broth for some “body” if you want.  Roasted garlic is another decadent addition.
  • Potato salads can be vinegar-based or mayonnaise-based – if you’re avoiding eggs, the vegan mayonnaises can be suitable stand-ins.
  • If you’re not planning to freeze leftovers, cubed potatoes make an excellent addition to vegetable or other soups in place of pasta.  Potatoes don’t freeze well, so if you’re planning to freeze some of the soup, separate that portion out before you add your potatoes.
  • If you love breakfast hash browns but aren’t eating butter, try cooking your shredded potatoes in a little coconut oil – the texture will be the same and don’t worry, the coconut oil doesn’t make your food taste like a piña colada!

Sauces, dressings, extras

  • Vegan mayonnaise makes a suitable base for salad and slaw dressings – I like cider vinegar (rice vinegar if I’m looking for a sweeter flavor), celery salt, and a little orange or pineapple juice (I save what comes in the fruit cans!) whisked together with Veganaise is delicious over shredded napa cabbage or broccoli stems!
  • Basic marinara sauce, if you’re not avoiding tomatoes, is always a favorite.
  • Homemade ketchup is easy and quite delicious – make up a batch and it keeps for weeks in the fridge.  Mix with veganaise and pickle relish for an allergen-free thousand island dressing!
  • There are many widely-available nut butters today – try one if you’re avoiding peanuts.
  • Be sure if you’re using prepared broths or boullion, they are gluten-free and dairy-free … I’ve been very surprised by the ingredients in some of those items.

Stand-bys

  • Salads
  • Hummus
  • Chili
  • Roasts
  • Vegetables, in their natural state (no flavor packs or sauces)
  • Nuts
  • Fresh fruits
  • Unprocessed, unpackaged foods
  • If you have to go with “convenience foods,” read the labels – organic is usually best but know what you’re getting!
  • Potatoes, rice (I prefer wild rice)
  • Coconut milk (I like canned but the refrigerated varieties that come in cartons in the alternative milk section of the grocery store are also good)

 Delicious resources

These are the websites I’ve visited most frequently for ideas when I get into a food rut.  I’m amazed by how much is available for those of us who choose to avoid allergens.

http://www.glutenfreegirl.com

http://glutenfreegoddess.blogspot.com

http://glutenfreeville.com/featured/100ideas (Gluten-free lunchbox ideas)

http://www.livingwithout.com

http://www.therawdessert.com

http://www.adventuresofaglutenfreemom.com

http://crockpot365.blogspot.com

This website is one that recently crossed into my consciousness and it’s AMAZING!  She adapts recipes to fit any elimination diet, so you don’t have to!

http://realsustenance.com/

There are also lots of cookbooks available – the sky is the limit and once you’ve gotten into the habit of eating without allergens, it gets easier; but nothing will compare to the relief that comes from seeing your baby comfortable again – and you may be surprised by how fabulous you feel, too. It’s a delicious world!

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Posted in allergies in a breastfed baby, breastfeeding, Elimination diet for breastfeeding mothers | Tags: , , , , ,

Posted by: Diana Cassar-Uhl, IBCLC | December 26, 2011

My baby won’t take a bottle!


As an IBCLC in private practice, I am sometimes asked for solutions when a breastfed baby refuses to take a bottle after his mother has begun regularly separating for a return to work or school.  This dilemma rouses an emotional response in me, because I experienced it to varying degrees with each of my three children, with tremendous emotional fallout.  I would apologize for the emotions that come through in my response, however, I have come to believe that our feeling side is often neglected in these situations, but it gives rise to the best solutions. I allow my emotions to remain on the surface and I share what my experience and knowledge point to in situations like these.

I feel profoundly sad for any mother and baby dealing with bottle refusal. Both are at the ends of their ropes and there is a circumstance (not always something mother can change) that is preventing them from being together as they were designed to be.  I believe, as La Leche League professes in its philosophy, “In the early years, the baby has an intense need to be with his mother which is as basic as his need for food.”  The stress of this wedge between them and the complications it presents can affect every aspect of their relationship.

My first concern is the mother’s support system. Is there a partner or support person who can focus his or her energies on taking care of mother so she can take care of her baby?  Are there extended family/friends who can bring over meals or come to do some housework on the weekends?  This mother must be supported in practical ways because she’s juggling both her job and her pre-motherhood expectations of how babies should behave.

A common secondary problem that stems from a baby refusing a bottle while separated from his mother is that he will begin to reverse cycle – he’ll spend his entire night, while mother is beside him, consuming the calories he missed while they were separated all day. “This isn’t going to be sustainable,” exhausted mothers tell me.  Of course it isn’t – something has to give, somehow.

Fortunately, baby’s needs evolve with each day. This doesn’t mean babies are “happy to separate,” it only means some aspects of the separation itself are a little more flexible.  Around the middle of the first year, baby will likely be ready for some solids, which lessens the (nutritional) impact of the separations a little bit.  In my case, my babies didn’t take solids until around 7 months, but when they did, I allowed solids to be fed by the babysitter and I only breastfed my babies.  This meant I didn’t feed a solid meal, usually, until closer to 12 months of age!  They would take one or two feedings of solids, but not daily.  When I was with my babies, we only breastfed.  This didn’t make them averse to solid food later, and didn’t complicate the “teaching them how to eat” business. I saw the solids as a stopgap to the problem of their bottle refusal.  This is one very strong reason why I try to encourage mothers, if it is at all possible, to delay their return to work/school for as long as possible.  Even making it to the 6-month mark opens options for dealing with the complications that regular separation can present.  If mother has to leave sooner, we can encourage her that, even if he never takes that bottle, her baby’s dependence upon her as sole source of nutrition does wane in time.

The situation that the baby is in also matters, especially when he is expressing his needs in a manner that makes it impossible for the caregiver to feed him.  A daycare center with lots of babies is often ill-equipped to handle such a situation.  My specifications that my babies never cry alone (I knew they would cry but I wanted them to be held or worn when they cried, never left alone) and be fed on demand were too much for a regular daycare.  I needed to find a creative solution, one that allowed my babies to be cared for by one person who didn’t have her hands too full to keep them engaged in a loving way, even as she could not substitute for me. I was fortunate that I was able to brainstorm and implement options that worked for us, and I recognize that other mothers might have to think even further outside the box to find ways to meet, or at least find a compromise toward, their babies’ needs.

I understand and remember how desperate a mother’s need for a prescribed solution to matters like these can be.  We want “Solution B” to  “Problem A”, and we are managing so many things we never expected to have to manage. But, in refusing the bottle, baby is clearly expressing some needs and we just can’t verify what those needs are … or, if we can, maybe we are too hardened or saddened by the realities of what our culture imposes on new mothers to acknowledge and address those exact needs.  The family’s response to these needs will be mirrored later in the child’s life, when how he eats isn’t the issue, but another situation will arise and the parents will be forced to either apply a “prescribed fix” to the situation or think flexibly about how to meet the needs of this child in a manner that respects them as bona fide NEEDS and preserves the family’s sanity.  The solutions will not always meet mother-in-law’s approval or be found in the parenting magazines or on the TV shows about babies, but they will be organic, fluid manifestations of how mothers and their babies adapt to threatening situations.

Here are some practical considerations for when a baby won’t take a bottle, or if he is otherwise expressing his discomfort with separating from his mother:

  • Can the mother stretch her maternity leave at all, in any way, so that she has even one more week with her baby?
  • Is the baby rejecting the bottle because the expressed milk doesn’t taste very good?  Some mothers have too much lipase, which begins breaking down her milk while it is stored, leaving the milk smelling and tasting “off.”  Some babies don’t mind this, but others seem to be very sensitive to it.  Try feeding milk expressed within a few minutes immediately and see if baby resists.
  • Can daycare be closer to where mom works so separation time isn’t as long and maybe they can nurse at lunchtime?
  • Can baby be brought to the mother at all?
  • Is she breastfeeding at the caregiver’s location on drop-off and at pick-up, lessening the number of feeds during their separation?  This will be especially helpful when solids are introduced, perhaps even covering the entire day.
  •  Is mom sharing sleep with her baby?  Napping together on weekends and days off?  Sleeping in on weekends while someone else wears the baby and does some housework in the early morning hours, bringing him to nurse as needed?
  • Can she work out a flex-schedule so that she’s working one fewer day a week, perhaps with a caregiver bringing baby to her at the end of the workday so they can nurse, then she puts in a few extra hours to enable the 3-day weekend?  Or a day off on Wednesday?  It never hurts to ask these things, and they’re not forever — just a few months until the baby’s needs evolve a bit.

Maybe the mom isn’t going to sleep much at night, maybe instead she will sleep after nursing the baby at home, wake for a few hours after dad/partner has given baby his bath, washed bottles and pump parts and prepared everything for the next day (I think babies love to be worn and talked to when someone is preparing their bottles and pump parts!), sleep again after the next nursing session, and cobble together 5 or 6 hours on work-nights.  No, not sustainable long-term, but also not necessary long-term … just necessary TODAY.  I realize these aren’t solutions that fit into the norms of our culture, but if they permit a family to balance its responsibilities in the context of meeting the real needs of their baby, isn’t that what matters?

Just after my youngest entered toddlerhood, I was asked to review Balancing Breast and Bottle (click on the title to see the companion website) by Amy Peterson and Mindy Harmer — it offers a comprehensive anatomical perspective on why some babies resist bottles, and practical tips for how to help them learn to.  This information would have helped me tremendously had it been available when my firstborn worked so hard to learn to breastfeed from my one-flat and one-inverted nipples, then demonstrated absolute frustration when I stuck every long-nippled bottle teat in her face starting at 6 weeks and finally giving up at 4 months.  It wasn’t gonna happen.  The book shows very clearly how to choose a bottle teat that more closely approximates the mother’s nipple and works with the baby’s anatomy.  It might be worth a try if they aren’t already too worked up and stressed out about the whole process.

I was back to work at 12 weeks, and through more tears and agony than I care to recall, I had to figure out how to keep my baby thriving and keep myself alive.  I switched babysitters so she was a 2-minute drive from my workplace.  We spent my lunch hour together, nursing at the beginning and at the end.  Whenever it was practical, I brought my baby with me to work and we just nursed when I could do that. On days I could go home at lunchtime, we napped together, then when Daddy came home, I finished my workday tasks.  Sometimes, I did my work after dark — she would sleep from 9-11:30 or so and I’d finish my projects and correspondence then.  I would rather have been sleeping, but my baby had needs of me and my job had expectations I had to meet, as well.  Breastfeeding wasn’t my problem.  Motherhood wasn’t my problem.  Otherhood was. I had to manipulate everything else so the breastfeeding and the mothering got done. I felt like a freak and wondered if I was setting my children and my family up for permanent misfit status … but I prioritized what was important to us and let the rest fall into order as it would.  Today, other than a still-messy house, we look like a regular family. :)

As in many situations, mothers have to define their own success.  We need to assess our situations for the “soft” walls — the ones that will give — so we can find the balance in our lives. What do I value?  How do I make my decisions, and with whose input?  Have I had 15 minutes since my baby was born to assess what his arrival has done to my value system?  Our solutions and situations won’t be the same, there will be no “right” or “standard” answer.  We all have to find our own way.  If a mother has all of the information she needs to make an informed choice, we have saved her from the Guilt-Monster.  She may regret later that her situation wasn’t different, but she will make her decisions based on what she has and what she can do, which is all any of us can expect of ourselves.  I can remember feeling downright ostracized by women who had no idea about my situation, women who raised their eyebrows at me and said “my family made a choice” as if I was making the “wrong” one.  I believe every mother wants to do what is best for her baby, but we are so bombarded by cultural messages of what is important, we lose touch with our instincts and our innate sense of what we can do.  As an IBCLC, when a mother welcomes me into her life, I do my best to offer her all of the information I have that pertains to her situation, and to remind her that sometimes, the best solutions are the ones that she comes up with herself.

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Posted in Bottle feeding a breastfed baby, breastfeeding, human milk, Working and breastfeeding | Tags: , ,

Posted by: Diana Cassar-Uhl, IBCLC | September 24, 2011

I believe in human milk for human babies


In 2006, I wrote this essay for This I Believe, which at the time was a regular feature on National Public Radio.  My essay was never read aloud on NPR, perhaps because it wasn’t well-written, or maybe because the topic wasn’t ready for public consumption yet.  At the time, I was advised not to tell people I was sharing my milk with babies who needed it, lest people think I was a fanatic or doing something unorthodox.  This notion, this opinion that I needed to keep my milk-sharing a secret, made no sense to me — I was healthy, had more than enough for my own babies, and … I was feeding this milk to my own babies!  Why shouldn’t a mother feed her baby my milk, the milk of another human mother she knew, before she fed him milk made from cows she hadn’t ever met?

Now, in 2011, what the World Health Organization has been saying for years, that donor milk is the biologically normal supplement to mother’s own milk, is practically common knowledge.  Today’s mothers can benefit from information that allows them to make a truly informed choice.  Some may still choose to feed cow’s milk-based or other formula to their babies, but thanks to initiatives like World Milksharing Week, the concept of human milk for human babies doesn’t have to stay underground anymore!

There are informal milksharing arrangements, such as those arranged through people we know or networks like Human Milk 4 Human Babies, which provides an outstanding FAQ page for families considering the use of donor milk.  There is also a more formal method of obtaining breastmilk, usually short-term, and for a baby who is premature or sick.  This involves using a milk bank — here in North America, a family would contact the Human Milk Banking Association of North America milk bank nearest to them for assistance.  Milk from a milk bank has been collected from several screened donors, pooled, pasteurized, and is distributed by prescription for babies who need it.

I have been lactating and breastfeeding my own three children for nearly 9 years (no break!).  In addition to my own children, there are three other children, all of whom I’ve met, who have been nourished by the milk my body made.

The first was an adopted baby who came to a family just north of where I live.  I don’t remember how I got connected to his parents, but I and another local mother happily pumped our milk so that they could bottle-feed human milk to their baby.  I was tandem nursing my older two children, the younger of which had just turned a year old.  The parents’ co-worker, who lived in my town, stopped by twice a week to pick up the cooler I had packed with bags of my milk.  The parents sent me pictures of their growing boy and thanked me often for my gift to him.  I met the whole family in person 2 years later, at the farm we all got our CSA shares from. A few tears were shed and hugs were exchanged when I recognized the boy and said “I’m Diana,” to his mother.  My children were excited to learn that the cute little toddler was their “milk brother.”

The second was the child of a dear friend, the one I wrote about in the This I Believe essay.  I pumped for her when she was first born (but didn’t have a whole lot to give her), and again about two months before her first birthday, when my own baby was born.  I had so much milk to share, since I was tandem nursing (my middle child spent most of his almost four breastfeeding years sharing with his sisters).  My friend told me her husband, upon seeing the supply of my milk I dropped off every few days, exclaimed “Diana could feed the world!”   I loved that idea, and was so happy that each ounce I was able to give them was one less ounce that little girl had to be artificially fed in her at-breast supplementer.  Her mother took many measures to produce about half of what her baby needed, and the donors they found (I was one of a few) helped make up the difference.

The third was a baby whose birth was attended by the same midwife that was at the birth of my third child.  I was tandem nursing my younger two children, had lots of milk, and wasn’t going back to work for a few months. My friend’s baby had turned a year old, and didn’t need all I had to offer, so for about a month, I was able to donate to this third family.  That baby’s mother had hormonal imbalances as a result of PCOS, and her body didn’t make all the milk her baby needed to thrive. I didn’t stay connected to her after my last contribution, around the time my own baby was three months old and I needed what I pumped for her when I went back to work.

I was, of course, proud to be able to provide milk for the three babies who received it, three babies who were not my own.  To me, however, it was remarkable that I actually enjoyed pumping for them — remarkable because I despised pumping for my own children when we were separated.  The difference?  I had to pump for my own babies because of an alteration to the biological norm, a deviation in what we were created to be.  I was thankful that pumping helped us sustain our breastfeeding relationship, but I would much rather have been directly breastfeeding my babies.  Pumping for those other babies, though, brought them a step closer to biologically normal than they might otherwise have been without me; my pumping made human milk available to those human babies.

I’m excited that Human Milk 4 Human Babies has launched this first annual World Milksharing Week, and eager to share other blogs or articles about it — so please call them to my attention!  I urge you to click on and read the links below:

International Breastfeeding Symbol Blog (Mamabear)

The Leaky B@@b: Because it could be my baby

Milk sharing: from private practice to public pursuit

PhD in Parenting — Breast Milk: Not a Scarce Commodity

Offbeat Mama: Why I choose to cross-nurse babies

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Posted by: Diana Cassar-Uhl, IBCLC | April 12, 2011

My thoughts on the vitamin D controversy


In April of 2011, Best for Babes unveiled a new website, and I was thrilled to be the first guest for the “Making Sense of the Science” blog section.  My article on vitamin D and breastfeeding has caused quite a stir on Facebook fan pages where its link was posted, such as The Leaky Boob and KellyMom, as well as on the blog post itself.  Rather than try to answer all of the excellent questions that were raised (some more kindly than others!), I will try to clarify the major issues here.

Be sure to read the article at Best for Babes, as this post relates directly to that.

A reminder:  I am an IBCLC, which stands for International Board Certified Lactation Consultant.  I am not a doctor.  It is not in my scope of practice as an IBCLC to prescribe or recommend a medical course of action to any mother/baby. I cite the recommendation that has been published by the American Academy of Pediatrics, but I also present other points for consideration, such as which factors an individual family might weigh when deciding whether to go with the AAP’s recommendation on vitamin D for breastfed babies … but at no time do I make a recommendation myself.

I wrote La Leche League International’s tear-off information sheet (Vitamin D, Your Baby, and You, 2010) after months of review of the literature, specifically the ongoing research by Drs. Carol Wagner, Bruce Hollis, and Sarah Taylor , which deals with the vitamin D status of pregnant and lactating women.  This research is very new (first reports were published in May of 2010) and perhaps your OB/GYNs, midwives, and pediatricians have not yet come across it.  This team’s studies are exactly what the National Institutes of Health/Institute of Medicine (IOM) have stated it needs more of (and is funding) in order to embrace vitamin D’s role in outcomes besides bone health: randomized, controlled trials.

A fabulous, comprehensive resource about this research is the book New Insights Into Vitamin D During Pregnancy, Lactation, & Early Infancy, written by the researchers. I was fortunate to hear Dr. Wagner present at a La Leche League educational event in July of 2009.

Before my exposure to Dr. Wagner’s work, I was, like many of you, very skeptical of any guidance that suggested my breastmilk wasn’t all my baby needed.  I believed “vitamins make expensive pee!” and I was emphatic about getting my nutrition from my Very Good Diet (really … it is Very Good).

But, here’s the thing I learned right away: vitamin D isn’t a nutrient.  It’s a pre-hormone, and most of us only get 10% of what we need from diet.  This made me ask the question, as many of you are asking: why, then, do we feel like our babies need to get their necessary vitamin D from diet?

Before I address this issue, let me comment on how the recommendation for 400 IU/day for babies was arrived at.  This is the amount of vitamin D that has been proven, through lots of data, to provide adequate “antirachitic activity” (prevents rickets).  This recommendation is based upon what the medical community knows about vitamin D and bone health.

Should our babies be getting all their vitamin D from breastmilk/diet?

Honestly, this is my million dollar question, one I can’t answer.  What I can do is muse out loud a bit about the alternatives.  One option is to completely disregard the research that suggests babies need 400 IU/day of vitamin D and just breastfeed and hope for the best.  Another is to completely buy into the AAP’s recommendation (which mirrors the IOM’s 2010 report) and supplement with 400 IU/day of vitamin D.  Other options include measuring vitamin D status in mothers and supplementing them, which improves the vitamin D status of both mother and baby (and eliminates the need to give babies anything else by mouth except our milk); still another alternative is sun exposure for mother, baby, or both.

Get out in the sun for vitamin D.

Of course, this is the solution that our bodies were created to live within … but there are several valid reasons why this option does not appeal to some families.

  • Legitimate concern about skin cancer and dermatological recommendations that we limit sun exposure altogether.  The key is to avoid sunburn!
  • Latitude – the research seems to agree that the 30th parallel (Houston) or 35th parallel (Atlanta) is the cut-off point for the sun’s year-round value. If you live south (or north, if you’re in the Southern hemisphere) of or near that and are outside each day, year-round, your vitamin D status may be adequate.  However, the further away you live from the equator, the less likely you are to be getting what you need from the sun for at least half of the year.  New York, for example, is located at 40 degrees … the sun’s rays aren’t potent enough to do their job most of the year in New York (which is why I said that even making snow angels naked in February wouldn’t augment your vitamin D status).
  • Clothing and sunscreen use – if it covers your skin, the sun can’t do its job.  Sunscreen completely blocks the rays that trigger vitamin D synthesis in your body, as does clothing.  Most of your body needs to be exposed, not just hands and face.
  • Skin pigmentation – those with darker skin need longer periods of time in the sun to get the same vitamin D production benefit as those with lighter complexions.  Perhaps this also means the darker among us don’t need as much vitamin D?  Or, consider that populations used to be distributed on our planet such that those with darker pigmentation lived close to the equator.

A brief lesson about how our bodies synthesize vitamin D after sun exposure:  there is a cholesterol in our skin that ultraviolet-B rays from the sun activates.  After 15-20 minutes of midday, mostly uncovered exposure for light-skinned individuals (at the right latitude or during the right season), a healthy body will synthesize 10,000 – 20,000 IU of vitamin D in the next 24 hours.  Those with darker skin tones may require up to an hour of exposure for the same benefit.  The cholesterol in the skin converts the UV-B rays to vitamin D3, which is then converted by the body to the active hormone, 1,25(OH)D.  (Keep in mind that many doctors unknowingly measure this 1,25(OH)D value, which may even be elevated in individuals with a 25(OH)D deficiency.)  A body can’t  “overdose” on vitamin D from the sun, because once the body has enough, synthesis shuts down (oral toxicity is possible, but improbable at sensible supplemental levels).  Vitamin D is fat soluble and is stored in the body.  Some postulate that we store up enough in the summer to carry us through most of “the dark season,” but start to really crave sunshine come February!  Anecdotally, some claim they avoided seasonal depression by supplementing with vitamin D throughout the winter.  Placebo effect?  Perhaps, but randomized, controlled trials are being conducted to support or refute this theory.

Please note: the old recommendation of 15 minutes a day of sun exposure to hands and face (which your doctor may still believe), year-round is not accurate.  Sun exposure alone may not be adequate for your body, or it may be … I don’t know, but the data I’ve seen in the 3 years I’ve spent on this topic suggests there are widespread insufficiencies of vitamin D.

My doctor says my level is fine.

This is another major point of contention in the medical community: the definition of vitamin D sufficiency.  As I stated in the article, the IOM sets 20 ng/mL of circulating 25(OH)D as “generally considered adequate for 97.5% of the population” and a level under 12 ng/mL as deficient (for bone health).  This level of vitamin D is fairly easy to arrive at with the current Recommended Daily Intake of 600 IU/day, and is sufficient for bone health.  However, there are smart people who suggest (and have data to support) that 32 ng/mL of circulating 25(OH)D is sufficient; levels between 20-32 ng/mL are “insufficient” and deficiency is defined by a level under 20 ng/mL.  There are other physiological factors taken into consideration when defining vitamin D sufficiency, such as the level at which calcium is best absorbed, the level at which bones are well mineralized, or the level at which parathyroid hormone is stable.  It is interesting to note that the IOM, in its review of data for its 2010 report on vitamin D intake, discovered adverse effects in some people whose circulating 25(OH)D was over 50 ng/mL.

In another corner we find Hollis, Wagner, and Taylor’s published findings from their RCT’s.  Their work focuses specifically on pregnant and lactating women.  One aspect of  study involves 3 groups of pregnant women, after the 12th week of gestation (double-blinded so neither the researchers nor the subjects know what group they’re in): one group is supplemented with 400 IU/day of vitamin D; one with 2000 IU/day, and the third group with 4000 IU/day.  The incidence of negative pregnancy outcomes, such as pre-eclampsia and preterm labor/delivery, is significantly reduced in the 4000 IU/day group, plus, the breastmilk of those mothers has more of that “antirachitic activity.”  There have been no adverse effects of the higher dose of supplemental vitamin D reported in any mothers or babies that have participated in this study.  More results are being published as additional cohorts complete the trials.

For lactation, preliminary findings indicate that a mother’s circulating 25(OH)D level needs to be at 50-60 ng/mL in order for her milk to provide all the vitamin D her baby needs.  At lower maternal circulating 25(OH)D levels, there is still vitamin D being conferred through breastmilk, just less.  Again, for me, this begs the question: should babies get their full daily complement of vitamin D from breastmilk?  Keeping in mind that there is data suggestive of such high circulating 25(OH)D levels being harmful over time in some individuals (one report showed higher incidence of prostate cancer in a group with a 25(OH)D level over 50 ng/mL … I don’t have a prostate but should I worry?), and also knowing, both from research and personal experience how difficult it can be  to reach that 50-60 ng/mL level of circulating 25(OH)D, even with abundant supplementation (preliminary findings suggest 6400 IU/day, nearly 11x the current RDI) … I’m leaning toward a combination approach.  Let me remind you: I’m not a doctor, and I’m just thinking out loud here – but, looking at the options available for ensuring adequate vitamin D status for me and my children, I like a multi-faceted approach.  Maybe moderate supplementation for me (or more aggressive supplementation when I’m pregnant and breastfeeding an infant), occasional supplementation for my children, and conservative sun exposure might take care of our vitamin D needs?  I don’t know for sure.  All of this information is still so new – and not just to me.

When your doctor says “your vitamin D status is fine,” by which standard is he defining “sufficiency?”  Does he value any of the still-being-studied claims that higher levels of 25(OH)D might affect conditions other than bone health, such as diabetes, certain cancers, multiple sclerosis, and respiratory illnesses?  Do you?

It’s a lot to consider, and frankly, the vitamin D controversy remains huge in the medical community, not just among us breastfeeding mothers.  It may be years before enough randomized, controlled trials produce the conclusive data needed to affect changes in public health guidelines … what will you do in the meantime?  The choice is yours, for your body and for your family.

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Posted by: Diana Cassar-Uhl, IBCLC | March 29, 2011

Breastfeeding in pregnancy


My son was a few weeks from his 3rd birthday, and lingering congestion and a cough weren’t passing.  He started running a fever and was nursing non-stop, which was starting to wear me a bit thin, since, at that point in my pregnancy (about 30 weeks), there wasn’t much milk and my breasts were very, very sensitive.  I made the rare decision to see a pediatrician.

The doctor confirmed that Simon’s right ear had his first ear infection.

Simon climbed into my lap and began nursing while the doctor prattled on about the antibiotic and other medications.  The doctor stopped in mid-sentence and his eyebrows shot skyward.

“What on EARTH is going on HERE?” he asked, clearly shocked.

“Umm … he’s nursing.  It seems to help him feel better,” I answered, figuring this guy had never seen a preschooler breastfeed before, and feeling rather pleased to be the one to expose him to it (I already had a bit of a rogue reputation in this small Army hospital).

“Do they know upstairs that you’re DOING THAT?”

Ah.  He was incredulous, not because of the older child on the breast, but because of the giant pregnant lady letting the child breastfeed.  By “upstairs,” he meant the doctors in the OB/GYN clinic, who had already thrown me in the crazy pile.

“Yes, they’re aware that I’m breastfeeding through this pregnancy.”

The doctor went on to warn me about all of the consequences that might result from my behavior.  Pre-term labor, small baby, psychological problems in the older child (yes, he really said that) … I smiled and nodded, then let him know that the boy on my breast had an older sister, not quite two years older.  She nursed when he was in the womb, and he arrived one day before 40 weeks gestation, barrel-chested and sturdy at 9 pounds, 4 ounces.  And the big sister was all too happy to share the return of the robust milk supply with her new brother.  I explained that we did something called “tandem nursing” and that we weren’t the only ones in the world who ever had.  I wish I could say I educated that doctor that day, but I think, more likely, it was all too much for him to accept.

I was confident in my decision to breastfeed through my second two pregnancies because I had done lots of research.  I was really fortunate that just 6 months before I became pregnant with Simon, La Leche League International had published Adventures in Tandem Nursing by Hilary Flower .  This book explained for me why breastfeeding through a pregnancy was OK for most mothers in uncomplicated pregnancies and helped me prepare for what I might expect as my pregnancy progressed.

For starters, I knew that I wasn’t in the small population of mothers for whom breastfeeding during a pregnancy was a bad idea; I had no issues with pre-term labor, cervical dilation, and there was no need for me to be on pelvic rest.  I learned that oxytocin, the “love hormone” that is secreted when I breastfeed, during orgasm, and in labor, does cause uterine contractions (which is why some people try nipple stimulation during labor if contractions are slow or not productive); however, in an uncomplicated pregnancy, the uterus is not receptive to these surges of oxytocin, whether triggered by sex or breastfeeding/nipple stimulation.  Until the baby is ready to be born, my uterus wouldn’t care so much that all this contraction-causing hormone was flowing around.

Knowing all of this was a huge comfort to me, because I did experience contractions in the late 2nd and 3rd trimesters.  They weren’t strong and I didn’t feel like I was endangering my growing baby, but I definitely felt them and they were definitely a result of the nursing session.  As well, by just after the midway point, my milk had mostly dried up and breastfeeding my toddler had become rather unpleasant.  We got through the rest of the pregnancy by limiting the length of the nursing sessions throughout the day (both of my older children were receptive to these compromises) and by me adopting some escapist mental techniques to get me through the bedtime nursing, which was always longer.

The first time I breastfed through a pregnancy, I did it because I didn’t have any idea how I might go about weaning my young toddler (she was 13 months old when I became pregnant with her brother) nor did I have any real desire to wean her.  I wondered if having an older nursling might help bring in a robust milk supply more quickly than I had the first time around (which would have come in handy in our situation of severe abnormal newborn jaundice/hemolytic disease of the newborn, experienced to some degree by all three of my children), or if my toddler could help relieve some of the engorgement of those early days.  I imagined that still being allowed to breastfeed might alleviate feelings of jealousy my older child might feel toward the new baby.  I felt certain, above all else, that breastfeeding through my pregnancy and tandem nursing would bring more benefits than sacrifices.

I was correct, but just barely.  Breastfeeding through pregnancy ranks pretty high on the list of the hardest things I’ve ever had to do in motherhood.

Thankfully, though, immediately after the baby was born (literally within the hour), breastfeeding the older child was no longer excruciating.  She did help bring in lots of milk and she also was happy to handle some of my engorgement, saving her brother from what would have likely been a few uncomfortable days or weeks.  I was surprised and amused by how GIANT my once-baby now felt in my lap and at my breast, compared with the newborn sibling, but the pain and unpleasant feelings were gone instantly.  I learned that this is because, upon delivery of the placenta, the progesterone level in the mother’s body plummets to approximately 10% of where it remained during pregnancy.  You know that tenderness you might feel in your breasts during the second half of your menstrual cycle?  Progesterone.  Now imagine that times 10 and you get some idea of what breastfeeding through pregnancy feels like for some mothers.  It’s totally understandable why many just won’t do it.  Other mothers have a different experience; some toddlers are a lot more amenable to weaning than I think mine would have been, as well.  There are so many factors and what works for one dyad may or may not be the best option for another.

As Anna, my eldest, approached her 4th birthday and Simon was nearly 2, we started to feel ready for a 3rd baby in our family … but I was pretty certain I would not want to tandem nurse through a pregnancy (though I knew a few mothers who had done this and survived).  She weaned in plenty of time before I became pregnant, and, while still unpleasant, breastfeeding Simon was easier than breastfeeding Anna had been during his pregnancy.  Perhaps it was because I knew better what to expect, or maybe it was because he was a year and a half older than Anna had been when I was pregnant with him, and breastfeeding less frequently than she had been.  The duration of tandem nursing was much shorter the second time around, too, because Simon is more than three years Gabriella’s senior.

We have some precious video of Simon after Gabriella was born.  I was on the bed, Gabriella was dressed and we were breastfeeding some more.  I was joking that she had to know what she was doing, given that I had earned most of my required continuing education credits for the IBCLC exam during her pregnancy!  Simon leaned in really close to observe Gabriella’s latch.

“Do you need to queeze it?” (Simon couldn’t yet pronounce his S-dipthongs … “queeze” meant “squeeze.”)

“No, sweetie, she gets the milk on her own.”

“Is she going to drink ALL OF IT?”  Simon asked urgently.

“No, Simon.  There will be plenty left for you when she’s done.”

The look of relief on his face was a priceless affirmation that I had made the right choice for us.  Anna remembers sharing her “bock” with Simon; Simon remembers sharing his “uns” with both of his sisters; Gabriella doesn’t remember that she ever had to share her “milkies” with Simon because he weaned before she had her first birthday.  She’s my last baby, and I won’t be breastfeeding through another pregnancy, but the experience of having done so is one I’m eager to share with mothers and healthcare providers who aren’t aware that it’s an option.

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Posted by: Diana Cassar-Uhl, IBCLC | February 24, 2011

Old enough to ask for it


Welcome to this April Carnival of Breastfeeding post!  The Motherwear Breastfeeding Blog and Elita, from Blacktating are sponsoring this blog-sharing event, with the theme “extended breastfeeding.” Be sure to check out the links to the other Carnival posts at the end of this one, and thanks for reading!

When my first baby, now 8, was about 3 months old, I shared a recital with my clarinet quartet.  We had our customary, post-performance gathering of celebration at one of the guys’ homes afterward, and, of course Anna was with me – I went nowhere without her.  I was the only woman in the group and my husband and I were the only couple present with children, so when it came time to breastfeed Anna, I excused myself to an upstairs bedroom.  (I feel compelled to mention that this behavior did not last long for me, since Anna and I were out and about A LOT and she needed to nurse A LOT and I got really sick of feeling exiled … and everyone got used to the fact that Diana was going to breastfeed around them.)

When I returned from nursing Anna, my curious co-workers started asking some questions.

“Does it hurt?”

“Is it … messy?”

“Is ‘special milk’ any different from the stuff you can buy, you know, in a can?”

I was only 3 months into motherhood at that point, but I was confident answering all of their questions and glad they started the conversation.  Things took an interesting turn, though.

“Just as long as I don’t have to look at it.”

“It’s OK when they’re babies, but when they’re old enough to ask for it, that’s just … gross.”

This “old enough to ask for it” business comes up a lot for me (my youngest is 3 and still enjoys “nursies” at wake-up and bedtime, as well as the occasional lazy afternoon).  It seems that public opinion makes provisions for the non-verbal child who breastfeeds, but one who can indicate his desire to nurse is a blink away from a pervert.  Turning gay.  Future child molester.  Porn star.  Right?

At the time, all I could do was laugh at my friends/colleagues.  I wasn’t educated enough to give them any hard science, but I knew one thing: at 3 months old – heck, at 3 DAYS old, Anna let me know, in no uncertain terms, when she wanted to breastfeed.  She “asked for it” by smashing her bobbly little head into my chest.  She made a little noise, like “Uh? Uh? Uh? Uh-uh-uh-uh-uh!”  There was no question what she was asking for.  Naturally, at 3 years old, Anna could tell me a lot more about her breastfeeding experience.  She could articulate what mamma-milk tasted like, (“macaroni” … my younger daughter says “strawberry jam”), which side she wanted, how long she wanted the nursing session to last, and why she still liked nursing (“because I love your smell, Mamma”).

In the 8 years since that early “public” breastfeeding experience, I’ve of course learned a whole lot about breastfeeding, the composition of human milk, the needs of human children, and I’ve experienced “child-led” weaning of my two older children.  (I will qualify: since I was tandem nursing at the time each of them weaned, I was definitely ready to see them move on from breastfeeding when they decided it was time, but I didn’t take significant measures to encourage their weaning … each weaned at around 45 months of age.)  The most significant reading I’ve done on the topic of breastfeeding “after they can ask for it” is by Katherine Dettwyler, Ph.D.  Her outstanding, enlightened research is summarized here.

(Read the link.  Seriously.  It’s not that long and it offers a perspective you probably haven’t considered before.)

When I contemplate Dettwyler’s projections for “normal weaning age” vs. the cultural expectations we have about babies and weaning, I’m fascinated by the other aspects of a baby’s development we, as a society, feel compelled to hurry along.  We want babies to wean; we want them to sleep all night, away from us; we want them to sit still and quietly and we want them to eat with a fork.  Why the rush for independence?

I do remember those years of feeling like a zombie.  My first two children are less than 2 years apart (we did this on purpose, but note we did that only once – baby #3 came 10 weeks after #2’s 3rd birthday) and the first was still an avidly breastfeeding toddler when her baby brother arrived.  In fact, she swore off all solid food when my milk came back – she gained 5 pounds in his first 2 months on my milk and a few bites here and there of the solids she had previously enjoyed (and eventually ate again).  It was around the time of my son’s birth that I believe I developed gluten intolerance, so the sheer exhaustion/lack of sleep was complicated further by painful rashes that covered most of my body and a thick fog that settled over every emotional and mental process I tried to have.  Both of them had reverse-cycled, sleeping their long stretch during the day when I was at work and waking to breastfeed frequently all night, every night.  But, my babies needed me, so I went with it.  I wasn’t trying to prove anything (no one was there to judge, anyway, except my husband, who was occupied with trying to balance his own parenting and career); I just felt, instinctually, that I was doing what needed to be done – nothing heroic, nothing special or above-average, just what my babies needed.  Now, they all sleep (though they do prefer to sleep together).  And they eat with forks!  It was all very no-frills and uncomplicated.  I fielded a lot of questions, and I confess I sometimes lied when I just didn’t feel like defending my family’s ever-adapting, “unorthodox” sleep situation anymore.  We traveled a lot (for work, mostly), and my children were always “at home” beside me, wherever we found ourselves.  I slept whenever I could, which meant that, in those years, I didn’t do much more than I really had to.  We made it work in spite of the cultural suggestions that what we were doing was abnormal, because it felt right to us.

The weaning, though, didn’t surprise me either time.  I had introduced the idea to each child when they started pre-school around their 3rd birthdays, more to let them know that most of their peers probably weren’t still nursing and that it was OK that we still did.  We talked about how someday, they wouldn’t want mamma-milk anymore, and how we would still snuggle and be close and loving as much as we wanted.  Around each child’s 3rd birthday, I could notice a distinct change in their latch – it had become very shallow and lazy, and not a whole lot of milk got transferred in a nursing session.  The fact that this became, at times, physically uncomfortable for me was a real clue that biologically, the need to breastfeed had waned a bit for my child, and the stark comparison between breastfeeding the younger sibling and the older one was evident every day – I had absolutely no physical aversion to nursing the younger child as much as he/she needed.

This morning, as always, my 3-year old daughter climbed into my bed after she woke up, and asked “Mamma, can you nurse me, please?”  Hearing her darling request each morning is still music to my ears, but the physical sensation of breastfeeding her isn’t as sweet.  “Drink it,” I remind her, or “scootch a little bit, Ella,” I tell her as I try to position her to a less abrasive place.  Sometimes, I say “you’re hurting mommy, honey,” and she adjusts for a few minutes, like she knows what she needs to do.  I know, though, that her weaning is imminent, perhaps sometime in the next few months.  After she nurses, she announces “done!” and asks if I’ll love on her for a few minutes.  We snuggle and talk about what’s ahead for the day, then we get up and her daddy gives her breakfast while I get myself ready.  Today, though, she surprised me by coming into the bathroom during my shower.  She opened the shower door, and just looked at me for a few seconds.

“Hi, Mamma!” she smiled.

“Hi, baby!  What are you doing?”

“I’m wearing tights!”  She’s always very excited when she wears tights.

“Yes, honey!  You look very pretty.”

I continued with my shower while she kept looking at me.  She spoke again, in her delicious little girl voice.

“Mamma, thank you for letting me nurse.  Bye!”

She left to go find her big brother, and I said a little prayer of thanks.  Not only is my child “old enough to ask for it,” she’s old enough to say thank you.

Be sure to read these other fantastic posts on the topic of extended breastfeeding:

Mamapoeki from Authentic Parenting: Extended Breastfeeding?

Mama Alvina of Ahava & Amara Life Foundation: Breastfeeding Journey Continues

Elita @ Blacktating: The Last Time That Never Was

Karianna @ Caffeinated Catholic Mama: A Song for Mama’s Milk

Judy @ Mommy News Blog:My Favorite Moments

Tamara Reese @ Kveller: Extended Breastfeeding

Jenny @ Chronicles of a Nursing Mom: The Highs and Lows of Nursing a Toddler

Christina @ MFOM: Natural-Term Breastfeeding

Rebekah @ Momma’s Angel: My Sleep Breakthrough

Suzi @ Attachedattheboob: Why I love nursing a toddler

Claire @ The Adventures of Lactating Girl: My Hopes for Tandem Nursing

Elisa @ blissfulE: counter cultural: extended breastfeeding

Momma Jorje: Extended Breastfeeding, So Far!

Stephanie Precourt from Adventures in Babywearing: “Continued Breastfeeding”: straight from the mouths of babes

The Accidental Natural Mama: Nurse on, Mama

Sarah @ Reproductive Rites: Gratitude for extended breastfeeding

Nikki @ On Becoming Mommy: The Little Things

Dr. Sarah @ Good Enough Mum: Breastfeeding for longer than a year: myths, facts and what the research really shows

Amy @ WIC City: (Extended) Breastfeeding as Mothering

The Artsy Mama: Why Nurse a Toddler?

Christina @ The Milk Mama: The best thing about breastfeeding

TopHot @ the bee in your bonnet: From the Mouths of Babes

Beth @ Bethstedman.com: Extended Breastfeeding: To Wean Or Not To Wean

Callista @ Callista’s Ramblings:  Pressure To Stop Breastfeeding

Amanda @ Postilius: Nursing My Toddler Keeps My Baby Close

Sheryl @ Little Snowflakes: Tandem Nursing- The Good, The Bad and The Ugly

Zoie @ Touchstone Z: Breastfeeding Flavors

Lauren @ Hobo Mama: Same old, same old: Extended breastfeeding

Tanya @ Motherwear Breastfeeding Blog: Six misconceptions about extended breastfeeding

Jona (Breastfeedingtwins.org): Breastfeeding older twins

Motherlove Herbal Company: Five reasons to love nursing a toddler


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Posted by: Diana Cassar-Uhl, IBCLC | February 21, 2011

Red tushies and green poop


I bet you didn’t think this blog was going to go below the belt!  I’m here, in your baby’s diaper, to talk a little about red tushies and green poop.

I know a bit about this because when my first December baby was born, her red tushie and green poop fit in with the Christmas décor, but didn’t seem … right.  She was exclusively breastfed, and at her two-week well-baby check, our pediatrician told me my breasts were so big, I was making too much milk, and I was overfeeding her.  He suggested I put my baby girl on a strict feeding schedule.  I laughed.  He had no idea how much she loved to nurse, and how impossible putting her on a schedule would actually be!

He told me her diaper rash was “normal,” even though we were changing her diaper frequently (sometimes as often as every two hours, an definitely immediately after she pooped), not using harsh detergents on her cloth diapers, she wasn’t allergic or sensitive to the absorbent materials in disposable diapers, and the diapers fit her well — no friction or other reason for discomfort.  We definitely didn’t have yeast. A yeast rash looks … angry.  It is red, raised, and covers most of the immediate area of genitalia, as well as “satellite” lesions that extend to the baby’s cheeks.  A yeast rash does not improve with diaper rash creams, and requires an antifungal agent to resolve. Talk to your doctor about probiotic supplements for your baby, especially after antibiotics or if you have/had thrush.  If your baby has a yeast diaper rash, it is likely that he has systemic yeast (candida) and you need to check for yeast in his mouth, as well as on/in your breast.  (Find more about thrush at this Thrush FAQ.)

Our little girl’s rash was a bright red ring around her anus.  Far from being normal, that red ring was a red flag! We began to notice that, after a particularly fussy or gassy period of time (pretty much every evening), that red ring became more pronounced and caused her pain.  Diaper rash cream may have been protective, but it stung her and made her cry (and broke our hearts).

My instincts didn’t agree with my pediatrician’s assessment that my little girl’s rash was normal and her green poop should be controlled by a feeding schedule.  I knew that breastfeeding was her comfort and something wasn’t right.  It was only 2002, but thankfully, a Google search of “bloody infant stools” came up hot for exactly what I needed: published research about protein sensitivity in breastfed babies.  I was surprised; I had no idea that half-gallon of milk I was consuming every two days (to wash down my mother-in-law’s incredible fruitcake, which provided my total subsistence during that bleary-eyed postpartum time) could pass into my milk and hurt my baby as if I was feeding her cow’s milk directly. Under normal circumstances, this doesn’t happen, but many mothers (apparently, I was one of them) have stressed or damaged digestive tracts.  Rather than breaking down and absorbing the nutrients we consume, our bodies instead allow these “invaders” to pass through our guts, to our bloodstream, and into our milk.  The most common food irritants are dairy (from any animal but cow’s milk seems to cause more problems than others), soy, eggs, and wheat.

While there is a wide range of normal in color for a baby’s bowel movements, a persistent mossy color can indicate something is up.  The green may also be tinged with blood (usually dark in color).  Consult your doctor immediately if you see blood in your baby’s diaper.  While bright-red blood typically indicates a fissure or other lesion near the opening to your baby’s anus, darker blood comes from further up and can indicate allergic/sensitive irritation or something more complex.  With or without the presence of blood, you may also notice that your baby’s bowel movements are frothy, foamy, or mucousy.  While this is fairly common, it is not normal and should be investigated.  This article from the Academy of Breastfeeding Medicine addresses allergic proctocolitis in the exclusively breastfed baby – feel free to print it out and bring it to your pediatrician for reference.

If your baby is older and eating solids, common allergens may be the culprit of colorful diapers.  Check out the Food Allergy and Anaphylaxis Network for more information.

Many reliable sources consider food sensitivities and red/green diapers related, and I have extensive elimination-dieting and diaper-watching experience as a mother of three breastfed diaper-fillers that confirms this.  In my practice, I have seen too many mothers and babies to count with this obstacle, and in nearly every case I’ve worked with, identifying and eliminating the offending food(s) resulted in a complete or near-complete resolution of the red ring AND the green poops, and reduced fussiness in the baby.

Another cause of green poop is oversupply/overproduction of milk, which can be related to an endocrine/hormone issue like postpartum thyroiditis.  If you have oversupply, it might be worth it to have your hormones checked, since it’s fairly common for things to get a little wonky in the postpartum period. In my experience, oversupply and a food sensitivity tend to happen together, so if you resolve an issue of oversupply and your baby’s diapers are still more colorful than seems normal, consider an elimination diet.

If the prospect of an elimination diet seems overwhelming for you, see this post and keep a few things in mind: first, it is temporary.  Most likely, you will be able to slowly re-introduce the problem foods into your diet after a few months.  Second, if you choose the alternative of weaning your baby to artificial baby milk, remember that those are made from the very allergens you are trying to avoid!  There are special preparations for very sensitive babies, but these are very, very expensive and rather than a few months of adjustment, you’re facing a financial investment through the end of your baby’s first year.  Third, many of us have been through this, and there are lots of resources and great products out there if you need to cut dairy, soy, gluten, eggs, or any other food from your diet.  You will survive and you might even find some new, healthier favorite options. You may be very pleasantly surprised to recognize that you feel better than ever after eliminating one or more of these foods, as well.

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Posted in allergies in a breastfed baby, breastfeeding, Elimination diet for breastfeeding mothers | Tags: , , , , , ,

Posted by: Diana Cassar-Uhl, IBCLC | February 17, 2011

The opposite of normal


You’re trying to not like me.  You’re mad at me because I’m calling breastfeeding normal, and you didn’t breastfeed.  Or you breastfed for awhile, it got complicated, so you weaned to artificial baby milk.  Or you pumped your milk and fed it to your baby in a bottle, which wasn’t actually breastfeeding but was human milk feeding and why do we have to split hairs here?

And you think I’m calling your behavior abnormal, because that’s the opposite of normal, right?  Abnormal.  Irregular. Odd.  Strange.  Defective.  Freak. It’s a slippery slope, isn’t it, when we want to call one behavior normal but there are all these nice, smart, loving people who don’t do that behavior … so what do we do?

What if we called those other behaviors alternative?  We have normal, and we have alternative.  Dictionary.com gives us 3 noun and 4 adjective definitions for this word.  Let’s work with this noun:

one of the things, propositions, or courses of action that can be chosen

… and  let’s call this our adjective:

employing or following nontraditional or unconventional ideas, methods, etc.; existing outside the establishment

So, we call breastfeeding the norm (normal) because biologically, it’s the next step for a mammal that gives birth to a baby, and we can call artificially feeding the alternative because it’s another thing, proposition, or course of action that can be chosen.  Now, when we describe breastfeeding, we’re still left with normal, because it’s still … well, normal.  Except, here in the United States, it isn’t culturally normal.  Go ahead, click on that link to the Centers for Disease Control and take a look.  Less than half?  Not exactly commonplace.  Run-of-the-mill.  Conventional.  Prevalent.  Standard.  Normal? And yet, the alternative, the option that supposedly follows nontraditional ideas, methods, etc. and exists outside of the establishment … that’s the behavior adopted by the pretty significant percentage of mothers and their babies (and yes, I see that data is a few years old, but I’m willing to put it out there in light of how relatively steady those numbers stayed over an 8-year period and of how similar the experiences mothers share with me are to the ones I was hearing about 4 years ago).

Does anyone else think this is kind of backwards?

Artificial infant feeding is an alternative.  It’s a viable choice when normal isn’t possible or when normal isn’t ideal.  And, while breastfeeding is most definitely normal, and, from the point of view of the baby, ideal, our culture has some improvements to make before breastfeeding feels ideal to every mother.  So we have alternatives.

The World Health Organization places breastfeeding as the optimal way for a baby to be fed, stating:

Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process with important implications for the health of mothers. As a global public health recommendation, infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond. Exclusive breastfeeding from birth is possible except for a few medical conditions, and unrestricted exclusive breastfeeding results in ample milk production.

(OK … wait!  Did you read that right?  This part:

while breastfeeding continues for up to two years of age or beyond

I guess I’ll have to write about that in another post!)

The World Health Organization, in its global strategy on infant and young child feeding, recommends viable alternatives when breastfeeding is not possible/chosen.  In order of biological normality, these are the World Health Organization’s recommendations for infant feeding:

  1. mother’s milk from mother’s breast
  2. mother’s milk fed through an alternate vessel (cup, dropper … bottle is last on the list because of safety/hygiene issues in some countries)
  3. milk from another healthy mother/wet nurse/donor
  4. artificial baby milk

Clearly, this is not the picture we see here in the United States, although organizations such as MilkShare and HumanMilk4HumanBabies are, of late, emerging from the hidden “counterculture” of mothers who provide their milk for other babies.  I’ve spent a long time trying to figure out where we’ve gone wrong as a culture, and I’m realizing the answer to that question is multi-layered and involves a web of money trails, myths, cultural gainsays that have penetrated our concept of what bodies are for, and so many other factors — but this answer does nothing to get us out of this hole.  We can’t untangle the mess that’s been made, we have to start over and reclaim our concept of normal. We can keep our safe, viable alternatives for those who need them, but the time has come to re-establish the normality our culture has allowed to slip through its very fingers.

Want to read more about this?  Check out Jessica, The Leaky B@@b’s blog post about how we can speak truthfully about infant feeding without slinging mud.

A Translation Guide for Navigating the Terrain Between Breastfeeders and Formula-Feeders

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Posted in breastfeeding, human milk | Tags: , , , , ,

Posted by: Diana Cassar-Uhl, IBCLC | February 15, 2011

Some can’t, some don’t want to, and other upfront announcements


Welcome to dianaibclc.com, and to normal, like breathing. I’m Diana.  Please read my about and disclaimer/disclosure pages.

My blog is going to make some strong assertions about how we feed our babies.  You may or may not agree with my assertions, but please be assured that I am not attacking you, your choices, or your opinions.  I want to state that up front.  Future posts in this blog will provide information about breastfeeding that may discourage you, or anger you in light of what your experience has been.  I join in your anger if you felt circumstances prevented you from meeting your breastfeeding goals.  I do not accept being made a target of your anger if my speaking the truth offends you.

Maybe you fed your babies formula (artificial baby milk, or ABM), and you assume that I think you don’t love your children or that you should be put in jail.  Maybe you were in one of those heartbreakingly tragic situations where your body, for whatever reason, didn’t make milk for your baby, and you assume that I think you didn’t try enough, or you weren’t smart enough, or …

You’re wrong.

I totally *get* that there are anatomical and hormonal reasons why some mothers don’t produce  milk (in fact, this has become an area of specialty for me), and that supplementing with ABM or donor milk is how your baby stays alive. I *get* that there are cultural and social reasons that lead mothers to choose against breastfeeding.  I also totally *get* that it’s possible to love your baby as much as I love mine and freely choose to not breastfeed.  I certainly don’t imagine that I’m in a position to determine what’s right for your family.

But I am in a position to declare this: no one makes any money when you breastfeed your baby.  OK, there are products that are companions to breastfeeding, products that, when the normal course of mothering a baby is disturbed, can support and continue the breastfeeding relationship, but ultimately, all most mothers need are a baby and a breast.  Yes, one breast can often get the job done!

There is a TON of money to be made if you don’t breastfeed. And, our very society is built upon the ability to make money … it’s called capitalism and it allows us to enjoy “The American Dream.” So, where’s the return on the investment of educating medical students about human lactation?  Doctors know painfully little about breastfeeding yet they’re on the front lines when mothers and babies have the most trouble.  Have you ever been to a medical school?  Check out the benefactors, the people, companies, and organizations they name libraries, auditoriums, and instructional wings after.  Have you ever been on a mother-baby ward?  What’s your labor nurse using to hold her ID tag?  Who donated her pen, or that little card for your baby’s bassinet that says “I’m a boy?”  That growth chart your pediatrician is looking at to determine whether your baby is thriving … where did it come from?  Did anyone tell you that breastfed babies grow at different rates than ABM-fed babies?  Or that the World Health Organization growth charts were produced with the biologically/normally-fed babies’ growth pattern as the average standard … so maybe your body DID make enough milk for your baby, and she was growing at an appropriate rate?

Undermining breastfeeding, marginalizing it, downplaying its normality is big business in the United States.  Because of this, I believe that advocacy for informed consent is necessary, that ABM be treated as a medical intervention with full disclosure of what the risks of not breastfeeding are, where ABM comes from, and what the alternatives are to using it.  Then, a family that chooses not to breastfeed goes in with eyes wide open.  The freedom to choose is still there, but the choice is completely informed.

When we have informed consent, our expectations are raised, and we seek help when breastfeeding doesn’t work, or we seek preventive action so that breastfeeding WILL work, and we educate ourselves as a society.  We accept what is biologically normal as culturally normal — not a lifestyle choice, not a trendy behavior for the counter-culture.  We stop questioning whether it’s OK to feed our babies in public and we stop trying to contort babies’ needs to fit our expectations.  Instead, we fit our culture around the needs of our youngest, most defenseless members, and we expect more from society.

Please click on the links in this post!  There are statements above that were inspired by others, and the links direct you to their work or further define the concepts I shared.

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