Posted by: Diana Cassar-Uhl, MPH, IBCLC | May 24, 2012

Yes, they’re 7 and 9 and yes, they’ve weaned.

This is Anna and Simon.  They’re my first and second babies, and they’re 7-1/2 and 9-1/2.  They’ve been weaned for a few years now, but since their mamma is an IBCLC, breastfeeding is part of their lives.

There have been a lot of questions over the last few weeks about how children who breastfed long enough to remember having done so feel about it.  Anna and Simon were happy to share about their breastfeeding experiences, and if you’ve got other questions, please post them in the comments and I’ll ask them!

I was definitely ready when Anna and Simon each stopped breastfeeding, because I was nursing a younger sibling each time (I had my three children in 5 years, almost to the day).  Both of them nursed through their first year of pre-K, which I was thankful for – they were still so young and since I worked full-time, leaving them in a school setting for a full day, 3 days a week was hard for me no matter how well I knew they were being nurtured there. Taking a few minutes to nurse when we all got home gave us the chance to reset and relax.  Could we have done that without breastfeeding?  Sure — but I don’t think we would have.  Breastfeeding sort of guaranteed that pause between the workday and the chaos of being home.  I was also really thankful we had breastfeeding to see us through their first major exposures to a classroom of kids (and germs).  Each of them weaned during the summer between pre-K years, after conversations with me (and with Anna, in Simon’s case!).  Both of them had lost their ability to latch and transfer milk; this was especially obvious in comparison to the younger sibling, who was breastfeeding efficiently.  While they weaned from breastfeeding, in the ensuing days, weeks, and months, we still spent a commensurate amount of time sitting together in our “milk chair,” being close and sharing a few moments when they might otherwise have breastfed.  As they wind down 4th grade and 2nd grade, Anna and Simon still enjoy (and, at times, demand!) regular hugs, kisses, and snuggles with me.  I’m happy to be their “home base.”

How old were you when you weaned?

Anna:  I don’t know, around 3-ish?  (She was 3 years, 8 months, and 5 days.  Her weaning was very intentional and definite.)

What do you remember about weaning?

Anna:  I remember not being sure if I was going to, but I finally decided to wean, and I yelled to daddy, “I weaned!”  I felt good that I had done a big-girl thing, but then I felt sad when I saw Simon still nursing and I couldn’t.  I remember telling him that weaning was the worst decision I ever made in my life, but I don’t think that anymore.

What do you remember about breastfeeding?

Anna:  It helped me stay healthy, helped me fall asleep at night.  When I was sad, it cheered me up.

What did you like best about breastfeeding?

Anna:  I still love your smell, and it reminds me of when we used to nurse.  I liked that it was with my mom, and I liked the taste.  I used to say it tasted like macaroni.  I liked how it made me feel – comfy and relaxed.  I super-liked that we did it a lot, and that you were always happy to nurse me, even if it was the middle of the night and you were tired. (Anna really did nurse “a lot.”  I’m glad she was first because I might have been worried about her had she followed one of the less-needy children.)

Do you remember sharing breastfeeding with Simon?

Anna:  Sometimes, but not really.

How do you feel when you see other people breastfeeding?

Anna:  I feel like, “hooray!”  I feel happy because that child must be healthy and happy and that mother wasn’t afraid to do what was best for her child, even in front of strangers.

Will you breastfeed your babies?

Anna:  Of course!  And I’m going to ask you to help me … if I have babies … which I probably will.

What do you want people to know about breastfeeding?

Anna:  That when you breastfeed, it will make you happy and proud.

A few weeks after their tandem nursing days ended: Simon, 2; Anna, almost 4

How old were you when you weaned?

Simon:  Um, around like, 4, I think?  (He was 3 years and 10 months old, but did ask a few other times after that – he didn’t remember how to latch on, though.)

How did you feel about weaning?

Simon:  I felt OK, because I could have other foods, but I missed it sometimes when I saw my little sister nursing.

Anna interrupts: Do you still miss it?

Simon:  Yeah, a little, but I’m older now, and I don’t need to nurse.

What do you remember about breastfeeding?

Simon:  I remember that it really helped me!


Simon:  It helped me when I was having a hard time.

What was your favorite thing about breastfeeding?

It made me feel safe, like I’m at home with my mom.

What’s breastmilk good for?

Simon:  It’s magic milk!  It’s good for pink eye, ear aches, and generally keeping you healthy.

What would you tell other people about breastfeeding?

It makes you healthy, gives you a better future, you know, not as many allergies, that stuff.  And that they should really breastfeed.  I loved nursing.

Do you remember sharing breastfeeding with your sisters?

Simon:  No, not really.  (Anna weaned when Simon was about 6 weeks shy of 2; Simon and Gabriella tandem nursed for about 8 months.)

How do you feel when you see someone breastfeeding?

Simon:  I feel great, like, WOW!  They’re nursing!

For an academic study of older childrens’ perceptions of breastfeeding, check out Dr. Karleen Gribble’s As good as chocolate’ and ‘better than ice cream': how toddler, and older breastfeeders experience breastfeeding

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Posted by: Diana Cassar-Uhl, MPH, IBCLC | May 11, 2012

Yes, she’s 4, and yes, she’s still breastfeeding.

This is Gabriella.  She’s my youngest daughter, and she turned 4 in December. 

Two weeks after her 4th birthday, Gabriella underwent a 3-hour craniofacial surgery to resolve a rare birth defect.  Two pediatric neurosurgeons and a pediatric plastic surgeon cut open my little girl’s head in an incision that wrapped from ear to ear.  They pulled her scalp and most of her face down, and scraped dermoid tissue from the bone between her beautiful eyes, reaching into the suture line to ensure my baby does not have to deal with the invasion of foreign tissue into her brain later in her life.

It took her a long time to wake up.  She ran a little fever in response to the anesthesia and the incredible shock to her system from having her face taken off.  Gabriella was so, so brave and compliant, letting the nurses adjust the tubes and probes that were all over her in the recovery room, content to rest if I held her hand.

We were admitted to her room later in the afternoon, after the recovery nurses felt comfortable letting her go.  Gabriella was starting to wake up, and was so happy to see her brother and sister when they came to visit the children’s hospital.  She was excited to show them the big fire truck to play on and the rooms filled with toys and activities.  With 5 days until Christmas, Santa Claus found some time to bring presents to the children in the hospital, and Gabriella was delighted.

But the morphine made her sick.  She was hungry and thirsty, but even ice chips made her throw up.  “I don’t want to throw up again, mamma,” she told me in her tiny, weak voice.  “I think nursies will help me.  Can I nurse?”

I had anticipated this moment for the months leading up to Gabriella’s surgery.  Her siblings had each weaned before their 4th birthdays, and I expected that Gabriella would do the same.  I half-hoped I would have breastfeeding as a tool to help my little girl through her most difficult life experience to date, but the rest of me worried that she might not wean and I would find myself on the defensive.

You see, we live in a time and place where we would rather see a magazine teeming with images of scantly-clad women on a beach than a mother breastfeeding her child on a bench.  A toddler who climbs into his mother’s lap to breastfeed is viewed as stunted and spoiled; his mother is accused of being a slave, or, worse, being a pedophile.

I worried that even the healthcare professionals charged with my daughter’s healing would strike me down if I comforted her at my breast.  I thought about how I might carry Gabriella, in her little hospital gown with happy tigers romping around on it and her IV line, into the not-so-clean, poorly lit bathroom in her room and let her nurse, with the door closed, while I sat on the toilet. I considered whether I might just nurse her in her bed and receive any confrontations that came our way, praying none of the staff were so ignorant of normal human biology as to call Child Protective Services in to investigate us.  This anxiety came on top of the worry that we hadn’t taken care of everything through our insurance, that my job might place unreasonable demands on me when my child needed me the most, that, maybe, something unexpected would happen during the surgery and my joyful little girl would emerge from it changed … or not emerge at all.

“Yes, darling.  Mamma will nurse you.”

We arranged her IV line so that neither of us would be on top of it.  We laughed when the automatic movement in the mattress, intended to change the position of the patient to prevent bedsores, surprised us as we got settled in to nurse.  Her eyes were puffy with fluid that was draining downward from her head, but I could see the relief in them.  It didn’t matter that we were on a plastic sheet on a noisy hospital ward with narcotic-induced nausea (hers) and utter exhaustion (mine).  She latched on, and we were home, safe, and together.  Gabriella nursed to sleep, and I drifted off, too, for the first time in days.

The shift nurse came in to check Gabriella’s vitals when she was still attached to me.  She smiled and asked “she’s holding that down OK, I take it?”  I made a joke about there not being much there anymore, but added “she doesn’t seem to mind.”  The nurse didn’t challenge me or attack.  She didn’t accuse me of molesting my sweet girl.

Yesterday, though, when TIME Magazine released its controversial cover photo of a mother and her preschooler, awkwardly and unnaturally posed with him standing on a chair with her nipple in his mouth and her staring vacantly at the camera, the accusations flew.  America called me “a feedbag for a bratty child,” wondered “how the hell is the kid going to survive kindergarten if he can’t go without boob at every meal?”  I was called “a slave to my kid” and told I am not teaching my children how to respect me, or anyone else, for that matter, by “indulging them.”  My children were called “overly dependent,” “unable to ever solve problems for themselves,” and “they’re gonna expect everything handed to them on a silver platter when they’re adults.”  I was directed to “cut the freaking cord, already” and to “stop getting your jollies off your kid sucking on your tit.”

I am thankful my children, at 9, 7-1/2, and 4, are unaware of what the society around them supposes about their lives.  They all remember breastfeeding; they still seek comfort in me, their mother.  The foundation is there for an enduring, loving relationship.

Being Old Enough to Ask for It doesn’t forbid a child from receiving comfort from his mother – however that mother chooses to comfort her child.  The older child isn’t breastfeeding all day or to meet nutritional needs, he’s nursing a few times a week because he still needs that “home base” connection to his mother, and breastfeeding has provided that basis since the moment he was born.  The preschooler who still breastfeeds goes to school with your children, but she doesn’t talk about nursing or cry for nursies at rest time – she behaves in age-appropriate, developmentally normal ways (and if she doesn’t, breastfeeding isn’t exacerbating whatever the issue is, rest assured of that).  Breastfeeding my 4-year old, postoperative child wasn’t disgusting, it was normal.  Nursing her back to sleep a few nights ago when she woke up in the middle of the night wasn’t indulging her, it was loving her the way she has come to expect to feel love and comfort from me, her mother.

Gabriella looks back on her time at “the hospital hotel” with smiles.  The hair that was shaved to allow the “boo-boo” is shorter than the rest of her hair and a little hard to control at 5 months post-op, but she puts on a headband and gets on her way.  She experienced no emotional trauma and has no lingering fears or worries about visiting doctors or being subject to tests (she spent nearly two hours AWAKE in the noisy tube for a full spinal MRI just a few months ago, in fact).  Might Gabriella be so confident and stable, even in the face of tremendous adversity, if she wasn’t still breastfeeding?  Perhaps she would be … but I’m thankful she and I know what’s best for her today, and I’m committed to ensuring families are not deprived of accurate information about the normality of breastfeeding an older child.

Posted by: Diana Cassar-Uhl, MPH, IBCLC | February 28, 2012

If breastfeeding is normal, let’s clean up the environment!

This post is taken directly from an assignment for a class toward fulfillment of my Master of Public Health, Environmental Influences on Human Health.  I seek to educate about dioxins, which are found in very high concentrations in human breastmilk.  Dioxin exposure (perhaps in utero) has been shown to have a profound effect on mammary gland development — rendering exclusive breastfeeding impossible in some cases.  Since the practice of incinerating solid waste has declined, so have dioxin levels in our environment; however, today’s new mothers were babies before this practice was changed.  While the prevalence of mammary hypoplasia is not epidemic, I see more of it in my practice today than statistics suggest I should, and I wonder whether environmental contaminants play a significant role in this phenomenon.

Dioxins are undesired by-products of chemical, manufacturing, and combustion processes related to industry in the presence of chlorine.  Processes that can result in the release of dioxins include bleaching paper pulp, heating mixtures of chlorine and organic compounds, incinerating chlorine-containing materials, and the production of pesticides, herbicides, and certain wood preservatives.  Incomplete combustion of wood products and industrial/municipal wastes, such as when incineration was the standard method of trash management, also results in dioxin formation.  Since methods of incineration of solid waste have changed, dioxin levels have gone down in the last quarter-century, but because dioxins are stable, non-water soluble compounds, once they are in the soil, they are difficult to get rid of (Moore, 2007).

There are 419 compounds that are identified as dioxins; of these, 30 are considered to be of significant toxicity (World Health Organization, 2010).  The term “dioxins” refers to chemically/structurally related chemicals:

  • 2,3,7,8-tetrachlorodibenzo para dioxin (TCDD)
  • polychlorinated dibenzo para dioxin (PCDD)
  • polychlorinated dibenzofuran (PCDF)
  • polychlorinated biphenyls (PBB’s) are dioxin-like with similar toxic properties, and are therefore categorized with the dioxin family

The most toxic of these are the TCDD’s.

Dioxins are among the most toxic substances to humans, potentially causing reproductive and developmental problems, damage to the immune system, and cancer.  In 1997, the World Health Organization’s International Agency for Research on Cancer declared that TCDD is a class 1 carcinogen, known to cause cancer in humans (Moore, 2007).  At levels far below those which are believed to cause cancer, dioxin exposure has been linked to reduced fertility (female and male), diabetes, and endocrine system disruptions (Environmental Justice Network, 2011).  A known endocrine disruptor, dioxin can block the action of estrogen in the body, change the number of estrogen receptor sites, alter the rate of production of hormones in the body, replace hormones on the carrier proteins in the bloodstream, and cause adverse health effects (some barely noticeable, others very severe) by making some or all of the naturally occurring hormones in the body unavailable for use (Moore, 2007).  Dioxins, while not themselves lethal, can cause health problems and are the cause of a skin condition called chloracne, which occurs at very high levels of exposure (U.S. Department of Health and Human Services, Food and Drug Administration, 2010). Because of their stability and persistence, dioxins do not break down and are difficult for the body to excrete; therefore, they bioaccumulate and are stored in fat tissue, creating a body burden of toxicity.  The half-life of dioxin compounds is estimated to be 7 to 11 years, representing a significant, long-term effect on the environment and the food chain (WHO, 2010).  This is of particular concern to women who become mothers; dioxin crosses the placenta, resulting in contamination of a baby before he is born.  Additionally, dioxin is stored in breast tissue and can be found in extremely high levels in the breastmilk of human mothers, especially those who consume a lot of animal foods or who live or work in/near the pulp and paper industry, incineration plants, or at hazardous waste sites (WHO, 2010).  It is important to note, however, that the benefits associated with breastfeeding far outweigh the potential risks associated with dioxin exposure (U.S. Environmental Protection Agency, 2011).

As 90% of human dioxin exposure is through food (WHO, 2010), this is obviously the route of exposure that we must address.  However, in order to enter our food supply, dioxin must first be produced by the processes mentioned above, after which time it enters the air, water, and soil.  Once there, it is many years before dioxin begins to break down; therefore, animals are exposed to dioxin compounds in the food they eat, which are sequestered in their body fat, and, when humans consume these animals and their milk (and, of course, their fat), the concentration of dioxins is very high.  As mentioned previously, this is of profound importance to babies in utero, who receive dioxins that cross their mothers’ placentas, and, once born, consume the milk at the top of the food chain, which carries the highest concentration of dioxin.  This is problematic because the consumption of milk is extremely high relative to the infant’s body weight.

Studies have indicated that dioxin exposure can affect mammary gland development in mammals, including humans (see Rudel, et. al; Fenton, et. al; and Markey, et. al in references).  In a culture that recognizes alternate methods of feeding as the norm, impact on mammary gland development may not serve as a huge motivator in changing policy to reduce dioxin exposure.  No functioning breasts?  Just bottle-feed!  Here in the United States, where the public health message is definitely to breastfeed, mothers who find themselves with insufficient glandular tissue/mammary hypoplasia are searching for answers — they want to know why their bodies failed to provide sole nourishment for their babies.

In dioxin exposure, perhaps we have found a fixable reason for the incidence of IGT in mothers?  If so, policy changes to eliminate the production of dioxins may lower the incidence of IGT population-wide. In the interim, I work to find methods of maximizing milk production for mothers who wish to provide their milk, even if only a small amount, for their babies … but this research could potentially open many important discussions about the implications of the toxins in our environment.

Because dioxins are not water-soluble, when they enter a river or a stream, they are absorbed by fatty fish, which then become unsafe to eat because the concentrations of dioxins in these fish are so high.  When cows are fed products that have been treated with pesticides, herbicides, or that are made from animal fats, the dioxins in those foods are stored in the fat, which is passed to humans, concentrated in the meat and milk of those cattle.  The possible exception to this is cattle that are vegetarian and completely grass-fed in an area where not more than naturally-occurring dioxin is found (areas away from industrial centers, pesticide and herbicide runoff, or affected by highly contaminated rainwater).  While dioxin formation is local to such areas, the distribution of dioxin is global (WHO, 2010).

The foods that are most highly contaminated with dioxins are:

  • beef
  • dairy products (cheese, ice cream, yogurt)
  • milk
  • chicken
  • pork
  • fish
  • eggs

(Schecter et al., 2005)

Clearly, those who are concerned with dioxin’s potential untoward health effects can significantly reduce their personal/family’s exposure by adopting a vegan diet, excluding all animal products.  I state this first because it is absolutely the most effective means an individual can adopt to reduce dioxin exposure in his or her life.  Another measure, consistent with U.S. governmental recommendations, is to reduce the amount of animal fat in one’s diet, resulting in a lower exposure, but not elimination of dioxin.  Using skim milk and consuming lowfat versions of dairy products will lower dioxin exposure, but some theorize that our bodies need the full-fat versions, preferably from locally-produced sources.  As mentioned previously, consumption of locally-pastured, grass-fed beef and milk, in areas away from current or former dioxin-producing processes, can also help to reduce personal levels of dioxin exposure.  There is continuing governmental monitoring of dioxin levels in our food supply, however, in my opinion, not enough is being done to clean up the meat and dairy products that are widely available to Americans who may not have access to or the ability to afford locally-produced, sustainable alternatives that are lower in dioxin and other harmful chemicals.  In this arena, however, dioxin is only a drop in the bucket full of issues that exist, along with genetically-modified organisms (GMO’s) in our food, federal subsidies for commodity crops like corn and soybeans that are incorporated into countless processed “food” items, and the use of ammonia and other chemical-containing fillers in factory-produced meats.  These fillers, while intended to combat the risk of E.Coli and other bacteria, are also part of the dietary dioxin load carried by the average American, and potentially cause more harm than good.  Adopting a vegan diet may be the answer to the dioxin question, as well as other questions, for many in our population, but this will not be practical for or preferred by all.

Because dioxins are produced in the presence of chlorine, reducing personal use of bleached products, such as tampons and coffee filters, and bleach itself, not only reduces the amount of dioxin an individual might be exposed to, it reduces the demand for these products, which cuts the need for manufacture and disposal of them.  Unbleached items may not be as visually appealing to our “bright and shiny” sensibilities, but are less likely to harm us or the environment around us.  Oxygen bleach works well in place of chlorine bleach for washing clothes; white vinegar, baking soda, and lemons are excellent non-bleach alternatives for household cleaning purposes.  Families are exposed to fewer dangerous chemicals, and less dioxin is released into the water treatment systems.

On the community level, regulation of pesticide and herbicide use can impact the amount of dioxin that is released into the environment.  Similar to household use of chlorine-bleached products, when pesticides and herbicides are passed up in favor of environmentally-sustainable methods of pest and weed control, the demand for production of these substances is reduced in addition to the lower proximate levels of dioxins.  Pulling dandelions with a device designed for this purpose, allowing grass to grow longer (to crowd out weeds), and using food-grade substances such as clove oil for weed control reduce our exposure to toxins.  Strategic planting of gardens and crops and allowing natural predators to take care of pests can help eliminate our need for pesticides on our food.  Along the same lines, individuals who choose organically or locally grown produce send a clear message that we do not want to consume harmful chemicals in our food.

It is important to note that, while we can reduce man-made release of dioxin, dioxin has existed on the planet for longer than humans have, and such natural events as forest fires and volcanoes will always be sources of dioxin that humans will be exposed to (WHO, 2010).

Plastics that are made from PVC (polyvinyl chloride) are implicated in dioxin release in their production, and when these plastics are burned intentionally or accidentally in home, vehicle, and landfill fires.  PVC production is increasing worldwide, and is now the world’s largest use of industrial chlorine, accounting for 30% of the world’s chlorine production.  PVC is used at an alarming rate in the production of building materials such as pipes and window frames, and in home products such as shower curtains and vinyl flooring.  PVC plastics are pervasive in our society as office supplies, furniture, credit cards, and other common consumer items.  In addition to the dioxins released in the production of PVC plastics, their use is problematic, as plasticizers are not bound to the materials and can leach out of the items into the air where they are being used.  PVC materials are difficult and expensive to recycle, because more PVC is needed to recycle PVC into a new product of the same quality.  The disposal of PVC creates an environmental hazard; if incinerated, PVC releases large amounts of dioxins and other chemicals into the air.  In improperly constructed landfills, the plasticizers in PVC can leach into the surrounding ground and soil, resulting in long-term contamination (Greenpeace, 1997).  If dioxin reduction is a global priority, the manufacture, use, and disposal of PVC materials cannot continue as it currently occurs.

Globally, there is good news for reducing our exposure to dioxin.  The United States and other countries have taken measures and implemented policies to enforce the reduction of dioxin production.  Beginning in the 1970’s, changes to incineration procedures were put into practice after the Clean Air Act was passed, and further controls on the major sources of industrial dioxin release were implemented in 1987.  Emission levels of dioxins have decreased 90% since 1987, which has resulted in lower exposures and amounts of stored dioxins in humans (U.S. Environmental Protection Agency, 2011).  However, since dioxins are so persistent and take many years to break down and be eliminated, continued efforts are necessary to reduce worldwide dioxin production and release, and additional time is required to allow the existing presence of dioxins to decrease.  Because of this time lag, even if current exposure levels do not decrease significantly, it is expected that the amount of dioxins built up in our bodies will continue to decline (Chlorine Chemistry Division of the American Chemistry Council, 2011).

While dioxin continues to be an environmental threat to human health, the reduction in dioxin exposure that has taken place over the last few decades has positively impacted humans across the planet with a corresponding decline in the body burden borne by each individual, especially in areas were industrial centers were major producers of dioxins.  Control over the practice of incineration and policies that regulate the production and use of certain pesticides and herbicides have been moves in the right direction, but because of dioxin’s persistence in the environment, time must elapse before the impact of these regulatory measures can be realized.  PVC production, use, and disposal remains the greatest obstacle to true dioxin reduction; perhaps if pressure is put on policymakers by informed consumers, change will occur as it did with regard to incinerators, which were previously the largest source of dioxin release.




Chlorine Chemistry Division of the American Chemistry Council. (2011). Dioxin exposures and body levels fall dramatically.  Retrieved from

Costner, P. (2001). Chlorine, combustion, and dioxins:  Does reducing chlorine in wastes decrease dioxin formation in waste incinerators? Greenpeace: Retrieved from

Environmental Justice Network. (2011).  Dioxin Home Page. Retrieved from

Fenton, S. E., Hamm, J. T., Birnbaum, L. S., & Youngblood, G. L. (2002). Persistent abnormalities in the rat mammary gland following gestational and lactational exposure to 2, 3, 7, 8,-tetrochlorodibenzo-p-dioxin (TCDD). Toxicological Sciences, 67(1), 63-74. 

Greenpeace. (1997). PVC – The poison plastic.  Retrieved from

Markey, C. M., Rubin, B. S., Soto, A. M., & Sonnenschien, C. (2003). Endocrine disruptors: from Wingspread to environmental developmental biology. Steroid Biochemistry and Molecular Biology, 83, 235-244.

Moore, G. S. (2007).  Living With the Earth: Concepts in Environmental Health Science.  Boca Raton, FL: Taylor & Francis. p. 201-204.

Rudel, R. A., Fenton, S. E., Ackerman, J. M., Euling, S. Y., Makris, S. L. (2011). Environmental exposures and mammary gland development: State of the science, public health implications, and research recommendations. Environ Health Perspect 119(8): doi:10.1289/ehp.1002864

Schecter, A., Cramer, P., Boggess, K., Stanley, J., Papke, O., Olson, J., … Schmitz, M. (2001).  Intake of dioxins and related compounds from food in the U. S. population.  Journal of Toxicology and Environmental Health, 63, p. 1-18.  Retrieved from

U. S. Department of Health and Human Services, Food and Drug Administration. (2010).Questions and answers about dioxins.  Retrieved from

U. S. Environental Protection Agency. (2011). Persistent Bioaccumulative and Toxic (PBT) Chemical Program: Dioxins and Furans.  Retrieved from

Vorderstrasse, B.A., Fenton, S.E., Bohn, A.A., Cundiff, J.A., & Lawrence, B.P. (2004). A novel effect of dioxin: Exposure during pregnancy severely impairs mammary gland differentiation. Toxicological Sciences, 78(2), 248-57.

World Health Organization. (2010). Dioxins and their effects on human health (Fact sheet No. 225).  Retrieved from

Posted by: Diana Cassar-Uhl, MPH, 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:


  • 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 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?


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.


  • 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.


  • 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!


  • 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!


  • 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!


  • 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.


  • 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. (Gluten-free lunchbox ideas)

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!

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!

Posted by: Diana Cassar-Uhl, MPH, 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.

Posted by: Diana Cassar-Uhl, MPH, 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

Posted by: Diana Cassar-Uhl, MPH, 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.

Posted by: Diana Cassar-Uhl, MPH, 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.

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

Old enough to ask for it

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

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 @ 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 ( Breastfeeding older twins

Motherlove Herbal Company: Five reasons to love nursing a toddler

Posted by: Diana Cassar-Uhl, MPH, 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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