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Colic in the Breastfed Baby
by Jack Newman, MD, FRCPC
Colic is one of the mysteries of nature. Nobody knows what it really is, but everyone has an opinion. In the typical situation, the baby starts to have crying periods about two to three weeks after birth. These occur mainly in the evening, and finally stop when the baby is about three months of age (occasionally older). When the baby cries, he is often inconsolable, though if he is walked, rocked or taken for a drive, he may settle temporarily. For a baby to be called colicky, it is necessary that he be gaining weight well and be otherwise healthy.
The notion of colic has been extended to include almost any fussiness or crying in the baby, and this may be valid since we do not really know what colic is. There is no treatment for colic, though many medications and behaviour strategies have been tried, without any proven benefit. It is admitted that everyone knows someone whose baby was cured of colic by a particular treatment. It is also admitted that almost every treatment seems to work-for a short time, anyhow.
The Breastfeeding Baby with Colic
Aside from the colic that any baby may have, there are three known situations in the breastfed baby that may result in fussiness or colic. Once again, it is assumed that the baby is gaining adequately and that the baby is healthy.
Feeding Both Breasts at Each Feeding
Human milk changes during a feeding. One of the ways in which it changes is that, in general, the amount of fat increases as the baby drains more milk from the breast. If the mother automatically switches the baby from one breast to the other during the feed, before the baby has "finished" the first side, the baby may get a relatively low amount of fat during the feeding. This may result in the baby getting fewer calories, and thus feeding more frequently. If the baby takes in a lot of milk (to make up for the reduced concentration of calories), he may spit up. Because of the relatively low fat content of the milk, the stomach empties quickly, and a large load of milk sugar (lactose) arrives in the intestine all at once. The protein which digests the sugar (lactase) may not be able to handle so much milk sugar at one time and the baby will have the symptoms of lactose intolerance-crying, gas, explosive, watery, green bowel movements. This may occur even during the feeding. These babies are not lactose intolerant. They have problems with lactose because of the sort of information women get about breastfeeding. This is not a reason to switch to lactose free formula.
- Do not time feedings. Mothers all over the world have successfully breastfed babies without being able to tell time. Breastfeeding problems are greatest in societies where everyone has a watch and least where no one has a watch.
- The mother should feed the baby on one breast, as long as the baby actually gets milk from the breast (see videos at www.drjacknewman.com) until the baby comes off himself, or is asleep at the breast from being full. Use breast compressions to keep baby drinking and not just sucking. Follow the Protocol to Increase Breastmilk intake. Please note that a baby may be on the breast for two hours, but may actually feed for only a few minutes. In that case the milk taken by the baby may still be relatively low in fat or not-no one can possibly know. This is the rationale for compressing the breast. If, after "finishing" on the first side, the baby still wants to feed, offer the other side. Do not prevent the baby from taking the other side if he is still hungry.
- The next feeding, the mother should start the baby on the other breast in the same way.
- The mother's body will adjust quickly to the new method, and she will not become engorged or lop sided.
- Just as there should be no "rule" for feeding both breasts at each feeding, there should be no rule for one breast per feeding. Let the baby finish on one breast (use compression to keep him feeding longer) but if he wants more, then offer the other side. Remember, a baby sucking without drinking is not getting any milk, not high fat, low fat, skim milk, or cream, baby is getting no milk! Keep baby drinking, use compressions.
- In some cases, it may be helpful to feed the baby two or more feedings on one side before switching over to the other side for two or more feedings, as long as baby has come of the breast from drinking. Putting a baby back on a breast that was just "emptied" may cause baby to fuss or pull at the breast or fall asleep but not be full.
- This problem is made worse if the baby is not well latched on to the breast. A good latch is the key to easy breastfeeding.
Overactive Letdown Reflex
A baby who gets too much milk too quickly, may become very fussy, very irritable at the breast and may be considered "colicky". Typically, the baby is gaining very well. Typically, also, the baby starts breastfeeding, and after a few seconds or minutes, starts to cough, choke or struggle at the breast. He may come off, and often, the mother's milk will spray. After this, the baby frequently returns to the breast, but may be fussy and repeat the performance. He may be unhappy with the rapid flow, and impatient when the flow slows. This can be a very trying time for everyone. On rare occasions, a baby may even start refusing to take the breast after several weeks, typically around three months of age.
- Fix the Latch. This problem is made worse if the baby is not well latched on to the breast. A good latch is the key to easy breastfeeding. No matter what you are told about how good the latch looks, try to improve on it. Think of it this way: if your chin is tucked into your chest while you are trying to drink you would become overwhelmed by the fast flow very easily. If you want to drink quickly you will throw your head back, chin in the air, and be able to handle the fast flow. This is the kind of position baby's head should be in while breastfeeding-his chin deep into your breast, his head in a tipping-back position, his nose up in the air away from your breast, and his chin far from his own chest. This position will help him to handle the faster flow of the let down.
- If you have not already done so, try feeding the baby one breast per feed. In some situations, feeding even two or three feedings on one breast before changing to the other breast may be helpful. If you experience engorgement on the unused breast, express just enough to feel comfortable. Remember, if the baby wants the second breast, the mother should offer it.
- Feed the baby before he is ravenous. Do not hold off the feeding by giving water (a breastfed baby does not need water even in very hot weather) or a pacifier. A ravenous baby will "attack" the breast and may cause a very active letdown reflex. Feed the baby as soon as he shows any sign of hunger. If he is still half asleep, all the better.
- Feed the baby in a calm, relaxed atmosphere, if possible. Loud music, bright lights are not conducive to a good feeding. Note, older babies tend to become very distracted as the flow slows down. Using compressions gently at first, and then more firmly as necessary to keep the speed of flow consistent, will often keep baby interested in staying on the breast longer, because he is drinking better.
- Lying down to breastfeed sometimes works very well. If lying sideways to feed does not help, try lying flat, or almost flat, on your back with the baby lying on top of you to breastfeed, or try leaning back in a chair. Gravity helps decrease the flow rate. Remember, baby may be frustrated at the inconsistent flow, so it may be necessary to lie down at the beginning when the flow is fast, and sit back up as the milk slows. Babies like the lying down position; they tend not to fuss with slower flow but tend to sleep.
- The baby may dislike the rapid flow, but also become fussy when the flow slows too much. If you think the baby is fussy because the flow is too slow, it will help to compress the breast to keep up the flow, see above, point (e). (handout Breast Compression).
If all else has not made things better:
- On occasion giving the baby commercial lactase (the enzyme that metabolizes lactose), 2-4 drops before each feeding, relieves the symptoms. It is available without prescription, but fairly expensive, and works only occasionally.
- A nipple shield may help, but use this only if nothing else has helped and only if you have got good help without any relief. This is a second-last resort.
- As a last resort, rather than switching to formula, give the baby your expressed milk by cup or bottle. Adding lactase to the expressed milk may help as well.
Foreign Proteins in the mother's milk
Sometimes, proteins present in the mother's diet may appear in her milk and may affect the baby. The most common of these is cow's milk protein. Other proteins have also been shown to be excreted into some mothers' milk. The fact that these proteins and other substances appear in the mother's milk is not, usually, a bad thing. Indeed, it is usually good, helping to desensitize your baby to these proteins. Ask about this if you have any questions.
Thus, in the treatment of the colicky breastfed baby, one step would be for the mother to stop taking dairy products or other foods, but only one type of food at a time. Dairy products include milk, cheese, yoghurt, ice cream and anything else that may contain milk, such as salad dressings with whey protein or casein. When the milk protein has been changed (denatured), as in cooking for example, there should be no problem. Ask if you have any questions.
If eliminating certain foods from the mother's diet does not work, the mother can take pancreatic enzymes, starting with 1 capsule at each meal, to break down proteins in her intestines so that they cannot be absorbed into her body and appear in the milk.
Please note: Intolerance to milk protein has nothing to do with lactose intolerance, a completely different issue. Also, a mother who is lactose intolerant herself should also still breastfeed her baby.
- The mother should eliminate all milk products for 7-10 days.
- If there has been no change, the mother can reintroduce milk products.
- If there has been a change for the better, the mother can then slowly reintroduce milk products into her diet, if these are normally part of her diet. (There is no need to drink milk in order to make milk). Some babies tolerate absolutely no milk products in the mother's diet. Most tolerate some. The mother will learn what amount of dairy products she can take without the baby reacting.
- IIf there is concern about the mother's calcium intake, calcium can be obtained without taking dairy products. But, 7-10 days off milk products will not cause any nutritional problems. Actually, evidence suggests that breastfeeding may protect the woman against the development of osteoporosis even if she does not take extra calcium. The baby will get all he needs.
- The mother should be careful about eliminating too many things from her diet. Everyone will know someone whose baby got better when the mother stopped broccoli, beef, bananas, bread, etc. The mother may find that she is eating white rice only. Our diets are too complex to be sure exactly what, if anything, is affecting the baby.
Be patient, the problem usually gets better no matter what. Formula is not the answer, but, because of the more regular flow, some babies do improve on it. But formula is not breastmilk. In fact, the baby would also improve on breastmilk from the bottle because of the regularity of the flow. Even if nothing works, time usually helps. The days and nights may seem eternal, but the weeks will fly by.
For videos showing how to latch a baby on, how to know a baby is getting milk, how to use compression, go to www.drjacknewman.com
Questions? see my book Dr. Jack Newman's Guide to Breastfeeding (called
The Ultimate Breastfeeding Book of Answers in the USA)
Handout Colic in the breastfed baby. Revised May 2008
Written and Revised by Jack Newman, MD, FRCPC 1995-2005
Revised by Edith Kernerman, IBCLC, and Jack Newman, MD, FRCPC © 2008
This handout may be copied and distributed without further permission, on the condition that it is not used in any context in which the WHO code on the marketing of breastmilk substitutes is violated.
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