StorkNet interview with
Jack Newman, MD, FRCPC
Author of
Ultimate Book of Breastfeeding Answers

click here for articles by Dr. NewmanIn celebration of World Breastfeeding Week, StorkNet is very pleased to include Dr. Jack Newman on our list of guests. Jack Newman, M.D. , F.R.C.P.C. is a pediatrician, and graduate of the University of Toronto medical school. He started the first hospital-based breastfeeding clinic in Canada in 1984. He has been a consultant with UNICEF for the Baby Friendly Hospital Initiative in Africa. Dr. Newman has practiced as a physician in Canada, New Zealand, and South Africa. He has published articles on the subject of breastfeeding in Scientific American and several medical journals. Many of his articles are available on StorkNet.

Dr. Jack Newman, author of The Ultimate Book of Breastfeeding Answers and Dr. Jack Newman's Guide to Breastfeeding, has replied to a selection of interview questions posted by StorkNet members. We are very pleased to present the following interview.

Vicki: Recently at my daughter Savannah's one year checkup, our pediatrician touched on a breastfeeding issue with me. (At 13 months I am still breastfeeding, usually 4-6 times a day.) She said that some studies are now finding that breastfeeding too frequently (as in the number of times a day the baby is breastfed) after the age of one, can lead to the baby becoming anemic. She said this can be very dangerous. Is this true? I have not been successful in finding any information regarding this subject.

Dr. Newman: Dear Vicki, I hope you misunderstood the pediatrician. Perhaps what she meant to say was that exclusive breastfeeding at a year may result in iron deficiency, which eventually leads to anemia. However, the studies demonstrating cognitive problems with anemia are not very convincing and faulty. But that is not the point. The point is, that if the baby is taking iron containing foods, such as meat, in reasonable quantities, there is no problem with frequent nursing. The baby will get iron from these other foods. It is only if the breastfeeding is so often that the baby is not eating other foods that a problem might arise. If your child is eating a wide variety of food in addition to breastfeeding, don't be even a little concerned. Jack Newman, MD, FRCPC

Gayesy: Dr. Newman, I am STILL (shock, horror!!) nursing my little boy who is almost three-and-a-half years old. He is slowly weaning himself, and now usually only wants to nurse once a day, sometimes not at all. I really believe in child-led weaning, and am thrilled to see the confidence and security Thomas has as he is allowed the freedom to wean at his own pace (although I personally do miss the more frequent nursing - up until 9 or so months ago, he was still nursing 10-12 times a day!!)

Recently, I have been having a problem with sore breasts. I am pretty sure it is not mastitis or thrush as I have had both enough times to know how rotten they feel. I am also sure that I am not pregnant (unfortunately). What could the problem be do you think? It doesn't hurt any more when Thomas nurses - just a constant feeling of tenderness. Could it be hormonal perhaps? I think I might have just started ovulating again (my periods returned about 9 months ago). Thanks so much for your time!

Dr. Newman: Dear Gayesy, To be honest, I don't know what is causing this problem. It would be easy to say it is hormonal, and that is a reasonable hypothesis, especially if you feel that you are just now having ovulatory periods, but it sounds as if your breasts are always tender. I don't have a good answer. Jack Newman, MD, FRCPC

Michelle: I am getting conflicting advice about extended nursing. My son turned one a few weeks ago and he is still nursing as his primary source of food. He is nursing a dozen times or more during the day, often just for a quick drink and reconnect time with me. He has a long nurse before each nap and before bed and usually nurses 1-2 times during the night as well. I don't have a problem with all this nursing, but I am concerned about his nutrition needs. He started eating solids at 6 months of age. He never really cared for them much. Now he will hardly eat anything. He eats maybe five small bites of food a day even though I offer him food all day long.

His pediatrician told me that he is filling up on my milk and that I need to change that. I no longer just offer him the breast; I wait for him to tell me he wants to nurse (he gives a clear sign by lifting my shirt). And whenever he gives me this sign now I try to offer him food instead, but he will have nothing to do with it and just pulls at my shirt until I let him nurse. About once a week though he will surprise me by eating a sizeable amount of solids at one meal. He also enjoys drinking water, so I give him 4-8 ounces a day. I have tried to give him fruit juices, diluted and not, but he throws down the cup. He will drink cow's milk, but I figure my milk is better than that so why give it to him.

He has always been a very active and large baby, off the chart in weight and around 90% in height, but he has slowed down drastically. At his one year appointment he weighed 25 lbs (85%) and was about 30.5 inches tall (75%). He has only grown 1/4 of an inch since 9 months and only 1.5 inches since he was 6 months old. His head has always remained steady at 50% His pediatrician isn't worried about his lack of height gain. He was diagnosed as being anemic at his 9 month appointment, but after one month of giving him an iron supplement his hemoglobin count was normal again. We are continuing to give him iron since his iron stores were still low at that point though. I had myself tested and while I wasn't anemic my iron was low as well so my doctor put me on a supplement .

My son obviously still emotionally needs to be nursing. It is a relationship I enjoy immensely as well so I want to continue to nurse him on demand until he decides to wean. My feelings are that he will eventually start to eat more solids. He has been eating table foods since he was about 8 months old and he will try just about anything, and seems to like different foods, but never eats more than one or two bites if that. Should I be worried?

Dr. Newman: Dear Michelle, No, there is no need to be worried. The only thing that breastmilk alone is deficient in for a 12 month old is iron, and he is getting extra. I would offer your baby food when you are at the table, and not food only for him, but much the same food as you are eating yourself, with few exceptions. (The exceptions being small, round, slippery things, like grapes or peanuts which can go down the wrong way). He might be much more interested in eating if you don't show him how interested you are in his eating. Just put food in front of him and let him eat.

You are right, your milk is better for your baby than cow's milk. Cow's milk offers no advantage at all. He is better to eat solids than drink cow's milk. Although dairy products do not have a lot of iron, cheese and yogurt are better ways of giving your baby dairy products than his drinking milk.

Height of a baby is very difficult to measure accurately. Your pediatrician is right not to worry. Jack Newman, MD, FRCPC

Michelle: When my son was 6 weeks old I had my gall bladder removed. Since that time (around 11 months now) I have had problems with diarrhea and occasionally with reflux. I have been given Questran for the diarrhea, which he assured me does not get absorbed through the intestines, but since I am nursing and plan to for as long as my son desires, my doctor did not want to put me on Prevacid, the medicine he would recommend for the reflux. He said that if it continued I could be put on a Pepcid or another similar medication. What anti-acid prescription medicine is the safest to take while nursing, and what effects does it have on my baby? Currently I am taking about 6 TUMS a day and depending on the risks to my child I am willing to live with the discomfort if needed. I have changed my diet (no caffeine, very little greasy foods and chocolate) and that has not helped. My son is also still nursing 12+ times a day at the age of 12 months.

Dr. Newman: Michelle, the best anti acid medication for the nursing mother is omeprazole (Prilosec). Lansoprazole (Prevacid) is very similar, but the baby is likely to get more of it than he will of omeprazole. The reason that omeprazole is so good is that it is completely destroyed by the acid in the stomach. Now, when you take it, it is covered by a special product which protects it against destruction in the stomach. Only small amounts get into the milk, but even that is immediately destroyed by the acid in the baby's stomach, so essentially he gets nothing.

The Prevacid is not as sensitive to destruction by acid, so the baby is likely to absorb some, but even then, it is better to take it, if that's what you need, than to stop breastfeeding.

Because of the tremendous good effects of breastfeeding and breastmilk for the child *and* the mother, it is rare that a drug requires the mother to stop breastfeeding. Often there are better and worse choices, but usually, even the worse choice is compatible with breastfeeding, if we look at the risks and benefits.

Famotidine (Pepcid) has very low levels in the milk, and it is probably the best drug of this type for the breastfeeding mother. Jack Newman, MD, FRCPC

Jaci:How often should I still be nursing my soon-to-be 11 month old? He wakes up and nurses at 6:00. He eats baby food for breakfast at 8ish, then around 11:00 he will have some juice, and nurse for 15-20 minutes. At 12:00 -1:00 eats two jars "Stage 2" baby food - one veggie, one fruit, drink some juice, and nurse again around 3:00. At dinner he eats the same two jars baby food, some water, plus he snacks all day with cereal, cookies, etc. At 6:30 pm he nurses for 15-20 minutes, eats a fresh fruit, drinks some juice, and then is up at 11:00 to eat, again at 3:00, and start the day at 6:00 am, same thing over again. I feel like he is eating all day long; he weighs 24 lbs., and is extremely healthy, but shouldn't he be just eating about three times a day now? Thank you.

Dr. Newman: Jaci, babies of 11 months should be breastfeeding when they want to breastfeed. Breastmilk is good for them, but there is more to breastfeeding than the milk. Babies often love to breastfeed, they are comforted by breastfeeding and they love to "get in touch" with their mothers so they breastfeed. Why limit it?

There may be times when you feel it is not appropriate for your baby to breastfeed, but they are easily distractible at this time, and usually you can make them forget about it. But if they are insistent, you should breastfeed. Nothing becomes more desirable than forbidden fruit, and if you refuse, it will become a battle and the baby usually wins. Except that nobody really wins. Better to breastfeed when he really wants and forget the rest. Better to forget counting the times. Jack Newman, MD, FRCPC

Deb: I was preparing an herbal tea, Ginsing Energy by Celestial Seasonings, and I looked on the side and it said "Consult your physician before using if you are pregnant or nursing." My question is will drinking this be harmful if I'm nursing my son?

Dr. Newman: Dear Deb, Companies say that to protect themselves. It is extremely unlikely that *any* drug, whether natural source or other, will get into the milk in any amounts that would hurt the baby.

There are herbs which can be dangerous, comfrey being one of them. But usually you can be sure that the baby will be fine. Jack Newman, MD, FRCPC

Jennifer B: Is it really possible for a woman not to produce enough milk, no matter how much she nurses? Also, how does the breast increase the milk supply without feeling fuller? I'm currently breastfeeding my three month old and I know he takes in more now than ever, but my breasts don't feel fuller than before. Thank you for your time!

Dear Jennifer, Yes, it is possible for a mother not to be able to produce enough milk, though usually, if the baby is not gaining weight well, it is because the baby is not getting the milk that is there. However, your question sounds like the baby is doing just fine. Just because your breasts don't feel full, this is of no significance at all. If the baby is gaining well and content, don't even think about it. The breast produces more milk without your feeling fuller. Miraculous isn't it?

Some mothers do get a drop in the milk supply when the baby is around three or four months. Sometimes this is due to going on the birth control pill with estrogens, sometimes because they are trying to get the baby on a schedule or overusing a pacifier, but usually there is no obvious reason. However, the baby is usually not content and not growing. There are many things that can be done for this (*not* including adding formula, by the way), but I won't go into this in detail now. If you really believe the milk supply is down, get back to me through email. Jack Newman, MD, FRCPC

Cindy: I have an unusual question that I have asked of many LC's and LLL (who I am very involved with). I am a firefighter. I've been one for 13 1/2 years. In that time I have had 2 children who are now going to be 7 and 4 in October. The youngest is still nursing. I have successfully breastfed both of them even though I have a schedule of 24 hours on duty and 48 hours off duty. No formula supplements.

My question is: Smoking cigarettes is known to be a hazard, but what about the fires I have been to in the years I've had my children and breastfed. If I was at work, I would pump and dump that first bottle after the fire, but would then save the rest for the next work day. I nursed my son two hours after coming home from a fire, and he didn't seem to mind it. There seem to be no studies on this, due to the fact that there probably are not many nursing firefighters.

My kids are very healthy. Each child has had only 2 doctor visits for illness outside of their well-baby and annual visits. I guess what I'm asking is there any long term effects I should be aware of. I was never at a very busy firehouse, so I went sometimes months without seeing a fire. Right now I work at O'Hare Airport and I've only had two small fires in the last three years. Thanks. Cindy

Dr. Newman: Dear Cindy, I would not pump and dump after a fire. There is no difference between the toxins in the smoke and any other drug. The amount that gets into the milk is very very small. I would say that if you yourself don't feel ill, the amounts in your blood are not likely to be high enough to cause your baby any ill effects, either in the short run or the long run. As you say, your children are very healthy, and the breastfeeding undoubtedly had a lot to do with it. Jack Newman, MD, FRCPC

Kathy: What would be some medical reasons for NOT being able to breastfeed?

Dr. Newman: Dear Kathy, There are very few reasons for not breastfeeding. In an affluent situation, HIV infection is probably one, though recent evidence suggests that *exclusive* breastfeeding for three months *may* actually protect the baby. The same is true for another virus called HTLV-1. That is, three months of breastfeeding seems to protect.

Some medications, but very few, are medical reasons for not breastfeeding. The vast majority of medications are safe during breastfeeding, and the majority of those that are a problem can usually be replaced by an equally effective drug which is not a problem.

Sometimes, of course, the mother has an illness which results in her being critically ill and then she cannot breastfeed, but as soon as she is able, she should breastfeed. That's about it. Jack Newman, MD, FRCPC

Kelchrsie: When I breastfed my first child he seemed to get big really fast; his weight gain was great. This time around my daughter is a lightweight in comparison. Is my breastmilk supply not as good?

Dr. Newman: Dear Kelchrsie, Every baby is different, and they don't always have to gain quickly. If the baby is gaining reasonably well, but just not as fast as your other baby, that's no problem. If the weight gain is too slow, here is what I do.

Protocol for "Not Enough Milk"

Here is the way I proceed for "insufficient milk supply" (actually, most mothers have lots, but the problem is that the baby is not getting the milk which is available).

1. Get the best latch possible. This needs to be shown by someone who knows what they are doing. Anyone can look at the baby at the breast and say the latch is good. This diagram shows how to get a good latch.

2. Know how to know the baby is getting milk (open-->pause-->close type of sucking). See handout: How to know my baby is getting enough milk located on StorkNet.

3. Once the baby is no longer drinking, use compression to increase flow to the baby. See handout Breast Compression located on StorkNet.

4. When the baby no longer drinks with compression, switch sides and repeat. Keep going back and forth until the baby does not drink even with compression.

5. Try fenugreek and blessed thistle. These two herbs seem to increase milk supply and increase rate of milk flow. There is more information on the handout Treatments for Problems 2.

6. In the evening when babies often want to be at the breast for long periods, get help to position the baby so that you can feed lying down. Let the baby nurse and maybe you will fall asleep. Or rent videos and let the baby nurse while you watch.

7. It is not always easy to decide if a baby needs supplementation. Sometimes more rapid growth is necessary. If possible get banked breastmilk to supplement if you can. If not available, formula may be necessary. However, sometimes slow but steady growth is acceptable. The main reason to worry about growth is that good growth is one sign of good health. A baby who grows well is usually in good health, but this is not necessarily so. Neither is a baby who grows slowly in poor health, but physicians worry about a baby who is growing more slowly than average.

8. If it is decided to supplement, the best way is at the breast with a lactation aid. Introduce the supplement with a nursing supplementer (lactation aid), not bottle, syringe, cup or finger feeding. See handout on Lactation Aid located on StorkNet. Supplement only after steps 3 and 4 above and the baby has nursed on at least both sides.

9. If the baby is older than 3 or 4 months, formula is not necessary and extra calories can be given to the baby as solid foods. First solids may include: mashed banana, mashed avocado, mashed potato or sweet potato, infant cereals, as much as the baby will take, and after the baby has nursed, if he is hungry.

10. Domperidone is a possibility. It is not a panacea. Check the handout on Domperidone on StorkNet. Jack Newman, MD, FRCPC

Shelley: I have an eight-month-old son who is still receiving most of his nutrition from breastmilk. His pediatrician says there are no health benefits to nursing past the first year, but I have always thought the benefits extended well into toddlerhood and older. What is the general consensus regarding the nutritive benefits of breastmilk past the first year? Thank you!

Dr. Newman: Dear Shelley, I believe your pediatrician is wrong. The value of breastmilk doesn't change just because the baby is 366 days old instead of 365 days old. Your milk still contains antibodies and other immune factors. It still contains factors to help the baby's brain develop. But breastfeeding is more than just the milk. It is a whole relationship, and unfortunately, it looks as if your pediatrician just doesn't understand that. Too bad. Here is a document we give out to mothers and which is located on StorkNet called "Breastfeed a toddler--why on earth?" Jack Newman, MD, FRCPC

Kelly: I've been exclusively nursing my now 7 week old daughter since birth. I've had a sore nipple ever since then and I can't seem to relieve it no matter how hard I try to get a good latch. Is this the side effect of a larger breast/nipple and what can I do to relieve it?

Dr. Newman: Dear Kelly, I think we now know that there are better and worse ways to achieve a good latch. I think the best way, is a way few lactation specialists are teaching, and that is the "asymmetrical latch." Here is the diagram that we think helps teach it, but it is difficult to learn from a diagram.

Yes, a larger nipple can make it more difficult, precisely because the baby latches on poorly.

I often use a nipple ointment, which I call "all purpose nipple ointment." It helps much of the time to get the nipples to heal up more rapidly. You need a prescription for it though.

mupirocin 2% ointment: 15 grams
nystatin ointment: 15 grams
betamethasone 0.1% ointment: 15 grams

You apply it sparingly after each feeding and do not wash or wipe it off. You use it until you have no pain, and then decrease usage over a week or two. Jack Newman, MD, FRCPC

Susan: My baby is almost 6 months and I've seen a lot of conflict in advice about iron supplements. Do you feel they are necessary? She has not started solids yet and doesn't seem to be terribly interested, so she may be solely nursing for some time still.

Dr. Newman: Dear Susan, No they are not. Unless your baby was born very prematurely, or lost a lot of blood somehow, he doesn't need iron supplements. He does need to start getting more iron in his diet however, because his stores are starting to run out about now. He got these stores while you were pregnant. The best way to get the baby to get extra iron is from his food, and the best food for iron is meat.

If your baby is reaching for food in your plate, give it to him (with the exception of slippery round things like grapes or peanuts). That will get him started eating food. Don't fiddle with cereal, it's one great overrated food. Jack Newman, MD, FRCPC

Lori: Hello, Doctor: What is the minimal recommended length of time for breastfeeding to achieve maximum benefits?

Dr. Newman: Dear Lori, There is no way to answer this question. The way to get maximum benefits is to nurse until the baby and you decide it's finished, and that will usually be between 2 and 5 years. Any breastfeeding is good for the baby and the mother though, and it is better to do 6 weeks than 3 weeks, and better to do 1 week than none at all. But if breastfeeding is going well for you, why stop? Jack Newman, MD, FRCPC

Sharon: Hello Dr. Newman, Before I was pregnant I took Minocin for acne. Now I am nursing. I haven't taken the drug in a year, but since it is a mild antibiotic, is it safe to take while nursing? My doctor says that he's not sure so better safe than sorry and to not take it. But my skin really needs it, so I thought I'd ask. Also, is it safe to take aspirin and ibuprofen for pain relief? Tylenol just doesn't do anything for me. Thank you! Sharon

Dr. Newman: Dear Sharon, All medications get into the milk in incredibly small amounts (usually). The baby gets much less on a pound for pound basis than you do, and almost always this amount will do him no harm. This is true for all antibiotics, actually, mild or otherwise. The same is true for analgesics. On a one time basis or rarely, aspirin is fine, but on a regular basis ibuprofen is better. My book, out in August in the U.S. (The Ultimate Book of Breastfeeding Answers. [Prima]), has a whole chapter on drugs and breastfeeding. Jack Newman, MD, FRCPC

Tica: I have a question regarding breastfeeding and the workplace. Does an employer have a legal obligation to make allowances for a lactating mother? Example: provide place to pump, time to pump, storage of milk?

Dr. Newman: Dear Tica, I don't know. I doubt it, but they should, shouldn't they? There may be some union agreement that may require management to do some of this, but I doubt there are any federal or state laws. You never know, though, but the problem is that there are fifty states in the US, and 10 provinces in Canada, and they could all have different laws. Jack Newman, MD, FRCPC

Ilene: Doctors have told me that breastfeeding a two and a half year old has no nutritional benefits as a two year old can eat anything and that I should stop. Is there value in continuing beyond two years of life? Thank you.

Dr. Newman: Dear Ilene, The doctors are wrong. I think I have already answered this question. Of course the baby can eat anything, but would they say that because a child of 2 can eat anything that he shouldn't have cow's milk. No, they wouldn't. They just don't like the idea of breastfeeding, and they make up any excuse to discourage mothers from breastfeeding their toddlers. Not only is breastmilk still milk with all its nutritional benefits, but it still has antibodies. But the most important thing is that the relationship is far more than the milk itself, and the wonderful thing about nursing a toddler is the relationship. One day these doctors may understand. Jack Newman, MD, FRCPC

Summer: I will soon be a first time mom and I definitely want to breastfeed but all I've heard is how much it hurts and your nipples become cracked how can I avoid this and make the easiest transition for the baby and me? Also is it a waste of money to buy a breast pump? Or should I rent one from the hospital?

Dr. Newman: Summer, breastfeeding should not hurt. When it does, it is because the baby is not latching on well. If the baby does not latch on well, not only does it hurt, but the baby doesn't get milk well. Which results in his staying on the breast longer, which causes more pain. But this should not happen. If it does, it can be fixed. It is worth it.

Deliver your baby where you get *good* support for breastfeeding. Think also about getting a good experienced lactation consultant to help you. Usually a breast pump is a waste of money. Jack Newman, MD, FRCPC

Goldy: I just took 6-week-old Rachel in to the doctor today to be weighed, and found she's only gained 4 ounces in the last month. The doctor suggested I pump half a dozen times daily to stimulate milk supply. I already breastfeed on demand and spend a good part of every day with a baby on my breast. How do I manage all this? Are there other things I could do to stimulate production? Could there be other explanations for her lack of weight gain? (I was going by her diapers, which seemed to be the right quality and quantity.) Any help would be appreciated!

Dr. Newman: Dear Goldy, Please read Protocol for "Not Enough Milk" above on this page. This is often the way I deal with this so called problem of "not enough milk." Babies are not necessarily feeding because they are on the breast. So the idea is to get them well fed, not just have them on the breast. I don't think breast pumping is the way to go. Jack Newman, MD, FRCPC

Cheryl: If you have a not so good diet while breastfeeding and eat fast food and have more fat than you should, will your baby be more apt to get fat?"

Dr. Newman: Dear Cheryl, No, breastmilk is remarkably independent of the diet you eat. It does change somewhat, but not because you eat junk food rather than other food. Be assured that your baby is getting the best nutrition, even if you are not. Jack Newman, MD, FRCPC

Kathryn: I will be going back to work in 4 weeks. My daughter will then be 24 weeks old. She refuses to take a bottle. What can I do to ensure that she can be properly fed while I am at work?

Dr. Newman: Dear Kathryn, You don't need to feed her a bottle. Don't even try anymore. If she is taking solid foods, she can eat those when you are at work. If anyone is concerned she needs extra fluids, they can be mixed in with the food. What difference does it make if she drinks it from a bottle or mixed with her food? She can, at her age, also start drinking from an open cup. She probably wants to already, so let her. Jack Newman, MD, FRCPC

Much appreciation to Dr. Newman for participating in our member interview. Check out his book The Ultimate Book of Breastfeeding Answers! Order through Amazon now! Also, visit StorkNet's Bookstore.

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