Colic in the Breastfed Baby
Colic is one of the mysteries of nature. Nobody knows what it really is, but everyone has an opinion. In a typical colic 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 crying, the baby is often inconsolable, though walking, rocking, or taking the baby for a drive might settle her temporarily. To be called colicky, it is necessary that the baby is gaining weight well and is otherwise healthy.
The notion of colic has been extended to include almost any fussiness or crying in the baby, and this might be valid, since we do not really know what colic is. There is no treatment for colic, although many medications and behavior strategies have been tried, without any proven benefit. Everyone knows someone whose baby was cured of colic by a particular treatment. Almost every treatment seems to work— for a short time.
In breastfed babies, there are three known situations that may result in fussiness or colic. (Again, it is assumed that the baby is gaining weight adequately and that the baby is healthy.)
1) Feeding Both Breasts at Each Feeding
Human milk changes during a feeding. One of the ways in which it changes is that the amount of fat increases as the baby nurses longer at 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 can result in the baby getting fewer calories, and thus needing to feed 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 that digests the sugar (lactase) may not be able to handle such a large amount of milk sugar at one time and the baby will have the symptoms of lactose intolerance— crying, gas, and explosive, watery, greenish 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.
What can be done?
a) Do not time feedings. Mothers all over the world have breastfed babies successfully without being able to tell time. Breastfeeding problems are most prevalent in societies where everyone wears a watch.
b) The mother should feed the baby on one breast, as long as the baby breastfeeds, until the baby comes off himself, or the baby is asleep at the breast. If the baby feeds for only a short time only, the mother can compress the breast to keep the baby nursing. 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. (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.
c) At the next feeding, the mother should start the baby on the other breast in the same way.
d) The mother’s body will adjust quickly to the new method, and she will not become engorged or lopsided.
e) 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 (compress milk into his mouth if necessary to keep him swallowing longer), but if he wants more, then offer the other side.
f ) In some cases, it might 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.
g) This problem is made worse if the baby is not well latched onto the breast. A proper latch is the key to easy breastfeeding.
2) Overactive Letdown Reflex
A baby who gets too much milk too quickly may become very fussy and very irritable at the breast, and could be considered colicky. Typically, the baby is gaining very well. A baby with this issue typically starts nursing and, after a few seconds or minutes, starts to cough, choke, or struggle at the breast. The baby may come off the breast, and often the mother’s milk will spray. After this, the baby will frequently return to the breast, but might still be fussy and repeat the performance. The baby 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 might even start refusing to take the breast after several weeks, typically around 3 months of age.
What can be done?
a) 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 can be helpful. If you experience engorgement on the unused breast, express just enough to feel comfortable.
b) Offer feeding before the baby is ravenous. Do not postpone the feeding by giving water (a breastfeeding baby does not need water even in very hot weather) or a pacifier. A ravenous baby will “attack” the breast and cause a very active letdown reflex. Feed the baby as soon as the baby shows any sign of hunger. If the baby is still half asleep, all the better.
c) Feed the baby in a calm, relaxed atmosphere, if possible. Loud music, bright lights, and lots of action are not conducive to a successful feeding.
d) Lying down to nurse sometimes works very well. If lying sideways to feed does not help, try lying flat on your back with the baby lying on top of you to nurse. Gravity helps decrease the flow rate.
e) If you have time, express some milk (an ounce or so) before you feed the baby.
f) 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.
h) This problem is made worse if the baby is not latched on well to the breast. A good latch is the key to easy breastfeeding.
i) Giving the baby two to four drops of commercial lactase (the enzyme that metabolizes lactose), before each feeding will sometimes relieve the symptoms. It is available without prescription, but it is fairly expensive and works only occasionally.
j) A nipple shield may help, but use this only if nothing else has helped and only if you have gotten good help without any relief. k) As a last resort, rather than switching to formula, give the baby your expressed milk by bottle.
3) Foreign Proteins in the Mother’s Milk
Some proteins present in the mother’s diet can be excreted into her milk and could 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 necessarily a bad thing. Indeed, it should be considered a good thing. Ask your healthcare provider or lactation consultant if you have any questions.
Nonetheless, one treatment is for the mother of a colicky breastfed baby to stop eating or drinking dairy products. These include milk, cheese, yogurt, ice cream, and anything else that contains milk.
Please note: Intolerance to milk protein has nothing to do with lactose intolerance. A mother who is herself lactose intolerant should also still breastfeed her baby.
What Can Be Done?
a) The mother should eliminate all milk products for 7–10 days.
b) If there has been no change, the mother can reintroduce milk products.
c) If there has been a change for the better, the mother should 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. One week off milk products will not cause any problems. Actually, evidence suggests that breastfeeding may protect a mother against the development of osteoporosis, even if she does not take extra calcium. The baby will get all he needs.
d) 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. A mother who takes all this advice at once might find that she is eating nothing but white rice. 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. Because of the more regular flow, some babies do improve on formula, but formula is not breast milk. In fact, the baby would also improve on breast milk from the bottle because of the regularity of the flow. Even if nothing works, time usually helps. The days and nights might seem eternal, but the weeks will fly by.
This article appeared in Pathways to Family Wellness magazine, Issue #22.
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