Will drinking coffee when you’re breastfeeding keep your baby awake?

coffee in disposable cup If you ingest caffeine when you’re breastfeeding it can pass into your milk, and may therefore be consumed by your baby1. From a health perspective, this is not a cause for great concern. Low doses of caffeine are not regarded as harmful, and indeed caffeine is sometimes administered to preterm babies to help reduce apnea (pauses in breathing of more than 20 seconds)2. The stimulant properties of caffeine that make it suitable for therapeutic use, however, could potentially affect babies in a less desirable way — in particular, by making them wakeful and irritable.

So, how likely is it that drinking too much coffee will cause your baby to lose sleep? Research investigating this issue shows that moderate levels of consumption aren’t likely to cause any problems. A study examining the levels of caffeine over a 12 hour period in the milk of women drinking their usual caffeinated beverages found that consumption of less than 100mg (roughly the amount in a single espresso) did not pass into milk at a detectable level3. It also found (as did an earlier study1) that the amount of caffeine that makes it into milk is greatly reduced — between 0.06% and 1.5% of the maternal dose — and that the level peaks an hour after consumption, and then declines, disappearing completely after 12 hours.

Could this small amount of caffeine cause sleeplessness? The available evidence indicates this is unlikely. In a study examining this issue, 11 breastfeeding mothers drank 5 cups of decaffeinated coffee a day over a 5 day period, and 5 cups a day of decaffeinated coffee with 100mg caffeine added over another 5 days4. The results showed that the babies’ average heart rates and the amount of sleep they got over a 24 hour period remained the same, regardless of whether their mothers had consumed caffeine.

According to the American Academy of Pediatrics, ‘moderate consumption of tea, coffee and caffeinated sodas is fine when you’re breastfeeding’. Although babies can ingest caffeine through breast milk, if their mothers are drinking around 5 cups of coffee a day it is unlikely to impact on sleep levels. People metabolize caffeine at different rates, of course, and young babies do it much more slowly than adults5, so it’s not impossible that drinking coffee will affect your baby, particularly if you consume it in large amounts. At low levels of consumption the chances of this being a problem are small, however, so most breastfeeding mothers can enjoy a coffee, tea or cola safe in the knowledge that is keeping them, but not their baby, awake.

  1. Arch Dis Child. 1979 Oct;54(10):787-9
  2. Cochrane Database Syst Rev. 2000;(2):CD000273.
  3. Pediatrics. 1984 Jan;73(1):59-63.
  4. Dev Pharmacol Ther. 1985;8(6):355-63.
  5. Arch Dis Child. 1979 December; 54(12): 946–949.

You’ll return to your pre-pregnancy cup size a year after giving birth… even if you’re still breastfeeding

bra and pants

For many women, an increase in cup size as breasts get ready for providing food is one of the first signs of pregnancy. After giving birth, they expand even further as they fill up with milk, but even after a feed, they remain bigger than they were previously, due to the increase in breast tissue required for milk production.

If you continue to breastfeed after solids have been introduced and cut down gradually, your breasts will slowly decrease in size, until you get to the point where you fit back into your old bras. At this point, you’d be forgiven for thinking they can’t possibly be providing your baby with much sustenance, but in fact they are probably doing more than you think. An intriguing article published in Experimental Physiology shows that whilst breast size is related to to the amount of milk produced for the first 12 months of breastfeeding, after this point breasts return to and stay at their pre-pregnancy size, even if they are still manufacturing milk1.

The study followed 8 mothers who breastfed exclusively for 6 months, and weaned after 18 months. Milk production over a 24 hour period was measured by test-weighing the mother2 and breast volume (their actual size minus the amount of milk produced) was calculated using a special ‘Computerized Breast Measurement’ system3 at 1, 2, 4 and 6 months after giving birth, and then at three monthly intervals until weaning.

Milk production – and breast volume - remained constant for the first 6 months, and both started to decline after this point as other food was introduced. By 15 months, however, breast volume had reduced to the level it was before the women gave birth, and remained at this point from then on even though the mothers were still producing on average 200g of milk a day. When the mothers weaned their babies completely, there was no significant further reduction in breast size.

The authors state that this occurs because breasts become able to make milk more efficiently: although an increase in breast tissue is necessary to initiate and sustain a high level of milk production, when it naturally declines as milk output falls, the remaining tissue is still able to produce a significant amount of milk.

For any mothers who are nursing past the 12 month mark but sceptical that their breasts are still up to the job, this will make interesting reading. Even though it may sometimes seem as if you don’t have anything left for milk production, the chances are you’re more than capable.

  1. Exp Physiol. 1999 Mar;84(2):435-47.
  2. J Pediatr Gastroenterol Nutr. 1987 Sep-Oct;6(5):758-63.
  3. Exp Physiol. 1992 Jan;77(1):79-87.

Nipple shields and milk yields: an update

In a previous post I questioned the received wisdom that using nipple shields will have a negative impact on your ability to nurse your baby (see nipple shields: always a bad thing?). The post challenged one of the main criticisms made of shields — that they slow milk transfer and may therefore mean your baby is inadequately nourished — on the grounds that most of the studies demonstrating this were conducted a long time ago, and more recent research indicates that this problem does not exist for modern shields1.

The researchers who conducted the study in question concluded that nipple shields do not affect the amount of milk babies consumed in a feed by weighing before them before and after they nursed: when a mother was using a shield, the amount by which her baby had increased in weight at the end of the feed was roughly the same as when she was breastfeeding directly. Whilst this result looks positive for nipple shields, ‘test-weighing’ babies in this way is not without its critics, so one could argue that concluding nipple shields have no effect on milk consumption based solely on this evidence is a little premature.

Since writing the post, a follow-up study has been published, this time looking at the relationship between shield use and infant weight gain over a much longer period2. 54 mothers who used a nipple shield provided by a nurse or lactation consultant in the period just after the birth of their babies were recruited for the study, and completed interviews when their babies were 2 weeks, 1 month and 2 months old. Over time, the proportion of mothers using shields diminished (at 2 weeks,  69% of the mothers were still doing it, at 1 month 48%, and at 2 months 33%) and at each stage the responses of women who were still using the shields were compared with those who weren’t.

The main aim of the study was to determine whether nipple shields had a negative impact on weight gain — if babies whose mothers were still using shields grew more slowly than those whose mothers had stopped, then this could be taken as an indication that medium to long term use of shields was causing a real problem. Happily, there was no difference between the groups: whether a mother used a shield made no difference to her baby’s pattern of weight gain.

There were a few complaints about nipple shields: 8 women thought they caused nipple soreness; 2 found them messy; 2 found them inconvenient and 3 had problems with them falling off. In spite of this, 90% of the mothers in the study said that using the shield was a positive experience, and 67% felt it helped prevent them from giving up breastfeeding.

If you are a mother who relies on a nipple shield to breastfeed, these results make reassuring reading. Although shields appeared to cause difficulties for a few women, these were generally minor, and crucially they concerned practical issues, not the health of their babies. As most women felt that shields helped to prolong the period that they were able to breastfeed, this study ultimately supports the view they could be an important intervention for mothers who are having problems, rather than something that will make them worse.

  1. J Obstet Gynecol Neonatal Nurs. 2006 Mar-Apr;35(2):265-72.
  2. J Clin Nurs. 2009 Nov;18(21):2949-55.

Can breast milk cure an eye infection?

eyeOne of the many healing properties attributed to breast milk is the ability to cure eye infections such as ‘pink eye’ – conjunctivitis – or ‘sticky eye’ – a gooey discharge that often accompanies conjunctival inflammation. Conjunctivitis is a common condition that rarely requires treatment, usually clearing up by itself within a week or two. For newborns, however, it can occasionally be quite serious, so ensuring it is properly treated is very important. For everyone else, it can be irritating and unpleasant, so any way of reducing the length of the infection is naturally welcome. Can breast milk really provide any relief?

A study in a hospital in New Delhi, India, examined the effect that routinely applying colostrum to babies’ eyes had on the likelihood of them developing an eye infection1. On one hospital wing, mothers were asked to put a drop of colostrum in their babies’ eyes three times a day; on another wing, mothers were asked not to apply anything. The infection rate was much lower in the babies who received colostrum: only 3 out of 51 babies in this group (6%) developed an infection, compared to 26 out of 72 in the control group (35%).

At first glance, this seems like a convincing result for colostrum, but a closer examination of the figures indicates this isn’t necessarily the case. The normal neonatal eye infection rate recorded at the hospital was just over 5% – roughly the same as the one recorded in the colostrum group. Rather than infection rates going down in the babies who received colostrum, it seems they went up – considerably – in those who didn’t. This may have occurred because the normal practice of wiping eyes with a sterile swab just after birth was abandoned during the study. Fewer babies in the study group may have got infections simply because their eyes were rinsed, not necessarily because it was with colostrum.

There is other evidence that breast milk could help ease the symptoms of conjunctivitis, however: in vitro tests show that colostrum, and to a much lesser extent mature breast milk, can potentially combat some of the bacteria known to cause neonatal eye infections2,3, and another study provides evidence that it does seem to be an effective treatment for eye infections in young babies4. At a hospital in Spain, babies diagnosed with neonatal sticky eye were treated either with antibiotics or breast milk. Babies treated with breast milk generally recovered much faster: 26 out of 45 (57%) of those receiving milk had recovered after 30 days, compared with 3 out of 20 (15%) of those receiving antibiotics. Whilst this does not provide conclusive evidence that breast milk is the optimal treatment for eye infections in newborns, the study’s results were deemed sufficiently encouraging to switch from antibiotic drops to breast milk at the hospital where it took place.

So does this limited evidence that breast milk can treat some neonatal eye infections mean it can be used to treat infections in older children, or even adults? Whether breast milk would have a beneficial effect is not clear: its antibacterial properties mean that it may help to clear up an infection caused by certain types of bacteria, but not necessarily one resulting from an allergy or a virus. Having said this, there is, of course, no harm in trying the breast milk option. If you’re currently nursing, it’s simple and free, and whilst it may not get rid of the symptoms, it almost certainly won’t make them any worse.

  1. J Trop Pediatr. 1982 Feb;28(1):35-7.
  2. J Trop Pediatr. 1996 Dec;42(6):327-9.
  3. J Reprod Immunol. 1998 Jul;38(2):155-67.
  4. J Trop Pediatr. 2007 Feb;53(1):68-9.

Breastfeeding and thrush: preventing reinfection

microwaveA bout of thrush when you are breastfeeding can be problematic in many ways. Not only are candida yeast infections often painful and tricky to diagnose, but they can also be remarkably persistent: antifungal medication may appear to alleviate the problem, but not eradicate it completely, or it may clear up one episode of thrush, only for another to appear a short time later.

One reason for the longevity of nipple thrush is the high potential for re-infection. Medication can keep yeast at bay while you are using it, but as soon you stop you become vulnerable to attack again. The most potent reservoir for candida species that your nipple comes into contact with is your baby’s mouth (even symptom-free babies are often carriers1), so ensuring this is treated with an antifungal at the same time as your nipples is essential for effectively combating thrush. It is not the only place spores can gather, however – hands and other objects can easily become colonized too, and whilst washing something that has only been in contact with candida spores for a short time can usually get rid of them2, certain objects are able to host thrush for quite a long period.

Towels and clothing are among the surfaces that are at high risk of habouring candida. A study looking at the length of time fungal spores could exist on a variety of fabrics used in hospitals found that candida survived for an average of 5 days after inoculation, and lasted longer on synthetic materials (polyethylene, polyurethane, spandex, polyester) than cotton or fabrics that were a mixture of natural and synthetic fibers3. Washing fabric can eradicate thrush, but it may need to be at a high temperature: one experiment found that candida spores could survive the wash at 50 degrees Celsius, but not 704 (although it should be noted that this research was conducted some time ago, and modern detergents may be more effective at lower temperatures).

The use of a pacifier is significantly associated with oral thrush in babies, indicating that dummies or soothers may also provide a friendly environment for candida spores1. A study examining the microorganisms prevalent on the surface of pacifiers showed that this was indeed the case. Like teeth and dentures, pacifiers can develop biofilms that play host to a complex array of microorganisms including numerous bacteria and funghi5. Biofilms are pretty persistent: simply ‘sterilizing’ with boiling water will not remove them5,6. It is not impossible to get rid of them, however, and in fact an effective means of doing this can be found in most domestic kitchens. When candida spores are subjected to microwaves for a sufficient length of time, their cell membranes are irreparably damaged, rendering them ‘inactivated’6. Three minutes immersed in water in a 650W microwave is able to eradicate candida from dentures7, and the chances are this is also an effective way of sterilizing pacifiers.

The best way of treating thrush is to take a sufficient course of antifungal medication, but to prevent it returning it is also a good idea to ensure that anything coming into close contact with nipples or mouths (such as towels or pacifiers) is kept free of rogue candida spores. Whilst washing hands in soapy water will generally decontaminate them, this is not necessarily the case for fabric or pacifiers, which can provide a home to yeast spores for some time, even after they have been superficially cleaned. To get rid of candida for good, there are two options: a hot wash or session in a microwave; or throwing everything out and starting again. Whilst the second option may be tempting, it may also prove rather expensive – fortunately the first option should do the job just as well.

  1. J Oral Pathol Med. 1995 Sep;24(8):361-4.
  2. Eur J Clin Microbiol Infect Dis. 1994 Jul;13(7):590-5.
  3. Clin Microbiol. 2001 Sep;39(9):3360-1.
  4. Br J Vener Dis. 1984 Aug;60(4):277.
  5. Nurs Health Sci. 2006 Dec;8(4):216-23.
  6. Mycoses. 2007 Mar;50(2):140-7.
  7. J Dent. 2009 Sep;37(9):666-72.
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