Bottles at Bedtime for Older Babies and Childhood Obesity

It’s possible that putting your baby to sleep with a bottle could have long term effects on your child’s health, according to a recent study.

Over 8,000 children who were part of the US Early Childhood Longitudinal Study were included in a recent study about feeding and obesity risk. Researchers, from Brigham Young University in Utah, found that putting an older baby to bed with a bottle could increase his or her chance of childhood obesity by 36 percent. How can this happen? Researchers hypothesized that when older babies are fed a bottle at bedtime on a regular basis or as part of their bedtime routine, babies become used to this and will take the bottle whether they are hungry or not. It can become a pattern. The problem is that this can discourage babies from being able to self-regulate their intake and result in their taking bottles at bed and naptime out of habit rather than when they need the calories. If babies eat more calories than they need every day, they gain too much weight.This pattern of needing to eat before sleep may continue into childhood or adulthood.

Research Meets Reality

We know that many families give bottles at bedtime and understand why you do. Nine percent of breast fed babies and 40% of formula fed babies were “put to bed with a bottle” at 9-months of age according to this study. However, it is unclear whether that means that these babies were given a bottle at bedtime by the parent or given a bottle to self-feed in the crib. It’s also not specified in this study whether or not these babies were put to bed with a bottle of breast milk or formula and breastfeeding to sleep is not mentioned at all. Therefore, we think these study findings need to be interpreted with caution since the question asked the parents in this study was vague.

But, the study findings are straightforward, bottles at bedtime increase older babies' risk of becoming obese. So, what are you supposed to do if bedtime bottles are already a habit?

Helpful Tips if You Do Put Your Baby to Bed with a Bottle

The problem is not the bedtime feeding itself but the excess calories. You want your older baby to learn to eat when he is hungry, not out of habit after he has had enough to eat during the day. The researchers recommended including feeding before bed only if the baby is showing hunger cues and to stop feeding when baby shows fullness cues. They also recommend not forcing your baby to finish the bottle so that he will sleep longer. Overfeeding past the baby’s fullness cues can also cause the baby to override his own body’s hunger cues making it easy for your baby to gain too much weight. 

Alternatives to the Bottle at Bedtime

If you do decide to stop giving a bottle at bedtime, we know that you may be worried that changing your feeding pattern will negatively affect your baby’s sleep. You will need some new tools to help your baby get used to sleeping without a bottle! A consistent bedtime routine will help your baby get to sleep and stay asleep more easily. Babies need help to relax and rest at the end of the day. Bedtime routines can be used to help your baby get so sleepy and calm that she can get the rest she needs. For examples of how to start or change a routine, click here. It’s also helpful to wait until you see signs that your baby is tired before starting your routine; that way she will fall asleep more easily.

AAP Recommendations on Weaning

You may be wondering when your baby should be off of the bottle completely. The American Academy of Pediatrics (AAP) recommends weaning your baby from the bottle before 18 months of age. This is important not only to prevent tooth decay but also to limit the amount of milk your child is drinking. It’s probably a good idea then to start weaning your baby off the bottle as soon as they are eating enough solid food at dinner time so that they don’t need milk at bedtime for nutritional purposes. For most babies, that's around 1-year of age.

We hope that we have provided you with enough information to be able to make an informed decision about feeding at bedtime. We know that this is a challenging topic and hope that the alternative tools we provided above are helpful if you do decide to change your bedtime feeding practices.

References

Gibbs BG, Forste R. Socioeconomic status, infant feeding practices and early childhood obesity. Pediatr Obes. 2013 Apr 2. [Epub ahead of print]

AAP Statement on weaning from the bottle

Pacifiers Part 2: Breastfeeding and Pacifier Use

By Jennifer Goldbronn, MAS, RD

Let’s talk some more about pacifiers! Today we will share evidence-based information about pacifier use and its effects on breastfeeding so that you can make an informed decision about whether or not to offer a pacifier to your infant.

Many parents use pacifiers as a tool to calm or soothe their infants. According to one study, about ½ of the babies in the United States are offered a pacifier by 2-weeks of age, and about 2/3 by 6-weeks. (Howard 1999)

Many breastfeeding professionals, however, recommend waiting until at least 4-weeks, or until breastfeeding is well established, before offering a pacifier to young infants. The American Academy of Pediatrics agrees, recommending that parents wait 4-6 weeks, or until breastfeeding is established. Let’s take a look at the evidence.

Why Wait?

A large, 2012 study of pacifier use found that pacifier use “most days of the week” before 4-weeks of age was associated with shorter breastfeeding duration. Mothers giving a pacifier before 4-weeks of age were 3 times more likely to have stopped breastfeeding than those who did not give a pacifier. Also, mothers giving a pacifier “most days of the week”, regardless of their babies’ ages, were 3 times more likely to stop breastfeeding compared to those who did not give a pacifier. (Mauch 2012)

In a study of the effects of pacifier use on breastfeeding duration, researchers found that pacifier introduction before 6-weeks of age was associated with an increased risk of shorter duration of both full (exclusive) and partial breastfeeding. They also found early pacifier use to be associated with fewer breast feedings per day. Women who introduced pacifiers were also more likely to report problems with milk supply at 12 weeks postpartum. (Howard 1999)

Both of the above studies are classified as observational (meaning the researchers just "observed" what people did on their own). Because of this, we can’t say without a doubt that pacifier use is associated with negative breastfeeding outcomes. When looking at the association between breastfeeding duration and pacifier use, it is unknown whether the pacifier use itself caused the breastfeeding problems leading to shorter breastfeeding or whether breastfeeding problems caused parents to start using pacifiers. However, it is plausible that in the early weeks of breastfeeding, pacifier use may interfere with moms' milk supply, lengthen time between feeds, and make it difficult for parents to see hunger cues.

Randomized controlled trials (RCTs) about breastfeeding and pacifier use would provide stronger evidence. Of 4 RCTs found as part of a 2009 systematic review, none showed a significant difference in breastfeeding outcomes associated with pacifier use. However, the studies were very different and difficult to compare. In those that compared pacifier use to non-use, it was found that many parents in the control groups, or “no pacifier” groups, still gave a pacifier even after they were instructed not to. (O’ Conner 2009)

Bottom line:

So, should you use a pacifier? That’s up to you. Most people use them but early use is associated with shorter breastfeeding duration. As our readers know, early on, babies will demand to feed many times per day. That demand is important for babies to be able to get enough to eat and for moms to build their milk supply. Waiting to introduce a pacifier seems a good idea and it is not a good idea to use one if you are having problems feeding your baby.

References

Howard CR, Howard FM, Lanphear B, deBlieck EA, Eberly S and Lawrence RA. The Effects of Early Pacifier Use on Breastfeeding Duration. Pediatrics. 1999;103;e33.

Mauch CE, Scott JA, Magarey AM, Daniels LA. Predictors of and reasons for pacifier use in first-time mothers: an observational study. BMC Pediatrics. 2012;12:7.
O’Connor NR, Tanabe KO, Siadaty MS, Hauck FR. Pacifiers and Breastfeeding: A Systematic Review. Arch Pediatr Adolesc Med. 2009;163:378-382.

Your Baby's Senses: Taste

By Jennifer Bañuelos, MAS

Last week, we started a series about sensory development with a post about hearing. Today, in the second part of the series, we will cover another of the 5 senses, taste!


Taste versus Flavor

In the medical dictionary, taste is defined as “the sense of perceiving different flavors in soluble substances that contact the tongue and trigger nerve impulses to special taste centers in the brain.” What does that mean to all of us non-doctors? It means that taste is basically a chemical reaction; when food (the soluble substance) hits our tongue, the chemicals in the food stimulate our taste buds, sending a message to our brain telling us if the food contains salty, sweet, sour, bitter, or umami compounds. Flavor, however, describes the perception about what is being consumed; it is the combination of 3 senses, what is tasted on the tongue, what is smelled with the nose, and the physical feeling of the food in the mouth (more on smell and touch in future posts). So, when we say something is “spicy” or “tastes like chicken” we are actually referring to flavor.

The Science of Taste

Although scientists have been studying taste for hundreds of years, they continue to discover new information. For example, it was originally believed that there were 4 basic tastes, sweet, salty, sour, and bitter, but over the last decade, scientists identified a 5th flavor, umami, described as a “pleasant savory taste.”(Umami Information Center) There is also new information about how the tongue and taste buds function and where they are located. Researchers have known that different areas of the tongue are more sensitive to specific flavors than others; the tip of the tongue is most sensitive to sweet, then along each side there are sensitive areas for salty, followed by sour, and bitter on the back of the tongue. The middle of the tongue was thought to be the least sensitive area. Recent research has indicated that our bodies may be much more complicated than described by this “tongue map.” There is now evidence that there may be taste receptors in other areas of the digestive tract, not just on the tongue! (Beauchamp 2011)

First Tastes

Babies’ first tastes occur long before birth. The amniotic fluid that surrounds a baby in the womb is affected by foods the mother consumes, so when the baby swallows this fluid, she is exposed to different flavors. In fact, studies have shown that babies may prefer flavors they were exposed to before they were born. (Beauchamp 2011) Maternal diet also affects the flavor of breast milk and studies indicate that babies who are breast fed may be more accepting of a variety of flavors once they start eating solid foods. (Beauchamp 2011; Maier 2008;)

Individual Taste

Some preferences are hard-wired into our brains. For example, babies are born with a preference for sweet and an aversion to bitter. (Beauchamp 2011; Schwartz 2009) Evolutionarily, this makes sense because foods that are sweet tend to by high in calories and bitter foods are often poisonous.

In a recently published study, researchers evaluated infant acceptance of the 5 tastes at 3, 6, and 12 months of age. By measuring both the volume consumed and facial expressions during consumption in the same infants at 3 different ages, they were able to present a more detailed picture of how taste preferences change with age compared to studies that only use 1 measurement. Much of what they found was consistent with previous findings; preference for sweet is present at birth and decreases with age, while acceptance of salty foods appears between 3 and 6 months of age. They also describe some novel findings. For example, for sour and bitter tastes, preference differed between the 2 methods of measurement; the consumption measurement indicated that the infants were indifferent to both tastes, but facial expressions expressed obvious rejection. They also found that as babies got older, they became more and more unique in terms of taste preference (once again, illustrating that all babies are different!). (Schwartz 2009)

Can you Teach Good Taste?

Although there is more to learn about exactly how our bodies sense tastes and flavors, using what is currently known, we have some suggestions to help parents promote a varied diet for their babies!

• Start when you are pregnant - Eating a varied diet while pregnant is good for you and will expose your unborn baby to all the flavors you love!

• Breastfeed – Continuing to provide a variety of flavors to your baby through your breast milk can increase acceptance of solid foods when your baby is old enough.

• Lead by example – If your baby sees you eating healthy foods, she’ll learn from you!

• Think outside the jar - Babies don’t need to be limited to rice cereal and applesauce. Although you should wait a few days before introducing a new food (to identify an allergy), babies can eat almost anything if it is prepared in accordance with their chewing and swallowing abilities.

• Be patient – Remember, babies’ preferences change over time. Also, studies have shown that it can take 10 to 15 times for a baby to learn to like a new food, don’t give up.

References:

Mosby's Medical Dictionary, 7th edition. Mosby Elsevier St. Louis, MO 2006

Umami Information Center, http://www.umamiinfo.com

Beauchamp G, Mennella J. Flavor Perception in Human Infants: Development and Functional Significance. Digestion (2011) 83(suppl 1):1-6.

Maier et al. Breastfeeding and experience with variety early in weaning increase infants’ acceptance of new foods for up to two months. Clinical Nutrition (2008) 27:849-857

Schwartz et al. Developmental changes in the acceptance of the five basic tastes in the first year of life. British Journal of Nutrition (2009) 102:1375-1385.

Answers to Mothers’ Common Questions about the First 3 Days Postpartum

In our previous post, we shared a study reporting postpartum mothers’ most common concerns in the first days and weeks postpartum. Their questions varied from concerns about their own post-operative care to those about feeding and caring for their infant. In today’s post, we’ll provide some answers to mothers’ most common questions about the first 3 days postpartum. For more detailed information on any of the topics below, please see the reference section at the end of this post.

Post-Operative Care


Whether you’ve had a C-Section or an episiotomy, it’s important to know what to expect from the procedure itself and how to care for the stitches and wounds afterwards. It’s important to breastfeed in a position that is most comfortable for you and doesn’t put pressure on your incision.

Cesarean Section
Wound care of your incision is monitored for redness and infection by your healthcare team while you are in the hospital. You will be encouraged to shower and get up to walk within 24 hours. You will also be prescribed pain medication. It is important that you feel comfortable asking for adjustments to the dosage if you are experiencing changes in pain. Pain management is important for healing and being able to comfortably care for your newborn. Once you are home, you may need someone to help you monitor your incision (from experience, it was difficult to see the incision myself). One last piece of advice from my own experience: place a pillow over the incision (on top of your clothing) because the area will be very tender, especially while holding your baby or adjusting your position.

Episiotomy
For episiotomies, wound care begins immediately. You will most likely be prescribed pain medication as well as a topical antibacterial cream for the incision itself. An ice pack will help with pain and inflammation. Sitting in a warm bath with Epson salt (“sitz bath”) 2-3 times per day will cleanse the wound and relieve some of the pain.

Uterine Massage
Uterine massage is important to help deliver the placenta and to aid in uterine contractions. This ensures that the uterus expels all of the excess tissue and returns to its normal size. Most nurses will do this for you while you are in the hospital.

Returning to Your ‘Normal’ Figure


I have to admit I was a little surprised to see this was a concern of mothers in the first few days postpartum! There is so much pressure in our society to conform to the ideal body image that we see in the media. Remember, it took you about 40 weeks to carry your baby to term, and most healthcare professionals say that it will take about 40 weeks or up to 1 year to get back to your pre-pregnancy weight. Pregnancy weight gain not only includes weight from your baby but from body fluids and tissues to support the growth of your baby as well. During the first few days postpartum, you should not push yourself too exercise too hard or too soon. Your body needs time to rest, relax, and heal. If you’re jealous of how svelte stars like Angelina Jolie and Reese Witherspoon manage to look red-carpet ready in just a few months after giving birth – consider this – if you had the money to hire a 24/7 personal trainer, nutritionist, chef, nanny, and buy an unlimited supply of Spanx, then you could look like them too!

Physical Activity in the Postpartum Period
How soon you can begin to exercise after giving birth will largely depend on what kind of shape you were in prior to your pregnancy and your fitness during pregnancy. Most people will say that you can resume activity and exercise “when you feel up to it” but moms recovering from a c-section may be asked to wait until their 6-week check-up before restarting an exercise regimen. For all moms, easy walks up to 30 minutes in length can begin a few days postpartum and you can slowly increase exercise intensity as your body regains strength.

Concerns about Your Baby’s 1st 3 Days

Recognizing Infant Illness
Newborn babies will cry, wake, and need to be fed often! Healthy newborns (after they are cleaned up!) will have warm, pink skin and will try to interact with you. If your baby abruptly changes his behavior – i.e. suddenly begins to cry more often than usual and cannot be consoled or becomes lethargic, this may be a sign of illness or injury. Keep in mind that sometimes a baby’s “good” behavior can be misleading. Babies that sleep all of the time, do not wake to feed consistently, or never cry may not be feeding or growing well. Call your pediatrician immediately. If you swaddle your newborn, it is important to un-swaddle them to change diapers and to monitor their skin tone and color. If you are worried that your baby may be sick, call your doctor or advice nurse.

Feeding
Newborns have very tiny stomachs so they can only eat very small amounts at a time. So if it seems like your baby wants to eat “all the time” – You’re right, he needs to eat frequently! During the first 3 days, babies should be fed whenever they show hunger cues -which can be up to 12 times per day! (Do keep in mind that cues may be unreadable or conflicting in the early newborn period. For more information about newborn behavior in the first 72 hours, click here. Twelve feedings per day may seem like a lot, but remember that feeding takes practice, so the more you do it during those first few days, the better you and your baby will become at breastfeeding! For more information about breastfeeding after a cesarean section, click here.

Note: Days 4 and 5 postpartum usually have the most feeds. Many mothers then think that they do not have enough breast milk. This is not true! This sudden increase in feeds helps prevent engorgement (from the rapid increase in milk supply around this time) and gives mom and baby lots of practice feeding, right when they need it most.

We hope the answers to these questions provide information to those of you who are new or prenatal moms with similar concerns! Next time we’ll address mothers’ most common concerns in the weeks and months after giving birth.

References
Cesarean Section:
http://www.mayoclinic.com/health/c-section/MY00214/DSECTION=what-you-can-expect

Uterine Massage: http://apps.who.int/rhl/pregnancy_childbirth/childbirth/3rd_stage/Cd006431_soltanih_com/en/index.html

Episiotomy:
http://www.mayoclinic.com/health/episiotomy/HO00064/NSECTIONGROUP=2

Postpartum Exercise:
http://www.mayoclinic.com/health/exercise-after-pregnancy/MY00477

Life with a Newborn: Days 2 & 3

Last week, I wrote about my experience during the first 24 hours after giving birth to my new baby, Charlotte. Today, I’ll describe days 2 and 3.

Days 2 & 3

• Even though Charlotte was more alert than she had been on the first day, she still slept a lot. On day 3, she seemed irritable, crying more than she had the 2 days before. She’d wake up about every 2 hours to eat and would be awake for up to an hour before dosing off again. Just like the day before, I was having trouble sleeping. Once I was able to shower and change into my own clothes, I was much more comfortable.

• I remember saying “She is just so stubborn!” It wasn't until my friend laughed that I realized that I was projecting behaviors of an older child onto my newborn daughter. Even though it really felt that way at times, Charlotte wasn't being stubborn, she was just being a newborn baby, adjusting to a whole new world. When I kept that in mind, I wasn't nearly as frustrated!

• Our hospital has a “rooming-in” policy, which means that the infants stay with the moms and are not taken to a nursery unless there is a medical need. Even though my husband and I saw this as one of the benefits of the hospital, there were times in the middle of the night that we found ourselves wishing we could send her to the nursery while we slept. Even though we were so tired, I noticed that we seemed to have the best feeding sessions in the middle of the night and those times helped boost my confidence about breastfeeding.

• Charlotte had trouble latching well, so we met with the lactation consultant several times. When she did latch on, she would fall asleep soon after. I started to get discouraged and despite my professional experience, I still needed help.

Charlotte and her big sister!

• Our older daughter, Olivia, enjoyed coming to the hospital to visit. Even though I was happy to see her, it was hard having her there for more than 20 or 30 minutes. The room was small, but there was a lot for a 2 ½ year old to mess with and I noticed that it was easy for the adults to lose track of time paying attention to the baby. I recommend working out a system ahead of time to ensure that the sibling visits aren't stressful.

Next Time: Days 4 & 5

Baby Behavior in the News! Feeding Method Doesn’t Affect Mom’s Sleep

Last week, a paper called “Infant Feeding Methods and Maternal Sleep and Daytime Functioning” by H.E. Montgomery-Downs and colleagues was published online by the medical journal Pediatrics (www.pediatrics.org). Its surprising findings showed up in newspapers, online news sites, on TV, and in blogs. The purpose of the study was to find out if there were differences in sleep patterns and experience among moms who were exclusively breastfeeding, mixed feeding with both breast milk and formula or only formula feeding. Even though many moms believe that breastfeeding leads to less sleep, the researchers found no difference in sleep experience among the groups, no matter how they measured it.

The study included results from 80 moms who had been studied when their babies were between 2- and 16-weeks old. The mothers were asked about how tired they felt, how long they slept, and how many times they thought they woke up. The researchers also asked the moms to wear a watch-like “actigraph” on their wrists that measured movements so that they would have a more objective measure of how many times moms were waking at night. Using all of these different ways to measure moms’ sleep, the researchers did not find any differences even though many people believe that giving formula makes babies sleep more. This is not the first study showing little or no difference in infant sleep despite how babies are fed.

All of the moms were tired during those first few weeks and things got better as their babies got older. That’s probably no surprise to Secrets readers. What’s important about this study is that it challenges a common myth; a formula-fed baby does not necessarily sleep more and wake less than a breastfed baby. Differences in babies’ sleep (we know that some babies sleep more and others sleep a lot less) are more likely to be related to differences in babies and rather than to differences in how they are fed.

What does all this mean to you? It means that 1) babies’ waking is part of new parents’ lives, that’s why parents need help and 2) switching to formula won’t necessarily help parents of newborns sleep longer. We know that Secrets readers have many reasons for their feeding and childcare decisions. We hope that our blog can help you keep up to date with latest baby behavior research.

Next time: A preview of a new (and very special) series

Quick response: Feeding a 3-week-old

We just received a question for one of our readers about a 3-week-old who sometimes is feeding quite frequently the morning and in the evening. Since feeding is such an important concern for babies and parents, we wanted to respond right away to this question.

Frequent feedings only at certain times of the day are called "cluster feeds" by most lactation professionals. Typically, frequent feedings are not unusual, especially among older babies who are trying to deal with overstimulation or growth spurts. In older babies, you'll see patterns of cluster feeding (in the evening) or for a few days while the baby works to increase the milk supply to meet his rapidly increasing needs.

With a 3-week-old, there are a few other things to consider. For many moms, the milk supply is still being established in the first month, so early cluster feeding may be just fine OR an early indicator that mom and baby may need a little help getting things back on track. First and foremost, you need to know how much weight the baby has gained since birth. Most doctor's offices are fine with requests from moms to check their babies' weight. If the baby's weight gain has been slow, the cluster feedings may mean that there may be a glitch with the breastfeeding. Your doctor or a lactation consultant should be able to help with that. If the weight gain is fine and baby is looking and acting healthy, it may be that the baby just needs a little time to be able to nurse more efficiently, may be sleeping a little too long between the other feeds, or may be very sensitive to stimulation around him. Again, your doctor or a lactation consultant can figure out what might be happening. Nearly all of these early glitches can be fixed easily.

Bottom line: Frequent "cluster" feeds are not unusual and not necessarily something to be concerned about (except that they are hard on new moms!) but they are one of those things that babies do that should get checked out by a professional. A quick weight check and a few words with someone who knows about lactation can set everyone's mind at ease.

Let us know how things go.