Nursing in Public When Baby on Nursing Strike

Weaning from the breast

Posted: April 2, 2013 | Reaffirmed: Mar 1, 2022

The Canadian Paediatric Society gives permission to print single copies of this document from our website. For permission to reprint or reproduce multiple copies, please see our copyright policy.

Master author(due south)

Barbara Grueger; Canadian Paediatric Lodge, Community Paediatrics Committee

Abridged version: Paediatr Child Health 2013;18(iv):210 Appendix

Abstract

Exclusive breastfeeding provides optimal diet for infants until they are six months old. After half dozen months, infants require complementary foods to meet their nutritional needs. This is when weaning begins. Weaning is the gradual process of introducing complementary foods to an babe'due south diet while continuing to breastfeed.

In that location is no universally accepted or scientifically proven time when all breastfeeding must stop. The timing and procedure of weaning need to exist individualized past mother and kid. Weaning might exist abrupt or gradual, take weeks or several months, be kid-led or mother-led. Physicians need to guide and back up mothers through the weaning process. This certificate replaces a previous Canadian Paediatric Society position statement on weaning published in 2004.

Key Words: Breastfeeding; Breast milk; Complementary foods; Infant; Weaning

Overview

Chest milk is the optimal source of diet in infancy. Breastfeeding protects infants from a broad array of infectious and noninfectious diseases. With few exceptions,[1] healthy term infants crave but breast milk (with vitamin D supplementation)[2] to encounter all their nutritional requirements until they are about six months old. The Canadian Paediatric Social club, Dietitians of Canada, Health Canada and the WHO recommend sectional breastfeeding for the showtime half dozen months of life and connected breastfeeding with complementary foods for up to two years and beyond (no upper limit has been defined).[3]-[6]

This argument addresses bug affecting the weaning procedure and the unlike ways weaning can occur. Information technology includes suggestions that physicians can offer to breastfeeding women about weaning and nutritional alternatives and for problems associated with weaning. This statement focuses on healthy term infants and its recommendations may not be appropriate for infants with special circumstances (eg, prematurity, chronic illness, failure to thrive). Information technology replaces the previous Canadian Paediatric Society position statement published in 2004.[3]

A review of the literature was performed using MEDLINE (1966 to 2012), the Cochrane database and relevant websites, including those of the WHO, the Canadian Paediatric Social club, Health Canada and the American University of Pediatrics. Given the limited nature of the evidence on weaning, the recommendations in this argument are based largely on adept opinion and consensus.

Historical and cultural perspectives

The term "weaning" comes from the Anglo-Saxon word "wenian" meaning "to become accustomed to something unlike". Weaning from the chest is a natural, inevitable stage in a child's evolution. It is a complex process involving nutritional, immunological, biochemical and psychological adjustments.[half-dozen][seven] Weaning may mean the complete cessation of breastfeeding (an "abrupt" or final wean) or, as described here, a gradual process of introducing complementary foods to the infant'southward diet while standing to breastfeed. The first introduction of foods other than chest milk marks, past definition, the beginning of weaning.

More often than not, infants were breastfed longer in ancient times[eight] than in Western societies today. Aristotle stated that breastfeeding should continue for 12 to 18 months, or when menses restarted in the nursing mother. Mothers in Zulu societies have traditionally breastfed their infants until 12 to 18 months, at which point a new pregnancy would be anticipated. Ancient Hebrews completed weaning at about three years. Around the world it is non uncommon for children to be completely weaned at two to four years of age.[9] Anthropological studies accept described last weaning at the following points: when the babe reaches four times his birth weight; when the infant'south age is six times the length of gestation (ie, 4.v years); or when the first molar erupts.[9][10]

The early on introduction of mixed feedings began in early 19th-century Western society. Prominent contemporary physicians such equally American Pediatric Society founders Dr. Luther Emmett Holt and Dr. Job Lewis Smith recommended that weaning begin at around nine to 12 months of age or when the canine teeth appeared. Smith recommended against weaning during the summer months considering of the risk of "weanling diarrhea". As weaning was recommended earlier and earlier, infant bloodshed increased. Introduction of weaning foods was an important cause of infant bloodshed in the 19th century. In the early 20th century, mothers were encouraged by the medical community to raise their children scientifically or "by the book". In the 1920s, the The states regime published Infant Care, referred to at the time equally the "skilful book" and read by women from all socioeconomic groups. It recommended cod liver oil, orange juice and artificial feeding.[viii]

In 2008, according to the Public Health Agency of Canada, 87% of children were breastfed for some period of time while simply sixteen.four% were exclusively breastfed for six months. Yet, this figure represents a steady increase in breastfeeding rates over the previous 5 years. Breastfeeding elapsing varies depending on maternal age. Only 11% of infants of mothers aged 25 to 29 years continue to breastfeed exclusively for six months, compared with xx% of infants of mothers 35 years or older.[11] The virtually common reason mothers give for weaning is a perceived insufficiency in milk supply. Women who breastfeed for longer than three months most often cite return to work every bit their reason for weaning.[11] Canadian breastfeeding practices may continue to improve because many mothers receiving employment insurance can delay their return to piece of work for 12 months postpartum.

Nutritional and developmental problems

At effectually four to half dozen months of age, most infants are developmentally set up to handle puréed foods. They are developing the oral motor coordination necessary to accept unlike food textures. However, they are at gamble for choking on chunky food pieces such equally basics, whole grapes and hot dog wheels that require advanced oral motor coordination non achieved before three years of age.

Sucking and chewing are complex behaviours with reflex and learned components. The learned component is conditioned by oral stimulation. If a stimulus is not applied while neural development is occurring, an baby may become a poor eater. There is a relationship between prolonged sucking without solids and poor eating.[7]

While it is ideal for infants to be exclusively breastfed for half-dozen months, it is also true that afterward a certain historic period, human being milk solitary cannot supply all of an infant'south nutritional requirements.[6][13] Private circumstances may make information technology appropriate for some infants to start complementary feedings as early on as 4 months of historic period.[13][xiv]

Historic period-appropriate intake of calories and micronutrients is of import for growth, motor and mental evolution.[12][thirteen] Delaying the introduction of nutritional solid foods much beyond six months of age puts an baby at risk for iron deficiency anemia and other micronutrient deficiencies.[xv] Picciano et al followed older weaning infants (12 to 18 months of age) by collecting data on dietary intake and growth. Many of the study children were ingesting less than the recommended levels of fat (less than 30% of full calories), iron and zinc. Grains, whole milk, dairy products and meats were identified as important sources of atomic number 26, vitamin E and zinc.[xvi]

Past iv to vi months of age, iron stores from nascence are diminishing, necessitating the introduction of iron-containing foods at six months of age for all infants.[4] Iron supplementation after the offset weeks of life or at 4 months of historic period for the exclusively breastfed baby has been recommended by some groups.[fourteen] When there is a filibuster in introduction of iron fortified foods, oral iron supplementation needs to be considered.[fourteen]

Iron from meat has the best bioavailability[4][17] and can be readily absorbed from the gastrointestinal tract. Later 6 months of historic period, when chest milk lone cannot provide enough protein, additional protein sources (such as meat, fish, egg yolk, tofu, lentils and cheese) are needed. Roughage should also exist introduced to the nutrition, although it is not clear when adding fibre becomes necessary. There is no conclusive evidence that delaying the introduction of eggs, fish and basics (including peanuts) beyond 4 to six months of age helps to avoid food allergies.[thirteen][eighteen][19] Equally a greater diverseness of solids and liquids are introduced to a infant'south diet, weaning volition progress.

The process of weaning

While the all-time method for transitioning from fully breastfeeding to consummate nutritional independence is not known, the process should come across the needs of both baby and mother.[20] Physicians may refer mothers to the La Leche League'south website and the Canadian Paediatric Lodge's Caring for Kids website (run into Resources for parents, below). Weaning tin can exist either natural (infant-led) or planned (mother-led).

Gradual weaning (infant-led weaning)

Gradual weaning occurs as the infant begins to take increasing amounts and types of complementary food while still breastfeeding on need. With gradual weaning, the complete wean usually occurs between two and 4 years of age.[8] In Western cultures, in that location remains a relative intolerance to this type of weaning and many mothers who breastfeed their older baby or kid become "closet nursers". Closet nursing takes place privately, at home. This relative secrecy tends to compound erroneous beliefs about appropriate breastfeeding duration.[7]

Planned weaning (mother-led weaning)

A planned wean occurs when the female parent decides to finish sectional breastfeeding without receiving infant'due south cues well-nigh readiness for this change. Reasons usually given for a planned wean include: not having enough milk or concerns about the babe'southward growth; painful feedings or mastitis; returning to work; a new pregnancy; wanting a partner or alternate caregiver to give feedings; or the eruption of a baby's first teeth.[11] These situations may result in premature complete weaning, despite the mother'due south original intent to continue breastfeeding. Regardless of whether or not a female parent wishes to continue some breastfeeding, the md should provide information and support her decision. A physician who is unsure nearly how to provide this support should consider referral to a breastfeeding practiced.

Meet the Appendix for an example of a gradual planned (female parent-led) weaning schedule.

Refusal to breastfeed: Nursing strikes

Gradual weaning should not be confused with a "nursing strike". Nursing strikes are temporary and tin issue from whatever number of causes, including the onset of menses, a change in the mother'southward diet, lather or deodorant, teething, or infant illness. An infant'south sudden refusal to nurse can occur at any time and may lead to complete weaning. The mother might interpret this every bit a rejection of breastfeeding and stop offering the breast. Unproblematic steps to manage a nursing strike include:

Making feeding time special and repose; minimizing distractions.
Increasing the corporeality of cuddling and soothing of the baby.
Offering the breast when the infant is very sleepy or only waking up.
Offering the breast frequently using different nursing positions, alternating sides or nursing in different rooms.

If the above steps do non consequence in restarting breastfeeding, a doctor should evaluate the babe to rule out possible affliction. Enlisting the help of a breastfeeding consultant should be considered.[iii][6][vii][xiii][20] No attempt should be made to 'starve' the baby into submission.

Abrupt or emergency weaning

Occasionally there is a need for abrupt or emergency weaning due to prolonged, unplanned separation of mother and infant, or severe maternal illness. Many mothers are inappropriately advised to wean when they are placed on medication, although very few medications are contraindicated during breastfeeding.[one] Absolute contraindicated drugs include antimetabolites, therapeutic doses of radiopharmaceuticals and near drugs of abuse. Other drugs must exist considered individually. The benefits of continued breastfeeding need to exist weighed against the risks of exposing an infant to the drug in breast milk.[21] A child's sudden illness need not be a reason for weaning. Physicians should encourage and back up mothers to breastfeed or pump and store breast milk until the babe is able to accept it.

Infants who are weaned abruptly might refuse a bottle. In these cases, a loving cup tin exist offered. The infant may initially refuse any other type of food from the mother, in which case an alternative caregiver may need to feed the infant. The mother should proceed to spend fourth dimension in close physical contact with the baby, if possible, and then that weaning is less psychologically traumatic for both mother and kid.

Abrupt weaning will probable cause the female parent some discomfort, especially if it occurs during the early postpartum period when her milk production is high. She should be advised to take analgesics and to express but enough milk that her breasts feel comfy. Cold gel packs, cold cabbage leaves or breast massage are reported to save engorgement, though a systematic review of these interventions did not find such treatments to exist more effective than a placebo.[22] Mothers need to spotter for signs of a plugged duct (an isolated pea-sized hard or tender area without local heat and systemic symptoms) during weaning, which can lead to mastitis. A comfortable and supportive bra can aid to reduce discomfort. Binding the breasts, which will atomic number 82 to more discomfort and tin cause blocked milk ducts, is non recommended. There is no demand for fluid restriction. Bromocriptine (Parlodel, Novartis Pharmaceuticals, Canada), a prolactin suppressant, is no longer licensed-as a 'dry-upward' medication. There have been reports of serious agin drug reactions in the mother, such equally seizures, strokes and fifty-fifty death, associated with its utilize.[22][24][25]

Whenever possible, weaning should be a gradual process. An abrupt wean is traumatic for the infant, uncomfortable for the mother and may effect in blocked ducts, mastitis or breast abscesses.[vii]

Maternal guilt

While mothers start to breastfeed with the all-time of intentions, they often see obstacles that can lead to weaning prematurely. It is important for physicians to explore a female parent's reasons for weaning and to provide information that will help her to make an educated decision about the process and timing of weaning. Once informed, a mother should not exist pressured to breastfeed for longer than she feels is advisable. As well, she should not be criticized for continuing to breastfeed for longer than the 'norm' in her culture.

Mothers may experience mixed emotions when starting to wean. While enjoying their newfound freedom, they may also mourn the passing of an especially intimate stage of relationship with their child. It is common for mothers to report feeling loss or sadness, even with gradual weaning.[7][25][26] Remind mothers that their baby is achieving a new social milestone: that of eating solids and drinking from a loving cup. As long every bit a mother approaches the weaning process with flexibility and sensitivity, the feel should be positive. The physician's role is to support and inform the mother while ensuring adequate diet for the infant.

Recommendations for physicians

Support exclusive breastfeeding, with vitamin D supplementation, for the first six months of life.
Encourage continued breastfeeding for up to ii years and beyond while providing advisable nutritional guidance.
Advise mothers to introduce iron-fortified foods in the form of meat, fish or iron-fortified cereals as first foods, to avoid fe deficiency.
Propose slow, progressive, natural weaning whenever possible.
Inform and back up breastfeeding mothers while ensuring adequate diet for their babies, regardless of the timing of weaning.

Resources for parents

Canadian Paediatric Society, Feeding your baby in the kickoff year and Weaning your child from breastfeeding.
Huggins K, Ziedrich L, Sears M, Sears, Westward. The Nursing Mother'south Guide to Weaning: How to bring breastfeeding to a gentle close and how to decide when the time is right (rev. edn., 2007). Boston: The Harvard Mutual Press.
La Leche League Canada: http://www.lllc.ca

Acknowledgements

This position argument has been reviewed by the Nutrition and Gastroenterology Commission and the Fetus and Newborn Committee of the Canadian Paediatric Society.

CPS Community PAEDIATRICS COMMITTEE

Members: Carl Cummings MD (Chair); Sarah Gander MD; Barbara Grueger Md; Larry B Pancer MD; Anne Rowan-Legg Medico; Ellen P Wood MD (Board Representative)
Liaison: Ruth B Grimes MB, CPS Community Paediatrics Department
Principal author: Barbara Grueger Doctor

References

Canadian Paediatric Club, Infectious Disease and Immunization Committee. Maternal infectious diseases, antimicrobial therapy or immunizations: Very few contraindications to breastfeeding. Paediatr Child Health 2006;11(8):489-91.
Canadian Paediatric Society, First Nations, Inuit and Métis Health Committee. Vitamin D supplementation: Recommendations for Canadian mothers and infants. Paediatr Kid Health 2007;12(7):583-9: world wide web.cps.ca/en/documents/position/vitamin-d (Accessed February 20, 2013).
Canadian Paediatric Guild, Customs Paediatrics Committee. Weaning from the chest. Paediatr Child Health 2004;9(iv):249-53.
Health Canada (2012). Diet for Healthy Term Infants: Recommendations from Birth to Half dozen Months. Statement of the Infant Feeding Articulation Working Grouping: Canadian Paediatric Society, Dietitians of Canada and Health Canada. http://world wide web.hc-sc.gc.ca/fn-an/nutrition/babe-nourisson/recom/alphabetize-eng.php (Accessed on September 25, 2012).
Kramer MS, Kakuma R. Optimal elapsing of sectional breastfeeding. Cochrane Database Syst Rev 2002;ane:CD003517.
Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession, 6th edn. Philadelphia, PA: Mosby, 2005:357-75.
Huggins K, Ziedrich L. The Nursing Mother's Guide to Weaning How to bring breastfeeding to a gentle shut and how to make up one's mind when the fourth dimension is correct, rev. edn. Boston: The Harvard Common Printing, 2007.
Piovanetti Y. Breastfeeding beyond 12 months. An historical perspective. Pediatr Clin North Am 2001;48(1):199-206.
Dettwyler KA. Time to wean: The hominid blueprint for the natural age of weaning in modernistic homo populations. In: Stewart-MacAdam P, Dettwyler KA, eds. Breastfeeding: Biocultural Perspectives. New York: Aldine de Gruyter, 1995.
Dettwyler KA. When to wean: Biological versus cultural perspectives. Clin Obstet Gynecol 2004;47(3):712-23.
Public Health Agency of Canada. Canadian Perinatal Wellness Report - 2008 edition. www.phac-aspc.gc.ca/publicat/2008/cphr-rspc/index-eng.php (Accessed on October eighteen, 2011).
Dewey Grand. Guiding principles for complementary feeding of the breastfed child. Pan American Health Organization, World Health Organization, 2003. www.who.int/child_adolescent_health/documents/a85622/en (Accessed on October 18, 2011).
Dewey KG. Nutrition, growth and complementary feeding of the breastfed infant. Pediatr Clin North Am 2001;48(one):87-104.
Baker R, Greer F and the Committee on Diet. Clinical Study: Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of historic period). Pediatrics 2010;126(5):1040-50. (doi:10.1542/peds.2010-2576)
Gidding SS, Dennison BA, Birch LL, et al. Dietary recommendations for children and adolescents: A guide for practitioners. Pediatrics 2006;117(ii):544-59.
Picciano MF, Smiciklas-Wright H, Birch LL, Mitchell DC, Murray-Kolb 50, McConahy KL. Nutritional guidance is needed during dietary transition in early babyhood. Pediatrics 2000;106(1 Pt. one):109-14.
Dee DL, Sharma AJ, Cogswell ME, Grummer-Strawn LM, Fein SB, Scanlon KS. Sources of supplemental iron amongst breastfed infants during the showtime year of life. Pediatrics 2008;122 Suppl 2;S98-104.
Fiocchi A, Assa'ad A, Bahna South. Food allergy and the introduction of solid foods to infants: A consensus document. Adverse Reactions to Foods Committee, American College of Allergy, Asthma and Immunology. Ann Allergy Asthma Immunol 2006:97(1):10-21.19
Greer F, Sicherer S, Burks AW, American University of Pediatrics Committee on Nutrition; American Academy of Pediatrics Section on Allergy and Immunology. Effects of early nutritional interventions on the evolution of atopic disease in infants and children: The office of maternal dietary restrictions, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics 2008;121(1):183-9120
Mohrbacher North, Stock J. The Breastfeeding Answer Book. Schaumburg, Ill.: La Leche League International, 2003.
Hale TW. Medications and Mothers' Milk, 14th edn. Amarillo, TX: Hale Publishing, 2010.
Oladapo OT, Fawole B. Treatments for suppression of lactation. Cochrane Database Syst Rev 2009;(ane):CD005937.
Dutt S, Wong F. Spurway JH. Fatal myocardial infarction associated with bromocriptine for postpartum lactation suppression. Aust North Z J Obstet Gynaecol 1998;38(ane):116-7.
Iffy 50, Lindenthal J, Mcardle JJ, Ganesh 5. Astringent cerebral accidents postpartum in patients taking bromocriptine for lactation suppression. Isr J Med Sci 1996;32(5):309-12.
Eglash A, Montgomery A, Forest J. Breastfeeding. Dis Mon 2008;54(6):343-411.
Wight NE. Management of common breastfeeding issues. Pediatr Clin North Am 2001;48(2):321-44.
Wu AC, Lesperance Fifty, Bernstein H. Screening for iron deficiency. Pediatr Rev 2002;23(v):171-8.
Committee on Diet. American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics. Pediatrics 2001;107(5):1210-3.
Hall RT, Carroll RE. Baby feeding. Pediatr Rev 2000;two(6):191-9.

Appendix

A sample schedule for a gradual, planned (mother-led) weaning follows:

Begin by substituting the kid's 'least favourite' feeding. The baby might have the substitute feeding more readily from an culling caregiver. Depending on the infant's age, the substitute tin be a complementary food, expressed breast milk, formula or (if age-advisable) cow's milk. Keep in mind that it is hard to know how much a baby unremarkably ingests while feeding from the breast: feeding stops when an baby is satisfied. Counsel mothers to resist the impulse to brand the infant 'stop' what is offered.
- Whole cow's milk should be avoided until a baby is at least nine, and preferably 12, months of historic period. No more than 720 mL (24 oz) of cow's milk or formula per day should be offered to a one- to two-twelvemonth-old. Drinking more than milk per day can result in iron deficiency anemia,[27] obesity, and a poor appetite for other foods.[15] Water is introduced along with complementary foods when the baby is six months old. Some parents may also wish to give fruit juice (100% fruit juice, not fruit "drinks") by cup at that time, though whole fruits are preferable to juice. The amount should be express to no more than 125 mL to 175 mL (iv to six oz) per solar day to avoid interference with the intake of nutritional food.[iv][15][28]
A second substitute feeding can be given in one case the infant is accepting the get-go well. This may be within a few days or a few weeks. Subsequent substitute feedings tin exist offered at a pace ideally determined by mother and infant together.
The babe should exist held and cuddled while feeding from a canteen. Both female parent and baby demand the extra closeness during the weaning process. Never prop a bottle. Bottle propping can put the baby at take chances for choking and causes early childhood caries. Drinking from a cup tin exist introduced at six months of age.
Solid foods need to be given at developmentally appropriate times. Initially, a few teaspoonfuls tin can be offered once a day. Single ingredient foods should be introduced one at a time every two to 3 days.[12][29] Gradually, the amount and number of servings and the variety of foods can be increased.
Partial weaning is an option for the female parent who wishes to continue breastfeeding. This can work well for the mother who is working or studying exterior the home. Early morning, evening and night feedings tin keep fifty-fifty if female parent and baby are separated during the day. For times spent away from her baby, a mother can express milk. Pumping should allow her to maintain production of milk. If she does non pump simply continues to breastfeed, the infant's weight gain will demand to be monitored more closely. Many older babies who have not previously been introduced to the loving cup or bottle reject to drink anything while their mother is away. Refusal tin cause a great deal of anxiety merely is usually temporary. These babies usually take solids in their mother's absence and increase the frequency and length of breastfeeding when she is home. To encourage the intake of fluids, advise offering the 'sippy-cup' or bottle when the child is sleepy, as for a nursing strike. 'Starving' the infant into taking the bottle is not recommended. Too, watching closely for signs of aridity or poor weight gain is imperative if the kid refuses to eat or potable in the mother's absence.[26]

Disclaimer: The recommendations in this position argument exercise not point an exclusive course of handling or procedure to be followed. Variations, taking into account individual circumstances, may exist advisable. Internet addresses are current at fourth dimension of publication.

hardnettspold1949.blogspot.com

Source: https://cps.ca/documents/position/weaning-from-the-breast