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General Guidelines for Breastfeeding Women

Nutrition recommendations

General Guidelines for Breastfeeding Women The period of lactation is a relatively brief and very special time in a woman's life that is fondly remembered with a measure of pride. During this unique phase in the childbearing cycle, a breastfeeding mother will need to take some extra care to assure that she produces and provides to her infant abundant, high-quality milk. Unfortunately, many misinformed women decline to breastfeed because they worry that they don't "know all the rules" or they fear they will have to make drastic changes in their lifestyle to accommodate nursing. Actually, most women find that few modifications in their daily life are required to breastfeed successfully. The few who do need to make significant lifestyle changes almost always discover that the rewards of nursing their baby far outweigh any temporary inconvenience in their usual routines. Once you survive the early weeks of new parenthood and get breastfeeding well established, you'll begin to appreciate just how convenient it can be to fit a nursing baby into your life. And the healthy practices you adopt while breastfeeding can become the foundation for a lifetime of increased health consciousness.

A Healthful Diet for Lactating Mothers
Because human milk represents the ideal food for young infants, it's only natural to focus first on the type of diet a mother needs to consume in order to produce nutritious milk for her baby. Concerns about the adequacy of their diet cause many women to doubt the quality of their milk. But a mother's diet doesn't have to be perfect in order for her to make adequate milk and to nourish her baby well. Human milk produced by women all over the world is amazingly uniform in its composition. When mothers are poorly nourished, the quantity of milk they produce may be reduced, but the quality of milk tends to be fairly consistent. The process of lactation assures that human milk will have the right amount of nutrients-even at the mother's expense, if she doesn't eat a balanced diet on a given day.

Keep It Simple and Build on Your Success
Since lactation follows pregnancy, chances are good that you already are familiar with the basics of sound nutrition. If you gained at least twenty-five pounds during your pregnancy and delivered a baby weighing more than about six and a half pounds, you probably already have an adequate diet. Just keep up the good work! Women who require additional nutrition counseling include those who gained less than twenty pounds during pregnancy or who gave birth to a baby weighing less than six pounds at term. Other women who should receive special dietary advice include those who are underweight with little body fat; who are on restricted or specialized diets; who have chronic health problems (such as diabetes) or medical conditions causing malabsorption (such as cystic fibrosis or inflammatory bowel disease); who suffer from eating disorders; or who delivered twins.

Specific Nutrition Recommendations for Breastfeeding Women
Eat three balanced meals a day and nutritious snacks. Consume a variety of foods in as natural a form as possible to obtain the calories, protein, vitamins, minerals, and fiber you need for optimal health. Eat plenty of fruits, vegetables, and whole-grain breads and cereals. Limit your intake of sugar, salt, fat, and highly processed foods. The Food Guide Pyramid shown on page 180 has replaced the former Four Food Groups as a suggested outline for daily eating. Because most American diets are too high in fat and saturated fat, the Food Guide Pyramid emphasizes food choices that help reduce fat intake. The layout of the guide visually reinforces the relative number of servings from each of the five major food groups. The largest number of daily food choices (six to eleven servings) should come from the bread and grain group. Whole-grain breads and cereals contain more vitamins and minerals and provide more fiber to prevent constipation. At least five servings of fruits and vegetables (two to four servings of fruits; three to five servings of vegetables) are recommended each day-most Americans fall short of this recommendation. Fruits and veggies are a nutritious, low-fat source of calories, vitamins, minerals, and fiber. Make an effort to eat vitamin A-rich produce often, such as carrots, spinach, sweet potatoes, and cantaloupe. Three servings of milk or other dairy products are suggested for breastfeeding women (four servings for teen mothers). Recent evidence has confirmed the importance of adequate calcium intake in the prevention of osteoporosis (brittle bones) in later life. Dairy products are the best source of dietary calcium. Milk and milk products also provide protein, vitamins, and minerals. If you don't like milk or have a milk allergy or milk intolerance, I advise you to get nutrition counseling and, if deemed necessary, to take appropriate supplements to replace essential nutrients in milk. Lactating mothers also should eat three servings of meat, poultry, fish eggs, nuts, or dry beans each day. Meat or meat alternates provide protein, vitamins, iron, and zinc. The small tip of the Pyramid serves as a reminder that fats, sweets, and soft drinks should be consumed only sparingly.

While your body is producing breast milk, it requires more calories than usual. Most lactating women will need to consume about 500 additional calories above their normal prepregnancy food intake. An individual mother's calorie requirements can vary widely depending upon her basic metabolism and level of activity. Nutrition experts recommend that breastfeeding women consume 2,700 calories per day. However, recent studies of healthy lactating women in the industrialized world showed their actual intake of food to be approximately 2,200 calories per day while breastfeeding, or about 15 percent less than the recommended value. Most nursing mothers will need to consume at least 2,200 calories per day to provide necessary nutrients and to maintain milk production. At this level of calorie intake, a lactating mother can still expect to lose weight gradually during the course of breastfeeding. This is because the body contributes an additional 500 calories each day from body fat stores to help subsidize lactation. Thus, it is nature's plan to store up extra fat during pregnancy so it will be available to contribute to lactation after delivery. Body fat stores are decreased during breastfeeding, particularly in the thighs and hips.

Fluids, food restrictions, vitamins, weight lossDrink plenty of liquids each day, since milk production uses additional water. Pour yourself a glass of water or nutritional beverage each time you sit down to nurse. Pay attention to your body's thirst cues. For example, some women report that their mouth goes dry as they start to nurse. Feeling thirsty is an important signal that you need to drink extra fluid. Constipation is another common indicator of the need for additional water. Staying well hydrated helps keep your bowels regular. Drinking scant fluids or becoming dehydrated can diminish your milk supply. However, contrary to popular belief, consuming excessive quantities of liquids offers no advantage over drinking to satisfy thirst.

In general, you do not have to restrict the kinds of foods you eat while you are nursing. One of the most popular myths related to breastfeeding is the widespread belief that nursing mothers must refrain from eating spicy foods, chocolate, beans, onions, and a host of other foods that could upset their infant's digestion and cause their baby to be fussy. The perpetuation of this misbelief only serves to make women view breastfeeding as excessively restrictive. The fact is that women all over the world breastfeed their babies while eating local diets that represent a wide diversity of foods, including curried and spicy foods and other fare that nursing mothers in America are cautioned to avoid. Ordinarily, you do not need to eliminate any specific foods from your diet if you are breastfeeding. Certain dietary restrictions are recommended, however, if you, the baby's father, or another of your children suffers from food allergies, asthma, eczema, or other type of allergic disease. A baby whose close relatives have allergic symptoms is at greater risk for developing allergic disease himself. Prolonged, exclusive breastfeeding is important for infants at high risk for allergic disease. The protective benefits of breastfeeding are further enhanced when the mother excludes common allergenic foods-milk and other dairy products, egg, fish, peanut, soy-from her diet during pregnancy and lactation. The allergic risk to her baby is also reduced if the mother rotates her foods, avoiding eating any single food on a daily basis. I must emphasize that women who eliminate major food groups, such as dairy products, from their diet will need nutrition counseling by a registered dietitian or their physician.

Continue to take your prenatal vitamins. Breastfeeding women risk depleting their reserves of vitamins and minerals. The vitamin content of milk depends on the mother's vitamin intake or stores. Ideally, foods, not supplements, are the preferred source of all nutrients. But for extra assurance, breastfeeding women usually are advised to continue taking any multivitamin-mineral supplements that were prescribed for them during pregnancy. Strict vegetarian mothers, in particular, should take a supplement of vitamin B12.

Getting Your Figure Back.
Immediately following delivery, women lose about twelve pounds, which represents the weight of the baby, placenta, amniotic fluid, and blood. In the following weeks, excess water is lost, amounting to approximately another five pounds. After the first month, breastfeeding women can expect to lose about one to two pounds each month while they nurse. The reason for the steady weight loss is that the process of lactation uses the extra body fat that was stored during pregnancy. Each day you breastfeed, your body subsidizes lactation with about five hundred calories from fat stores. After the first three months, breastfeeding women generally lose weight more rapidly than bottle-feeding mothers and return to their prepregnancy weight sooner.

Avoid rapid weight loss during breastfeeding. Many new mothers are preoccupied with their body image and find the idea of rapid weight loss highly desirable. But trying to return too quickly to your prepregnancy weight by drastically reducing your calorie intake is likely to result in diminished milk production. Women who were at normal weight prior to their pregnancy are advised not to lose more than two pounds per month after the first month of breastfeeding. Overweight women can lose up to four pounds a month. More rapid weight loss, or consuming fewer than 1,800 calories per day, places a woman at risk for reduced milk production. Remember, lactation is the body's only elective process. Inadequate caloric intake is perceived by the body as a form of stress. Your body might try to conserve energy in reaction to this stress condition by reducing the energy needs of lactation. Inadequate milk supply can result. It is far preferable to lose weight gradually after pregnancy (after all, it took you nine months to gain it!). Increasing your physical activity through moderate exercise and adhering to a healthy diet will result in steady-and more permanent-weight reduction, without compromising your breastfeeding goal. Instead of resorting to drastic dieting measures, just focus on reducing the total fat and saturated fat in your diet and on reducing your intake of high-calorie snack foods. For most women, breastfeeding provides an ideal time to accomplish gradual weight loss because of nature's plan to use body fat for milk production.

Seek professional help if you think you could have an eating disorder. Our society's preoccupation with thinness has contributed to an epidemic of eating disorders, principally among young women. Anorexia nervosa is one of the most extreme eating dis-orders. Life-threatening emaciation can result from the relentless pursuit of thinness by active food-restricting practices and severe weight-control measures. Bulimia is another common eating disorder that is characterized by episodes of binge eating (rapid consumption of a large amount of food in a short period of time). Binge episodes are frequently followed by self-induced vomiting and use of diuretics and laxatives to rid the body of food. Obviously, such eating behaviors can severely interfere with successful breastfeeding. Reduced body fat stores and highly erratic eating patterns can prevent a mother from producing an adequate milk supply. It is beyond the scope of this book to offer specific help for women with eating disorders, but I feel compelled to mention the problem because it is so prevalent and so devastating. Countless women remain chronic victims of eating disorders and the often incapacitating psychological difficulties that accompany them. If I am speaking to you, I urge you to obtain a referral for professional help from your physician. As a new parent, you owe it to yourself and your baby to reclaim your health.

Let the nutritional implications of breastfeeding renew your emphasis on lifelong healthy eating. Many women, myself included, are particularly receptive to nutrition information during pregnancy and the course of breastfeeding. I found I was more motivated to eat in a healthful manner while I was nursing a baby. Somehow, my conviction to give my baby ideal nutrition served to heighten my awareness of my own and my family's eating habits. The increased attention I gave to learning more about good nutrition had a positive ripple effect on my whole family's long-term health.

Exercise, hygiene, restExercise During Lactation
Being physically active is an important aspect of a healthy lifestyle and helps create a positive outlook on life. Women who exercise regularly may wonder whether breastfeeding imposes any restrictions on their level of activity. Research has shown that moderate aerobic exercise has no adverse effect on lactation, and it significantly improves the cardiovascular fitness of mothers. Some breastfeeding women report that their babies are fussier and even refuse to nurse after they exercise. One study has shown that babies prefer preexercise milk over the milk their mothers express following strenuous physical activity. Presumably, babies temporarily were turned off by the increased levels of sour-tasting lactic acid present in milk after mothers worked out. Plan to nurse your baby just before you exercise, since lactic acid remains elevated in milk for approximately ninety minutes afterward. Another reason it is preferable to nurse before exercising is that vigorous jostling of the breasts when they are full can cause leakage of milk into the tissues. This, in turn, can produce a local inflammation that predisposes a woman to a full-blown breast infection (mastitis). In my experience, lactating women are more prone to mastitis following vigorous upper body activities such as jumping rope, rowing, raking, vacuuming, scrubbing, and aerobic exercise. The risk can be reduced by exercising after the breasts have been emptied well by nursing or pumping. You should wear an athletic bra that provides good support. If you experience one or more bouts of mastitis that occur within a day or so after vigorous upper body exercise, you should switch to a lower-impact activity and see if the problem resolves.

Hygiene for Breastfeeding Women
Every new mother has days when she wonders where she'll find the time to shower, let alone dress. Feeding and caring for a newborn can be all-consuming at first. When a mother is nursing, feedings initially take longer, are closely spaced, and can't be delegated to anyone else. It's easy for a mother to doubt that she will ever have time to put on makeup, fix her hair, take a bubble bath, or do her nails again. Many a new mother is still wearing her bathrobe by midafternoon, having found no time to spend on her personal care and appearance. In addition to the time crunch, some new mothers are so preoccupied with their baby's welfare that they are reluctant to shower while leaving their baby unattended and out of earshot in another room.

Remember, we parent and nurture others from our own emotional overflow. Taking time to attend to your daily hygiene needs is fundamental to self-care. And self-care is not selfish; it is self-preservation. Structure your time to allow for a daily shower or bath at the minimum. I recall one woman who got up early for a leisurely bath and personal time before her husband awoke to go to work. Another-a frazzled mother of twins-postponed her shower each day until her teenage daughter came home from school and could watch the babies. Many depleted mothers find a shower to be thoroughly rejuvenating, no matter how exhausted they are. Enlist the help you need to spend some precious time each day refreshing yourself.

A daily shower or bath provides sufficient cleansing for your breasts and nipples. You also should wear a clean nursing bra every day, as long as you are leaking milk. Most nursing mothers need to wash their bra daily because it inevitably becomes soiled with milk. If you wear breast pads, change them frequently, as moist pads can harbor germs.

It's surprising how many people don't adhere faithfully to the basic principles of hygiene taught in kindergarten: Wash your hands before meal preparation or eating and after using the bathroom. If you have grown lax in this area, now is a good time to begin reinforcing sound hygiene habits. For a breastfeeding mother, this also means washing your hands before you nurse your baby or pump your breasts and after all diaper changes. With a new baby in your home, you're probably worried about the risk of illness in your infant, and frequent handwashing is one of the best ways to reduce infections in your family. Don't be shy about telling relatives and guests that the doctor says they should wash their hands before holding the new baby and after changing her diapers.

Getting Sufficient Rest
New parenthood and sleep deprivation go hand in hand, since the night feedings that are essential for newborns inevitably disrupt the parents' sleep. Although new parents are wisely admonished to "sleep when the baby sleeps" during the day, most succumb to the temptation to do laundry, address baby announcements, prepare and clean up meals, or perform other chores whenever their baby dozes off. Too often, parents underestimate the magnitude of their exhaustion and the vital importance of rest. Even if things are going relatively smoothly, round-the-clock care of a new baby day after day, week after week, takes a physical toll. When breastfeeding isn't going well, you can bet that parental exhaustion is even greater. Troubled feedings can take an inordinate amount of time, yet fail to satisfy the baby's hunger, leading to chronic infant fussiness and poor family sleep patterns. Profound parental fatigue can cloud one's judgment, cause depression and discouragement, and squelch the joys of new parenthood. To keep from getting so depleted, temporarily curtail any activity that isn't absolutely essential, go to bed earlier, take your daytime naps like a prescription, sleep with your baby if it makes nighttime feedings easier, or arrange for a relief caretaker for a few hours.

Alcohol, drugsPersonal Habits
Expectant mothers typically are conscientious about modifying any lifestyle habits that could pose a risk to their developing baby. Most are eager to comply with advice to abstain from alcohol or illicit drugs, stop smoking, avoid caffeine, decrease their consumption of junk foods, and eliminate unnecessary medications. Basically, the same health principles recommended for pregnant women continue to apply during lactation. I have encountered many women who are so committed to their babies' welfare that they are able to overcome destructive personal habits on behalf of their infant even when they previously have been unsuccessful in doing so for their own good. Many women acknowledge that the positive lifestyle changes they make while carrying and nursing a baby represent a significant bonus to their own well-being.

Alcohol
The risks to the fetus of alcohol consumption during pregnancy have been well publicized. Fetal alcohol syndrome can result in stunted growth, mental retardation, and abnormal appearance. Fortunately, most women are motivated to abstain from alcohol during pregnancy.

Following delivery, many women wonder whether they can safely drink any alcoholic beverages while breastfeeding. Advice concerning alcohol consumption during breastfeeding has been very confusing. For years, nursing mothers were reassured that a glass of beer or wine would help them relax and facilitate their milk ejection reflex. Beer was believed to raise prolactin levels and improve a mother's milk production. Recently, however, a study showed that babies obtained less milk when nursing after their mothers drank some alcohol. Alcohol is passed readily into human milk, and consumption of large quantities can sedate the nursing infant and cause other adverse effects. Both binge drinking by nursing mothers and daily drinking of even small amounts of alcohol now is believed to be harmful to breastfed infants. One study has shown lower motor developmental scores at a year of age in breastfed babies whose mothers consumed one or two alcoholic drinks daily.

Current recommendations are that nursing mothers can drink an occasional beer or glass of wine. To completely forbid alcohol during breastfeeding would probably discourage some women from nursing. On the other hand, permitting some alcohol intake during lactation should never be misinterpreted to condone heavy consumption among women with a drinking problem. I advise breastfeeding mothers to limit their consumption of alcoholic beverages to two drinks per week. You should not breastfeed for at least 2 hours per drink consumed to mimimize the presence of alcohol in your milk. I no longer suggest a glass of beer or wine to relax an anxious mother or to enhance her milk production or improve her let-down reflex.

If you are struggling with an alcohol problem, I urge you to face it. Don't put off any longer getting the help you need and deserve!

Recreational Drugs
Recent studies have shown that up to 10 percent of babies are exposed to an illicit substance while still in the uterus. This distressing statistic is a sad testimony to the rampant drug abuse that plagues our society. I must take a rigid stand on illicit drug use by breastfeeding women. Marijuana, speed, crack, cocaine, heroin, and the other mood-altering drugs of abuse do appear in breast milk and pose a very serious threat to the nursing baby. Several instances have been documented in which breastfed infants were harmed when they ingested an illicit drug through their mother's milk. Infant fatalities have occurred, and a few mothers have been charged with felony child abuse-and even murder-because they used illicit substances that endangered their breastfed babies. The American Academy of Pediatrics strongly insists that no drug of abuse, including amphetamines, cocaine, heroin, marijuana, and PCP, should be taken by nursing mothers. I can't say it emphatically enough: substance abuse is incompatible with breastfeeding! In addition to posing a serious hazard to nursing infants, drugs of abuse are detrimental to the physical and emotional health of mothers (whether they breast- or bottle-feed). A drug-abusing mother is emotionally unavailable to her baby and is incapable of meeting her infant's emotional and physical care needs.

Having stated this, let me make it clear that I do support former substance-abusing women in their desire to nurse their babies while staying clean. Such women may be able to breastfeed provided they: remain drug-free; are enrolled in a drug treatment program; receive close follow-up, with regular postpartum urine drug screening; and test negative for HIV. Discuss your situation with both your own and your baby's doctors.

Tobacco, caffeine, medications

Tobacco
Most adult smokers began using cigarettes while still in their teens and never expected to get hooked. The majority of smokers want to quit, and nearly half try to do so each year. But nicotine is highly addictive, and it can take several attempts until you succeed in quitting for good. Smoking has been shown to increase the risk of prematurity and low birth weight. If you have been a smoker, it's likely that your pregnancy provided the impetus for you to stop or cut down significantly. I certainly hope that was true for you, and if so, I commend you for your efforts. While women who smoke can still breastfeed their babies, it is far preferable for you to quit. Few habits pose as great a risk to your own health as smoking. You can add years to your longevity and vastly improve your quality of life by kicking the habit. Furthermore, evidence is mounting that secondhand smoke causes irritation of the lungs, eyes, nose, and throat and poses a major health risk to children. Among the most seriously affected are young infants whose parents smoke. These passive smoking babies are more likely to suffer a host of harmful effects, including infections of the lower airway, such as bronchiolitis and pneumonia; chronic respiratory symptoms; asthma and wheezing illness; acute ear infections and chronic middle ear fluid; and childhood behavior problems. Passive smoking also is a risk factor for sudden infant death syndrome (SIDS), the unexplained death of an apparently healthy infant.

The risk is greater for increasing number of cigarettes smoked, as well as the total number of smokers in the household. Breastfeeding offers some protection against SIDS for infants of nonsmokers, but not smokers. For your baby's sake, make every effort to abstain or at least reduce your smoking habits (see "Drugs for smoking cessation" in this article on medication safety for nursing mothers). If you do smoke, NEVER smoke around your child, and resolve to make your home (and car) smoke-free because smoke can linger in the air and affect your baby even if she isn't present when you light up. Remove all ashtrays from your home as a reminder not to smoke inside.

In addition to the risks of passive smoking, breastfed infants also get exposed to the breakdown products of nicotine and pesticides used on tobacco plants that pass into human milk. Furthermore, some studies have demonstrated that women who smoke produce less milk than nonsmokers. Nevertheless, breastfeeding may still be preferable to formula-feeding for babies of moderate or light smokers. For one thing, the risks of passive smoke are the same for breast- or bottle-fed babies. The protective effects of breastfeeding against wheezing, ear infections, pneumonia, and upper respiratory illness can help mitigate the adverse effects of secondhand smoke.

Caffeine
Most women limit their caffeine consumption during pregnancy or give it up completely because of the remote possibility of caffeine harming the fetus or causing the baby to be underweight. Now that you've gotten caffeine out of your system, it just makes good sense to consume it in moderation while you nurse your baby. You can probably drink two caffeinated beverages each day while you breastfeed without bothering your baby. A cup of coffee has more caffeine than tea, caffeinated soft drinks, or hot chocolate. Some infants may be very sensitive to even small amounts of caffeine, so if your baby seems more irritable after you drink a caffeinated beverage, you will want to cut back.

Medications
Both prescription and over-the-counter medications can pass into breast milk to some degree and be ingested by the nursing infant. Fortunately, the amount of drug that appears in milk usually is too small to adversely affect the baby. Only rarely is a prescribed medicine incompatible with breastfeeding. Nevertheless, it is important to be aware of medication safety guidelines for breastfeeding women and tell your physician that you are breastfeeding whenever you need to take a medication. The prescribing physician can consult a drug-safety database called LactMed and can usually select a drug to treat your condition that will not pose any risk to your nursing baby. You also need to notify your baby's doctor about any medications you plan to take in case you need to observe your baby for possible side effects.

ContraceptionContraception and Lactation
Spacing children at least two or three years apart has several advantages. Your first infant can enjoy the luxury of your undivided attention throughout his babyhood before having to share your time and energies with a sibling. Sibling adjustments usually are easier when the older child has acquired sufficient language skills to communicate his natural ambivalence about a baby brother or sister. Two or three years between births gives couples ample time to renegotiate their relationship before the family dynamics shift once again. And spacing pregnancies allows a mother time to replenish her nutrient stores. Most new parents agree that family planning gives them the peace of mind to thoroughly enjoy their new role before contemplating another pregnancy.

Breastfeeding and contraception are very interwoven. For one thing, breastfeeding has an effect on a woman's fertility. The return of menstrual periods is delayed in breastfeeding women compared with women who formula-feed their babies. In addition, various contraceptive methods can have an effect on breastfeeding by diminishing a mother's milk supply. Finally, becoming pregnant during lactation has an effect on breastfeeding because the prenatal hormones markedly diminish milk production. The following information should help you, together with your partner and your physician, select a contraceptive method that is most suited to your needs.

Lactational Amenorrhea Method
It has long been recognized that breastfeeding has an inhibitory effect on ovulation and fertility after childbirth. Fully breastfeeding women sometimes go a year or longer without having a menstrual period. Until recently, however, the contraceptive effect of breastfeeding had not been formally studied. Recent research has documented that a woman who continues to fully breastfeed her infant and who has no vaginal bleeding after fifty-six days postpartum (i.e., her menstrual periods have not returned) has less than a 2 percent risk of pregnancy during the first six months postpartum. The delay in both ovulation and return of menstrual periods after childbirth that is attributed to breastfeeding has been called "lactational amenorrhea." Using lactational amenorrhea as an introductory method of contraception after childbirth is known as the Lactational Amenorrhea Method (LAM). LAM is now recognized as a highly effective temporary family planning method for breastfeeding women in the early months after delivery. By providing natural protection against pregnancy for up to six months postpartum, LAM gives a nursing mother time to choose a more permanent method of contraception with which she is comfortable. It is critical that a woman meet all three criteria for LAM before using it as protection against pregnancy. The three conditions are: (1) less than six months postpartum; (2) amenorrheic (no periods yet); and (3) fully breastfeeding. It must be emphasized that when any one of these three conditions change, the woman needs to begin using another family planning method to continue her protection against pregnancy. You also should use another family planning method if you are unwilling to accept even a small risk of pregnancy.

Nonhormonal Methods of Family Planning
In addition to LAM, other nonhormonal methods of preventing pregnancy include condoms, diaphragms, cervical caps, vaginal sponges, spermicides, intrauterine devices (IUDs), and natural family planning (rhythm method or periodic abstinence). Permanent options include tubal ligation or vasectomy. These nonhormonal family planning methods have no effect on breastfeeding and pose no risk to the nursing infant. You will want to discuss the respective pros and cons of these options in greater detail with your health care provider and your partner.

Combination Oral Contraceptive Pills
Combination birth control pills contain both estrogen and progestin and are the most effective method of birth control. The main concern about using combination oral contraceptives during breastfeeding is the fact that estrogens may reduce a mother's milk supply. Although hormones may pass into breast milk, no immediate or long-term negative effects on infants have been proved. Ideally, combination birth control pills should be delayed at least six months to minimize their potential impact on breastfeeding. I also believe that mothers who take these pills should be warned about the possibility that their milk supply could decrease. Despite the possible risk of diminished milk production, some nursing mothers choose this method of family planning because of its effectiveness. If you decide to take combined oral contraceptives, try to avoid other behaviors that could decrease your milk supply. For example, I have encountered women who started taking a combined oral contraceptive just as they went back to work, started giving their baby supplemental formula, and allowed their baby to sleep through the night. When their milk supply diminished significantly, it was difficult to sort out which of the various "insults" was most responsible.

Progestin, periods, breast pumping

Progestin-Only Hormonal Methods
Included in this category of contraceptives are the minipill, implants (such as Norplant), and injectables (such as Depo-Provera). These progestin-only hormonal methods are thought to avoid the adverse effects of estrogen on milk supply. When possible, it is best to delay their use at least six to eight weeks postpartum until breastfeeding is well established. Although some hormone passes into breast milk, no adverse effects on breastfed babies have been shown. While implants provide up to five years of protection, the injectables last only about three months.

Return of Menstrual Periods
Most bottle-feeding mothers will be menstruating by the third month postpartum, while fully breastfeeding women are often amenorrheic (not having periods) for many months after delivery. The duration of amenorrhea generally is related to the amount and frequency of infant suckling at the breast. Amenorrhea is shorter for women who breastfeed in a token fashion or on a rigid schedule. Menstrual periods are delayed longer in women who breastfeed their babies on demand, around the clock and who delay the introduction of solid foods for about six months. Typically, menstrual periods resume within a month or so of interrupting full breastfeeding (i.e., when a baby starts sleeping through the night or the mother starts replacing breastfeedings with formula supplements). The return of menstrual periods may be associated with diminished milk supply and a declining prolactin level (the hormone related to milk production). Since decreased milk supply can cause a baby to lose interest in nursing, a woman may find she is unable to breastfeed as long as she had wanted.

A few women experience early return of their menstrual periods despite nursing frequently, through the night, and without supplements. Many of these women continue to produce abundant milk while having periods each month. Other menstruating women perceive that their milk supply diminishes just before and during their periods. They feel they have more milk at other times in their cycle. I recall one woman who experienced sore nipples each month around the time of her period. I speculate that her cyclic nipple pain might have been due to a temporary decline in milk, causing her baby to nurse more vigorously. The return of menstrual periods does not mean a woman needs to wean her baby. However, she should assume she is fertile and could conceive, even if she is less than six months postpartum. The early return of menses (less than six months) should prompt a woman to evaluate her breastfeeding routines and consider whether her milk supply might be low. Even if that is the case, continued partial breastfeeding is still possible.

Being Separated from Your Nursing Infant
Ideally, breastfed babies should accompany their mothers wherever they go and nurse at will. Such unrestricted breastfeeding assures that the baby's needs are promptly met and that the delicate balance between milk supply and infant demand is preserved. If you must be separated from your baby for a short period, you will want to nurse her just before your departure, leaving her with a full tummy. Ideally, you would be able to time your absence to your baby's usual feeding pattern and return before she is ready to nurse again.

If you will be gone past a feeding time, it is preferable for your baby to be fed your expressed milk rather than infant formula. Many nursing mothers learn to express their milk by hand or with a pump shortly after their milk comes in. By removing residual milk after several nursings, a mother can accumulate a couple of ounces of expressed breast milk which can be fed to her infant in her absence. It's a good idea to have a stockpile of frozen breast milk on hand in case you cannot be pres-ent to nurse your baby for some reason . If you do miss a feeding, it is important to empty your breasts when you are away from your baby so your milk supply won't decrease. If your breasts remain full past a feeding time, it sends a message to your body to produce less milk. Thus, skipping nursings without emptying your breasts can decrease your milk supply.

Numerous breast-pumping options are available, ranging from inexpensive hand pumps to battery-operated, small electric, and even hospital-grade rental electric pumps that empty both breasts simultaneously. If you will miss a nursing only occasionally, you can plan ahead to leave a bottle of expressed milk in your absence. Don't expect to pump a full bottle after first nursing your baby, as your supply is closely matched to your baby's needs. Many women pump only an ounce or less of residual milk after nursing their baby. Hand expression or a manual pump can be adequate for collecting milk after several nursings until you obtain sufficient volume for a full feeding. You will get more milk when pumping after an early-morning nursing than you will later in the day. The second breast used at a feeding usually has more residual milk. You can pour the milk you collect from multiple pumpings on a single day into the same bottle. Keep the storage bottle capped and refrigerated, and use the contents within forty-eight to seventy-two hours. Ideally, women who will miss multiple feedings should use a hospital-grade rental electric pump with a double collection system to pump their breasts at their baby's usual feeding time. Hospital-grade rental electric pumps are not only more convenient but also provide maximum efficiency in preserving your milk supply.