Colic in the Breastfed Baby
is one of the mysteries of nature. Nobody knows what it really is, but
everyone has an opinion. In the typical situation, the baby starts to
have crying spells about two to three weeks after birth. These occur
mainly in the evening, and finally stop when the baby is about three
months old (occasionally older). When the baby cries, he is often
inconsolable, though if he is walked, rocked or taken for a walk, he may
settle temporarily. For a baby to be called colicky, it is necessary
that he be gaining weight well and be otherwise healthy. However, even if the baby is gaining weight well, sometimes the baby is crying because he is still hungry. See below.
The notion of colic has been extended to include almost any fussiness or
crying in the baby, and this is not surprising since we do not really
know what colic is. There is no treatment for colic, though many
medications and behaviour strategies have been tried, without any proven
benefit. Of course, everyone knows someone whose baby was “cured” of
colic by a particular treatment. Also, almost every treatment seems to
work, at least for a short time, anyhow.
The Breastfeeding Baby with Colic
Aside from the colic that any baby may have, there are three known
situations in the breastfed baby that may result in fussiness or colic. Once again, it is assumed that the baby is gaining adequately and that the baby is healthy.
Feeding both breasts at each feeding or feeding only one breast at each feeding
Human milk changes during a feeding. One of the ways in which it changes
is that, in general, the amount of fat increases as the baby drains
more milk from the breast. If the mother automatically switches the baby
from one breast to the other during the feed, before the baby has
“finished” the first side, the baby may get a relatively low amount of
fat during the feeding. This may result in the baby getting fewer
calories, and thus feeding more frequently. If the baby takes in a lot
of milk (to make up for the reduced concentration of calories), he may
spit up. Because of the relatively low fat content of the milk, the
stomach empties quickly, and a large amount of milk sugar (lactose)
arrives in the intestine all at once. The enzyme which digests the sugar
(lactase) may not be able to handle so much milk sugar at one time and
the baby will have the symptoms of lactose intolerance—crying, gas,
explosive, watery, green bowel movements. This may occur even during the
feeding. These babies are not lactose intolerant. They have problems
with lactose because of the sort of information women get about
breastfeeding. This is not a reason to switch to lactose-free formula.
It is also very important that you realize that a baby is not
drinking milk from the breast just because the baby is making sucking
movements on the breast. He may be “nibbling” not drinking and
therefore the baby is not getting higher fat milk just because he is on
the breast and sucking.
Do not time feedings. Mothers all over the world have
successfully breastfed babies without being able to tell time.
Breastfeeding problems are greatest in societies where everyone has a
watch and least where no one has a watch.
The mother should feed the baby on one breast, as long as the baby
actually gets milk from the breast, (see videos at nbcionling.org) until
the baby comes off himself, or is asleep at the breast from being full
or is nibbling even with compression. Use breast compression (see the
information sheet Breast Compression) to keep baby drinking and
not just sucking. Follow the Protocol to Manage Breastmilk intake (the
Protocol is found on the website as well as the video clips at the
website nbcionling.org to help use the Protocol). Please note that a
baby may be on the breast for two hours, but may actually be drinking
milk for only a few minutes. In that case the milk taken by the baby may
still be relatively low in fat. This is the rationale for using
compression. If, after “finishing” the first side, the baby still wants to feed, offer the other side. Do not prevent the baby from taking the other side if he is still hungry.
This is not a suggestion to feed only one breast at a feeding. You
might be able to do it, and that’s fine, but not all mothers can manage
it. You might find it possible in the morning when you have more milk
(as most mothers do) but not in the evening when you have less milk (as
most mothers do). If you insist on feeding on just one side, you may
find your baby is “colicky” in the evening when he is, in fact, hungry.
At the next feeding, start the baby on the other breast and proceed in the same way.
Your body will adjust quickly to the new method and you will not become
engorged or lop sided after a short while. But remember this: feeding
on one side at a feeding, if you can manage it, will reduce the milk
supply so that what may work now (breastfeeding on one breast at a
feeding) may not work as the milk supply decreases. Therefore do not
keep the baby to one breast, but “finish” one side and if the baby wants
more, offer the other side. See Section ‘F’.
It is not a good idea to feed the baby on just one side, to follow a
rule. Yes, making sure the baby “finishes” the first side before
offering the second can help treat poor weight gain or colic in the
baby, but rules and breastfeeding do not go together well. If the baby
is not drinking, actually getting milk, there is no point in just
keeping the baby sucking without getting any milk for long periods of
time. You should “finish” one side and if the baby wants more, offer
How do you know the baby is “finished” the first side? The baby is no
longer drinking, even with compression (see the video clip and
information sheet on compression) This does not mean you must take the
baby off the breast as soon as the baby doesn’t drink at all for a
minute or two (you may get another milk ejection reflex or letdown
reflex, so give it a little time), but if it is obvious the baby is not
drinking, take the baby off the breast and if the baby wants more, offer
the other side. How do you know the baby is drinking or not? See the
video clips at the above website.
If the baby lets go of the breast on his own, does it mean that the baby
has “finished” that side? Not necessarily. Babies often let go of the
breast when the flow of milk slows, or sometimes when the mother gets a
milk ejection reflex and the baby, surprised by the sudden rapid flow,
pulls off. Try him again on that side if he wants more, but if the baby
is obviously not drinking even with compression, switch sides.
In some cases, it may be helpful to feed the baby two or more feedings
on one side before switching over to the other side for two or more
feedings, as long as baby has come of the breast from drinking. Putting
a baby back on a breast that was just “emptied” may cause baby to fuss
or pull at the breast or fall asleep but not be full.
This problem is made worse if the baby is not well latched on to the breast. A good latch is the key to easy breastfeeding.
Overactive Letdown Reflex
A baby who gets too much milk very quickly, may become very fussy and
irritable at the breast and may be considered “colicky”. Typically, the
baby is gaining very well. Typically, also, the baby starts
breastfeeding, and after a few seconds or minutes, starts to cough,
choke or struggle at the breast. He may come off, and often, the
mother's milk will spray. After this, the baby frequently returns to the
breast, but may be fussy and repeat the performance. He may be unhappy
with the rapid flow and impatient when the flow slows. This can be a
very trying time for everyone. On rare occasions, a baby may even start
refusing to take the breast after several weeks, typically around three
months of age. What can you do?
- Get the best latch possible.
This problem is made worse if the baby is not well latched on to the
breast. A good latch is the key to easy breastfeeding. No matter what
you are told about how good the latch looks, try to improve on it.
Think of it this way: if your chin is tucked into your chest while you
are trying to drink you would become overwhelmed by the fast flow very
easily. If you want to drink quickly you will throw your head back,
chin in the air, and be able to handle the fast flow. This is the kind
of position baby’s head should be in while breastfeeding—his chin deep
into your breast, his head in a slightly tipped-back position, his nose
away from your breast, and his chin far from his own chest. This
position will help him to handle the faster flow of the let down. See
the information sheet When Latching and the video clips.
If you have not already done so, try feeding the baby one breast per
feed. In some situations, feeding even two or three feedings on one
breast before changing to the other breast may be helpful. If you
experience engorgement on the unused breast, express just enough to feel
comfortable. Remember, if the baby wants the second breast, the mother
should offer it.
Feed the baby before he is ravenous. Do not hold off the feeding by giving water (a breastfed baby does not need water even in very hot weather)
or a pacifier. A ravenous baby will “attack” the breast and may cause a
very active letdown reflex. Feed the baby as soon as he shows any sign
of hunger. If he is still half asleep when you put him to the breast,
all the better.
- Feed the baby in a calm, relaxed atmosphere, if
possible. Loud music, bright lights are not conducive to a good
feeding. Older babies tend to become very distracted as the flow slows
down. Using compressions gently at first, and then more firmly as
necessary to keep the speed of flow consistent, will often keep baby
interested in staying on the breast longer, because he is drinking
Lying down to breastfeed sometimes works very well. If lying sideways to
feed does not help, try lying flat, or almost flat, on your back with
the baby lying on top of you to breastfeed, or try leaning back in a
chair. Gravity helps decrease the flow rate. Remember, the baby may be
frustrated at the inconsistent flow, so it may be necessary to lie down
at the beginning when the flow is fast, and sit back up as the milk
slows. Babies like the lying down position; they tend not to fuss with
slower flow but tend to sleep.
The baby may dislike the rapid flow, but also become fussy when the flow
slows too much. If you think the baby is fussy because the flow is too
slow, it will help to compress the breast to keep up the flow, see
section ‘e’. (See the information sheet Breast Compression).
If all else has not made things better:
On occasion giving the baby commercial lactase (the enzyme that
metabolizes lactose), 2-4 drops after each feeding or between breasts if
you give both, relieves the symptoms. It is available without
prescription, but fairly expensive, and works only occasionally. It is
difficult to understand why it would work, since the enzyme is broken
down in the baby’s stomach but sometimes it does seem to work.
A nipple shield may help, but use this only if nothing else has helped
and only if you have had access to good help without any change. This
is the second-last resort. Please note that a nipple shield is only
very rarely the answer to any breastfeeding problem and in most
situations it makes the situation worse, not better.
As a last resort, rather than switching to formula, give the baby your
expressed milk by cup or by bottle if baby won’t take a cup. Adding
lactase to the expressed milk may help as well.
Foreign Proteins in the Mother's Milk
Sometimes, proteins present in the mother’s diet may appear in her milk
and may affect the baby. The most common of these is cow’s milk protein.
Other proteins have also been shown to be excreted into some mothers’
milk. The fact that these proteins and other substances appear in the
mother’s milk is not usually a bad thing. Indeed, it is usually good,
helping to desensitize your baby to these proteins. Ask about this if
you have any questions.
Thus, in the treatment of the colicky breastfed baby, one step would be
for the mother to stop taking dairy products or other foods, but only one type of food at a time.
Dairy products include milk, cheese, yoghurt, ice cream and anything
else that may contain milk, such as salad dressings with whey protein or
casein. Check labels on prepared foods to see if they include milk or
milk solids. When the milk protein has been changed (denatured), as in
cooking for example, there should be no problem. Ask if you have any
If eliminating certain foods from the mother’s diet does not work, the
mother can take pancreatic enzymes (Cotazyme, Pancrease 4, for example),
starting with 1 capsule at each meal, to break down proteins in her
intestines so that they are less likely to be absorbed into her body as
whole protein and appear in the milk. Of course, your chances of not
being able to produce enough of your own enzymes from your pancreas are
very low (unless you have cystic fibrosis, for example), but it has been
shown that whole protein does get absorbed into the breastfeeding
mother’s body and into her milk and adding the enzymes may decrease the
amounts of whole protein entering your body and getting into the milk.
Please note: Intolerance to milk protein has nothing to do with
lactose intolerance, a completely different issue. Also, a mother who is
lactose intolerant herself should still breastfeed her baby.
Eliminate all milk products for 7-10 days.
If there has been no change for the better in the baby, the mother can reintroduce milk products.
If there has been a change for the better, you can then slowly
reintroduce milk products into her diet, if these are normally part of
your diet. (There is no need to drink milk in order to make milk, for
example, so if you don’t drink milk normally, don’t while you are
breastfeeding). Some babies will tolerate absolutely no milk products in
the mother’s diet. Most tolerate some. You will learn what amount of
dairy products you can take without the baby reacting.
If you are concerned about your calcium intake, calcium can be obtained
without taking dairy products. Speak with your doctor or a dietician.
But, 7-10 days off milk products will not cause you any nutritional
problems. Actually, evidence suggests that breastfeeding may protect the
woman against the development of osteoporosis even if she does not take
extra calcium. The baby will get all he needs.
Be careful about eliminating too many things from your diet all at once.
Everyone will know someone whose baby got better when the mother
stopped broccoli, beef, bananas, bread, etc. You may find that you are
eating white rice only. Our diets are too complex to be sure exactly
what, if anything, is affecting the baby.
One more piece of information. Some babies are hungry even if they
are gaining weight really well. This may occur for several reasons,
some mentioned earlier in this information sheet. One more way a baby
can be hungry and nevertheless gain weight well is that you are limiting
the feedings; for example, you feed the baby 10 or 20 minutes a side.
If you have a lot of milk, the baby may gain weight well and still be
hungry. So don’t limit feedings.
Be patient, the problem usually gets better no matter what. Formula is not the answer,
but, because of the more regular flow, some babies do improve on it.
But formula is not breastmilk and breastfeeding is much more than
breastmilk. In fact, the baby would also improve on breastmilk from the
bottle because of the regularity of the flow. Even if nothing works,
time usually helps. The days and nights may seem eternal, but the weeks
will fly by.
Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond.
To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002.
Written and revised (under other names) by Jack Newman, MD, FRCPC, 1995-2005
Revised by Jack Newman MD, FRCPC and Edith Kernerman, IBCLC, 2008, 2009