Painful breasts are the second most common reason that women give up breastfeeding in the first two weeks. Engorged breasts can hurt! And this can happen both at the beginning and ending of the nursing season, as supply adjusts to meet demand.

This is one of the reasons that I encourage new mothers to work with lactation consultants to learn practical wisdom about breastfeeding. The lactation consultants at Stanford, where I work, recommend cool cabbage leaf compresses between nursings as part of their engorgement solution. Use green cabbage leaves. Crush them with a rolling pin if the leaves don’t fit well to the shape of your breasts. Or cut off the tops of the leaf veins – whatever gives you the best fit. The leaves can stay on for about 20 minutes, two or three times a day, perhaps with a cold compress over them. Some suggest putting them on after every feed, and leaving them on until the cabbage wilts, but others are concerned that this will reduce the milk supply.

During weaning, they can be left on continuously. One study, published in the June 1993 Birth, found that women whose engorgement was treated with cabbage leaves experienced greater relief and were more likely to continue nursing (76 percent versus 58 percent). Women who used the cabbage leaves preventatively, while their milk was first coming in, tended to report less engorgement. I wish I had known about that when my children were nursing!

A later study in the March 1995 Journal of Human Lactation, found that chilled gelpaks and chilled cabbage leaves both result in a significant drop in engorgement pain. Although both worked equally well, the majority of women studied preferred the cabbage leaves. In the September 1995 issue of the same journal, researchers reported that when women had chilled cabbage leaves on one breast and room temperature cabbage leaves on the other, the relief of engorgement was significant, and was the same on both sides; use whatever temperature is more comfortable for you. I’ve even known some women who like warm cabbage leaves.

What about the cabbage leaf extract creams you can buy? The Cochrane Systematic Review, which analyzes data from all available studies, concluded in 2001 that although cabbage leaves may help, cabbage leaf extract preparations do not – save your money!

Some remedies and solutions promoted to breastfeeding moms truly help; others are myths, or are even harmful. Experts in lactation are invaluable resources. Cabbage leaves are just one of many useful ideas you might get from your local lactation consultant.

Dr. Greene’s Answer:

Milk supply is a concern of many mothers. You will likely be able to produce plenty of milk. Still, your mother’s and grandmother’s experience makes it even more likely that you would benefit from working with a lactation consultant when your baby is born (something I encourage for all first time moms).

Many factors work together to determine milk supply. Prolactin is the main milk-producing hormone. Oxytocin is the hormone that causes the milk to “let down” so the baby can get it. At the beginning, a mother’s body does not know how much milk it needs to produce. A supply-and-demand dance with the baby helps to set the production levels.

The more often and more effectively a baby nurses, the higher mom’s prolactin levels, and the more milk is produced. Frequent, short nursing stimulates milk production more than longer nursing less frequently. Getting plenty of fluids is also important for mom’s to make plenty of milk.

Many women are told that they are not making enough milk, even when the baby is getting plenty to grow and thrive:

• If the mother is not able to express much milk
• If she doesn’t feel a let-down reflex
• If she doesn’t leak much
• If the baby seems hungry in only an hour
• If the baby starts spending less time at the breast
• If the baby still enjoys a bottle after nursing

Most of the time, these are false alarms.

There are several better ways to tell that a baby is getting enough milk:

• The baby is making plenty of wet diapers for his age
• He is making plenty of poop for his age
• He is growing as expected.
• He usually seem satisfied or sleepy immediately after nursing.

Whatever happened with your mother and grandmother, there is a good chance that you will be able to produce enough milk for your baby with expert support and advice from a good lactation consultant.

Dr. Greene’s Answer:

Each meal is a matter of life and death for children with propionic acidemia. Children need protein in order to grow and thrive, but for these children extra protein is a deadly poison.

Here’s the problem: The amount they need to grow is a little more than the amount they can handle. Each meal becomes a delicate balancing act that can make the difference between normal development and long-term disability.

Knowing that your baby has this precarious illness must make the desire to nurse and comfort your baby even stronger. But, as cruel as it seems, even breastmilk can be dangerous, unless it is used in just the right way.

Propionic acidemia is one of what we call the inborn errors of metabolism. The individual metabolic disorders are rare, but taken as a group they are fairly common. I do know women who have nursed successfully with metabolic disorders. Some of the metabolic disorders make nursing difficult but still a great benefit.¹ Others make nursing harmful.²

Normally, when we eat protein in our food, our enzymes break the protein down into molecular building blocks. We then reassemble these into the specific protein molecules and other substances our bodies need. Proteins are made up of amino acids.

In propionic acidemia, one little enzyme is missing, but this is enough to change an entire life. Without the enzyme propionyl CoA carboxylase, some common amino acids in protein (isoleucine, valine, threonine, and methionine), are only partially processed. One of the intermediate stages, propionic acid, builds up in the bloodstream.

The propionic acid causes poor feeding, vomiting, dehydration, floppiness, and lethargy, which usually show up in the first weeks of life, and can progress rapidly to coma and death. Seizures occur in about 1/3 of babies. If a baby survives the first attack, similar episodes may occur during an unrelated infection, constipation, or following a high-protein meal.

Some children sail through the early months without apparent problem and don’t come to attention until much later in life.

Before it was recognized and treated, propionic acidemia was usually fatal. With right treatment, it is possible for children to grow and develop normally. The right treatment is crucial. It greatly improves children’s odds but is not the whole story.

Some children are treated perfectly and still have bad outcomes. Others receive no treatment at all and thrive. Even within the same family, there can be wide variability of this disease. One boy was first diagnosed at age 5 because of mental retardation; his 13-year-old sister turned out to have the same level of enzyme deficiency but had no symptoms at all!³

The cornerstone of treatment is to restrict protein. Other measures can be helpful (supplementing with L-carnitine, supplementing with thiamine,⁴ using antibiotics to kill gut bacteria that produce amino acids, using alkaline treatment to decrease acid, treating any constipation immediately, etc), but without restricting protein, none of the other treatments help.

Generally with the low-protein diet, regular protein must be restricted to 1.0-1.5 g/kg per 24 hours. To get enough protein to grow and thrive, kids can supplement this with specially made proteins without isoleucine, valine, methionine, and threonine. This allows the total protein to be increased to 1.5-2.0 g/kg per 24 hours.⁵ The baby needs to be carefully monitored, especially during times of stress or infection, to achieve just the right balance of protein.⁶

I was not aware of anyone who had breastfed successfully with propionic acidemia, so I contacted Iraj Rezani, M.D., the Chief of the Section of Metabolic Disorders at the Temple University Children’s Medical Center and the author of the leading pediatric text on propionic acidemia. He explained that the act of nursing is impossible, even once a day, because the concentration of protein in human milk (1.5%) is just too high-even in small amounts. In those few precious days after a baby is born and before a mom’s milk comes in, the concentration of protein is even higher in the little bit of colostrum that appears. Breastmilk must be pumped, diluted, and carefully measured to be safely used.

In the past few years, researchers at the Istanbul Medical Faculty in Istanbul, Turkey, have studied the possibility of safely breastfeeding children with inborn errors of metabolism. Unfortunately, to date, only one child with propionic acidemia was included in their studies. During three months of breastfeeding, that child had two metabolic emergencies and was quickly switched to a low-protein formula. (Journal of Inherited Metabolic Disease. 28(4):457-65, 2005.)

Ross Labs (with whom I have no affiliation) has designed a comprehensive line of medical foods designed to meet nutrition needs in people with this and other inborn errors of metabolism (more than 3 dozen in all). I applaud them for addressing the needs of families with these rare conditions. Propimex-1 is a ready-to-feed formula for infants and toddlers. Propimex-2 is designed for children and adults with propionic acidemia.

I am hopeful that, in your baby’s lifetime, gene therapy will be able to replace the missing enzyme. For now, liver transplantation is the most effective way to do this.⁷ But unless and until your child has the enzyme replaced, the propionic acidemia diet should be followed carefully.

I feel for the poignancy of your situation. Because your baby was diagnosed before birth, I suspect there may have been another baby in your family who died. How hard this time must be for you!

I am a huge fan of nursing, but I am also confident that the love you already feel will surround and caress and comfort and nourish your baby. When people are denied their eyesight, their other senses become more powerful. I observe that when people who want to nurse are denied the opportunity, all of the other ways of bonding give rise to unexpected levels of closeness.

Dr. Greene’s Answer:

I’m glad about your decision to breast feed your baby. Although breast feeding can pose challenges (and joys), it is still true that mother’s milk is the perfect food for babies. Milk is, in fact, the basic food for all mammals. Why then do people often experience difficulty tolerating milk?

The difficulties can be caused by two different substances: milk sugar (lactose) and milk protein. Each of these substances produces its own particular problems. Lactose is the sugar in milk. It is the same for any kind of milk–breast, cow, goat, or sheep. A person who is lactose intolerant tends to have gassy symptoms, bloating, and diarrhea after eating dairy foods. These symptoms can be avoided if the person drinks lactose-free milk. Alternatively he or she could take pills such as Lactaid, which enable the intestines to digest lactose without any problem. There are far more people in the world who do not tolerate lactose than people who do. About 80% of all people over age 3 are lactose intolerant. This statistic applies to Native Americans, Asians from the Far East, Southeast Asians, Africans, African-Americans, and Native Australians. It does not apply to Caucasians, however: only 15% of Caucasians in the U.S. are lactose intolerant.

The statistic also does not apply to babies. Infants from all parts of the world do tolerate lactose–otherwise they couldn’t digest breast milk well. Their bodies make an enzyme, lactase, which enables them to digest the sugar in milk. As a result, in healthy full-term infants lactose intolerance is extremely rare. It is more common in premature babies, who are sometimes lactose intolerant until they begin to approach their original due dates. At that point, their bodies start making lactase. Newborn lactose intolerance is quite obvious, usually manifesting as discomfort with each feeding. Babies with lactose intolerance are treated with formula that is based on cow’s milk but is lactose-free, or else with a soy-based formula. Elemental formulas, which are much more “pre-digested” than usual formulas, also work well for these infants.

Healthy full-term babies can temporarily become lactose intolerant, though, during and after a bout of diarrhea, since diarrhea can cause them to lose the enzyme. Infants regain their tolerance after the diarrhea has ended and their bodies have had time to make more of the enzyme. Eventually, however, in most populations as the babies mature their bodies gradually make less and less lactase. As they grow into toddlerhood, they no longer tolerate milk of any kind.

The other component of milk that can cause people problems is its protein, which comes in two basic forms–casein and whey. The specific proteins differ slightly depending on which mammal the milk is from. The mammal whose milk most often creates digestive difficulties for humans is the cow. Intolerance to cow’s milk protein follows the opposite pattern from lactose intolerance, since it is not uncommon in newborns but becomes much less common the older children get. It is estimated that between 2% and 7.5% of healthy infants have significant intolerance to the protein in cow’s milk. The problem is particularly common in families with strong histories of eczema, allergies, or asthma.

Babies with this intolerance can have discomfort even if they are exclusively breast fed. The difficulty arises when the mother eats or drinks cow’s milk protein. The protein passes into her breast milk and from there into the baby’s digestive system. Antibodies to this protein have been found in infants who are intolerant, providing evidence of the link between the mother’s diet and her baby’s digestive troubles.

A study published in the January 1996 Journal of the American Dietetic Association looked carefully at infants’ symptoms of fussiness or colic and how they varied with maternal consumption of 15 different foods. Maternal consumption of cow’s milk was far more associated with the symptoms of colic than consumption of any other food. The study found that women who drank cow’s milk were twice as likely to have infants with colic compared to other breast feeding moms. Another study found that half of women with colicky babies who dropped cow’s milk saw marked improvement in their babies’ symptoms. A third investigation found that there were higher levels of cow’s milk protein in the mothers’ milk of colicky infants than in the milk of mothers whose babies were not colicky.

These studies strongly suggest that if your breast fed baby is colicky, it is worth a try to eliminate cow’s milk from your diet. You will want to avoid cheese, ice cream, milk in a glass or on cereal, yogurt, puddings, custards, cream sauces, and butter. This is not a quick fix, however. Cow’s milk protein can remain in breast milk for up to two weeks after the mother has stopped eating dairy foods. To see whether dropping dairy really makes a difference for your child, have your dietary experiment last about 3 weeks. If the change in your eating habits does improve your baby’s colic, you will probably want to remain off dairy at least until the typical colicky period is over, when your baby is 12 to 16 weeks old. If your child’s colic was severe and it turns out that he or she is especially sensitive to cow’s milk protein, you may want to avoid dairy even longer. Although many babies become tolerant of cow’s milk protein before their first birthdays, some children can take a full year or longer, and some never become tolerant.

During this period, as a mom you need to remember your own physical needs. First of all, you will need another source of calcium. You will need to take in at least 1200 mg daily. If you do not, the calcium you lack in your diet will be taken from your bones! Calcium is found in Tums, sesame seeds, bok choi (Chinese cabbage), canned non-boneless salmon and sardines, and dark green vegetables such as collard greens, spinach, turnip greens, and kale. Some brands of orange juice are fortified with calcium. Tofu is also a good source of calcium, but unfortunately as many as 20% of babies who are sensitive to the protein in cow’s milk are also sensitive to soy. You can try drinking almond milk, coconut milk, or rice milk in place of cow’s milk. Stores that sell vegan foods have non-dairy butters and cheeses available as well.

You may also need to be careful about your own body’s developing an intolerance to lactose. While avoiding cow’s milk protein, you will also have stopped consuming milk sugar. Your body may respond to the lack of milk sugar by stopping its production of the enzyme lactase. You would then start having digestive difficulties once you reintroduced milk to your diet. Ways to help prevent this problem are 1) try eating goat’s or sheep’s milk (for example, in French cheeses such as chevre). The proteins in these kinds of milk are less likely to cause your baby problems than the proteins in cow’s milk; 2) consume small amounts of cow’s milk used in recipes. Thorough cooking of cow’s milk alters the form of the protein, making it less likely to upset your baby’s digestion; and 3) when you do reintroduce dairy to your diet, do so gradually.

All of this may sound like a lot of work, but for parents with a colicky baby, the changes can be well worth the effort. There are other benefits to mom’s avoiding cow’s milk, too. According to the September 1993 Journal of Investigative Allergy and Clinical Immunology, studies have shown that the frequency and severity of asthma, eczema, and allergies are significantly reduced for as long as 5 years when breast feeding mothers give up cow’s milk for at least 3 months.

In answer to your question, then, your switching to lactose-free milk or taking Lactaid pills would not help your colicky baby, because those products still contain the protein in cow’s milk. Temporarily giving up the dairy products you love so much might make a real difference, however. You might find that what you lose in your diet will be made up to you in the smiles on your baby’s face.