Gastroenteritis in the Breastfed Baby

This article specifically discusses infection of the gastrointestinal tract because it is the most common acute infant illness that too many physicians and other health professionals insist require the mothers to interrupt breastfeeding.  Unfortunately, any and all possible acute infections in their breastfeeding baby or toddler have been given as a reason for mothers to stop or interrupt breastfeeding.  The principles mentioned here also apply to any acute infant infection.  It should be noted that many types of illness not caused by gastroenteritis may cause vomiting and diarrhea.  Typical are infections outside the gastrointestinal tract; for example, pneumonia. Or, another example, appendicitis. If parents have any doubts that this is anything but a “tummy infection”, the baby should be seen promptly by a doctor.

Gastroenteritis in the breastfed baby (vomiting and diarrhea due to infection) 

Because of a whole system of interacting immune factors present in breastmilk, exclusively breastfed babies only rarely get gastroenteritis (an infection of the intestinal tract, usually due to a virus such as rotavirus, or less commonly, to bacteria or other microorganisms). If the exclusively breastfed baby does get gastroenteritis, it is unusual for it to be severe and almost always it is mild. And the best treatment for gastroenteritis is continued breastfeeding. The immune factors present in breastmilk not only prevent gastroenteritis, they also help to cure it, and a number of factors present in breastmilk help the gut to heal.

Even partially breastfed babies/toddlers are relatively immune to getting gastroenteritis.

Therefore, the first step in the treatment of gastroenteritis is to continue breastfeeding, as frequently as the baby desires. Not only will continued breastfeeding help in treating the infection, breastfeeding will maintain the baby’s hydration. If the baby is already eating food but is not willing to eat while sick, it is fine to stop other food temporarily and continue only with breastfeeding.  On the other hand, if he is willing to eat food, he should be allowed to eat.

Usually, the only treatment that is necessary for the vast majority of cases of gastroenteritis is breastfeeding. According to the World Health Organization, page 10: “Breastfeeding should always be continued.”

Breastfeeding is more than milk

It should not be forgotten how much comfort and security the baby or toddler receives from breastfeeding.  This is particularly important when the baby is sick and perhaps feeling miserable.  Furthermore, a baby who will breastfeed when he is sick will give some reassurance to the parents that the baby is not so sick that they need to worry (more than parents usually worry).  Thus, breastfeeding calms and reassures the baby; and the fact that the baby gets comfort from breastfeeding reassures and calms the mother.

But how do we deal with the vomiting and the diarrhea?

As long as the baby’s hydration is well maintained by breastfeeding, there is no need for any other treatment.

The only other treatment that might be necessary, with a strong emphasis on “might”, in more severe cases (rare in exclusively breastfed babies) is oral rehydration solution. Oral rehydration solutions of any kind are only necessary if breastfeeding is not keeping up with the baby’s requirements.  However, some pediatricians/family physicians recommend special solutions “at the first sign of gastroenteritis”, an absurd recommendation in the breastfed baby or toddler.

Breastfeeding alone may not keep up with the baby’s requirements, for example, if the mother’s milk supply has decreased for whatever reason.  In the usual situation, this would occur only once the baby is eating plenty of solids.  However, once the baby wants to breastfeed more frequently, as is likely when the baby feels unwell, the milk supply will rise to the occasion.  It is worth taking a look also at the article on late onset decreased milk supply.

On rare occasions, fluid loss in the baby/toddler is so rapid or abundant that the baby becomes lethargic and does not breastfeed.  Oral dehydration fluids can be tried, but often the baby/toddler will not take them either.  If this is the case, the parents should seek immediate medical care for the baby.

You might be interested that oral rehydrating solutions were developed for resource poor countries where the high cost of intravenous rehydration and the requirement for hospitalization to administer it put a great burden on health resources. Furthermore, in many resource poor places, the baby’s hydration status and general well being are difficult to monitor when there are few health professionals for many sick babies/toddlers and the laboratory may not be as reliable as it should be.  Oral rehydrating solutions give the right amount of water and salts (sodium and potassium) for most babies and were especially made so that a litre (or quart, more or less) of the solution costs pennies.  However, formula companies, always looking for the quick way of making money on sick babies, now sell oral rehydrating solutions (and maintenance solutions, which are unnecessary for the breastfed baby) for many dollars a litre.  Last time I looked 1 litre of oral electrolyte solution was $12 (For a mixture of water and salt! The profit margin must be huge).

In the past, before the formula companies got in on the game, diarrhea, especially if associated with vomiting, was treated with frequent, small amounts of fluid given to the baby. Flat soda pop (yuck) was a frequent recommendation. There was even an instruction by some doctors to alternate one cola (higher in sodium) with another (higher in potassium).

In fact, with breastfeeding, the baby gets frequent small feedings. The mother essentially keeps the baby at the breast, almost constantly. After the initial large intake of breastmilk at the beginning of a feeding (after the baby wakes up from a sleep, say), the baby will then be getting only small amounts of milk and the sucking at the breast helps the baby’s stomach to empty (gastrocolic reflex), thus reducing vomiting. What if the baby vomits? The mother should put him back to the breast.

Even rarer in the exclusively breastfed baby is the need to rehydrate the baby with an intravenous solution.

Drugs to prevent/treat vomiting and diarrhea

It is important to realize that medication to prevent vomiting and diarrhea is almost never necessary and usually does not work anyway.  And can be harmful. Even if they do seem to work, it’s not a good idea to use them. Vomiting and diarrhea are the body’s method of ridding the intestines of the virus or bacteria as well as the toxins formed by these germs. Treating the vomiting and diarrhea with medication may actually prolong the illness and cause it to recur.

• Dimenhydrinate (Gravol) is an antihistamine frequently used orally or as a rectal suppository to decrease vomiting. There is no good proof that it actually works to decrease vomiting. It can, however, cause excessive sleepiness (lethargy), which can confuse the clinical picture: Is the baby lethargic because of the drug or because he is becoming sicker? Such drugs should not be used.

• Loperamide (Imodium) which is supposed to decrease the diarrhea should also not be used, for the same reason as mentioned above: diarrhea is the body’s way of getting rid of the germs and toxins that cause the infection of the gut.

• Antibiotics are rarely if ever necessary in ordinary gastroenteritis since the majority of gastroenteritis is caused by viruses (norovirus, for example) and not bacteria. Even if caused by bacteria, they are not a good idea, except in unusual circumstances.

The best “drug” for vomiting and diarrhea due to infection is breastfeeding.

Prolonged diarrhea

In the typical case of gastroenteritis, the vomiting does not usually last for more than two or three days and the diarrhea rarely much longer than a week or so.

If the diarrhea lasts more than a week or so, it is often due to the fact that babies are eating low fat foods, typically and “traditionally” the “BRAT” diet widely recommended in the 1960s and before, as a slow “gentle” way to start food after gastroenteritis: banana, rice, apple sauce and toast. It has already been mentioned that if the child with gastroenteritis is willing to eat food, he should continue eating, but the food should not be low in fat. Adding fat to the child’s diet will usually stop the “prolonged” diarrhea. Note that breastmilk contains a lot of fat especially if the mother has been breastfeeding for over a year.

Various companies, including formula companies, have started to produce special products for diarrhea, especially “oral rehydrating solutions” with carrots and rice. Really, carrots and rice? What for? All that stuff, being low in fat, will prolong the diarrhea and, of course bring in lots of money for the formula companies, who win three times; once for the formula which put the child at risk for diarrhea, second for the “special” formulas for diarrhea, and third for this carrot and rice rubbish.

The bowel movements of the exclusively breastfed baby can seem to be diarrhea

The bowel movements of exclusively breastfed babies are often quite loose, even watery.  Furthermore, they can be frequent (7 or 8 times or even more in a day is not rare), and can be green or seem to have no substance at all. As long as the baby is drinking well at the breast, is generally content, and gaining weight well, there is no problem. However, if not all of these three conditions apply, then something may be wrong.  But note that a hungry baby who is sucking his fingers a lot of the time may seem content, so this “sign” that all is okay is maybe not a good sign that all is okay.

One cause of frequent green bowel movements, sometimes even with small amounts of blood can be due to late onset decreased milk supply .The way to deal with this is to increase the baby’s intake of milk from the breast.

Spitting up

Spitting up is different from vomiting in that vomiting is usually forceful and happens out of the ordinary pattern of the baby’s behaviour. Often the baby is just not his “usual self”. With spitting up, the milk comes up often almost without anyone really noticing. Not the baby, and not the parents until the parent holding the baby feels his/her shoulder wet.

If the baby is drinking well from the breast, gaining weight well and is generally a happy baby, then spitting up even a lot, is not bad. In fact, it is probably good. Breastmilk is full of immune factors (not just antibodies, but dozens of others as well that all interact with each other). These immune factors protect the baby from invasion by bacteria and viruses by lining the baby’s mucous membranes (the linings of the gut, respiratory tract and elsewhere). This lining, this barrier, prevents the bacteria and viruses from entering the baby’s body and blood. A baby who spits up has double protection, forming this barrier when the baby drinks the milk and it goes to the stomach and then when he spits it up. This may be particularly important as it is the upper part of the gut and respiratory tract which is most exposed to bacteria and viruses. I frequently use this example of how breastfeeding is so different from formula and bottle feeding. Spitting up formula, if all else is going well, is probably not bad. Spitting up breastmilk, if all else is going well, is probably good. Good, because the immune factors that cover the lining of the esophagus are replenished by spitting up.

If you need help with breastfeeding, make an appointment at our clinic.

Copyright: Jack Newman, MD, FRCPC, Andrea Polokova, 2017, 2018, 2021