Finish the
First Breast First
by Melissa Vickers
Huntingdon, Tennessee,
USA
from LEAVEN, September-October 1995, p. 69-71
We provide articles
from our publications from previous years for reference for our Leaders and
members. Readers are cautioned to remember that research and medical information
change over time
I have repeated the "Composition
of the Milk" speech over the phone to anxious mothers so many times
my husband has it memorized. I wish someone had given the speech to
me when my daughter was a baby--we both would have been a lot happier!
Merrilee was one of those babies who nursed all the time, fussed at
let-down, then randomly threw up volumes of my precious milk. She was
fussy between feedings, and although she fussed and fought when I offered
the breast, she took great comfort from it once she latched on. Had
this been my first child, I do not know how I would have coped.
Merrilee was six years old
when I finally found a probable explanation for her exasperating behavior.
I attended a conference where Michael Woolridge, a researcher from Great
Britain, spoke about his studies of colic and overfeeding in breastfed
babies. One of his handouts was a paper he and Chloe Fisher (co-author
of Bestfeeding: Getting Breastfeeding Right For You) had
written. Reading "Colic, 'Overfeeding,' and Symptoms of Lactose Malabsorption
in the Breast-Fed Baby: A Possible Artifact of Feed Management" (Lancet
1988) and hearing Woolridge's explanation gave me the same "aha!" feeling
I had felt at my first La Leche League meeting!
In order to fully appreciate
the potential benefits of the Woolridge research, let's first take a
look at how the let-down reflex and regulation of milk supply normally
work. These two processes are keys to understanding the problem and
solution.
The Let-down Reflex
The let-down reflex is the
express mail equivalent of milk production. It is a hormonally driven
process that gets the milk from the upper portions of the breast through
the ducts to the sinuses beneath the areola, out the nipple and finally
into a baby's waiting mouth. According to THE BREASTFEEDING ANSWER BOOK:
During breastfeeding,
the baby's suck stimulates the let-down. When a baby begins to nurse,
the rhythmic motion of his jaws, lips and tongue send nerve impulses
to the mother's pituitary, the master gland in the brain, by way of
the hypothalamus. Two hormones, prolactin and oxytocin, are then released.
It is the oxytocin that stimulates the let-down reflex, causing the
band-like cells surrounding the milk-producing cells (alveoli) to constrict
and squeeze out the milk from all parts of the breast. This muscle action
sends the milk through the ducts to the milk reservoirs (lactiferous
sinuses) about an inch behind the nipple, so that it is available to
the baby.
THE BREASTFEEDING ANSWER
BOOK goes on to say that the "most reliable sign of the let-down is
a change in the baby's sucking and swallowing pattern from quick sucks
with occasional swallowing to long, slow sucks with regular swallowing
or gulping." If you ask a nursing mother to describe her baby's suck-swallow
pattern, she will describe the above pattern. She may also add that
the sucking and swallowing will taper off, as if her baby is resting
a bit, and then the slow suck/regular swallowing starts back up again.
At this point I assure her that her body is working just as it should.
It is those later sucking bursts that indicate that the mother is having
multiple let-downs. These are normal, common and responsible for squeezing
out the fattier hindmilk later in the feeding. Often the only clue that
a mother has that she is experiencing the later let-downs is this predictable
suck-swallow pattern, regardless of whether she feels the let-downs.
Some women barely feel any let-downs, while others experience a tingly
sensation in the breast every time the milk lets down.
As a general rule, the more
obvious it is to the mother that her milk is "letting down," the fuller
her breasts are. Remember that milk production is based on supply and
demand--how much milk the breast makes is determined by how much milk
is removed from the breast. If the baby takes a lot of milk, the breast
makes a lot to be ready for the next time. This is a truly remarkable
system!
The Composition of
the Milk
Equally remarkable as the
milk production system is the change in composition of milk throughout
the course of a feeding, something that no artificial baby milk will
ever be able to claim. Foremilk, the initial milk that baby gets upon
latch-on, is much like skim milk. It is initially satisfying, high in
volume and low in fat and calories. As the feeding progresses, the fat
content goes up and the corresponding milk more closely resembles whole
milk. Finally, toward the end of the feeding, the hindmilk is high in
fat, high in calories and low in volume. Think of hindmilk as a rich
creamy dessert. Lactose (milk sugar) concentration is relatively constant
throughout the feeding.
Part of Woolridge's research
in recent years has measured milk intake and the fat content of the
milk. His studies show that there can be quite a wide variation in fat
content of fore- and hindmilk in some mothers. Others show very little
difference in fore- and hindmilk.
Baby-Led Feedings
Woolridge stresses the importance
of turning over control of the feedings to the baby. Babies are smart--they
know what they need. According to Woolridge, a baby will nurse until
he gets the calories he needs. A corollary to that is the volume of
milk consumed is less important than the calorie count. An efficient
nurser will trigger the later let-downs and receive more of the fattier
hind milk.
It takes more than just an
efficient nurser to get to the hindmilk. It also requires time and patience
on the mother's part and education as to the importance of allowing
the baby to stay on one breast long enough to get that hindmilk. The
obvious question is, how long does it take? According to Woolridge and
Fisher, a baby who is satisfied and comfortably full will come off the
breast by himself. This is when we see that marvelous "drunken sailor"
look that comes with a full tummy. Some babies will reach this point
more quickly than others; some will never seem to reach the point of
coming off by themselves. This may be an indication that the baby is
not nursing efficiently and may benefit from some help with positioning
or latch-on. Often just lifting the breast from underneath will allow
the baby to drain the breast more effectively. Routine breastfeeding
guidelines often tell mothers to limit total time at the breast and
to use a set time interval of five to ten minutes to determine when
to switch from one breast to the other. Limiting baby's nursing on each
side to only five or ten minutes can be counterproductive when viewed
in terms of the change in milk composition. For some mothers, nursing
on both breasts at each feeding is important in terms of keeping up
milk production and relieving engorgement, but the baby should be finished
with the first breast before being switched to the other side.
A Typical Scenario
Let's take a look at why
arbitrary switching to the other breast may lead to problems. First
of all, if a mother is timing feedings and giving equal time at each
breast, the baby is going to be getting a lot of the foremilk--the skim
milk--especially if the mother is one with a greater difference in fat
content between fore- and hindmilk. Remembering that baby will try to
feed until he gets his calories, he must take a lot of skim milk to
get those calories. When he takes a lot of milk from the breast, the
breast responds by making lots of milk. Large quantities of milk mean
greater flow and more forceful let-down--which is like trying to breastfeed
from a fire hydrant!
If the baby is drinking large
quantities of milk, then he is also consuming large quantities of lactose
or milk sugar. Babies can handle a certain amount of lactose, because
they make lactase--the enzyme necessary to digest that sugar--although
the supply is limited. Too much milk may mean more lactose than the
baby has lactase to handle, setting up a problem similar to lactose
intolerance. Any of you who suffer from lactose intolerance can immediately
sympathize with the discomfort that baby will feel! The high lactose
content in the intestine leads to diarrhea, which is further complicated
because a low fat content in the milk will cause rapid stomach emptying.
Sometimes the stomach "empties in the wrong direction," causing these
babies to spit up--they consume more milk than they can comfortably
hold. Compounding the problem, if baby doesn't get the calories he is
after, he will want to eat sooner.
Think back to all the calls you
have received from the mother who worries that she doesn't have enough milk
because her baby breastfeeds "all the time." Or maybe she believes her baby
does not like her because he fights the breast. Or he sputters at the breast,
spits up what appears to be a lot of milk and has frothy green diapers.
Or she experiences major leaking in between feedings or at let-down. These
mothers are probably suffering from an overactive let-down, brought on by
mismanagement--interference with the normal "flow" of milk--and are prime
candidates for being helped by the research findings of Woolridge and Fisher.
(For more information on the overactive let-down, the symptoms and suggestions
for treatment, see Mary Jozwiak's article
that follows.)
So How Do We Help
These Mothers?
Have you ever watched a mother
cat nurse her kittens? Each kitten nurses in one spot until he is finished.
Mama Cat does not play "musical chairs" with her kittens! Perhaps a
more "natural" way to nurse is to let the baby finish the first breast
first.
Tell pregnant women and mothers
of newborns about the importance of making sure that their babies nurse
long enough to get that hindmilk. If you explain the process to them,
it will make sense to them, and if it makes sense, they are more likely
to implement this way of nursing. Encourage them to let their babies
nurse on one side until they come off. Then they can burp them or change
them. If the baby still seems hungry, the mother can offer the other
side and let her baby have what he wants. She can then start on that
second side for the next feeding.
By nursing mostly on one
side per feeding, the baby gets all the calories he needs in less volume
of milk. When the mother's body adjusts to this way of feeding, she
only makes milk to replace what the baby takes. So, she is more comfortable
and less likely to leak. Her baby may be less colicky and often gains
weight at a better rate. He is less likely to fight the breast since
he is no longer nursing the "fire hydrant." And, he may go longer between
feedings if he is having a "meal" that includes both the "appetizer"
(foremilk) and the "dessert" (the hindmilk).
Evelyn Byrne, retired Leader
and IBCLC, reminds us of the importance of follow-up with these mothers.
Baby may be noticeably calmer after a few feedings, but the method may
require "fine tuning" for a couple of weeks. Baby's weight gain should
improve if he is getting more hindmilk. If it doesn't, if he loses weight
or has fewer wet diapers, breastfeeding management should again be evaluated.
A reminder that it often takes as long to get out of a problem as it
did to get into the problem may help the mother look ahead.
Nursing Patterns Can
Vary
Now, I am sure that you know
of many mothers (including perhaps yourself) who nursed both sides every
feeding and did just fine. This is just another indication of the adaptability
of the human body! If the system that the mother is using is working
for her, then there is no reason to change it. However, it may still
help her to hear about how her milk changes during the feeding. Knowledge
is a powerful tool! And, some mothers may actually be relieved to hear
that it is not necessary to switch breasts at every feeding--particularly
those mothers who may be struggling to get their babies latched on well
in the first place.
It may be that the mothers
who do nurse both sides equally every feeding are just lucky enough
that they can make this system work. Or, there may be something else
at work as well. Woolridge speculates that perhaps the women who show
the greatest variation in fat content are the ones who most benefit
from the "finish the first breast first" method of feeding. The women
whose milk changes very little can nurse any way they want and the babies
can get what they need.
Woolridge's research represents
another example of the science of lactation backing up the art of breastfeeding.
It also confirms what La Leche League Leaders seem to do naturally--encourage
mothers to look to their babies for cues.
References
La Leche League International.
THE WOMANLY ART OF BREASTFEEDING, 5th ed. Schaumburg, Illinois, 1991.
Mohrbacher, Nancy and Julie
Stock. THE BREASTFEEDING ANSWER BOOK. Schaumburg, Illinois: La Leche
League International, 1991.
Melissa Vickers is APL
for Tennessee, USA, and a Contributing Editor for LEAVEN. She is the
mother of two children and a board certified lactation consultant.
Page last edited Sun Oct 14 09:31:52 UTC 2007.
