Supply and Demand ~ (part 2)
Dear parent, breastfeeding or pregnant mom, friend of breastfeeding and interested individual. In part one, we looked at “getting breastfeeding started”, here we will look at some common questions parents have regarding mom’s milk supply and baby’s feeding behaviour.
What is Fore-milk and Hind-milk?
You may have heard that mothers produce two kinds of milk: “fore-milk”, the thinner milk the baby gets first, which has a lower fat content; and “hind-milk”, the high-fat, creamier milk that follows. These terms can make it seem as if the breasts produce two distinct kinds of milk, which is not the case. A woman’s breast really only makes one type of milk, the higher-fat milk that we typically think of as “hind-milk”. When you drink milk from a glass and you look at the empty glass, can you see “milk” left behind on the sides of the glass? Well the same thing happens in the breasts.
Diana West and Lisa Marasco explain the process in their book, “The Breastfeeding Mother’s Guide to Making More Milk”: The fat globules in the milk tend to stick to each other and to the walls of the alveoli (“factories” where the milk is made). Milk is made continually and between feedings, when the alveoli gets to full to hold the milk, milk starts moving down the ducts toward the nipple, leaving more and more of the fat “stuck” further back in the milk ducts. The more time between feedings, the lower the fat content of the “fore-milk” available to baby at the beginning of the feeding. Once the let-down (or *Milk Ejection Reflex/MER) is triggered (by baby’s feeding, moms pumping, etc.), the milk is squeezed out of the alveoli, down the ducts by the contracting muscles cells surrounding the alveoli. The fat globules begin to dislodge and move down the ducts. So the further into the feed, the higher the fat content of the milk, as more and more fat globules are forced out. The end result is that the milk gradually increases in fat as the feeding progresses8.
* Milk Ejection Reflex/MER happens when baby sucks at the breast, stimulating the very sensitive nipple/areola area, sending a nerve message to the brain, which causes the hormone oxytocin to be released into the bloodstream and this hormone causes the muscle cells around the milk glands (alveoli) to tighten and squeeze the milk out.
Diane Wiessinger (www.normalfed.com/) talks about a “three course meal”. From the description above you can see baby may start with the soup (so called “fore-milk”) and as the milk “lets-down” baby goes over to the main meal and ends the feed with the high-fat “chocolate-pudding” dessert which is what satisfies baby’s hunger (and babies feed for calories, not for volume!).
How can I ensure an abundant milk supply?
In part one I told you that successful breastfeeding = lots of milk + good latch from baby + confident mother + all in a basket of support. Bear with me now ;-), lots of milk (a good milk production) = sufficient glandular tissue + intact nerve pathways & ducts (your breast anatomy plays a role here) + adequate hormones & hormone receptors (your physiology plays a role here) + adequate frequent, effective milk removal & stimulation (here mom & baby are role-players). So let us say all is fine regarding the aforementioned, what can you do to ensure an abundant supply? As I also mentioned in part 1: For the best start in breastfeeding, feed as soon after birth as baby is ready and stay in Skin-To-Skin contact with baby for as long as possible, until breastfeeding is going well.
Research shows the more milk removed from your breasts / the more baby feeds during the early days, the more milk you will make by the time you go home from the hospital, and to top it off; milk production on day 6 is significantly associated with milk production at week 6. Also if you remember from the previous post: “the single most important factor in establishing successful breastfeeding is the volume of milk produced in the first one to two weeks postpartum”. You will have a lot of milk in the first 2 weeks or so, until your body has figured out what baby needs / asks for, and then the supply start to settle. We always say it is much easier to bring down a high supply than to build up a low supply. So FEED, FEED, FEED! Remove the milk from your breasts a MINIMUM of 8 times during a 24 hour period in these early days and weeks to ensure an abundant milk supply.
To facilitate feeding, room-in with your baby for the first 6 weeks to 6 months. This means let your baby sleep in your room 24/7 as this facilitates breastfeeding and is associated with a shorter time to effective latch, increased milk supply and longer duration of the breastfeeding relationship.
How do I know baby is getting enough milk?
Weight gain is the “acid test” of how a baby is doing. If baby is gaining well on mom’s milk alone, then baby is getting enough. A 5-7% weight loss during the first 3 – 4 days after birth is considered normal. Once mom’s milk “comes in” (remember from part 1, around 3 – 4 days after birth), baby stops losing weight and usually starts gaining again. Baby should regain birth weight by 10 days to 2 weeks. The average weight gain for baby is 170 g/week but 200 – 300 g/week is normal for the first 3 – 4 months. If these goals are not met, call an IBCLC!
Another sign to tell you things are going well is baby’s dirty nappies. Dirty nappies are telling us that baby is getting in the calorie-rich “hind-milk” which pushes up the weight (and gives pooh nappies ;-). We would like to see 3 – 4+ dirty yellow / seedy / runny pooh nappies per day (after day 4). Stools/pooh should be yellow by day 5 (no meconium – that black sticky “tar”-like pooh of day 1 and 2), and about a credit card or larger in size and usually loose (soft to watery, maybe seedy or curdy).
Expect one wet nappy on day one, increasing to 5 – 6 by one week. To feel what a sufficiently wet nappy is like, pour 3 tablespoons (45 ml) of water into a clean nappy (if baby wets more often, then the amount of urine per nappy may be less). Urine should be pale and mild smelling.
Other signs baby is getting enough milk might be: mom’s breast feels softer and baby seems reasonably content after a feeding. Baby is alert, active and over a period of time, is meeting developmental milestones.
How do I know that I am producing enough milk?
The short answer: baby is gaining weight!
If a baby is thriving on exclusive breastfeeding for her/his first six weeks, that mother is set till six months. She is already producing as much milk as her baby would ever need. The amount of milk breastfed babies consume daily between 1 and 6 months of age stays remarkably stable, on average between 750 – 1050 ml / 24 hours. This means that when breastfeeding is going well, after about 1 month, milk production doesn’t need to increase by much. After reaching this level, a mother can focus primarily on maintenance until 6 months, when her baby’s milk intake will decrease with the introduction of solid foods. This is the reason we stress at The Breastfeeding Clinic that mothers aim for a MINUMIM of 8 breastfeeds in a 24 hours period for at least the first month – to build her milk supply and get baby’s breastfeeding established. At about a month, when baby is drinking about her / his top supply, s/he will be using about half of what s/he consumes and pooh out about the other half as unused, digested milk. Parents will notice from here onwards, baby pooh-ing less often but more per nappy as more and more of the almost liter of milk is used during 24 hours.
How often will baby feed?
Normal breastfeeding during the first week is different from normal breastfeeding during the second week and beyond. As mentioned in part 1, after birth baby’s new-born tummy is the size of a marble, only able to hold 5 – 10 ml per feed. In the first few days the tiny tummy will expel extra milk rather than stretching to hold it. By day 3 baby’s tummy expands to hold more milk (30 ml). By 2 weeks baby’s tummy can hold 60 – 75 ml, and at a month about 90 – 120 ml per feed.
During the early days baby will be feeding a lot to help transition from constant feeding in the womb to intermitted feeding in the outside world. As said, baby is born with a small stomach, s/he gets small amounts of colostrum, that digests quickly, so for many babies this = very frequent, sometimes non-stop, breastfeeding.
During the first few weeks, a lot of babies will probably not feed on any kind of regular schedule either. Most babies bunch their feeding together at certain times (called cluster feedings), and go longer between feedings at other times. Baby could feed 8 – 12 times in a 24 hour period, maybe 2 – 3 hours apart.
During these early days it may be a good idea to keep track of the number of feedings every 24 hours, but ignore the interval between feedings. If we look at the clock, we need to remember that breastfeeding and babies have been around a lot longer than the clock so there are no rules to feed 2 or 3 or 4 hourly!! Baby is very smart and will tell you when s/he is hungry. Remember form part 1, early feeding clues will be wriggling, smacking lips, rooting, putting hand to mouth or chewing hands, fussing, etc. A crying, frantic baby needs to calm down first before attempting to latch-on. So let baby’s hunger guide you in feeding her/him. If baby sleeps more than ONE 4 hour stretch ONCE in 24 hour period you might have a hard time fitting in that minimum of 8 feeds during a 24 hour period. Thus until breastfeeding and milk production is well established (at about a month) and baby is growing appropriately, feed a MINIMUM of 8 feeds during a 24 hour period. I am sure you have this message by now?!
Ignorant advice is to let your breast refill before feeding. The emptier your breasts, the more milk you will make. It is a law of supply and demand. Your breasts are like factories, if the demand is going to be low, the supply is going to be low. Research shows milk contains a small whey protein called Feedback Inhibitor of Lactation (FIL). The role of FIL appears to be to slow milk synthesis when the breast is full. Thus milk production slows when milk accumulates in the breast (and more FIL is present), and speeds up when the breast is emptier (and less FIL is present), thus feed-feed-feed-feed!
Now something you might not have known: A mother’s breast storage capacity refers to the maximum volume of milk available to her baby when her breast is at its fullest. Research by Donna Ramsay, et.al show unrelated to breast size, breast storage capacity is determined by the amount of room in a mother’s milk-making glandular tissue. Breast size is determined primarily by the amount of fatty tissue. The maximum volume of milk in the breasts each day can vary greatly among mothers. Two studies found a breast storage capacity range among its mothers of 74 to 606 g per breast. What does this mean? It means that if you have a small storage capacity in your breast they might, for example only hold about 60 ml per breast and by age 1 month your baby’s tummy can hold ±120 ml of milk per feed – so baby will want to feed from both breasts about 8 – 10 times a day to get the milk s/he needs in 24 hours. S/he will probably continue to feed like this every few hours day and night for some time so s/he can get the milk s/he needs and you can keep up your supply. And you can and will provide enough milk for baby to grow and thrive!
Another mom’s breasts can for example, hold maybe 120 ml per breast; she has a large storage capacity. Her 1 month-old baby takes only 1 breast per feed, and as this baby grows, her/his tummy grows and s/he takes in more milk per feed (say 180ml, 120ml from breast A and a bit from breast B) AND the number of feeds s/he takes per day goes down to maybe 6 per day, because this is enough for her/him to take in the milk s/he needs over 24 hours. S/He might even start stretching longer at night at an earlier age.
Another bit of interesting research: Healthy, exclusively breastfed 1 to 6 month-old babies consume 0 to 240 g of milk between 6 and 18 times during 24 hours, with 64% of babies breastfeeding 1 to 3 times at night. On average, 67% of the available milk is consumed at each breastfeeding. The fat content of breast milk varies between mothers (22.3 – 61.6 g/L) and within and between breastfeedings. What does this mean? It means your baby (and your body/breasts) is an individual and will tell you when s/he wants to feed again, not the clock, not a book, not a 3rd party.
How long should I breastfeed my baby?
Let us first look at this question in terms of minutes: Remember I just said when feeding baby it is better to be guided by your baby’s hunger than by the clock? How often do we eat and drink? At least every 90 minutes!! What about baby? Does s/he have a choice? How long do we eat, 10 minutes or an hour? What about baby? Is it fair to force her/him into a schedule then?
When baby is feeding nicely, one can hear the swallows frequently as a whispered “kuh”, more during the first 5 – 10 minutes of feeding and less frequently thereafter. Baby may feed actively with that long-drop-in-the-jaw movements (described in part 1) for ± 15 – 40 minutes per feed, possibly on the same breast and may drain the 1st breast before taking the 2nd breast, or not (start with that one next time).
Each baby has a unique style of feeding (see www.normalfed.com). Some infants get right down to business, suckling vigorously and efficiently without much hesitation. These “barracudas” contrast sharply with the “gourmet” feeders, who take their sweet time, playing with the nipple at first, sampling a meal, and then eventually getting started. Some babies rest every few minutes, as if savouring their feeding, or even fall asleep during the feed – these “suck and snooze” babies can / may exasperate moms who do not have all day to feed, here breast compressions works well to get baby started again.
(For tips on breast compressions: www.breastfeedinginc.ca).
At the beginning of a feed baby may need a minute or two to stimulate the milk ejection reflex (or let-down), if taken away or switched to the other breast after a few minutes – baby may not get the high calorie milk to satisfy her/his hunger, only the lower calorie milk to quench the thirst and a little main meal. This baby will stay hungry, not gain weight and not have pooh nappies (but will have a lot of wet nappies). Let baby feed until s/he is satisfied, if s/he is interested in more food you can offer the other breast. Maybe get help with baby’s latch, if baby still seems unsatisfied after that time and / or after offering the other breast.
Letting baby feed on one breast as long as s/he wants, before offering the other side helps baby get to the “hind milk”, (remember the three course meal?) and they tend to have less colic, less reflux and be more content.
Now let us look at this question in terms of years ;-): breastfeeding is not all or nothing, chant with me: “some breastmilk is always better than none”. La Leche League says the breastfeeding relationship should continue until the child has outgrown the need. The decision how long to feed should not be made on basis of guidelines of 3rd parties (grandmothers or friends advising mom on the subject etc.). Breastfeeding is such an intimate experience that it should be MOM AND BABY who decide when this time should come to end it.
Most women do not start out breastfeeding their babies with a three or four year stretch in mind. Most women might start out, with an idea of a few weeks or months, then before they know it, that major activity of the early weeks has become a minor activity and a way to, not only nourish their baby but also sooth their baby when s/he is anxious, tired, over stimulated, sick or hurt. It makes parenting so much easier. It becomes a way of mothering through breastfeeding. Research done by Katherine A. Dettwyler, show the durations of breastfeeding that are physiologically normal for humans are between 2.5 years to 7.0 years.
Feeding a child at the breast is like a “fix”, same as we adults need our morning coffee or evening cocktail, but without the “caffeine jitters or bleary aftereffects”. When you talk to mothers whose toddlers breastfeed, they will confirm their children do not need to suck on thumbs, hair, clothes or other objects to calm or cope. Toddlers breastfeeding learn trust and dependence on other humans, to go to a person for comfort, Norma Jane Bumgarner calls it “like sitting down to a cup of tea with a sympathetic friend”, now doesn’t that make you feel good?
Breastfeeding should be easy and trouble free. The basis of breastfeeding is getting the baby to latch on well. A baby who latches on well gets milk well, and stimulates the mother’s body to make what baby need. A baby who latches on poorly has more difficulty getting milk and when a baby is latching on poorly, s/he may also cause the mother nipple-pain, a decrease in milk supply and eventually premature weaning.
Next time we will look a few aspects of “Pain and Discomfort”.
Leana, a mother of 3 beautiful breastfed children, has a degree in Nursing (from University of Stellenbosch) and she is a qualified Perinatal Educator (University of Johannesburg). She has been helping many parents prepare for birth and early parenthood through antenatal classes in Stellenbosch and Somerset West. Leana is also a La Leche League Leader and IBCLC (International Board Certified Lactation Consultant). Over many years, together with two colleagues at “The Breastfeeding Clinic” in Somerset West and Stellenbosch, she has helped many families nourish their babies with breastmilk.