Finish the First Breast First
by Melissa Vickers
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.
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.
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.