I have had a private practice for more than 30 years (and been a nurse for more than 45 - yikes!).  For the first 15 years, of my practice, the major problem I saw was insufficient milk.  For the last 15 -20 years, the major issue I see is "too much milk".  What has changed?

You all know this past scenario: most babies born in hospital, stayed 3 days for vag. delivery and 5 days for CS. There was no skin to skin, all babies went to the nursery / brought out to mom every 4 hours in the day.  If the mother wanted to breastfeed, the baby was brought to her with a bottle of glucose water or formula (depending on the year) and were told they must give the supplement (or be starving their baby). At night, mothers were told they didn't have milk (yet) so were given a sleeping pill / the babies given formula in the nursery. I hated working in the nursery.  The babies would be screaming or worse: throwing up / choking on the formula.  I was often the only person to look after 35 of  them.  I can only thank an angel for never letting a baby die on my shift. It was routine, to keep my eyes roaming around the room for these choking babies. I couldn't hear them because of the chaos from the others but I would see them turning blue. If a mother saw this happen, we were instructed to tell her that this was a good  because the babies were getting rid of mucus!!!???   Pacifiers, provided by the hospital, were routinely used.  CS babies went to the SCN where they were kept NPO for 24 hours / mothers  were not instructed to pump (there were no pumps). Formula gift packs with free samples and coupons (marked, "For the Breastfeeding Mother") were given at discharge. Women were seen, (once) in the community by the public health nurse who knew little about breastfeeding management, (and who gave more formula samples).  The same scenario was repeated by the doctor.  The formula companies provided health care professionals with "Infant Feeding Seminars".  (Nurses got a coffee and a donut, the docs got a meal and wine).  As you can imagine, our breastfeeding success rate was very low (and I saw very few mothers with big supplies - the babies that were crying were not gaining because there was insufficient milk.)

Today likely 95% of my clients have midwives.  Most still deliver in hospital but they room-in and usually go home within 12 hours (some deliver at home). These mothers do not supplement with formula, (have no samples in their homes) do not use pacifiers and feed on demand.  Many have crying babies and .... too much milk.  It makes sense, to me, that it would be survival of the species to have too much of something not insufficient!

 In the distant past when I saw mothers with colicky babies I suggested eliminating foods from their diets, scissor hold, sitting the baby up in football or reclining, (if the milk was coming too quickly), getting help so they could get away from their screaming babies. The paediatricians prescribed medication (some with alcohol).  Some women were told to stop breastfeeding because the baby was lactose intolerant / allergic to her milk.  

Today, the typical baby, (that I would see) would be 5 - 6 weeks old, feeding at one breast (sometimes both), gulping and choking, throwing -up, feeding 10 - 15 x / 24 hours (short feeds), huge, frequent, explosive foamy yellow (often green) stools, very heavy wet diapers and usually gaining rapidly, (often above the 90%). The mother's breasts are engorged, painful, leaking and her milk often sprays across the room. The small baby gulps and chokes but the older baby often refuses the breast because he is afraid of choking (imagine lying on your side and someone putting a hose, turned on full blast in your mouth).

I manage this scenario by *"finishing" the first before offering the second. ("Finishing" is in brackets because the breast is never completely empty). You can call this what you want but I call it fine tuning.  If the mother has a huge supply and the baby gets just the first (foremilk) watery milk (as shown in the sample photos) because there is no room in his tummy for any of the richer fatter milk (when the majority of milk has left the breast) he will be hungry again soon because the watery milk leaves the tummy quicker than milk with some fat in it.  We know that the way to build a low milk supply is to feed more frequently / switch nurse but in the case where the mother already has a big supply and the baby didn't get any fat he needs to feed again quickly so builds her big supply even bigger. Supply and demand right? The same reason a woman can make enough for 5 babies. The brain doesn't know that a lot of the milk it is sending is thrown-up, or eliminated in urine and feces ... it just responds to the demand (stimulation).

My suggestions:
Tthis plan has worked for hundreds of clients.  I don't go out of Vancouver but people come to see me from all over the province (have never advertised and don't have a website).  I have had only one client in the last 10 years, who didn't "fix" her situation with my suggestions (she had severe allergies and needed to eliminate foods from her diet).

1.  take a history, plot out his weights / ensure gaining well with no supplement
2.  ensure baby is latching with a big open mouth. Many are only nippling because they are used to just catching the milk as it pours into them. You need to see the mother / baby - many tell you the baby has a good latch but he doesn't. (Once you have seen the mother and baby you can follow up by phone).
3. eliminate the pacifier - he doesn't get milk from it needs to learn to work at the breast
4.  if using both breasts at a feed, use just one.  If the unused one is uncomfortable, leave it open to drip or gently take off just 1 teaspoon (5 mls). Many women think they should pump the unused one but a "light goes on" when you explain this will make even more milk. Some women will tell you they take "off a little in the shower" but you ask them what a "little is" you find you it is likely more than an ounce.
4. three days later, if baby still gassy / too much milk, use 1 breast for 2 feeds - teach the mother how to do breast compressions - the baby does not know how to get the milk, (he needs to work to work hard) as the letdowns get smaller and less forceful - he thinks the well is "empty" (usually after about 10 minutes when the milk is not pouring in any longer).
5.  make a change, (use 1 breast for longer), approximately every 3 days until the "problem" has disappeared.  I call this "going up the ladder".  (The mother needs to give her breasts a chance to adjust to the decreased stimulation and the baby needs to learn how to work harder). (I teach all my mothers to do a daily check of their "empty" breast to prevent mastitis). 

Some of my clients find the situation has stabilized by using 1 breast per feed or 1 breast for 2 feeds but many of my clients need to "climb the ladder" and use 1 breast for 12 - 15 hours (if still too much milk at that point I occasionally suggest using a cabbage leaf for short periods).  If at any time she feels her supply has decreased too much, she uses the other breast sooner.  She needs to know that for the first few days her "problem" will seem worse because there will be a lot of milk by the time the baby gets back to the first breast. However, some mothers almost immediately notice the baby is more content, sleeping longer periods, has stopped throwing up and his stools are yellow.  If I don't see these mothers, (ffor the first time) until around 8 weeks, it can take 3 - 4 weeks, of the plan, to cut the supply down to a comfort level for her and the baby.

 Keep a close eye on the baby's weight (some of them have no idea how to work at the breast) - if they don't gain weight the mother thinks the plan isn't working but she just needs to help him more with breast compressions. 

*a mother knows she has "finished" the breast if the milk looks rich and creamy and there is not much coming.  

Many of you likely follow a plan similar to what I have tried to write out but there seems to be others who want to know about how long on the first breast etc. or don't believe there is a problem when the mother has a huge amount of watery milk and the baby is gaining weight well but miserable.  There are not two different milks in the breast, there is milk that changes from watery to rich, (just like juice is thick in the bottom of the bottle and watery at the top) and there is not one piece of info that fits all mothers and babies - we need to look at each mother and baby separately and ... fine tune?

Renee (in Vancouver, Canada)



  

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