Hi Virginia,
It's quite an old paper. The only example I've been able to find where someone has attempted to determine using a prospective study design the proportion of women physiologically incapable of fully breastfeeding (if anyone is aware of any other work I'd be glad to hear of it).  I think though that the need for weight gains of 200g per week may have resulted in an over estimate.
Karleen Gribble
Australia

Neifert, M., S. DeMarzo, et al. (1990). "The Influence of Breast Surgery, Breast Appearance, and Pregnancy-Induced Breast Changes on lactation Sufficiency as Measured by Infant Weight Gain." Birth 17(1): 31-38.
	ABSTRACT: We conducted a prospective study of the associations between several biologic and surgical breast factors and the onset of lactation in 319 healthy, motivated, primiparous women who were breastfeeding term, healthy, appropriate for gestational age or large for gestational age infants. During the last trimester of pregnancy, subjects' breasts were examined for surgical incisions, size, symmetry, and nipple protuberance, and women estimated their prenatal breast enlargement. At two visits in the first two weeks postpartum, infants were weighed naked, and mothers reported the magnitude of postpartum breast engorgement when their milk came in. Breastfeeding was evaluated at each visit, and interventions were recommended for problems, with emphasis on maximizing milk yield. Lactation was deemed sufficient when an exclusively breastfed infant achieved an average weight gain of 28.5 g or more per day between the two visits. Infants gaining less than 28.5 g per day with breast milk exclusively, and those requiring formula supplement returned for a third visit at or before 21 days of age, when final lactation outcome was assessed based on weight gain between the second and third visits. Within three weeks postpartum 85 percent of the mothers achieved sufficient lactation, whereas 15 percent had persistent milk insufficiency despite intensive intervention. Of the study population, 6.9 percent had undergone previous breast surgery. Women with periareolar breast incisions were nearly 5 times more likely to have lactation insufficiency than were those without surgery (relative risk [RR] = 4.55; 95 percent confidence interval [CI] = 2.21–9.43; P < 0.001). Insufficient lactation was significantly associated with minimal prenatal breast enlargement (P < 0.02) and minimal postpartum breast engorgement when milk came in (P < 0.001). Although not statistically significant, women with inverted nipples were more likely to have lactation insufficiency compared with those with normal nipples (RR = 2.94; 95% CI 1.05–8.20; P= .07). The findings from this study indicate that certain biologic and surgical breast variables are associated with lactation insufficiency.


On 26/06/2013, at 9:08 AM, vgthorley wrote:

> Hi Karleen,
> I am shocked, but on the other hand not surprised.  Recommended weights have been gradually creeping up. That figure would ensure that even more babies are put onto artificial baby milks very early in life. I wonder how this is being justified pyshiologically, because I think the onus of proof lies with people who set figures.
> Two of my own four babies wouldn't have made this level of gain. The first one, when I had iatrogenic lactation failure, gained on human milk (donor milk from another mother offered by staff, and a small amount of my own milk), but her gains dropped off and flattened out when she was given two different brands of cow's milk-based mixtures, eventually receiving the full amount calculated of ABM. I relactated, thanks to LLL, and she resumed gaining on my milk alone. All of my babies, except the first (who was being topped up with artificial milk by the midwives), regained and exceeded their birthweights by 7 days.  She took longer.
> I don't have the records for the first 2-4 weeks for him, but the next baby gained an average 120g per week (60 one week, 180g the next, on a regular basis), and was ahead on other milestones.  The nurse who weighed him wasn't impressed! With the third baby, probably the biggest gains were while I was tandem breastfeeding and I noticed he gained more in the weeks his brother was more demanding,  In weeks 2-4, his weight gain per week was 5.5 ounces (165 g), and for the next two months it averaged at least 240g  p/w. My fourth baby fitted the figures Karleen cited, except for the gain for the week to age 3 weeks (a respectable 180g). She was my best gainer, till she fell off the graph around the time she started solids and gained very little for several months. Reason unknown, but all her other milestones were met and the child health nurse was happy with her progress, as was I. What surprised me, when I dug out the baby books for my youngest two children (the only complete baby records I still have), was how much they gained in their early months.
> Why am I citing this personal history? Because it shows a different story, with babies who had other patterns. People working with babies tend to like numbers and this number will be remembered, cited without question, and applied - and babies who are doing nicely, being breastfed frequently enough and transferring milk effectively, will be unnecessarily topped up. They will be exposed to artificial food very early in life and the mother's confidence in her body may be undermined.
> I should now go and look at the paper cited.  Karleen, do you have the citation to share, please?
> Virginia
> 
> Dr Virginia Thorley, OAM, PhD, IBCLC, FILCA
> Brisbane, Queensland, Australia


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