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Date: | Wed, 6 Feb 2008 05:40:11 -0500 |
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When a baby goes to breast the nipple stimulation travels to his
mothers hypothalamus
where it has two inhibitory effects. It inhibits the release of
dopamine, "prolactin
inhibiting factor" and it inhibits the release of GnRH, gonadotropin
releasing hormone, the
first hormone in the cascade of hormones toward ovulation.
Prolactin levels stay elevated above the baseline in a mother's blood
stream
for about three hours after a nipple stimulation. What this tells me
is that after three
hours without nipple stimulation the hypothalamus has been free to
make enough
dopamine that it has had an inhibitory effect on the pituitary's
production of prolactin.
All we have to do, is do the math- 24 hours in a day divided by 3
hours means 8 breast
emptyings a day is the cusp of good lactation. Since the inhibitory
effect of dopamine brings
the prolactin levels down to baseline after three hours have elapsed
it would be better for
milk production if mothers kept their nursings under three hours apart
at a minimum!
If we in the field of lactation use the success of "performance
outliers"- women who have
success with nursing just 8 times a day as the basis of our
recommendations to all
women we are going to undermine the success of most breastfeeding
mothers.
This is because in the real world real things happen that make one day
different from the
next.
In the early postpartum period women have more prolactin than they
deserve just based
on their breastfeeding frequency. This is called the prolactin safety
net. Nature is kind
and gives mothers extra prolactin while they are learning how to
breastfeed. If the
mother learns to read her baby's non-crying cues to nurse she will be
nursing more than
8 times a day which will put her in good stead when her prolactin
safety net goes away 3-
4 months postpartum.
But if a mother is a "scheduler" instead of a cue-feeder and her
schedule is every three
hours instead of every 2 to 2 1/2, or if the mother has a baby who
can't latch and she has
been told to pump just 8 times a day she will have gotten herself into
the habit of sitting
at just the cusp of lactation. This is fine during the period of the
prolactin safety net but it
sets up bad habits for the period after the safety net has passed.
I personally don't want mothers sitting at the cusp of lactation..I
want them to have some
wiggle room for the demands of real life so I recommend that they
think of 9 or 10 breast
emptyings a day as the minimum and 8 emptyings divided evenly
throughout the day and
night as the bare, bare minimum!
The prolactin safety net is two nets really, in my opinion. The first
net sustains some milk
production though 2 weeks of inadequate removal.
The second prolactin safety net will sustain a dyad where frequency is
at the cusp or sub-opitmal
for about 3-4 months.
If a mother is sitting at the cusp of lactation (8 breast emptyings a
day) what happens
when the prolactin safety net goes away or if the mother occasionally
or even regularly
begins to fall under 8 nursings a day- the milk supply drops
precipitously.
Even the mother fastidiously nursing every 3 hours sometimes will have
an off day and
will nurse only seven times a day, or perhaps she and/or her baby will
start to take a
long stretch of sleep. After all she has been led to believe "sleeping
through the night" is
normal and she also has the expectation (and I hardly ever hear even
lactation
consultants counter it) that as the baby gets older she won't have to
nurse as often.
Nothing could be further from the truth. Newborns with tiny tummies
and the greatest
metabolic rates of their lives may nurse 12 or more times a day, but a
mother with a 6
week old nursing 8-10 times a day should not have the expectation that
she will ever be
able to nurse less than 8 times a day and expect to have a copious
milk supply during the
period of exclusive breastfeeding.
Again its a numbers game. If a mother is dropping below 8 breast
emptyings a day that
necessarily means she is taking at least one stretch of four or more
hours between nipple
stimulations. When the mother goes about four hours without nipple
stimulation she in
effect has told her body that the baby is older and doesn't need that
much milk anymore
and it OK to get pregnant again.
Since milk reverts back to colostrum during a pregnancy this is a
potentially catastrophic
message to be sending to the brain when the baby is under six months
of age and
optimally we would not like this message to result in an ovulation
until after the baby is
over a year old.
By going too long between nipple stimulations the hypothalamus is
disinhibited- it will
make GnRH which in turn will stimulate the pituitary to make FSH,
follicle stimulating
hormone. Follicle stimulating hormone stimulates a follicle on the
ovary to ripen and a
ripening follicle makes estrogen. Estrogen competes with the prolactin
on the milk-
making cells and milk production will go down.
If a mother regularly goes 4-6 hours once a day between breastfeeds
the ripening ovary
may actually proceed to ovulation and after ovulation the corpus
luteum will make
progesterone. Progesterone works against prolactin's ability to
stimulate the production of
mRNAs which code for casein proteins...which if that doesn't lower
milk volume should at
least change the composition of breastmilk.
Now I hear howls of protest from mothers all the time who tell me they
let their babies
regularly sleep 4-6 hours at night and they still have "plenty of
milk." I generally have
found one of two things to be true in these instances.
1) the mother is nursing frequently enough during the day that she is
making enough
prolactin that this prolactin is able to counteract the estrogen made
during the long
stretch of sleep. Estrogen antagonizes prolactin but the reverse is
also true:prolactin
antagonizes estrogen. The mother is not in fact ovulating (even if she
is having periods)
because her estrogen levels are not rising high enough cause LH to
surge producing an
ovulation, and thus she is correct her milk supply is perfectly fine.
Although she does not have optimal breastfeeding practices in terms of
maximizing milk
production she has plenty of milk to keep this particular baby happy.
I have noticed that
mothers of baby girls seem to need to nurse with less breast feeing
intensity than
mothers of boys and in fact we see the growth curves for girls are a
little different than
those for boys.
(Mothers who are performance outliers at the high end of milk
production seem not to
notice any difference in breastfeeding intensity between their boys
and girls but moms in
the middle do. That is if moms are over producers of prolactin or have
an extra bit of
glandular tissue both their boys and girls take a long stretch of
sleep at night.
At the other extreme if mothers are particularly sensitive to the
presence or absence of
nipple stimulation neither their boys nor their girls take a long
stretch of sleep at night.
Mothers who are particularly sensitive to the presence or absence of
nipple stimulation
don't necessarily have less glandular tissue, their bodies just seem
to react faster to an
alteration in nipple stimulation. They remain amenorrheic longer with
frequent nursing,
but they also sense a sudden drop in milk supply when the nipple
stimulation becomes
less frequent.)
There are also mothers who have enough glandular tissue to sustain a
baby exclusively at
the breast but they don't have so much that they can nurse with the
average frequency.
These moms may never find themselves nursing under 12 times a day
during the
period of exclusive breastfeeding.
2) Obviously the other thing that can be happening when the mother and
baby take too
long of a stretch of sleep at night and especially when there is more
than one long stretch
between nipple stimulations in a 24 hour period is that the mother
only thinks her supply
is good but in fact it is not. Some mothers think that if their baby
still goes eagerly to
breast or doesn't spend a lot of time in a full blown cry that means
her milk supply is
good.
But upon questioning you will find the devil is in the details. I
often find the baby was an
under performer in terms of weight gain, but the mother has no idea
what is normal for
cue-fed breastfed babies, and if her pediatrician is satisfied so is
she.
She does not know it is not normal for a baby to loss ten percent and
not regain birth
weight before two weeks of age. She does not know her baby should have
gained well
over seven ounces a week in the early weeks and can be expected to
double birth weight
by four months of age if he is cue-fed.
She also doesn't realize one of the reasons she feels compelled to
offer solids earlier than
six months is that some part of her knows the baby is hungry. If she
managed to hold off
on solids until the baby was six months the baby ate a lot of solid
food when it finally was
offered to him because she in fact had an undersupply and the poor kid
was hungry.
If solids are offered too early babies may displace breastmilk with
solids because the
baby is essentially being force-fed, it's swallow or asphyxiate, but
older babies are
perfectly capable of exerting their will in terms of eating solids and
any baby who
consumes a lot of solid food anywhere between 6- 12 months is
revealing exactly what
the shortfall is between his mother's milk production and his caloric
need.
With optimal breastfeeding management mothers' milk supplies are so
good there often
isn't much if any shortfall at all in the first year and the mother
expresses she has trouble
getting her baby to eat solids even though she would like him to.
With optimal breastfeeding management I think we LCs should expect
that babies will not
eat a lot of solid food until they are between 15 months to two years
of age, and since
breastmilk is the most nutrient dense food a baby will ever have there
is no reason to
prefer it be any other way.
Sorry for this digression but solids and early weaning demonstrate how
sub optimal
frequency results in under supply over the course of lactation.
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