Nan, You wrote, (in part) after reading Gonneke's article http://www.internationalbreastfeedingjournal.com/content/2/1/11 

<<I have a question though, how early in the game can we determine that
someone is going to over produce.  For instance, case number 4, the baby is
only 4  days old. How could we determine at 4 days that the mother is an
over producer and not just temporarily over producing as so many women in
the first week or so  postpartum do.  I have heard of and recommended a
complete drainage for women with engorgement during this time period (with
excellent results) but would be weary of starting block feeding so early and
perhaps tamping down a milk supply that hasn't been fully established.  I
would love to hear your opinions on this.>

 
I hope when you were reading Gonneke's article you made it all the way to the end to my letter to the editor. It explains what I view as a possible answer to some of your questions through what can be imagined through the past and future "lens" of histology research. 


After reading some embryology, surgical and histology sources, I'm not sure I am presently convinced about the upper and lower limits of the number of lobes in the normal lactating breast derived from ultrasounds on just several dozen lactating mothers. (I do not really mean to sound disparagng about such research, but I believe our profession needs to reach out to other disciplines all over the world that have been directy examining breast tissue of women of reproductive age under the microscope for many, many decades since the invention of the microscope, in fact.)

 
It has been my experience that differences in birthing experiences, specifically as to whether mothers get IV fluid in excess of 2000 cc. in any one 24 hours, and especially if IV Pitocin is used for induction, augmentation, or for long hours of 3rd stage management, may enter into judging this. The formation of edema presents a longer chemical pathway for the proper proportions of hormones and nutrients to travel before reaching the cell walls of the lactocytes in the necessary amounts, for all to be present in the cell at the same time before Lactogenesis can commence. 

 
In my imagination, a mother who has an abundance of actual milk by day 4 (not mainly interstitial swelling in large part from edema), probably did not have much such intervention. She is probably one of those with close to the full complement of ducts formed during her embryonic period within her own mother's womb. She will thereby go on to develop more lobes, lobules and acini than a mother who did not. And of course, each new placenta is capable of stimulating sometimes even more new acini, thus more binding sites for hormones. 

 
I think this would be a good "heads-up" that if "standard one-size-fits all" breastfeeding instructions (e.g. "nurse both sides at EVERY feeding") are given, she will be set up to overproduce. In my view, it is the "one size fits all" instructions that are the major problem! "First breast first" and let the baby decide about the second breast is often a much better plan, IME, if a "one size fits (most) all" set of instructions is desired.

 
Since making use of FIL is one of the major factors at work in electing to leave one breast unnursed for a certain time period, I believe after full drainage, even at 4 days, it is reasonable to select a short block of 3 hours to start with. Using one breast for all feedings in that 3 hour time period, and using the other breast for the next 3 hours, etc. would certainly not compromise the establishment of supply. (unless she has a multiple birth!!)

 
If overfullness, very early or late, can be managed that way, fine. If it is still a problem after a day or so, a 4 hour block can be used, and then if necessary, go on up to a 1 hour larger block each day. It's important to avoid "full drainage" more than once, or twice at the most. I have seen many mothers who eventually arrive at a pattern of 12 hours "rest/FIL time" for one breast, and 12 hours "rest/FIL time", i.e. nursing all feedings on the same side during that 12 hours, and then switching to the other breast during the next 12 hours. (Spring and fall, that works out to one side for daytime and one side for night feedings. )

 
(I believe Dr. Newman once gave an example of one mother who took it on herself to use only one side for a 24 hour period, and the other side for the next 24 hours. I agree with him that that seemed pretty extreme, risking plugged duts and mastitis, but for her, I hear it worked.)

 
You DID write "I would love to hear your opinions on this."  Just my $.02 worth;-)
 
K. Jean Cotterman RNC-E, IBCLC
WIC Volunteer LC, Dayton OH

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