Catherine, (and everyone)

What you say - that the babies who gain weight the best are those 
whose mothers have the lowest creamatocrit at the end of the feeding 
- is fascinating!   I'm not the least surprised to hear it because it 
seems logical to me that the higher the milk supply, the higher the 
overall intake, of lactose _and_ protein _and_ fat, and the better 
the baby would gain weight.  But it seems to fly in the face of the 
argument for correction of foremilk/hindmilk imbalance, which is put 
forward so often as a problem that needs to be rectified, but which 
nevertheless worries me a lot since it intuitively seems to make so 
little sense.

I've just been working with a mom whose baby was 35% underweight at 5 
months.  She reported a history of an unhappy baby which had been 
attributed to "foremilk/hindmilk imbalance" at about 2 months.  She 
followed advice to resolve this by block-feeding in order to increase 
the fat content of her milk.  My take on this (after the event, of 
course,  ...) was that the baby's distress was probably due to an 
unrecognized already inadequate intake, and that block-feeding would 
have left the un-fed breast deliberately and unnaturally undrained 
for several hours, several times a day, thus decreasing an already 
low supply still further, ie compounding a pre-existing problem.

We know that leaving the breasts too full results, over time, in a 
dwindling breastmilk supply, and that more efficient and more 
frequent drainage boosts production.  And that the emptier the breast 
the higher the fat content of the milk (fat content being a marker 
for breast drainage).  So I guess the paradox that intrigues me now 
is how mothers with consistently lower fat in their milk (the marker 
for less thorough drainage, which theoretically would depress 
production over time) can have babies who consistently gain weight better.

Could we take this one step further and hypothesize that mothers with 
higher fat content in their milk are those who under-produce, as the 
reports you cite, Catherine, seem to suggest?  In other words, that 
fat-content in the milk is a marker not only for inadequate drainage, 
but also for low production?  Is it a cause, or a 
consequence??  Studies on adult obesity seem to suggest that 
low-carb, high-fat diets result in somewhat increased weight loss 
compared to low-fat, high-carb diets.  Why should babies respond any 
differently to sugar and fat intake?  Conversely, I know, from 
working with stabilized prem babies who are fed higher-than-average 
quantities of as-it-comes breastmilk (?high volume, 
high-lactose/low-fat) that they can gain weight very quickly (up to 
75g/day), whereas I haven't read that manipulation of EBM in order to 
provide them with low-volume, low-lactose/high-fat milk, as described 
in many LACTNET posts, achieves this phenomenal result.    So the key 
to weight-gain seems to be lactose intake.  And, coincidentally, 
lactose-output is also the driving force for breastmilk production.

So do we need to re-visit the recommendation to "correct" 
fore-milk/hind-milk imbalance???   And for mothers with low 
breastmilk production, how do we maximize lactose-output?  Catherine, 
I'd love the references for the research you cite.  And - anyone - 
I'd welcome comments on my rather rambling thoughts above.  Perhaps 
these principles are already set out somewhere in a nice review article?

Pamela Morrison IBCLC
Rustington, England

>Date:    Thu, 30 Jul 2009 20:37:28 -0400
>From:    "Catherine Watson Genna, IBCLC" <[log in to unmask]>
>Subject: Re: Bariatric surgery and lactation
>
>........If there's no fat in the pumped milk, it most likely means the breast
>wasn't emptied well! The way milk is produced, protein, sugar and fatty
>acids are all kept in balance, so it's very , very unusual for there not
>to be enough fat in the milk. Studies also show that the babies that
>gain best are those whose moms have the LOWEST creamatocrit at the end
>of the feeding (in other words, their moms make more milk, and the
>babies have emptied the breasts less by the end of the feed).
>
>Catherine Watson Genna, IBCLC NYC

             ***********************************************

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
2. To start it again: set lactnet mail
3. To unsubscribe: unsubscribe lactnet
4. To get a comprehensive list of rules and directions: get lactnet welcome