I have been musing about the various posts there have been on this in the
last few weeks, plus what I understand by these terms.  It seems to me we
have been conflating two sets of terminology here.  Foremilk is defined by
Lawrence (5e) as 'the first milk obtained at the onset of suckling or
expression.'  She adds 'Contains less fat than later milk of that feeding
(i.e. hind milk).'  Hind milk is defined: 'milk obtained later during the
nursing period, that is, the end of the feeding.  This milk is usually high
in fat and probably controls appetite.'

Ok, so we have a definition to do with the timing of the milk in the
feed -- the first milk of the feed and the late milk of a feed -- mixed in
with a definition of the fat content of the feed.  NOTE that the fat content
of lower in foremilk and higher in hind milk is SPECIFIC to the milk from
one mother (or one breast of one mother) during a particular feed.   So, as
has been remarked in posts, especially referring to the work of Hartmann and
his colleagues over the last two decades or so, you might find that one
mother has higher fat in her foremilk at one point in the 24 hours than in
her hindmilk at another point in the 24 hours. This is a natural result of a
variety of influences on the fat content -- some of them due to feeding
patterns (culturally mediated), circadian rhythm, etc.

It seems to me that we can speak of an imbalance in the fat compared to
other elements of milk over 24 hours.  This is treated under the heading of
foremilk/hindmilk imbalance in the 2000 edition of Bestfeeding (Fisher,
Renfrew and Arms) and under the heading of 'too much milk' in Riordan and
Auerbach (2e).  I think the notion of fat imbalance (which is often, it
seems to me, an iatrogenic condition) is useful to help us explain to
ourselves what is going on.  Often better attachment of the baby to the
breast, enabling more efficient milk removal, is a key to re-balancing the
baby's intake of what he/she needs from milk.

Is it useful to characterise this as something to do with foremilk and
hindmilk?  If we mean 'foremilk' is the first milk -- no matter what the
content, this way of talking about it sounds like nonsense.


Also, to me the terms pre-suppose another 'middle' milk.  Fore means the
first few swallows, hind, the end.  How can we then think of the two lasting
throughout the feed, as some have mentioned in their posts?  Surely the fat
content of the milk at any one moment is different from at other moments in
the feed, and it may change due to various factors, not just linearly over
time.  So, further let-downs, breast compression, the baby slipping her
mouth into a less effective position for suckling, etc etc might influence
the content of the milk.

I find that this fore/hind terminology is creeping out to women.  They don't
understand it (asking, when does fore stop and hind start), it seems only to
result in concerns and worries about the quality of their milk -- rather
along the lines of the ancient roman tests for good milk from a potential
wet nurse, and about as scientific.  they want to get as little foremilk as
possible, assuming that fat and growth is the 'best' part of the feed -- and
feeding into the anxieties of comparison of human milk's appearance with
cow's milk.

Now, add this definition, in the cox, Owens and Hartmann paper Kathleen
posted the URL for recently,
(http://mammary.nih.gov/reviews/lactation/Hartmann001/index.html) and which
was up-dated in 1998:  'For many years it has been known that the fat
content of milk that is expressed from the breast following a breastfeed
(hind-milk) is higher than in the milk before a breastfeed (fore-milk).'
So the foremilk is the milk expressed *before* a feed and the hind is what
is left after the baby has done.  Now these will be pretty close to the
first and last milk a baby gets, but are clearly a research definition.
And how could we have an imbalance in the baby between the milk expressed
before a feed and the milk left afterwards???

I have a really useful post from Joy Anderson, May 19, 1999 on this topic,
which concludes by saying that Hartmann "believes we should stop talking
about 'foremilk'
and 'hindmilk' altogether as it is often meaningless".  I agree.  (and I
recommend the full post to you all).  If we are talking about re-balancing
fat content of the feeding process, lets talk about that.  And for goodness'
sake, let us all use the same definition of fore and hind milk, if we do
talk about them.  Is foremilk the earliest milk of a feed / pre-feed
expressed milk or drips or what?  Is there a middle milk and if not, how
useful is it to divide the feed up and name the whole of it in terms of
proportions of the first and last types of milk?  Is it a useful way of
conceptualising milk for women or for us?  (personally I have often got
caught up in discussions with mums on this topic and never really felt it
has been helpful, but maybe I have not thought of a way to make it useful).

I also note that the Woolridge, Ingram and Baum paper in the Lancet of 1990
[Do changes in pattern of breast usage alter the baby's nutrient intake?],
does not mention the terms fore or hind milk [they talk about pre-feed and
post-feed fat values of the milk of the women they studied] -- anybody know
when these terms entered our vocab, anyway??

Magda Sachs
Breastfeeding Supporter, BfN, UK

             ***********************************************
The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(TM)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html