Some additional info I heard at a research conference: alveoli muscular structures act similarly to heart muscle structures in that the more they are stretched, the harder they contract - sort of like a balloon that is partially filled with air will not travel as far when released as one that is completely full of air. A second fact (from Donna Ramsey's research) is that milk starts to retreat after let-down within about one minute. If a baby is compressing (or a pump flange), the milk retreats more quickly and more thoroughly - into less full areas of the breast. The next let-down is less forceful. I like to think of the analogy of a wave at the beach. You can feel the force of the wave, but quickly feel the undertow even as the wave is still coming in. Isn't it funny how there are so many good nature analogies to how the breasts work? The breast pushes out the milk - the baby's job is to keep it coming by drinking and not squeezing the ducts. I have seen a lot of arching babies with accompanying symptoms of bloody stools, compression of the nipple, gassy, fussy, moms with initial oversupply, then eventual after 8 weeks or so, undersupply, babies who gain weight quickly, then fizzle. Some of these babies act like Type 3 or 4 tongue-ties, but with the right kind of body work, positioning on mom's part, keeping supply going, they can work themselves out. In my area, there's VERY few (if any) ENT's that are willing to clip anything beyond a type 1 or 2 frenulum!
-----Original Message-----
From: Lactation Information and Discussion [mailto:[log in to unmask]] On Behalf Of Susan Burger
Sent: Tuesday, January 06, 2009 11:10 AM
Subject: Re: Mixing apples and oranges
Dear all:
I often find we discuss a conglomeration of "diagnoses" without actually teasing out what is really going on. In some cases these "diagnoses" are truly overlapping. In other cases, we may be merely assuming that these are overlapping when they are not. I think it is important to look deeply into what we are actually assessing and what we are merely assuming.
The discussion of blood in the stools has provoked any number of diagnoses with what I feel is inadequate information.
Assumption 1: Overactive milk ejection reflex is the same as oversupply.
In many cases, mothers with an oversupply may have a more forceful milk ejection reflex if the breasts are very full at the time of feeding. However, there are two scenarios where this may not apply.
Scenario A: Mothers who initially have an oversupply sometimes have babies who cannot remove milk efficiently if their breasts are not overly full. So, the baby is dutifully kept on one breast per feed and never really drains it. The baby underfeeds and is cranky, mom gets engorged, the supply drops, and ultimately the initial oversupply ends up as an undersupply. This requires a careful assessment of how the baby is feeding and how to help the baby do a better job of transferring milk.
Scenario B: Mothers who have a very forceful milk ejection reflex and small breastmilk storage capacity. These are what I call the "squirt and stop" breasts. The baby gulps rapidly, needs a breather, but then really is hungry and needs that second breast. Again, one must really assess milk transfer to distinguish between the rapid milk ejection with large storage capacity and rapid milk ejection with large storage capacity. I have seen far too many women come into my clinic with a baby that is failing to thrive because someone listened to the first gulping and declared that they should only feed on one breast. Then we have the unecessary hard road back of rebuilding what was initially a perfectly good milk supply.
Assumption 2: Foremilk/hindmilk imbalance is the cause of a baby's fussiness.
Personally, I have not seen one shred of evidence that has isolated foremilk hindmilk imbalance as a problem. I read one study that "theorized" its existence as a cause of fussiness, but I have never seen proof that it exists. I do think it is possible that you can pump an excess "feed the freezer" enough to reduce the fat that gets into a baby, but if all the milk is going into the baby then the variation in fat content eventually evens out over the course of a 24 hour period. I think the actual cause of fussiness may be due to the following scenarios:
Scenario A: Baby chokes due to a forceful milk ejection reflex. The solution to this is using gravity to position the baby in ways that make it easier to handle the spray.
Scenario B: Baby eats too quickly. This may or may not be overlapping with Scenario A.
In this case, paying attention to the baby's cues is very important for periodic burping and feeding breaks.
Scenario C: Baby eats too much because indigestion feels like hunger. This commonly overlaps with either A or B or both. Again, careful reading of the baby's cues to offer burps and breaks and assist digestion with positioning can be helpful. I find that these babies will often lick down what they just regurgitated and the licking is often misinterpreted as hunger.
For all of the above, watching the cues as to whether or not the baby needs burps and breaks and assessing milk transfer are important. A minority of these babies will LIMIT what they eat and grow poorly because they have figured out that this reduces discomfort. I've seen many that will ONLY eat 2 ounces, some that will eat only 1 ounce and a baby with severe reflux that could only eat 1/3 to 1/2 ounce at at time. The majority seem to eat more than they need because they keep getting milk, when what they really want is to quell indigestion by sucking. For a baby that is capable of finishing a feeding on one breast, avoiding a second experience of a rapid milk release on the 2nd breast or gulping down even more milk when experiencing indigestion from eating too quickly or too much may reduce fussiness.
Finally, anytime anyone suspects that the baby is allergic, I think that they should follow Jennifer Tow's observations that this may be linked to maternal gut health.
Best, Susan Burger
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