Dear all:

I am still mulling over some of the advice for Nalah -- the one and only breastfeeding case study in the WHO Training Manual.  

The mother of an undernourished six-month old can only breastfeed two or three times a day when she leaves her baby with a neighbor when she goes to work and breastfeeds four to five times a day when she takes her baby with her.  Under prompting from the counselor, the mother admits she switches breasts before her baby drains the first breast.  

It seem to me that it highly unlikely that any six month old would not be able to drain a breast quickly, let along an undernourished six month old whose mother has not been able to feed frequently. The case study was not a severely malnourished marasmic baby -- it was a moderately malnourished baby that would be avidly trying to get milk (based on my observations of what babies did in the malnutrition wards and communities I visited in Niger).  

The counselor in this case study warns the mother about fore-milk/hind-milk imbalance and suggests leaving her baby longer on the first breast. I actually find this advice dangerous given the studies that Cathy Genna posted to Lactnet. When supply is low, it takes less time to get to a higher fat content.  It is the volume of milk, not the fat content that is likely to have been compromised in this hypothetical scenario. If this mother stops offering the second breast, each breast is going to be drained half as often, further diminishing the supply that is already likely to be low.  

I actually think this is a developed area problem that is being applied to made up case study that sounds like it is supposed to be in a developing area.  

I personally think that the rising fat content may actually compensates for circumstances when a mother's supply is physiologically on the low side.  If a mother is on the low end of the production capacity -- her baby is going to end up getting more fat -- which may compensate for lack of volume.  If a  mother is on the high end of the production spectrum -- her baby is going to end up getting sufficient volume.  

Best, 

Susan Burger

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