Well, this has become *much* more controversial than I expected, but I guess
it would be unrealistic to expect all 2000 of us to agree!

Firstly, if breastfeeding were so "natural" that all babies were born hungry
and demanding following unmedicated, vaginal deliveries, then in an ideal
world we would never see engorgement and there would be no need for LCs.  I
think it can be safely said that we see the problems!  However, aren't we
missing something?  The wonderful variation amongst mothers?  It is as
impossible to say that all mothers should express to comfort on Day 3, as it
is to say that no mothers should relieve over-full breasts, ever!  And a
quick double-check with my cook/housekeeper (my mine of cultural info and
folk-lore concerning the Shona culture in Zimbabwe) confirms that new
mothers delivered by traditional midwives in his home village of Guruve *do*
express their milk if they become too full in the first few days after
birth.  So although we might logically suppose that *all* peoples who live
in cultures where births are natural don't "need" to express, once again we
can't generalize.  And, just as an aside, Africa has a high percentage of
"home-births", but have you seen the maternal mortality statistics?

Someone asked if expressing overfull breasts in the first few days doesn't
lead to chronic over-supply?  Fortunately, in my experience, it doesn't.
Why not? Because the breasts are so wonderfully adaptive.  If the alveoli
stay just a little too full, they make just a little less milk, and a little
less etc. The period Day 4 - Day 9 holds the potential for serious
engorgement, and some women just naturally seem to produce more milk than
others, sometimes enough for two or three babies.  Leaving the breasts very
full at this stage IMHO leaves a mother at risk for mastitis and low milk
production later.  Whereas taking care of potential engorgement during this
time (by drainage, by whatever means!) results in a gradual reduction in
milk production by about Day 10.  During this time, the baby's appetite has
usually increased, and the baby's intake and the mother's output "meet" -
usually.  If you consider that a 5 day old baby may be taking about 400
ml/24 hours, but that by the end of the first month the mother may have
maximized her milk production and may not need to increase it further, and
that this process requires functional milk producing cells, it seems logical
to assist the mother to promptly resolve engorgement should it occur.

If some of the colostrum is lost (meaning the transitional milk, the mix of
colostrum and mature milk which is produced for the first fortnight?) is
this really an issue?  I don't think it can be.  Do twins/triplets miss out
on the antibodies and special things produced by the *other* breast?

Furthermore, should we automatically blame hospital practices for being the
root cause of all these ills?  I work with mothers who have 24 hour rooming
in, no bottles, no formula, and there are no rules - the mother is
encouraged to breastfeed her baby as she sees fit. Often there have been no
interventions and yet still the baby is mucousy, sleepy, anorexic. Sometimes
it just happens that the mother produces more milk than even a very
demanding baby can take.  Mothers are variable.  Babies are different.
Obviously we need to advocate for mothers and babies to have ideal births
and baby-friendly hospital practices, but in the meantime, as Cathy says, we
have to work with *this* mother and *this* baby and *this* unique set of
circumstances and I see a lot of engorgement.  I also hear about a lot of it
when working with *other* babies who gain slowly or not at all at 2, 3, 6
weeks. Feeding "on demand" for these babies has been disastrous. IMHO
prevention is much better than cure, and I see protecting the milk supply as
a major responsibility.

I only have 2 rules: #1, feed the baby.  #2, drain the breasts.  Then we
work on the other stuff.

Pamela Morrison IBCLC, Zimbabwe

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