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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