Hi Susan

Since you asked, I'll chip in, but not sure that I can help to shed 
much light on the tantalizing questions you raise.

Firstly, regarding possible higher prolactin levels in slimmer 
mothers, I recall research done in West Africa somewhere by the 
Prentices, where they looked at milk production and seasonal food 
intake.  During the lean season, didn't they supplement the mothers 
with high-protein biscuits, and find to their consternation that it 
didn't improve milk yield, but did result in an earlier return to 
fertility - ie with more food (higher BMI) prolactin levels were 
suppressed to the point that the women ovulated at an earlier time 
than was "normal" for them?

Secondly, regarding intuitive observation of infant cues, my 
observation is that African mothers do feed their babies on cue.  The 
sight of a mother breastfeeding anywhere is unremarkable, while the 
sound of a baby crying draws stern criticism from all within 
earshot.  I can only actually recall hearing babies cry while in the 
supermarkets, usually when the mother would be at the check-out 
queue, frantically jiggling and/or swaying in an attempt to pacify 
the baby on her back long enough to pay for her shopping and get 
outside to put him to the breast.  I also don't recall ever seeing a 
mother 'change sides'.  She'd feed the baby until he was happy, then 
swing him back on to her back, do the wrap-around thing with the 
blankets and towels and go on her way.  I never ever saw a 
dummy/pacifier in an African child's mouth, and almost never saw an 
African child in a push-chair/buggy/stroller - they were either on 
the breast or on the back.  And of course mothers always slept with 
their babies and breastfed any time during the night.  One of the 
African paediatricians told me that during 20 years practising in 
Harare, he'd never known of a case of SIDS in an African baby.

As to over-supply in African mothers, personally I never knew an 
African woman complain about it, though I had quite a few clients who 
had mastitis and even abscess, so clearly, it happened.  Also the 
doctors were extremely quick to prescribe antibiotics for anything 
resembling mastitis because it was a requirement that they had to do 
a stint in the rural areas before setting up their practice in the 
city, and they had all seen a lot of abscesses, and were adamant that 
prevention was key.

My personal "take" on over-supply probably comes, to a large extent, 
from noting the cultural differences (European vs African) in the 
expectations about babies.  My European clients were obsessed with 
"wind" and colic, and would consistently take a lot of effort to burp 
the baby after breastfeeding (whether one side or two).  Whereas 
African mothers never did this, though babies were upright after 
feeding as a result of being strapped back on the back.  It has to be 
a cultural myth I think that feeding causes gas or wind.  The 
European mother would feed the baby, eventually the baby would go 
blissfully to sleep on the breast, whereupon the mother would 
abruptly sit him up or throw him over her shoulder, and start rubbing 
or slapping his back to get up a burp.  I found that grandmothers 
often took it upon themselves to perform this required behaviour and 
were often really rough. Sometimes the baby would burp, but often 
not.  But by now he's wide awake, and irritable, and needing to suck 
in order to get back to sleep.  So the mother, of course, interprets 
this as the baby being starving, puts him back to the breast, and the 
cycle starts again - the baby never has a chance to go to sleep and 
becomes more and more distressed.  Eventually the mother would decide 
the baby couldn't still be hungry, so she'd put him down, with a 
dummy, and he'd sleep for hours.

Could it be that this pattern - frequent feeds, followed by fairly 
long sleeps (because by now the baby has had a lot of milk) and 
comparatively long periods for the breasts to fill - accounts for at 
least one cause of the phenomenon of oversupply??   In theory, when 
the breasts become too full they make less and less milk, and adjust 
the supply to the demand. But though breasts are very responsive over 
time, they are less responsive in the very short term.  It take about 
4 days for them to adjust supply to demand - either to increase or 
decrease milk production.  Could it be the erratic nature of the 
"demand" side of our Western cultural expectation for babies which 
causes thorough drainage followed by too-long periods to re-fill?  I 
think the San hunter-gatherers (I'm also not quite sure where you put 
the exclamation point ...I think it might be !Kung...) show us that 
feeding very often, with very short intervals, is physiologically the 
norm for human breasts, and the protein/fat/lactose composition of 
breastmilk would bear this out too.

But then again, the wonderful research from W Australia shows that 
different mothers have different storage capacity in the 
breasts.  Maybe this is another reason for apparent over-supply - 
those with a lower storage capacity possibly being less able to get 
away with this erratic kind of nursing pattern??  Could it be that in 
the early postpartum, those mothers who are able to avoid engorgement 
are able to increase their storage capacity (this is certainly my 
experience with my clients) and it is these women who are also able 
to get away with high-volume breastfeeds followed by long 
culturally-acceptable feeding intervals??

Intuitively then, the answer to apparent over-supply would seem to be 
feed the baby one breast per feeding at much shorter intervals. From 
the fore-milk/hindmilk point of view, sure, the baby would receive 
low-fat milk for a bit, but not for very long.  The milk in undrained 
breasts will lead to down-regulation in supply and eventually lead to 
milk that again has a normal ratio of fat to volume, so that the 
"problem" of lactose-intolerance (fast gastric emptying time) would 
resolve.  It all comes out in the wash, as you say. The catch to 
this, though,  from the Western cultural point of view, is that 
because the breasts will respond by actually making less milk the 
baby will continue to need feeding more frequently.  The mother needs 
to know that she can't have it both ways - a lower supply AND long 
feeding intervals.

 From a baby-management point of view, the mother also needs to know 
that wind in the stomach (swallowed air, for which she burps the baby 
- completely unnecessary IMHO) is not related to lactose overload in 
the intestine - overwhelming available lactase and causing gas from 
the other end! - and more likely with long feeding intervals and 
high-volume feeds.

I agree, Susan, there are so many questions yet to be answered ...

Pamela Morrison IBCLC

------------------------------------------------
>Date:    Sat, 9 Feb 2008 22:27:42 -0500
>From:    Susan Burger <[log in to unmask]>
>Subject: Re: Oversupply or asynchrony
>
>I'm missing Pamela Morrison's voice and I want Rachel Myr to pipe up hear=
>  ---- although I=20
>don't know the sleep norms in Norway.
>
>But, I'm thinking about the anatomical variations we see and wondering wh=
>at really=20
>happens in cultures that did not have as much disruption to normal sleep =
>rhythms and=20
>practiced intuitive observation of infant cues for decisions on switching=
>  breasts.  It=20
>dawned on me that we are talking about block feeding, which I do use.  An=
>d I never ever=20
>tell mothers with an oversupply to pump just a little to take the edge of=
>f --- I tell them to=20
>drain completely once a day if they need to in order to prevent blocked d=
>ucts.=20
>
>Here is the part that I can't figure out.  Why is it that the Kung (I for=
>get where the=20
>explanation point goes) feed their babies constantly --- as in many Afric=
>an cultures up to=20
>20 times a day and their babies are almost never unhappy.  Granted I was =
>single when I=20
>worked in Africa, but I don't ever remember mothers complaining about any=
>thing that=20
>ressembles colic, but I wasn't asking and I was not really considered a "=
>woman" yet=20
>because I hadn't had a child.=20=20
>
>Yet here we are in our modern societies having a problem where we have to=
>  stretch out=20
>breast drainage for long periods of time.  At least in the US, bed sharin=
>g is considered so=20
>dangerous that the New York City department of health is considering taki=
>ng infants away=20
>from their mothers for doing so --- and have not specified if this is mer=
>ely for the=20
>mothers who are truly at risk of overlaying on their infants or for every=
>one.
>
>I can't blame this on increasing rates of obesity in developed countries =
>because that=20
>would presumably lead only to more fatty tissue, not more milk storing ti=
>ssue (and some=20
>of the women in Africa were quite obese at least in Central Africa.=20=20=
>=20
>
>I actually don't believe in foremilk/hindmilk imbalance.  This is a theor=
>y that no one has=20
>successfully "proven" in a form that I believe yet.  Over the course of a=
>  24 hour period, if=20
>the baby is getting all the milk that is taken out of the breast, the bab=
>y is getting varying=20
>levels of fat and it should all come out in the wash.
>
>Could it be, that these mothers and babies fall out of synchrony because =
>the norm is to=20
>push the limits of tolerance.  That is, at the slightest sign the baby is=
>  done, the baby is=20
>wrapped up and taught to "sleep" or "not become reliant on mom".  If the =
>baby has an=20
>anatomical variation that might be perfectly fine in some other intuitive=
>ly feeding culture,=20
>that baby might be fine.  But, pushing things to the limit, what was once=
>  a "normal" range=20
>of variation is no longer functional in an environment where babies are s=
>lipped off the=20
>breast as soon as possible.  These mothers might then appear to be "overs=
>upplies"=20
>because their breasts are not getting adequate drainage because of premat=
>ure removal of=20
>the breast.  American culture has a firm belief that babies use mom as pa=
>cifiers.  Then=20
>the baby slips off the breast more and more because the breast is overly =
>full.  And thus=20
>begins a vicious cycle of asynchrony.  Then mom starts round after round =
>of food=20
>elimination to her own detriment, getting more and more stressed out as s=
>he eliminates=20
>the food she likes and/or needs.=20=20
>
>I have trouble believing that lactose --- the sugar that is so high in br=
>east milk ---=20
>somehow causes intolerance for the baby.  Gut transit time yes, but lacto=
>se, I'm not=20
>convinced.=20=20
>
>Would those babies with posterior tongue ties actually do better in an en=
>vironment where=20
>mom had sufficient support to enable her to do so and actually had a surr=
>ounding culture=20
>that enabled her to really growing up and embracing the concept that she =
>will actually=20
>enjoy a lot of contact with her baby?  Is the poor feeding a matter of in=
>adequate time and=20
>contact with mom --- and the SYMPTOMS from inadequate drainage appear whe=
>n there is=20
>insufficient contact?
>
>Is the preponderance of babies who seem to regurgitate painfully a produc=
>t of trauma=20
>during the birthing process that has never fully been addressed?  Or perh=
>aps a product of=20
>lack of skin contact and baby wearing.  Babies in Africa are always carri=
>ed upright on the=20
>back --- never sideways and never with their chins in their chests.=20
>
>And why is it that these babies do better lying down at night with both m=
>om and baby=20
>horizontal?  Does that skin contact relax mother and baby in ways that ar=
>e not possible=20
>during the day when they both are expected to be "efficient".
>
>And in defense of mothers --- just read any mothering magazine and really=
>  count up the=20
>number of messages about all the things she is SUPPOSED to be to so many =
>other people=20
>than her baby.=20=20
>
>Some days everything I think I know seems to get called into question.
>
>Best, Susan Burger

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

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