When a baby goes to breast the nipple stimulation travels to his  
mothers hypothalamus
where it has two inhibitory effects. It inhibits the release of  
dopamine, "prolactin
inhibiting factor" and it inhibits the release of GnRH, gonadotropin  
releasing hormone, the
first hormone in the cascade of hormones toward ovulation.

Prolactin levels stay elevated above the baseline in a mother's blood  
stream
for about three hours after a nipple stimulation. What this tells me  
is that after three
hours without nipple stimulation the hypothalamus has been free to  
make enough
dopamine that it has had an inhibitory effect on the pituitary's  
production of prolactin.

All we have to do, is do the math- 24 hours in a day divided by 3  
hours means 8 breast
emptyings a day is the cusp of good lactation. Since the inhibitory  
effect of dopamine brings
the prolactin levels down to baseline after three hours have elapsed  
it would be better for
milk production if mothers kept their nursings under three hours apart  
at a minimum!

If we in the field of lactation use the success of "performance  
outliers"- women who have
success with nursing just 8 times a day as the basis of our  
recommendations to all
women we are going to undermine the success of most breastfeeding  
mothers.
This is because in the real world real things happen that make one day  
different from the
next.

In the early postpartum period women have more prolactin than they  
deserve just based
on their breastfeeding frequency. This is called the prolactin safety  
net. Nature is kind
and gives mothers extra prolactin while they are learning how to  
breastfeed. If the
mother learns to read her baby's non-crying cues to nurse she will be  
nursing more than
8 times a day which will put her in good stead when her prolactin  
safety net goes away 3-
4 months postpartum.

But if a mother is a "scheduler" instead of a cue-feeder and her  
schedule is every three
hours instead of every 2 to 2 1/2, or if the mother has a baby who  
can't latch and she has
been told to pump just 8 times a day she will have gotten herself into  
the habit of sitting
at just the cusp of lactation. This is fine during the period of the  
prolactin safety net but it
sets up bad habits for the period after the safety net has passed.

I personally don't want mothers sitting at the cusp of lactation..I  
want them to have some
wiggle room for the demands of real life so I recommend that they  
think of 9 or 10 breast
emptyings a day as the minimum and 8 emptyings divided evenly  
throughout the day and
night as the bare, bare minimum!

The prolactin safety net is two nets really, in my opinion. The first  
net sustains some milk
production though 2 weeks of  inadequate removal.
The second prolactin safety net will sustain a dyad where frequency is  
at the cusp or sub-opitmal
for about 3-4 months.

If a mother is sitting at the cusp of lactation (8 breast emptyings a  
day) what happens
when the prolactin safety net goes away or if the mother  occasionally  
or even regularly
begins to fall under 8 nursings a day- the milk supply drops  
precipitously.

Even the mother fastidiously nursing every 3 hours sometimes will have  
an off day and
will nurse only seven times a day, or perhaps she and/or her baby will  
start to take a
long stretch of sleep. After all she has been led to believe "sleeping  
through the night" is
normal and she also has the expectation (and I hardly ever hear even  
lactation
consultants counter it) that as the baby gets older she won't have to  
nurse as often.

Nothing could be further from the truth. Newborns with tiny tummies  
and the greatest
metabolic rates of their lives may nurse 12 or more times a day, but a  
mother with a 6
week old nursing 8-10 times a day should not have the expectation that  
she will ever be
able to nurse less than 8 times a day and expect to have a copious  
milk supply during the
period of exclusive breastfeeding.

Again its a numbers game. If a mother is dropping below 8 breast  
emptyings a day that
necessarily means she is taking at least one stretch of four or more  
hours between nipple
stimulations. When the mother goes about four hours without nipple  
stimulation she in
effect has told her body that the baby is older and doesn't need that  
much milk anymore
and it OK to get pregnant again.

Since milk reverts back to colostrum during a pregnancy this is a  
potentially catastrophic
message to be sending to the brain when the baby is under six months  
of age and
optimally we would not like this message to result in an ovulation  
until after the baby is
over a year old.

By going too long between nipple stimulations the hypothalamus is  
disinhibited- it will
make GnRH which in turn will stimulate the pituitary to make FSH,  
follicle stimulating
hormone. Follicle stimulating hormone stimulates a follicle on the  
ovary to ripen and a
ripening follicle makes estrogen. Estrogen competes with the prolactin  
on the milk-
making cells and milk production will go down.

If a mother regularly goes 4-6 hours once a day between breastfeeds  
the ripening ovary
may actually proceed to ovulation and after ovulation the corpus  
luteum will make
progesterone. Progesterone works against prolactin's ability to  
stimulate the production of
mRNAs which code for casein proteins...which if that doesn't lower  
milk volume should at
least change the composition of breastmilk.

Now I hear howls of protest from mothers all the time who tell me they  
let their babies
regularly sleep 4-6 hours at night and they still have "plenty of  
milk." I generally have
found one of two things to be true in these instances.

1) the mother is nursing frequently enough during the day that she is  
making enough
prolactin that this prolactin is able to counteract the estrogen made  
during the long
stretch of sleep. Estrogen antagonizes prolactin but the reverse is  
also true:prolactin
antagonizes estrogen. The mother is not in fact ovulating (even if she  
is having periods)
because her estrogen levels are not rising high enough cause LH to  
surge producing an
ovulation, and thus she is correct her milk supply is perfectly fine.

Although she does not have optimal breastfeeding practices in terms of  
maximizing milk
production she has plenty of milk to keep this particular baby happy.  
I have noticed that
mothers of baby girls seem to need to nurse with less breast feeing  
intensity than
mothers of boys and in fact we see the growth curves for girls are a  
little different than
those for boys.

(Mothers who are performance outliers at the high end of milk  
production seem not to
notice any difference in breastfeeding intensity between their boys  
and girls but moms in
the middle do. That is if moms are over producers of prolactin or have  
an extra bit of
glandular tissue both their boys and girls take a long stretch of  
sleep at night.

At the other extreme if mothers are particularly sensitive to the  
presence or absence of
nipple stimulation neither their boys nor their girls take a long  
stretch of sleep at night.
Mothers who are particularly sensitive to the presence or absence of  
nipple stimulation
don't necessarily have less glandular tissue, their bodies just seem  
to react faster to an
alteration in nipple stimulation. They remain amenorrheic longer with  
frequent nursing,
but they also sense a sudden drop in milk supply when the nipple  
stimulation becomes
less frequent.)

There are also mothers who have enough glandular tissue to sustain a  
baby exclusively at
the breast but they don't have so much that they can nurse with the  
average frequency.
These moms may never find themselves nursing under 12 times a day  
during the
period of exclusive breastfeeding.

2) Obviously the other thing that can be happening when the mother and  
baby take too
long of a stretch of sleep at night and especially when there is more  
than one long stretch
between nipple stimulations in a 24 hour period is that the mother  
only thinks her supply
is good but in fact it is not. Some mothers think that if their baby  
still goes eagerly to
breast or doesn't spend a lot of time in a full blown cry that means  
her milk supply is
good.

But upon questioning you will find the devil is in the details. I  
often find the baby was an
under performer in terms of weight gain, but the mother has no idea  
what is normal for
cue-fed breastfed babies, and if her pediatrician is satisfied so is  
she.

She does not know it is not normal for a baby to loss ten percent and  
not regain birth
weight before two weeks of age. She does not know her baby should have  
gained well
over seven ounces a week in the early weeks and can be expected to  
double birth weight
by four months of age if he is cue-fed.

She also doesn't realize one of the reasons she feels compelled to  
offer solids earlier than
six months is that some part of her knows the baby is hungry. If she  
managed to hold off
on solids until the baby was six months the baby ate a lot of solid  
food when it finally was
offered to him because she in fact had an undersupply and the poor kid  
was hungry.

If solids are offered too early babies may displace breastmilk with  
solids because the
baby is essentially being force-fed, it's swallow or asphyxiate, but  
older babies are
perfectly capable of exerting their will in terms of eating solids and  
any baby who
consumes a lot of solid food anywhere between 6- 12 months is  
revealing exactly what
the shortfall is between his mother's milk production and his caloric  
need.

With optimal breastfeeding management mothers' milk supplies are so  
good there often
isn't much if any shortfall at all in the first year and the mother  
expresses she has trouble
getting her baby to eat solids even though she would like him to.

With optimal breastfeeding management I think we LCs should expect  
that babies will not
eat a lot of solid food until they are between 15 months to two years  
of age, and since
breastmilk is the most nutrient dense food a baby will ever have there  
is no reason to
prefer it be any other way.

Sorry for this digression but solids and early weaning demonstrate how  
sub optimal
frequency results in under supply over the course of lactation.

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