Battle with the bottle

April 3, 2009 — Elizabeth Jay

bottleWhen C was a few weeks old, and I was expressing to take the pressure off my beleagured nipple, she would gulp down whatever ended up near her mouth – even milk straight from the fridge. I didn’t enjoy feeding her bottles, but it was a necessary evil, and as the health visitor told me, if I wanted her to take a bottle later on, I needed to introduce it at that point anyway. She also mentioned that if I wanted C to carry on accepting bottles, I’d need to keep it up, giving her at least one per week. I endeavoured to do this, more or less, although I was reluctant to do it really frequently as it seemed to make her windy and more likely to be sick. I have to admit that part of it was laziness as well. Since breastfeeding had become less painful, it was proving to be amazingly convenient, whereas expressing and bottle feeding was a bit of a hassle.

On my husband J’s birthday, we went out for a meal without C for the first time. My sister came over to look after her, and even though we were only going to be a couple of hours, I wanted to have a bit of wine, so thought it would be better to give her a bottle that evening. I expressed milk in the morning, and defrosted some frozen stuff just in case. My sister didn’t need to use the milk in the end (C had a substantial meal just before we left), but I thought my blood-alcohol content was probably a bit high when I got back, so I decided I ought to leave it an hour or so. C seemed pretty peckish, so J settled down to bottle-feed her. Half an hour and a lot of agitation later, very little had gone down, and we ended up trying to distract her until I could feed her again. I wasn’t particularly worried by this turn of events, but realised that we were going to have to make this bottle thing a lot more regular to ensure that C would take one readily when I wasn’t available to feed her.

The plan was for J, who would normally be feeding her in my absence, to give her a bottle of expressed milk each evening. Simple. Except that rather than making bottles appear more desirable, it transformed her into a small bundle of rage who wouldn’t have them anywhere near her. She turned her head and pushed them away with her hand (at least it was helping her motor coordination), refusing to swallow even the milk that happened to leak into her mouth by chance.

After a few nights of this, I was at my wit’s end. I hadn’t really considered that she might refuse to feed from a bottle in my absence. It had been so easy! Now I realised that I might have to accept that she’d reached the point where she might flat out refuse, even if she was really hungry. It wasn’t that she didn’t know how to do it (a couple of times she’d sleepily suckled for a few seconds), but rather that she didn’t want to. C had realised that she could decide what to take into her mouth, and unfortunately for me, milk from a bottle simply wasn’t on the approved list…

Posted in Bottle feeding, Journal. Tags: , , , , , . 2 Comments »

Not enough milk? The “symptoms” you don’t need to worry about.

March 15, 2009 — Elizabeth Jay

glass of milkA huge proportion of women worry that they aren’t satisfying their babies through breastfeeding alone, and many give up as a result. Much of the time, however, they are worrying about nothing. Although the precise relationship between perceived and actual milk supply isn’t well researched (see insufficient milk: all in the mind?), it is certainly the case that many of the “symptoms” that women think indicate they aren’t producing enough milk are actually completely normal, and can in fact be indicators that breastfeeding is going well.

In an article for Australian Family Physician journal, Dr Lisa Amir summarizes the common misconceptions of low supply. They include your breasts feeling softer, your baby taking less time to feed or feeding more frequently, your baby seeming unsettled or settling better on formula, and your baby’s growth appearing to slow down after three months1. In the absence of any genuine indicators of ill health, none of the above are a cause for concern, yet they perturb many mothers to the extent that they stop breastfeeding. Why do mothers interpret these commonplace occurrences as signs that their milk production is diminishing, and what actually causes them? The sections below address each ‘symptom’ in turn, outlining why they can be misconstrued as a problem with milk supply, and explaining what actually causes them.

•    Your breasts feel softer

After the problems with engorgement that can occur in the post-birth period, it should come as a relief when breasts go back to a softer, more normal consistency. In reality, it can be somewhat unnerving. If you’re used to rapidly filling up with milk, any decline in this can give the impression of a dwindling supply. In fact, your breasts are simply adjusting to maximize their efficiency, by producing as much milk as your baby needs, but not going overboard – an important process, given how energy intensive it is to produce milk. Initially, production is controlled by hormones that are released after giving birth, causing a significant amount of milk to appear regardless of whether a woman intends to breastfeed. Within a few days, however, the amount produced starts to be determined by the amount of milk that your baby takes at a feed2. The quantity of milk required by your baby increases rapidly to start with, but by the end of the first month it has stabilized, and your production becomes fine-tuned too, so you can supply your baby with exactly what she requires, without wasting energy by producing too much3. This isn’t to say you can’t make more if necessary, but simply that you won’t do it unless the demand is there.

•    Your baby takes less time to feed

Whilst the amount of milk a baby has at each feed remains relatively consistent as he gets older, the speed at which he takes it on board increases. A five month old baby sucks more frequently and ingests more milk with each suck than a two-month old, meaning that he can get through a meal much faster4. Although this gives the impression that he isn’t getting as much milk, you can be reassured he is – he’s simply getting it in a shorter time.

•    Your baby is unsettled, or seems to settle better on formula

The research into colic, crying and the type of food a baby receives presents a confusing picture. Some studies show babies sleep longer if they are breastfed5, while others say formula fed infants are more settled6. One problem that frequently arises with the research in this area is that feeding method is confounded with style of care-giving, and cross cultural studies indicate that the the latter might have a much greater impact on how irritable babies are than the former5. The main thing to remember is that there are many factors affecting how much your baby cries: if you are feeding on demand, a problem with your milk supply is unlikely to be one of them.

•    Your baby feeds more often

A long term study in Sweden has shown that the number of feeds a baby takes in a day can vary by a huge amount, both from baby to baby, and for the same baby over time7. A change in feeding frequency is not unusual, and is not associated with a problem with your milk supply.

•    Your baby’s growth slows after three months

What if your baby has been gaining weight steadily, and then suddenly starts to falter?  The amount of weight babies put on may vary over time for many reasons, but an apparent slow-down from around three months should pretty much be expected. Although the new WHO growth charts were published in 2006, many health care providers (including my own) still aren’t using them, so your baby’s growth is being compared with that of formula fed infants. The really important thing to remember in this situation is that it is actually the breastfed babies’ pattern of weight gain that is considered desirable, so formula fed infants whose growth curve continues to climb are actually gaining too much weight. Or at least this is what the WHO states – presumably the rest of the medical profession will catch up in the next few years.

The issues discussed above frequently cause mothers to worry that they aren’t producing enough milk when in reality their supply is absolutely fine. A baby may cry, fuss or feed more frequently because she is hungry, but this does not mean that her mother is unable to provide her with sufficient milk. The efficient nature of milk production means that if a baby indicates that he needs more milk by taking more at a feed, then the breasts will increase production as required.

The only time to worry is if your baby appears physically ill. If her growth has genuinely stalled, or she is continually tired, weak and listless, there may be a problem: if you’re in any doubt, consult a professional. Just keep in mind that any other ‘symptoms’ of low supply are probably nothing of the sort: as long as your baby is healthy, you almost certainly have nothing to worry about.

  1. Aust Fam Physician. 2006 Sep;35(9):686-9.
  2. Exp Physiol. 1993 Mar;78(2):209-20
  3. J Midwifery Womens Health. 2007 Nov-Dec;52(6):564-70.
  4. J Reprod Fertil. 1999 Mar;115(2):193-200.
  5. Early Hum Dev. 2000 May;58(2):133-40.
  6. Early Hum Dev. 1998 Nov;53(1):9-18.
  7. Acta Paediatr. 1999 Feb;88(2):203-11.
Posted in Insufficient milk, Research. Tags: , , , , , , , . 1 Comment »

Where does fore-milk end and hind-milk begin (and does it actually matter?)

March 3, 2009 — Elizabeth Jay

milk-creamAccording to the World Health Organization, breastfeeding provides all the nutrition your baby requires for the first six months of life. This entails satisfying both hunger and thirst, and to meet both these needs you might have heard that your breasts produce two distinct types of milk: thin, watery ‘fore-milk’ to quench thirst; and creamy, calorie-rich ‘hind-milk’ to satisfy hunger.

These apparently different types of breast milk are described in various ways, but a distinction is generally drawn between a watery/creamy consistency, and thirst/hunger. There is also an implication that you need to make sure your baby gets enough hind-milk in order to gain weight. According to DrPaul.com:

‘Foremilk is the milk which is first drawn during a feeding. It is generally thin and lower in fat content, satisfying the baby’s thirst and liquid needs.
Hindmilk is the milk which follows foremilk during a feeding. It is richer in fat content and is high in calories. The high fat and calorie content of this milk is important for your baby’s health and continuing growth.’

ParentingWeb.com carries a similar description:

‘Foremilk, a bluish-white milk that is lower in fat than the hindmilk is the milk your baby receives in the first part of the feeding.
The hindmilk, which follows the foremilk, is richer and higher in fat than the foremilk. The hindmilk provides most of the nutrients your baby needs to gain weight and grow, and it satisfies his hunger.’

Valorie Delp on Families.com goes a step further, and says you can actually see the difference between the two:

‘If you’re really into science, pump a bottle of milk and let it sit out on the counter for awhile. You’ll see the milk separate into two distinctive layers. . .one being much fattier than the other. That’s hind milk and foremilk.’

Valorie’s demonstration is appealing, but it’s unfortunately some way off the mark. The separation she describes is simply the fat in the milk rising to the surface, not a different type of milk. This illustrates quite neatly the problem with using the terms ‘fore’ and ‘hind’: it reinforces the impression that the breast produces two types of milk, when in fact it makes only one. The descriptions shown above aren’t entirely inaccurate – milk does indeed change consistency during a feed – but this happens gradually, rather than suddenly.

The change occurs due to an increase in the fat content of the milk as a feed progresses – hence the ‘creamy’ label attached to hind-milk. It isn’t simply the case of the longer the feed, the fattier the milk, however. A study published in Experimental Physiology demonstrates that the fat content is related to the ‘emptiness’ of the breast: the less milk it contains, the greater the proportion of fat in the milk1. This means that if a baby has a 4oz feed when the breast is only storing half its potential milk volume, it will contain more fat than a 4oz feed taken when the breast is three-quarters full.

The amount of fat in your milk therefore varies considerably throughout the day, depending on the time since the last feed, the amount of milk consumed at the last feed, the amount of milk consumed at the current feed… It sounds complicated – how on earth do you make sure that your baby is getting enough? The short answer is that you don’t need to. Whilst fat is an important constituent of your baby’s diet, so are protein and carbohydrate, and both of these are found in the watery rather than the fatty part of the milk. The evidence also suggests that weight gain is related simply to the volume of milk consumed, and not its fat content2, underlining the nutritional importance of all the components of breast milk.

If you are breastfeeding on demand, the bottom line is that you don’t need to worry about the ‘type’ of milk your baby is getting. Babies can show a wide variety of feeding patterns, suckling for varying lengths of time and at varying intervals over the course of a day, and maintain a healthy weight3. The terms ‘fore-milk’ and ‘hind-milk’ do have their place: in scientific studies, they are used to describe the samples of milk taken at the beginning and end of a feed. In more general usage, however, they often produce a confused and inaccurate picture. They split milk into two types (when there is actually only one), and imply that the fat contained in milk is somehow more nutritious than the rest of it. In fact, nutrients that are important for health and growth are contained in both components of breast milk, so the implication that the fatty part is for ‘eating’ and the watery part for ‘drinking’ is somewhat misleading. The important thing to remember is that ensuring your baby’s thirst and appetite are satisfied is not a complicated undertaking – it’s simply a matter of letting her feed when she wants to.

  1. Exp Physiol. 1993 Nov;78(6):741-55.
  2. Paediatr Perinat Epidemiol. 2002 Oct;16(4):355-60.
  3. Pediatrics. 2006 Mar;117(3):e387-95.Click here to read
Posted in Fore/hind milk, Research. Tags: , , , , , , , , , . 40 Comments »

Milk stasis – not infection – is the main cause of mastitis

February 24, 2009 — Elizabeth Jay

holding_babyPrior to my brush with it, I thought that mastitis was caused by a bacterial infection. This is not completely unreasonable, given that this is precisely how numerous ‘health’ websites define it (FreeMD, eMedicineHealth, HealthSquare to name just a few). When you consider that the symptoms of mastitis can include a fever as well as redness, lumps and pain in the breasts, and treatment can involve antibiotics, the definition seems to make sense.

Unfortunately, it turns out to be somewhat misleading. Whilst bacterial infection may play a part in mastitis, it is in fact inflammation of the breast tissue that is at the root of the condition, and causes the majority of the symptoms. The World Health Organization describes mastitis as ‘an inflammatory condition of the breast, which may or may not be associated with infection’1. They summarize the uncertain relationship between bacterial infection and mastitis as follows:

Many lactating women who have potentially pathogenic bacteria on their skin or in their milk do not develop mastitis.
But:
Many women who do develop mastitis do not have pathogenic organisms in their milk.

This basically means that you can be carrying the bacteria associated with mastitis – and even have it in your milk – without developing the condition, and conversely, you can succumb to mastitis when there is no evidence you’re carrying the bacteria.

So, if mastitis isn’t due to an infection, what does cause it? It appears that the inflammation that characterizes mastitis is a consequence of ‘milk stasis’: milk is produced, but then remains in the breast, rather than coming out during feeding. Milk stasis can occur for many reasons, including blockages in the ducts, a decrease in feeding frequency and poor attachment1,4. It’s also possible that stress might play a role, by both increasing milk production and delaying the letdown reflex2. Why milk stasis goes on to cause inflammation isn’t so clear, though it could result from inflammatory substances found in milk irritating the breast tissue, or an immune reaction to certain milk proteins3.

Although bacterial infection is not often the primary cause of mastitis, it is sometimes thought to exacerbate the symptoms3. Determining the precise role it plays, however, is a tricky business. Firstly, it is very hard to ensure that milk cultures are sterile, so it isn’t always possible to know that the bacteria found in a woman’s milk haven’t in fact come from her skin when the sample was taken1. Secondly, as stated above, harmful bacteria can be found in the milk of women who don’t have mastitis, indicating that there is not a simple cause and effect relationship between the two. One possibility is that mild changes initiated by milk stasis may be exacerbated by bacterial activity: symptoms could be considered to be on a scale, from a reduction in milk output but no pain (known as subclinical mastitis), to breast abscess and severe pain, with increasing amounts of bacterial involvement as you move from one end to the other3.

What does all this mean if you find yourself suffering from mastitis? Perhaps the most important thing to remember is that the symptoms are probably due to a milk flow problem, so your top priority should be to address any causes of this. This might include making sure your baby is properly latched on, feeding more frequently and emptying the breast properly at each feed. Many doctors also choose to treat mastitis with antibiotics, although there is a lack of consensus as to which ones to use, and even whether it’s appropriate to use them at all (see when should mastitis be treated with antibiotics?). Whether or not you take medication, the most important thing is to keep the milk moving. Whilst feeding with mastitis doesn’t appear to pose a risk to you or your baby, stopping could well do: not only will it make the symptoms worse, but it will almost certainly jeopardize your milk supply5. Mastitis is a common reason for giving up breastfeeding, but it needn’t be – focus on sorting out your feeding technique and you should hopefully make a rapid recovery.

  1. Mastitis: causes and management. World Health Organization; 2000.
  2. Mediators Inflamm. 2008;2008:298760.
  3. Arch Dis Child. 2003 Sep;88(9):818-21
  4. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD005458.
  5. Am Fam Physician. 2008 Sep 15;78(6):727-31.
Posted in Mastitis, Research. Tags: , , , , , , , , , , , , , , , , , . 3 Comments »

My mystery rash is mastitis!

February 19, 2009 — Elizabeth Jay

telephoneSix weeks down the line, I felt I had really turned a corner with breastfeeding. My nipples were definitely starting to heal, and C seemed to be getting plenty of milk. Admittedly, she was pretty noisy at times (‘clicking’ noises were a regular occurrence) but as the milk was clearly going down her I didn’t really worry when I noticed a pinkish patch starting to appear on the inside of my left breast.

A couple of days passed, and the patch had turned into a definite rash: a wedge-shaped stripe running from the top right to the nipple of my left breast. It didn’t hurt, and I still wasn’t overly perturbed, but I thought I should probably find out what it was.

By this stage, contact with the health visitor had long since ceased, and although I had planned to ask at the weighing clinic, in the end it just didn’t seem the right time. In any case, my recent experience had taught me that the most likely response of any health professional would be to recommend I speak to a counsellor, so I decided to pre-empt them, and got on the phone.

This time I decided to call La Leche League. Like the NCT counsellor I had spoken to previously, the lady who answered the phone had a pretty brusque bedside manner. Never mind – I needed answers, not sympathy. When I had described my symptoms, she replied, without skipping a beat, ‘ah, classic early stage mastitis.’ What?! But it didn’t hurt! This, she agreed, was unusual, but she suspected it was because I had caught it so quickly. If I left it any longer, the pain would definitely arrive. How old was my baby?, she asked. When I said 6 weeks, I could almost hear her wearily shaking her head at the other end of the phone. ‘This is such a common problem at this stage. Women think they’ve really got the hang of breastfeeding and become complacent, so they don’t adequately respond to the fact that their baby has started to get much heavier, and he ends up being poorly attached.’ My heart sank. I had been thinking that I’d pretty much got it sorted. I’d been a bit worried about the clicking noises, but had put them down to the torrent that was released by my letdown these days. Whether or not that was the cause, it seems I should have heeded them as a potential sign of a poor latch.

I put down the phone relieved that I had caught the problem early, but somewhat panicked at the thought of what it might turn into if I didn’t (a fever and a potential hospital admission. No pressure then.) Although her advice – to avoid further inflammation by keeping the breast as empty as possible – seemed straightforward enough, following it involved solving a latch problem that I hadn’t even realized existed. Feeling pretty fed up, I picked up C, and set about perfecting my breastfeeding technique all over again.

Posted in Journal, Rash/Mastitis. Tags: , , , , , , , , , , , . 1 Comment »
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