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How to Breastfeed - Finish the First Breast First.

Melissa Clark Vickers
(From LEAVEN, September-October 1995, pp. 69-71)

The Letdown Reflex
The letdown reflex is the express mail equivalent of milk production. It is a hormonally driven process that gets the milk from the upper portions of the breast through the ducts to the sinuses beneath the areola, out the nipple and finally into a baby's waiting mouth. According to THE BREASTFEEDING ANSWER BOOK :

During breastfeeding, the baby's suck stimulates the letdown. When a baby begins to nurse, the rhythmic motion of his jaws, lips and tongue send nerve impulses to the mother's pituitary, the master gland in the brain, by way of the hypothalamus. Two hormones, prolactin and oxytocin, are then released. It is the oxytocin that stimulates the letdown reflex, causing the band-like cells surrounding the milk-producing cells (alveoli) to constrict and squeeze out the milk from all parts of the breast. This muscle action sends the milk through the ducts to the milk reservoirs (lactiferous sinuses) about an inch behind the nipple, so that it is available to the baby.

THE BREASTFEEDING ANSWER BOOK goes on to say that the "most reliable sign of the let-down is a change in the baby's sucking and swallowing pattern from quick sucks with occasional swallowing to long, slow sucks with regular swallowing or gulping." If you ask a nursing mother to describe her baby's suck-swallow pattern, she will describe the above pattern. She may also add that the sucking and swallowing will taper off, as if her baby is resting a bit, and then the slow suck/regular swallowing starts back up again. At this point, I assure her that her body is working just as it should. It is those later sucking bursts that indicate that the mother is having multiple letdowns. These are normal, common and responsible for squeezing out the fatter hind milk later in the feeding. Often the only clue that a mother has that she is experiencing the later letdowns is this predictable suck-swallow pattern, regardless of whether she feels the letdowns. Some women barely feel any letdowns, while others experience a tingly sensation in the breast every time the milk lets down.
As a rule, the more obvious it is to the mother that her milk is "letting down," the fuller her breasts are. Remember that milk production is based on supply and demand--how much milk the breast makes is determined by how much milk is removed from the breast. If the baby takes a lot of milk, the breast makes a lot to be ready for the next time. This is a truly remarkable system!

The Composition of the Milk
Equally remarkable as the milk production system is the change in composition of milk throughout the course of a feeding, something that no artificial baby milk will ever be able to claim. Foremilk, the initial milk that baby gets upon latch-on, is much like skim milk. It is initially satisfying, high in volume and low in fat and calories. As the feeding progresses, the fat content goes up and the corresponding milk more closely resembles whole milk. Finally, toward the end of the feeding, the hind milk is high in fat, high in calories and low in volume. Think of hind milk as a rich creamy dessert. Lactose (milk sugar) concentration is relatively constant throughout the feeding.

Baby-Led Feedings
Babies are smart--they know what they need. A baby will nurse until he gets the calories he needs. A corollary to that is the volume of milk consumed is less important than the calorie count. An efficient nurser will trigger the later letdowns and receive more of the fatter hind milk.
It takes more than just an efficient nurser to get to the hind milk. It also requires time and patience on the mother's part and education as to the importance of allowing the baby to stay on one breast long enough to get that hind milk. The obvious question is, how long does it take? Ababy who is satisfied and comfortably full will come off the breast

by himself. This is when we see that marvelous "drunken sailor" look that comes with a full tummy. Some babies will reach this point more quickly than others; some will never seem to reach the point of coming off by themselves. This may be an indication that the baby is not nursing efficiently and may benefit from some help with positioning or latch-on. Often just lifting the breast from underneath will allow the baby to drain the breast more effectively. Routine breastfeeding guidelines often tell mothers to limit total time at the breast and to use a set time interval of five to ten minutes to determine when to switch from one breast to the other. Limiting baby's nursing on each side to only five or ten minutes can be counterproductive when viewed in terms of the change in milk composition. For some mothers, nursing on both breasts at each feeding is important in terms of keeping up milk production and relieving engorgement, but the baby should be finished with the first breast before being switched to the other side.

A Typical Scenario
Let us look at why arbitrary switching to the other breast may lead to problems. First of all, if a mother is timing feedings and giving equal time at each breast, the baby is going to be getting a lot of the foremilk--the skim milk--especially if the mother is one with a greater difference in fat content between fore- and hind milk. Remembering that baby will try to feed until he gets his calories, he must take a lot of skim milk to get those calories. When he takes a lot of milk from the breast, the breast responds by making lots of milk. Large quantities of milk mean greater flow and more forceful letdown--which is like trying to breastfeed from a fire hydrant!
If the baby is drinking large quantities of milk, then he is also consuming large quantities of lactose or milk sugar. Babies can handle a certain amount of lactose, because they make lactase--the enzyme necessary to digest that sugar--although the supply is limited. Too much milk may mean more lactose than the baby has lactase to handle, setting up a problem similar to lactose intolerance. Any of you who suffer from lactose intolerance can immediately sympathize with the discomfort that baby will feel! The high lactose content in the intestine leads to diarrhea, which is further complicated because a low fat content in the milk will cause rapid stomach emptying. Sometimes the stomach "empties in the wrong direction," causing these babies to spit up--they consume more milk than they can comfortably hold. Compounding the problem, if baby does not get the calories he is after, he will want to eat sooner.
Think back to all the calls you have received from the mother who worries that she does not have enough milk because her baby breastfeeds "all the time." Or maybe she believes her baby does not like her because he fights the breast. Or he sputters at the breast, spits up what appears to be a lot of milk and has frothy green diapers. Or she experiences major leaking in between feedings or at letdown. These mothers are probably suffering from an overactive let-down, brought on by mismanagement--interference with the normal "flow" of milk--and are prime candidates for being helped.

So How Do We Help These Mothers?
Have you ever watched a mother cat nurse her kittens? Each kitten nurses in one spot until he is finished. Mama Cat does not play "musical chairs" with her kittens! Perhaps a more "natural" way to nurse is to let the baby finish the first breast first.
Tell pregnant women and mothers of newborns about the importance of making sure that their babies nurse long enough to get that hindmilk. If you explain the process to them, it will make sense to them, and if it makes sense, they are more likely to implement this way of nursing. Encourage them to let their babies nurse on one side until they come off. Then they can burp them or change them. If the baby still seems hungry, the mother can offer the other side and let her baby have what he wants. She can then start on that second side for the next feeding.
By nursing mostly on one side per feeding, the baby gets all the calories he needs in less volume of milk. When the mother's body adjusts to this way of feeding, she only makes milk to replace what the baby takes. So, she is more comfortable and less likely to leak. Her baby may be less colicky and often gains weight at a better rate. He is less likely to fight the breast since he is no longer nursing the "fire hydrant." And, he may go longer between feedings if he is having a "meal" that includes both the "appetizer" (foremilk) and the "dessert" (the hindmilk).
Evelyn Byrne, retired Leader and IBCLC, reminds us of the importance of follow-up with these mothers. Baby may be noticeably calmer after a few feedings, but the method may require "fine tuning" for a couple of weeks. Baby's weight gain should improve if he is getting more hindmilk. If it doesn't, if he loses weight or has fewer wet diapers, breastfeeding management should again be evaluated. A reminder that it often takes as long to get out of a problem as it did to get into the problem may help the mother look ahead.

Nursing Patterns Can Vary
Now, many mothers who nurse both sides every feeding do just fine. This is just another indication of the adaptability of the human body! If the system that the mother is using is working for her, then there is no reason to change it. However, it may still help her to hear about how her milk changes during the feeding. Knowledge is a powerful tool! And, some mothers may actually be relieved to hear that it is not necessary to switch breasts at every feeding--particularly those mothers who may be struggling to get their babies latched on well in the first place.
It may be that the mothers who do nurse both sides equally every feeding are just lucky enough that they can make this system work. Alternatively, there may be something else at work as well. Perhaps the women who show the greatest variation in fat content are the ones who most benefit from the "finish the first breast first" method of feeding. The women whose milk changes very little can nurse any way they want and the babies can get what they need.

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