01 Sep 2012

Fore-milk, hind-milk, enough milk, and research.

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As a lactation consultant in private practice, I want and need to keep up with the latest research and clinical techniques. One way I do this is by reading what other clinicians write on lists, blogs, and groups. While there are many new topics to discuss on these internet sites, one topic often repeats: the discussion and concern about fore-milk/hind-milk imbalance.

Why are mothers worried about foremilk/hindmilk imbalance?

Breastfeeding was virtually invisible for generations; once most women started giving birth in hospitals, in the early 1900s, breastfeeding rates dropped. At the same time, the formula industry was assuring healthcare providers that their product was as safe and good as human milk. Consequently, the public was told that formula feeding was an adequate substitute for breastfeeding, and certainly convenient for those women who had to leave their babies in the care of someone else while they worked outside the home. Breastfeeding became regimented in hospital maternity wards, with mothers advised to sterilize their nipples with alcohol before feeding, to nurse their babies on a gradually increasing schedule (1 minute per breast per feed for the first day postpartum, 2 minutes per breast on the second day, and so on) and at 4-hour intervals. These hospital recommendations were a guarantee that most mothers would, and did, have problems. Without accurate advice or encouragement, most women gave up on breastfeeding.

In 1956, seven housewives met in a park in Chicago, Illinois. They were all nursing their infants and talked about it, helping and encouraging each other; they invited friends to join their gatherings. Mothers found that they could get help from other mothers, and that they didn’t have to stop breastfeeding but could find solutions to difficulties. Mothers gathering together to talk with other mothers was a happy and popular event, and spread across the land. The informal gatherings gradually evolved into a formal organization, today’s La Leche League International. Breastfeeding entered its renaissance.

As breastfeeding entered the popular consciousness, healthcare professionals wanted to be able to answer mothers’ questions but didn’t have any science from which to draw. As a result of the dearth of scientific information, healthcare professionals would extrapolate from the dairy industry or use bottle-feeding formula recommendations and apply those concepts to breastfeeding. (Artifacts of this rediscovery of breastfeeding persist today, although the art and science of human lactation and breastfeeding are gradually replacing those old sayings with reliable advice.) Healthcare professionals were eager for more precise information that was specific to human lactation, and research articles started to appear in a variety of scientific journals.

On August 13, 1988, Woolridge and Fisher published a study in Lancet that gave birth to the term ‘foremilk/hindmilk imbalance’. Woolridge and Fisher described a manipulation of the infant feeding pattern that resulted in a resolution of colic, and ‘oversupply’ syndrome, as they felt that babies with oversupply syndrome were getting too much foremilk and not enough hindmilk. At that time, new mothers were often advised to feed for 10 minutes on one side, switch sides, and let the infant finish on the second side. While this recommendation worked for many mothers and babies, it wasn’t comfortable for all babies. Some developed what was called “oversupply syndrome”, colic, fussiness, and watery, scalding diarrhea. This was attributed to babies receiving too much low-fat volume of foremilk (the milk at the beginning of a feed) and insufficient high-fat hindmilk (the milk at the end of a feed). The solution was to let the baby set the pace, for the baby to feed on the first breast for as long as it wanted, and if it wanted more after that, to use the other side.

As with many recommendations made for one specific clinical situation, this particular concern about foremilk/hindmilk balance was adopted by healthcare professionals, who passed this concern on to everyone they worked with. I remember myself, during the 90s, saying in my classes, “The milk at the beginning of the feed is like skim milk and the milk at the end of the feed is like cream. Your baby needs both.” This advice lead to a popular misconception and telephone calls and consultations from worried mothers whose first statement was, “I don’t think my baby is getting enough hindmilk.”

Some moms were worried because although their baby nursed for 3 minutes per feed and was rapidly gaining weight, they were sure their baby wasn’t getting any hind milk. These mothers had some idea that a baby had to stay on the breast for X amount of minutes for the milk to switch over to hindmilk. Other moms thought that the foremilk was useless, and that the hindmilk was the best. Dr. Karin Cadwell describes the nursing patterns of the !KungSan mothers of the Kalahari desert, who nurse an average of 2.5 minutes every 15 minutes. She then asks, “when did their babies get the hind milk?” This example illustrates how real life has its own answers that research can not find. What a mother learns can become a problem, especially when she is looking for answers from the outside, from books and from other people. Babies don’t know about studies, and have been breastfeeding well for millions of years.

I wish that new mothers would keep their new babies close by, to learn about breastfeeding from the real expert. For most mothers, letting the baby set the pace works best. The baby wants to grow (so it can get the car keys and drive away). When permitted to set the pace, and nurse when it wants for as long as it wants, from the very first feed, then milk supply and breastfeeding usually find a comfortable equilibrium a week or two after birth. The occasional situation where things aren’t going well, require professional assistance; those situations are the exception rather than the rule.

Research on human milk has, for the most part, merely opened the door to more questions. The bottom line is that the baby guides the feeding. Give the baby every opportunity, from the very first nursing, to nurse when it wants, as much as it wants. This means surrendering to the baby’s needs for a few weeks, while your baby weans from the continual feeds of the placenta. Once breastfeeding is in the groove, then you can start to change things.

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