Wednesday, 22 July 2015

The (Un)necessary Breast Milk stash?

Some of the concerns I hear most frequently from breastfeeding mums are around windy, gassy babies with green frothy poo.  Often when we discuss how feeding is going she mentions she is expressing each day.  When I ask why she is expressing, by far the most common answer I hear is "I just want to have a wee stash in the freezer, just in case".  Do you recognise this?  If you do, do you know what it is in case of?  Do you know how much you need?  Do you know when you need it?  Do you actually need it at all?  

Regular expression for a freezer stash in the early weeks can lead to a problem of oversupply.  If your 3 week old baby is drinking 20oz a day, for example, and you are expressing 5 Oz a day for your stash, you are removing 125% of what your baby needs each day.  That gives your body the message that your baby is drinking that extra amount and so the body continues to make more milk than is needed by your baby.  The extra milk in your Breasts is under higher pressure and this causes letdown to be faster.  This can have a few effects.  If can mean that your baby struggles to keep up with flow and swallows air.  It can mean that your baby gets more milk delivered to his stomach than he wants or needs, leading to him being overfull and to vomit.  When your supply matches your baby and you are feeding on cue, your baby is able to regulate his intake of sugar/fat content in the milk (discussed more here).  If you are expressing this may upset your baby's regulation of intake and he may get more lactose rich milk.  This can lead to extra fermentation in the gut causing gas.  It also passes through the stomach quickly and when it hits the intestine the lactose pulls in water causing watery and sometimes green frothy stools.  Add it all together and you get wind, gas, watery stools and an upset baby which, frequently, is mis-diagnosed as reflux.
Daily expressing doesn't cause an problem for every dyad, but it does for many, particularly if expressing starts in the first few weeks when milk supply is being calibrated to your baby's needs.  For some mums and babies even expressing small amounts in the early weeks can make a difference.

Pregnancy websites, magazines and shops make us feel like a Breast pump is an essential piece of breastfeeding equipment, and expressing is something that is necessary, but not everyone needs to express their milk.  For most people their baby will be with them during much of the duration of their breastfeeding, and for most of those who do leave their baby it is for short periods.  Maybe for an appointment or a few hours with friends.  Those mums don't need a huge freezer stash.   A few ounces is probably all that is needed.  This is very different to the unpurposeful, ever building stash - the one which comes from daily expressing and freezing for days and weeks just to have in the freezer.

Is a stash with no real purpose partly about lack of confidence in breastfeeding?  When we constantly hear comments about how often our baby is feeding and hear others querying if our baby is getting enough, it can be reassuring to see the milk flowing, to see bottles or bags stocked, to see the abundance that your body can produce.  The ounces of milky liquid goodness.   The oxytocin boost can be intoxicating, but ultimately is it created by anxious thinking in a society dominated by bottles and measurements?

If you have a hoard of milk in the freezer, how do you feel about using it?  Are you happy to give it to your baby when an outing does arise and let it dwindle down or are you attached to the idea of the stash?  If someone suggested donating to the milk bank, for example, would you feel anxious about losing the milk?  For many the stash becomes the goal in itself and then, all too soon, the milk reaches it's expiry date (6 months in the freezer) and must be dumped.  It seems like such a travesty to dump this amazing nutritious milk full of antibodies and stem cells and growth factors and cancer fighting properties.  It's a bit like saving for a rainy day and the bank going bankrupt before you ever had a chance to enjoy your money.  

If you find yourself not wanting to use the milk in the freezer, maybe ask yourself what you are saving it for?  If you find yourself worried about not having enough in the freezer perhaps open the door and look at it again. Realise all that milk came from you.  You.  Just you.   Milk doesn't come from the freezer.  It comes from you.  You are everything your baby needs.  There is no scarcity.  You don't need to worry about Jon Snow appearing to tell you, "Winter is coming" (Sorry, I couldn't resist :-)  ).  You are abundant.  Your milk is plentiful.  You are enough.   

The targeted stash

So how much is reasonable for a freezer stash?  That very much depends on what the "just in case" is and how long the separation will be.  If your "in case" scenario is for something like an afternoon or an evening away, you can estimate how much your baby might need for that kind of a timeframe and plan your stash around that.  On average, a baby between the ages of 5 weeks and around 6 months (or whenever he starts eating solids) drinks around 25-30 of milk a day (range of 22-41 Oz).  Before 5 weeks it will be less and after he starts eating solids the milk needed will gradually reduce as calories from solids increase.  Let's take a 6 hr afternoon or evening separation as an example for easy mathematics.  You can estimate the milk you need by looking at the day as a whole.  So if your baby takes 28 Oz over 24 hrs then in a quater of that time (6hrs) he will need around 7 Oz.  This is a simple example and obviously will need tinkering from dyad to dyad.  If your baby sleeps a long stretch at night and takes most of his milk during the day you may need to leave a little more.

You can also estimate how much to leave by your baby's normal feeding rhythm during the time you will be away.  If your baby normally feeds twice during that time frame, and you know that on average breastfed babies take 2-4 Oz in a feeding, then you may want to be able to grab 4oz x 2feeds = 8 Oz from your freezer.  This is just is few ounces, not a freezer full of milk. Obviously your baby may take more or less depending on how your caregiver feeds your baby (read here about how to protect breastfeeding while offering bottles) and most mums want to leave a few ounces more than what they think their baby will drink, again "just in case".  That's completely understandable, and sensible.  Just be careful that you limit it to a few ounces and don't start building a 'just in case' stash for your 'just in case stash'!

Have you been building your stash with the idea of returning to work in the back of your mind?  When your baby is small and feeding intensely, the thought of returning to work and having to leave enough milk for your baby is overwhelming.  It's no wonder we feel like we need to have milk built up.  It seems rational until you consider the practicalities.  We're lucky here in Northern Ireland.  We have 39 weeks of statutory maternity leave and many women manage to take this entire time.    What hard to visualise now is that your tiny baby will be a 9 month old infant by then, a 9 month old who will likely be well established on solids and his breastfeeding pattern will look entirely different to what it does now.  He may not actually need any expressed milk during your workday.  He may breastfeed when you drop him off and at pick up and drink water during your work time (depending on how long you are away of course).  If he does have mik, it is likely to be nothing like the amount he is drinking right now,
Even if you are returning at 6 months the pattern will look very different. 
Have you thought about how milk changes as your baby grows?  The milk you produce for your 9 month old or even your 6 or 4 month old is different from the milk you produce for your 1 month old.  Your milk is perfect right now for the stage your baby is at right now.  When you reach the stage of returning to work the milk you will be producing then will be perfect for your baby then.  You don't need to build up a store of milk now.  Often mums work a day ahead.  So, when you return to work on Monday you leave 1 days milk with childcare.  This is the only milk you needed in your stash - again only a few ounces.  On Monday you express at work when you would normally be feeding your baby.  You store that milk and give it to your childcare provider on Tues.  On Tues you express for Wed.  No stash required, and your baby gets fresh mik full of antibodies for the viruses and bugs which he is exposed to now.
Expressing at work might seem awkward and impossible at first glance, but employers have obligations obliged to breastfeeding mothers for this to happen (see further reading section below).  If you want to to talk about whether you need to express at work and how this could work for your circumstances, talk to a breasfeeding counsellor or IBCLC (International Board Certified Lactation Consultant).

A small amount of milk in the freezer can be useful.  Maybe even enough for day or two, but anymore than that can cause more problems than it solves.  If you are expressing for a freezer stash I would urge you to think about what your stash is for and how much you need.  Consider if you need to do it now, or if it can wait till breastfeeding is easy and well established for both of you.  Consider waiting till past the 5 weeks and think about how the amount may affect your baby.  Think about how whether it would suit you and your baby better to express small amounts over a longer period, or to have a few one off expression sessions.  If you are having concerns about your baby and fussiness/gas/ green stools, consider whether your expressing could be related and chat to a breastfeeding counsellor or IBCLC to discuss the impact.  
You don't need a freezer full of milk.  The milk you are making right now, is perfect for your baby right now.  Stashing milk is only feeding your electricity bill.  Feed your baby instead.  Enjoy your abundance together.  You are the real just in case stash.

Thursday, 9 July 2015

Foremilk/Hindmilk and Weight Gain

One of the things that women seem to worry about most is making sure that their baby feeds for long enough to reach "the hindmilk".  This is dealt with in lots of articles online but it has come up so frequently recently (particularly in combination with low weight gain) that I felt the need to add another voice.   

What is foremilk and hindmilk?
The simple answer - it is all just milk!  Your body doesn't make 2 kinds of milk.  It just makes milk.  There are no ducts which make and store skimmed milk while others store double cream, nor is there a switch that happens after feeding for a set length of time which suddenly taps into the hindmilk store and brings it online for your baby.

What happens is that as the milk sits in your breast, the fat globules stick together and stick to the walls of the alveoli and ducts.  If you have seen expressed milk you may have noticed that as it sits it develops a fat layer at the top as the fat globules stick together.  This is essentially what happens in the breast.
This means that when your baby begins to feed the first milk is higher in water and carbohydrate and lower in fat.  This is as it should be.  It is thirst quenching and all the carbohydrate is needed for the huge amount of brain development that is ongoing.  Most women have a letdown within the first 1-2 minutes of a feed.  During a letdown the ducts expand in diameter and muscle cells contract and squeeze milk (and the fat globules) down the ducts.  This means that the fat starts to get pushed down (yes within the first minute or 2 of a feed!).  As the feed continues the milk gets gradually and continually fattier and fattier as the fat is moved down.  So there isn't a point where you suddenly tap into hind milk.  There is no distinction - there is just milk.  
That is not the whole story though.  Fat content varies enormously through the day and from woman to woman.  In the morning we tend to have higher volume of milk with less fat (that's why you feel fuller in the mornings) and in the evening we tend to have less volume (that's why you worry about not feeling full) but the milk is higher in fat.  An emptier breast has higher fat content than a fuller breast (so babies who feed frequently get more fatty milk).  Studies have suggested that women with baby boys tend to have more fat content than baby girls.  Women who have been lactating for over a year tend to have more fat content that those who are newly lactating.  Women who use massage during feeds or use breast compression have more fat content in the milk than those who don't.

Why does this foremilk/hindmilk thing matter?

For a mum with a full term healthy baby It shouldn't matter at all.  Unfortunately it does matter because women worry about it and they change the way they breastfeed because of it.  They often stay longer on one side to reach the hind milk. If we can get our heads out of the way and just relax into right brain breastfeeding, follow our baby's cues and breastfeed on demand then there is no need to worry about foremilk and hindmilk.  It's doubtful that other mammals wonder about whether their baby is getting enough fat in the milk, and far fewer of them have issues with feeding their babies than humans do.  If our baby is latching well, feeding effectively at the breast and we are feeding on cue then our milk will match baby's needs and our baby will create exactly the right fat content for him by how frequently and for how long he feeds.  A baby is the only one who knows the composition of milk that he needs.

Given that the first letdown happens usually within a minute of a feed, you can see how we should be cautious about any advice to stay on one breast for [insert arbitrary number ] minutes in order to get the hind milk.  Feeds shouldn't be timed.  It doesn't make sense.  We have to get away from this idea of our breasts and babies as uniform units who all create and drink similar volumes in a similar amount of time.  We are individuals and so are our babies.  Each woman stores different amounts of milk in her breasts with an individual fat composition, and our babies have an individually shaped and sized mouth, individual muscles and create individual vacuum. One baby may take what he needs in 10 minutes and another may take 40 minutes .  The time isn't important.  What is important is that the baby is drinking well (not just sucking) when he is at the breast.  You don't need to spend 40 mins on one breast to get hindmilk if your baby drank well and cued that he was ready to swap sides earlier.

There aren't many breastfeeding rules that fit across all women - but one of them is this:  Switching sides more frequently will stimulate more milk production.  Staying on one breast and avoiding switching will lower production.  Too many mums in the early weeks stick to one breast for long periods aiming to get the hind milk, only to find that their baby has low weight.  Ironically many of these mums are trying to get the hind milk because they believe it will help with weight gain.  If you have found yourself in this situation contact an IBCLC (International Board Certified Lactation Consultant) or an accredited Breastfeeding Counsellor.  Changing the feeding pattern can get things back on track quickly with the right support.  In most cases switching more frequently increases milk supply.  The larger supply and increased amount of milk taken in by the baby then increases weight gain.

The first 5 weeks are crucial for stimulating milk production, and a mum changes from producing teaspoons of colostrum after birth to producing anywhere between 25-35 Oz a day in a few short weeks.  It's an enormous change and your breasts need lots of stimulation to meet that demand.  Sticking to one side for too long risks lowering your chances of exclusively feeding your baby.

It is the volume of milk that a breastfed baby drinks which is linked 
with growth - not the amount of fat.  

Don't be afraid to swap sides with your newborn.  If you find that you have too much milk later it is easily resolved, but building your supply after the first few weeks is harder.   Effective feeding and a good intake of milk volume is what is important for weight gain, not how much fat a baby gets in one particular feed.  Watch your baby during a feed, not the clock.

Part 2 - Hindmilk & Calories

Further Reading
A great blog looking at how milk changes through the course of a feed, complete with photos ever couple of minutes during the feed: 
Article on how milk fat content changes in human milk -

How fat content is tailored to gender and circumstance -

Is My Baby Getting Enough Milk (Jack Newman) -