Sunday, 7 October 2018

Calories and Hind Milk. Exposing the Myth with the Numbers

A few months ago I wrote a blog on Foremilk and Hindmilk.  That blog was inspired by the fact that I was frequently visiting mums of low weight gain babies who had been advised to keep baby on one side for various lengths of time in order to get the "hind milk".  There was a big focus on the hind milk being fatty and therefore important for weight gain.  I wrote the Foremilk and Hindmilk blog in order to explain how this was not actually helpful, and in fact was generally detrimental for those low weight gain babies.  I explained how our bodies do not make 2 types of milk, nor is there any mechanism to switch to some different kind of milk at some arbitrary time into the feed and how milk gets squeezed down the ducts during the muscular contractions of a letdown.  If you haven't read that blog, please have a read through it now, as this blog is devised to be an addition or part 2 to that one.

The hindmilk=weight gain myth is a very pervasive one, and I am certainly hearing of mums on a weekly basis being advised to get the hind milk to boost calories and weight gain.  Often really judgmental terms are used like "the good milk", as if the milk in the first part of the feed is somehow not good!  I want to completely expose this myth, by looking at the composition of a feed, by looking at fat variability in milk and by looking at the calories available in milk carbohydrate, protein and fat.

Fat Content
So, lets start by considering how much fat we have in human milk.  If you google, or look up a breastfeeding textbook you will probably find the figure of 3-4%, but in fact fat content is extremely variable.  It's variable depending on the time of day (lower in the morning and higher in the evening), but also extremely variable from mother to mother and depending on age of baby.  Fat content can range from 22g/L to 62g/L depending on the mother (Kent et al 2006).  To give those figures some meaning lets look at 1oz or 30ml of milk.  One mother may have 0.66g of fat in that 1 oz of milk, but another mother may have 1.86g of fat in that milk.  If we convert that to calories the mother with the lower fat content provides around 6 calories from milk fat in that 1 oz of milk.  The mother with the higher fat content provides around around 17 calories from milk fat in that 1 oz of milk.  That's a massive difference.  A few years ago I remember watching a presentation of a study looking at milk fat difference over the course of the day.  It was quite astonishing.  From memory it showed that for some women fat content might range from 3% at their lowest concentration to perhaps 7% at their highest.  Another woman in contrast might have 9% at her lowest concentration and 20% at their highest.  So one women will have more fat at their lowest concentration time of day than another at their highest. 
I can't find the study and wish I could so if anyone is aware of it, please do let me know. 
Fat also varies by sex, with boy babies getting fattier milk than girl babies.  Milk is individual to each woman and baby and that is why each finds their own feeding and switching sides rhythm.  In fact a 2002 study (Mitoulas 2002) looking at fat content in breastmilk and weight gain found that the growth rate of children in the study was not related to the percentage of fat in the milk - it was related to the overall 24 hr milk volume, not the individual composition of the milk.

The breakdown of a milk ejection
In the previous blog I discussed how a letdown or milk ejection happens within the first 2 minutes of a breastfeed.  This ejection is triggered by a release of oxytocin in response to the baby stimulating nerves around the areola.  We know from studies that on average the amount of milk which is ejected in a letdown is approximately 1oz / 30ml and we know that milk ejection (or letdown) is vital to the transfer of milk.  It is ONLY during a letdown /milk ejection that a significant amount of milk is transferred to the baby.  Research also suggests that between letdowns a baby may get very small amounts of milk - perhaps only 10ml. (Ramsay et al 2004, Ramsey et al 2006).  This means that the letdown is key.  A baby attached to the breast who never triggers a letdown, or who stays on for a long time never getting a second letdown is likely getting very minimal amounts of milk.

So, lets look at how a letdown or milk ejection works.  For the purposes of simplicity, lets think of the breast like a cluster of grapes or berries on a plant (much like the picture here).  The grapes are like the alveoli in our breasts.  The alveoli are little balloon like sacs which make and then contain the milk until it is removed by breastfeeding or expressing.  Coming out of each alveoli is a little ductule tube (like the stalk on the grape) and these small ductules join together into larger ducts (like the grape stalks join into a larger main stalk) and these larger ducts lead to the nipple.  Around each of the alveoli /grapes in the breast we have a tiny network of muscle cells latticed over it - almost like a spider web over each grape, and these muscle cells are key to the letdown. 

When a baby is at the breast the suckling causes us to release a surge of oxytocin.  Most people who are familiar with pregnancy associate oxytocin with the muscular contractions in the uterus, but oxytocin does the same thing with the muscle cells around the milk alveoli.  It causes them to contract and push the milk out of the alveoli into the duct.  In addition to this the ducts dilate (or get wider) in order to  facilitate a fast flow of milk.  It is these changes that women normally feel when they feel warmth or tingling during a letdown.  It is also this surge of oxytocin which causes those afterpains when breastfeeding as the uterus is contracting back down after birth.  A milk ejection lasts a very short time, often just a couple of minutes and then it's over.  So the baby gets a good quantity of milk during this 2 minutes and then is back to very little milk transfer.

Up to 45% of the milk available in the breast is released during the first milk let-down (Ramsay et al 2006).  If we include the time it takes to trigger the letdown and the time that the contractions are happening, this generally will take less than 5 minutes.  So take that in - up to 45% of the milk available is likely released to the baby in the first 5 mins.  As letdown/milk ejection is hormonal it affects both breasts at the same time.  This means that the breast the baby is not latched to also has milk squeezed down the ducts.  Many women will notice leaking in this other breast, and this is also how passive collection bottles that attach to the other breast work to collect milk - the little bit of vacuum they create works in combination with the letdown/milk ejection pushing milk to the nipple.  Even when leaking doesn't happen the milk will still have been squeezed down the ducts and be sitting close to the nipple area ready for feeding.  Over time, if this milk is not removed it will migrate back up the ducts into the alveoli.  This is a crucial point when we talk about why switch nursing works to increase milk intake!

Once breastfeeding is established and a baby is drinking a full supply of milk (around 6 weeks), on average a woman will have 3-4 milk ejections at each feed.  If we think that a full supply is around 800ml of breastmilk, and a baby will feed approximately 8-12 times a day we can see that the numbers fit very nicely together.  If we assume that a milk ejection is around 30ml and it happens 3 times in a feed  (90ml), then over 8 feeds the baby would get 720ml.  These are obviously approximations and women can have different milk production, different capacity for milk storage and different patterns of milk ejection but it helps to illustrate the point about the importance of the milk ejections.

We only get a milk ejection in alveoli which are full.  Alveoli which are full, will eject their milk when we get that oxytocin burst.  Think of a full squeezy bottle, and how a little bit of pressure causes the contents to squirt out.  Now think of that squueezy bottle only a third full and how that little bit of pressure no longer has much of an effect.  We need to squeeze much much harder to have the same ejection effect.  Similarly in the breast, we don't get a milk ejection in partially full alveoli. 

Low Milk Supply & Milk Ejections
That takes us on to the issue of low milk supply, milk ejections and swapping sides.  Usually I find that this advice about staying on one side is given to mums around 2-3 weeks if their baby is not back to birthweight.  The fact that baby is not back to birthweight at that stage tells us that something is already slightly slow about the amount of milk the baby is drinking, and if a baby isn't drinking enough or stimulating the breasts well, then milk production doesn't rise sufficiently.  We can assume that these mums need a little help in getting more milk production underway.  At 2-3 weeks a baby is, on average, drinking around 60-90ml per feed  (600-750ml per day) in order to gain appropriately.  Otherwise healthy babies who are not at birthweight at this age are not drinking this amount of milk and that is why the gain is slower than average.

What I typically see in practice is that those babies are going to the breast, perhaps taking a little longer than average to trigger a letdown, the letdown is shorter than average, and a lot longer between letdowns.  This is simply a function of how much milk is in the breast (how many alveoli are full of milk) and how quickly milk is being created.  The baby simply falls asleep after the first letdown, or stays attached and sucks on and off but never gets a 2nd letdown.  If they fall asleep and unlatch they typically wake a very short time later -maybe 10-15 mins later and want to relatch as they are still hungry - but if put back to the same breast they don't trigger a letdown and suck for a short time before falling asleep again.  These babies have a constant cycle of feeding, but never seeming totally satisfied.  They may be feeding for what seems like all day.  Even more worrying are the babies that fall asleep and are very hard to rouse for another feed.

So does sticking to one side help or hinder calorie intake in these babies?  Well, again, it's all about the letdowns.  Let's take 2 scenarios  - the 1st is where mum sticks to one side to get the hind milk.  The 2nd is where we switch nurse - as I've suggested on this blog on low weight gain.  For the purposes of the scenarios we'll assume that in both cases the amount of milk the baby drinks before the 1st letdown is 10ml, and that in each letdown the baby gets 30ml.  We'll assume that between letdowns the baby transfers only 10ml.  We'll work with the average fat content of 4% in the first letdown on either breast, and we'll assume a fat content of 6% on the 2nd letdown on either breast.  We'll assume that 10ml "foremilk" before the first letdown has a fat content of 3%.  Yes these numbers are a bit contrived and it wouldn't work like this in practice where fat would gradually increase through the feed, but it will allow us to illustrate a point. 

SCENARIO 1 - Staying on 1 Side
10mls of "foremilk" at 3% = 0.3g of milk fat = 2.7 calories
30mls from 1st MER at 4% = 1.2g of milk fat = 10.8 calories
10mls between MER at 5% = 0.5g of milk fat = 4.5 calories
Baby then falls asleep during this period of drinking (so may in fact not get 10mls but we'll work with that figure)
Total calories from milk fat here - 18 calories
Total quantity of milk = 50ml
7% carbohydrate = 3.5g = 14 kcal
1% protein =0.5g = 2kcal
TOTAL calories = 34 kcal

SCENARIO 2 - Switching sides once
10 mls of "foremilk" at 3% = 0.3g of milk fat = 2.7 calories
30mls from 1st MER at 4% = 1.2g of milk fat = 10.8 calories
Mum swaps sides.  Milk is already near the ducts and so baby starts drinking straight away
30mls from 1st MER (2nd side) at 4% = 1.2g of milk fat = 10.8 calories
Total calories from milk fat - 24.3 calories
Total quantity of milk = 70ml
7% carbohydrate = 4.9g = 19.6 kcal
1% protein = 0.7g = 2.8kcal
TOTAL calories = 46.7kcal

So swapping sides just once has provided over extra 30% of milk volume and around the same percentage in calories.

In the previous blog I actually suggest swapping a 2nd time to try to get a 3rd letdown.  This is because swapping once the flow slows on that first breast often keeps the baby awake because he/she gets instant flow on the other side.  Young babies really respond to the flow of milk.  If milk is flowing they drink if they are hungry.  If the milk slows down they fall asleep.  After 2 letdowns a baby may be full and go to sleep full and contented, sleeping for a full sleep cycle rather than a few minutes, or if not yet full they have the energy reserves to work for a short time to trigger that 3rd letdown - which will now be much higher in fat.  A young baby may not want the 3rd letdown or may take a small amount and come off full, but just to illustrate let's look at how that 3rd letdown increases the figures in addition to the 46.7kcal above.

Mum swaps sides for the 2nd time
10mls between MER at 5% = 0.5g of milk fat = 4.5 calories
30mls from 2nd MER at 6% = 1.8g of milk fat = 16.2 calories
Total calories from  milk fat now - 45
Total quantity of milk = 110ml
7% carbohydrate = 7.7g = 30.8 kcal
1% protein = 1.1g = 4.4 kcal
TOTAL calories = 80.2 kcal

As this demonstrates - yes, fat content increases as the feed goes on.  Yes, if a baby drinks more from one side they will get more calories BUT a low gaining baby doesn't actually do this.  A low gaining baby falls asleep after the first letdown so simply doesn't get these extra calories.  Babies will stay latched when sleeping.  They will suck lightly and may look like they are feeding, but they are not because they are not swallowing, or at least not in any volume.  Unless they trigger a letdown they just aren't getting much volume of milk.
A mum's milk supply is based entirely on how much milk is removed so the more letdowns a baby drinks, the more the mum's milk supply is stimulated and the more milk she produces.  This is why switch nursing moves a low gaining baby very quickly from that low gain pattern into a normal gain pattern, and once they are gaining appropriately (so we know mum's milk supply is now ok) she can stop actively managing the switch nursing and instead allow the baby to determine when it's time to stop. 

I hope this has made sense.  I don't think I can make it more clear than this  - the idea of staying on one side longer to get the more calorie rich milk simply isn't appropriate for a baby who isn't gaining weight well.  It will work for a baby who is already gaining appropriately and a mum with a good supply (although the baby may complain as he/she wants faster flowing milk), but it won't work for a baby who is already having difficulties with getting enough milk.  In practice it doesn't help the weight gain and creates a never ending cycle of feeding, which frankly isn't sustainable for either.

Please let's stop telling mums to stick to one side to increase weight gain.

Further Reading

1.  Kent et al 2006 Volume and frequency of breastfeeds and fat content of breastmilk throughout the day PEDIATRICS 117(3):e387-95

2.  Mitoulas et al 2002 Variation in fat, lactose and protein in human milk over 24h and throughout the first year of lactation The British journal of nutrition 88(01) 


4.  Ramsay et al 2004 Ultrasound imaging of milk ejection in the breast of lactating women.   2004 Feb;113(2):361-7.
5.  Ramsay et al. 2006 Milk flow rates can be used to identify and investigate milk ejection in women expressing breast milk using an electric breast pump.   2006 Spring;1(1):14-23.

6.  Gardner et al 2015 Milk ejection patterns: an intra- individual comparison of breastfeeding and pumping . 2015; 15: 156.

7.  Bergman 2013 Neonatal stomach volume and physiology suggest feeding at 1-h intervals.  
 2013 Aug;102(8):773-7. doi: 10.1111/apa.12291. Epub 2013 Jun 3.

Saturday, 25 August 2018

Experiences of Tongue Tie Treatment in Northern Ireland

As an IBCLC (International Board Certified Lactation Consultant), I work a lot with tongue tie or anklyglossia and deal with many families who come to see me because they suspect a tongue tie.  I may be educating families about tongue tie, working through complex breastfeeding issues that aren't resolving through basic support,  assessing a baby's tongue movement during a consultation, referring babies to a surgeon / tongue tie clinic, or helping with breastfeeding after the tongue tie has been released.  More and more however I find that I am being contacted by parents who have already had a tongue tie released, but their experience has been that the release has not resolved their problems.  Also more and more I hear that these babies have been referred "just in case" there is a tongue tie, or because "there may be a slight tie".  I have also heard from parents who tell me their baby's "tie " was snipped even though they were having no breastfeeding difficulties, breastfeeding was comfortable, baby was content and gaining well.  All of this concerns me in how tongue tie is being assessed, treated and followed up, so I decided to try to get some feedback from parents about their experiences of tongue tie treatment in Northern Ireland.

Before we go into the experiences it's important to state that tongue-tie (anklyglossia) is a condition which can cause enormous problems for breastfeeding, and even for bottle feeding and eating solids for some babies.  It affects somewhere in the region of 3-10% of babies (most studies put it at around 3-5%), and has a genetic basis so we often see it run in families.  A tongue tie occurs when there is an abnormal frenulum (piece of issue below the tongue)  which prevents the tongue from moving properly.  A frenulum is NOT a tongue tie.  A frenulum is normal and almost all of us have a frenulum, and its job is to stabilise the tongue.  A tongue tie only exists if the frenulum is abnormal, and that can only be determined by an assessment to see how the tongue moves rather than just looking at whether a frenulum is present.  Without a correct assessment a normal frenulum can be misdiagnosed as a tie.  Please see my earlier blog on the difference between a normal frenulum and a tongue tie, and the kind of assessment needed.

In Northern Ireland we have approximately 25000 babies born each year.  Around 50% of those begin breastfeeding - so around 12500 babies.  Currently NICE guidance is only available to treat tongue tie in babies who are breastfeeding, so we might expect somewhere in the region of 375 - 1250 of those babies to have a tongue tie.  It is my understanding that over 3000 babies a year are currently being treated.  If anyone can get me exact figures on this, I'd love to see them.
Two weeks ago (August 2018) I created a survey to ask parents for their experiences of tongue tie assessment and treatment in Northern Ireland in the last 2 years.  I collected 295 responses, and this is a summary of the data.  I present a summary of the data below with some explanation of what is happening in practice.

The Survey

QI - When was the baby referred or diagnosed?  Diagnosis of a tongue tie can only medically be given by the surgeon / practitioner who performs tongue tie release procedures (frenotomy), so although a midwife / HV /  IBCLC may be able to assess, to state that tongue movement is restricted and to refer for a procedure, they cannot actually diagnose.  This is why the question states referral / diagnosis separately.  In NI the length of time between referral and seeing the tongue tie clinic should only be a few days.  Two tongue tie specific clinics currently exists, one within the Northern Trust, situated within Antrim Hospital, and one in a Belfast clinic serving the rest of the trust areas.  I am aware that a very small number of  people are referred through ENT and this is often a much longer process due to waiting lists.  A smaller number again, may see an ENT surgeon privately through private hospitals.  The vast majority of babies are currently referred in the first 2 weeks (over 50%).

Q2 - Did you see a lactation consultant or breastfeeding specialist for assessment and support?  NICE guidance on ankylglossia states that "breastfeeding is a complex interaction between mother and child, and that many factors can affect the ability to feed. Skilled breastfeeding support is an integral part of the management of breastfeeding difficulties."
HVs and midwives do not have the same training in resolving breastfeeding difficulties or in tongue tie assessment as a specialist, such as a community based IBCLC or hospital breastfeeding coordinator, and a referral pathway exists to specialists if issues are not resolving through basic breastfeeding support.  Private IBCLCs are also available in the community.
The survey results showed that almost 60% of breastfeeding dyads were not seen by a breastfeeding specialist.

Q3 - Who made the referral for treatment?  Referrals can be made to most NHS tongue tie clinics by a midwife, HV, GP or an IBCLC.    Referrals through ENT generally come from HV/ GP or midwife.  Some surgeons also offer a private service and parents may choose to self refer to a private surgeon.
The survey showed a mixed result for this.  The majority (almost 40%) came from a midwife.  This ties in with the fact that most babies were referred in the first 2 weeks, as women generally continue to be under the care of community midwives for the first 10 days postpartum.  A further almost 30% are referred by a HV (who usually takes over care at around 10 days).  The figures I find most interesting here are the fact that 42% of babies see a lactation consultant /breastfeeding specialist but only half of those babies are actually referred by a lactation consultant/breastfeeding specialist.  I see 2 possible causes for this - but am interested in feedback for any different reasons.  The 2 causes for this that jump to mind are: 1) that the lactation consultant / breastfeeding specialist who saw the baby did not believe there was a tongue tie or a need to refer; or 2) the baby was seen at the tongue tie clinic by a lactation consultant / breastfeeding specialist.  This 2nd option is undoubtedly the case at the Antrim clinic where an IBCLC undertakes the procedure, but I'm not aware of breastfeeding support at any other clinic locally.

Q4 - Did you receive follow-up feeding support?  The NICE guidance for treatment of ankyloglossia  emphasises the importance of support by referring to a study which found that 95% (19/20) of babies who had support from a lactation consultant had improved breastfeeding 48 hours after tongue- tie division, compared with 5% (1/20) of babies in the control group (p < 0.001). (Hogan 2005).  In the survey I suggested that this support may come from either the clinic or the person who referred, and I did this because there are very different services offered in different clinics.  Best practice would be that a surgeon /practitioner either has breastfeeding support experience or works with an IBCLC/breastfeeding specialist to provide this.  This follow up may be different in different clinics.  With regards to breastfeeding - for those who were given good support before hand, given clear expectations and a plan to work on after the procedure, it is likely that something like a phone call to re-iterate the plan and check progress against it may be enough.  For others it may require more intensive in person support.  From a medical/surgical perspective the surgeon/practitioner may want to follow up for his/her own information on the results of the procedure.
The survey found that disappointingly almost 60% of people felt that they had no follow up feeding support whatsoever.  It may be that there is a gap here that people are falling through.  It may be that some HVs/midwives/GPs who refer believe that there will be breastfeeding support and follow up provided at the clinic in the same way that if you refer to physio or orthopaedics for example, that team takes over the care.  In practice however, it is my understanding that only the Antrim clinic has staff trained in breastfeeding, and the other clinics are essentially surgical clinics only.

Q5 - Were you told how feeding might be affected by the procedure - essentially I was asking about expectations going into the procedure.  A tongue tie release can often be presented as an instant "fix" to breastfeeding problems, however in my experience this is not the case in practice.  In reality for most
babies there are still issues to work through, and feeding may actually get worse temporarily.  Understanding what typically results from the release is vital to setting expectations.  There are also many variations of anatomy and some babies are likely to have better results than others from the procedures, and this is important to discuss also.
The survey found that experiences were almost 50/50 with only 54% having been told how the surgery would affect feeding, and 46% who were not told.  This seems quite surprising given the the surgery is presumably being undertaken due to feeding difficulties?
Some of the comments showed that quite unrealistic expectations had been set or that nothing was discussed:

"I was advised that my daughter should be able to latch straight away. It took a further 6 weeks of 2 hourly expressing before she latched"

"It was assumed feeding would be magically fixed"

"Absolutely nothing before or after... absolutely distraught"

"Just that she will need to learn to feed again"

Q6 - Was the tongue assessed by function and appearance (best practice) or appearance only.  Again the difference is dealt with in details in this previous blog on a tongue tie versus a tongue frenulum

Research suggests that we can only accurately assess using both function and appearance as this is the only way to tell whether a frenulum is normal or abnormal.  Without this functional assessment we risk carrying out procedures on babies who do not need them.
41% of people felt that their baby's tongue was assessed by function and appearance (best practice).  The larger number (almost 50%) however felt that it was assessed on appearance only.  9% may have been unsure and chose to comment instead.  These comments suggested that the parents felt that no real assessment had been done, or they felt unsure of what kind of assessment had been done, e.g. 

"Neither!! Just cut and told to go into the next room to feed my baby"

"Unsure how assessment was done ... a finger in the mouth I think"

"Appearance only but could see that the tongue didn't go passed bottom lip also but no thorough assessment completed"

"Not sure about this actually"

Q7- Did you feel your baby was in pain following the procedure?  We're sometimes not very good at distinguishing when a baby is in pain.  As late as the 1980s we actually conducted open heart surgery on infants without anaesthesia as it was believed that they didn't feel pain.  It is just horrific to think of now.  Some babies sleep through scissor tongue tie release so it may be reasonable to assume that those babies don't feel any significant pain during the procedure.  Others are clearly very distressed at the procedure and continue to be so afterwards.  A 2004 study found that 85% cried for approximately 20 seconds and that 0.5% seemed to be in pain for 24 hrs (Griffiths 2004).  My survey found that 75% felt their baby was not in pain afterwards, 17% felt there was a little pain, and around 7% felt their baby was in moderate pain or a lot of pain.

Q8 - Did the procedure resolve the feeding difficulties that it was designed to resolve?  The survey found a very mixed bag here.  Almost 15% felt that the procedure made no difference whatsoever.  This is a very high number and the possibilities here are that: 1) the issue wasn't caused by a tie and the frenulum was misdiagnosed; 2) the tie wasn't adequately released.  With the 2nd option here you normally see some kind of a change in feeding however.  Re-attachment also would typically cause an initial improvement, but these families saw no difference.  Almost 50% found that all the problems resolved in the weeks following the procedure.  Nearly 5% had  some improvement but required a second procedure which resolved the problems.  This may have been due to incomplete release.  22% had some improvement.  There is no way to tell from the survey if these babies were reassessed in order to see if the tie had been completely released, or whether they had a good surgical outcome and the remaining problems were unrelated to the tie.

Q9 - Did the procedure make any difference to the decision to breastfeed or bottle feed?  36% of people felt that the procedure was vital to allowing them to continue breastfeeding and they would have weaned without the procedure.  6% felt that the procedure was not effective and therefore they weaned
to formula due to the feeding problems.

Q10 - In this question I asked if the families felt informed and supported throughout the entire process of assessment, the procedure and afterwards.  The survey showed a very mixed experience here again.  Only 46% felt that they were given adequate information and support throughout with 54% feeling they
were not.  The comments expanded on this, e.g.

"Didn’t have this, was referred, got it cut, end of story. No follow up etc"

"I researched myself for info. Am now expressing and bottle feeding as milk transfer poor and baby prefers quick flow of bottle. Gutted."

"Verbal consent wasn't even taken on reflection. A truly horrible experience"

"I knew a tongue tie could effect feeding, however my baby fed brilliantly from the first day, she never really even lost any weight. I was told the tongue tie may effect her speech in years to come."

"I was told at birth he had a tongue tie and that was it"

"I haven’t felt supported at all, only that this could be the reason he’s not feeding well so let’s have it done and it might or might not help!"

Best Practice

Overall I think what has come through in the survey consolidates what I am seeing in practice with clients, and clearly shows there is a lot of improvement that is needed in order to provide babies and their families with the care that they deserve.  Best practice tells us that where there are breastfeeding difficulties which are not resolving through basic breastfeeding support, that mother and baby should be seen by a breastfeeding specialist (IBCLC, breastfeeding coordinator etc).  If support is given by them and a tongue tie is suspected, the tongue should then be assessed on both function and appearance.  In this way there should be a good identification of the tongue being restricted in some way.  Referral can then take place.  The clinic ideally will work with an IBCLC and will provide follow up support afterwards.
To look at how this affects the results I then filtered the survey to look at only the following cases:

Baby was seen by an IBCLC/breastfeeding coordinator (Q2 answered Yes)
Baby was referred by an IBCLC/breastfeeding coordinator (Q3 answered Yes)
Tongue was assessed by both function and appearance (Q7 answered Yes)

This gave a sample of 36 babies.  In this sample 75% received follow up after the procedure (as opposed to less than 45% in the whole survey.  86% felt that they were given information about what to expect after the procedure (as opposed to 54%).  Only 6% felt that the procedure made no difference (as opposed to 15%).  I think this is a very stark difference - 2.5 times of a difference, and again consolidates the research that being seen by a specialist and assessing by function and appearance will better identify whether there is a tongue restriction and whether surgery is likely to make a difference.  42% said that it allowed them to keep breastfeeding and they would have weaned without the procedure (as opposed to 36%).  This may reaffirm that IBCLCs/breastfeeding specialists are seeing more complex issues.  Only 3% weaned to formula as the problems weren't resolved as opposed to 6% of the entire sample.  Again this is very dramatic that following best practice meant that half as many people stopped breastfeeding.  70% of the sample felt that they were given adequate information and felt supported throughout (as opposed to 46%).  To my mind, 70% is still very low, but it's still a big improvement.

I wanted to publish this survey in order to give some feedback to those who had participated.  I have tried to keep my analysis as objective as possible.  No comments have been included that personally identify any clinics, or healthcare staff.  Overall however the survey does reaffirm my concerns that we are not adequately supporting breastfeeding families around tongue tie, either through providing access to specialised support, or through assessment and treatment of tongue tie.
The stats are better if you push for best practice however.  So ask for it.  If you are having problems that are not resolving through midwife/HV support it is advisable to see a specialist.  Voluntary breastfeeding groups such as La Leche League have highly trained counsellors.  They will not be able to assess a tongue tie but can provide high quality breastfeeding support and will tell you if you need further assessment or support.  Within the NHS you can see the community lactation consultant if there is one in your area, or the hospital breastfeeding coordinator.  The gold standard is to see an IBCLC who can provide the highest quality care, and they are available both in the NHS and in private practice.

Through this blog I have also linked my previous blogs on tongue tie assessment, other causes of tongue dysfunction and what to expect following release.  These contain some of the information that I provide to my clients around tongue tie.  As a region, we need to do a better job at supporting families around tongue tie so that only babies who need the procedure get it, those who get it get good information and that everyone gets the best breastfeeding support possible. 

Sunday, 15 April 2018

How much milk does a breastfed baby drink in first week? Your body may be producing much more than you think!

Most people are familiar with the fact that in the very first days after birth small
quantities of colostrum are produced, and babies are therefore drinking small volumes.  Many of us have seen "belly balls" in antenatal classes or online sites, which often have a small marble representing day 1 and something like a ping pong ball for day 10.  The balls are usually described as representing the size of a newborn's stomach, and the small size of the ball and stomach is emphasised in order to reassure new parents that their newborn needs very small amounts of milk.  The aim is to reduce the concern of not enough milk.  These visual aids can be very helpful for reassuring parents in situations where everything is actually going well.  They can be helpful when milk volume is progressing as it needs to and weight gain is proceeding as expected, but the parents are questioning low supply as they weren't prepared for how frequently a breastfed baby may feed (most of us aren't).  The balls can illustrate the size of a feed and how a baby needs to keep feeding frequently.  On the other hand however if breastfeeding isn't going well, weight is continuing to drop or isn't increasing as expected after birth, the image of the small balls can be misleading as they don't always get across the message of just how rapidly we expect milk production to increase, and how milk intake increases by a significant amount every day over the first 10 days.

Without a sense of this rapid increase, a mum who has been advised that her baby isn't gaining well can be very confused if her HCP advises that she should give a certain volume of supplemental milk (ideally expressed milk) which to her seems much larger than the marble she may have in her mind.  In consults I've met women who had been advised they needed to increase supply but were contacting me as they felt their supply was fine, due to the fact that they could always express some milk.  When we discussed the volumes expected by day x the mums' were sometimes quite shocked at the volume expected and it allowed them to make sense of the advice given.  Of course there are also cases where parents are advised to give large supplements which aren't needed, and in any case where low weight gain is an issue, the first step is to evaluate and improve feeding.  Poor weight gain is an indicator of a feeding issue to be resolved, and although supplementing may be part of the solution, it is also sometimes suggested where not needed.

The purpose of this blog isn't to detail where and when supplements might be needed or how they should be given - those situations are as individual as each family.  This blog is designed to give an overview of how much milk a mum can expect to produce if a baby is drinking well over the first 10 days, or how much she can roughly expect to express (if exclusively expressing), and perhaps to make some sense of the volumes that parents may be asked to supplement.

Stomach Volume and Intake
This is where we first have to address the issue of the shooter marble at birth and some misconceptions around it.  The marble is used to illustrate a volume of around 7 ml, as research suggests this is an average volume in  a typical feed of colostrum may on day 1 [1].  

This 7 ml is the size of a feed, i.e. the volume of colostrum typically consumed.  It is not the size of a newborn baby's stomach.  In fact a newborn stomach is more likely to be around 20ml according to Nils Bergman's research [2].  A feed of colostrum does not fill the stomach to capacity at birth, nor does it provide the full energy requirements of a baby on day 1- but it is not designed to.  A baby is born with a store of glycogen to use as an energy store.  After birth hormones are released in order to liberate the glycogen store to provide the baby with extra energy.  It is estimated that 70% of the glucose requirements for the brain are met by this glycogen with the remainder coming from milk feedings and also from ketones in fat stores [1].  This is why a baby loses some weight after birth.  Again, it is by design that the fat stores are used to provide energy for the first day or 2, until larger volumes of milk are being produced and consumed.  Whereas some might suggest that babies should be given formula in order to ensure all their energy requirements come from a food source and therefore not have such a drop in weight, the research suggests that this actually affects their ability to access alternative sources of fuel, such as ketones, in their own body ([3][4][5]).

"As part of a newborn's natural adaptation from womb to world, in addition to usig his glycogen stores for bain fuel, he can access other fuel sources, such as ketone bodies and lactate.  Giving formula, however has been found to suppress a baby's ability to use ketone bodies for fuel.  The more formula he consumes, the less he can access this alternative fuel"
Nancy Mohrbacher - Breastfeeding Answers Made Simple [6]

This actually has a long term effect.  Although formula fed infants do use less fat stores, and therefore lose less weight, research has found that formula fed babies who gain significantly more weight in the first week than breastfed babies are at greater risk of obesity several decades later.  The researchers suggested that this first week was a period of "chronic disease programming"  [7].

Over the course of the first day intake could vary significantly depending on how often a baby feeds, and how well each feed goes.  Babies can be quite sleepy after birth perhaps due to labour drugs or birth interventions, and whereas one baby may only be feeding 6 times in that first 24 hours, another baby with a straight forward birth who doesn't have separation from mum and is held skin to skin may feed 12 times or more.  Those babies can clearly be taking in quite significantly different amounts of milk.  Research shows a range in the first 24hr of 7-123 ml [1].  These are hugely different calorie intakes.  Allowing calories of 53.6 kcal per 100ml in colostrum  [8] a baby taking in only 7ml over a whole day is receiving just under 4 calories from food.  A baby taking in 123ml is receiving about 66 calories.  Those 2 babies will have very different demands from their glycogen and fat stores to make up the required calories.  Walker lists the average colostrum intake over the first 24 hours as 37ml.  The more frequently that a baby feeds in the first 24 hours the more calories are available to baby, less fat stores are needed, and thus weight loss reduces.

Day 2

In the days following birth the level of progesterone in the body from pregnancy drops.  This increases the volume of colostrum.  On day 2, milk intake is much higher than day 1.  One study details an average of 185ml over day 2, with a lower range of 12ml and an upper range of 379ml [9].    This would be an average of perhaps 15-20 ml in each feed.  Another Dutch study listed in Walker's book [1] placed the day 2 intake at 44 - 335ml with an average intake of 14ml at each feed Milk production has effectively doubled between day 1 and day 2.

Day 3

It is common for milk volume to increase significantly around day 3.  In lactation texts this is referred to as "the onset of copious milk production" or "secretory activation".  Many people refer to it as "milk coming in".  At this stage progesterone has dropped to a level that allows the walls of the breast ducts and alveoli to become more 'watertight' and to contain more milk (discussed more in this previous blog).  Milk volume increases dramatically from this point onwards.  Average milk intake on day 3 is 408ml [1] with a lower range of 98ml and upper range of 775ml), which may work out as approx 30-50ml in each feed, again effectively doubling from day 2.  At this stage women often feel their breasts as being much fuller and often start to become aware of having milk ejections (or letdowns) while feeding.
Although it is common for milk to come in on day 3, it can be delayed by a day or 2 for many reasons.
Milk volume is also affected by whether it is a first baby or a subsequent baby.  One study found that women who had previously breastfed were around 1 day ahead of first time mothers in terms of milk volume, producing 142ml more on day 3, so volumes can vary stubstantially.

Day 4

Day 4 sees another increase to an average of 625 ml a day [1] (lower range 378 ml and upper range 876 ml), which may be around 50-70ml in each feed if you assume 8-12 feeds a day.  Nils Bergman however suggests that a physiological feeding pattern is for a newborn is to feed roughly once an hour taking around 20-30ml in each feed.  This would give a similar volume of around 600ml.  The amount of milk a mother has on day 4 is predictive of her milk supply going forward (unless there is an intervention to change volume).  One U.S. study looking at exclusively expressing found that milk volume on day 4 was predictive of milk volume at 6 weeks [10], so a good supply on day 4 is a good prediction of good volume weeks later.

Day 7

"When breastfeeding is going well, by the end of the first week, a mother's milk production has increased from an average of 37ml to 56ml on the first day to a mean of 610ml per day by Day 7"
Nancy Mohrbacher - Breastfeeding Answers Made Simple [6]

This average on day 7 is lower than the average on day 4, but this may simply reflect that more women are producing around 600ml by day 7, and there isn't the large upper and lower range difference.

Milk volume continues to increase after day 7 to around 800ml a day which would be considered a full supply.  Some women may be producing 1000ml or more, and obviously those feeding twins or other mutiples will be producing significantly more if breastfeeding exclusively.

Making Sense of Weight Loss / Gain

This is quite incredible when you think about it.  The birthing body changes from producing around 1 oz of colostrum over the course of day 1 to over 20oz 1 week later.  If breastfeeding is going well and you are simply putting baby to the breast on cue women often have no idea of the large volumes of milk they have suddenly started producing in such a short time frame.  Conversely, because this isn't often talked about, women who have perhaps not had the best start to breastfeeding, and are expressing in the first week often don't have any idea of how much milk they should be getting when expressing, or how much their baby needs.

It's also only when you consider the incredible change in volume in the first week that we can often start to make sense of volumes that are suggested when giving milk from bottle / cup /syringe etc.  If a baby is not latching on day 5 and a HCP suggests giving 60 ml of milk (ideally expressed breastmilk) every 3 hours, this can seem like a large amount for a baby born only 5 days ago if your memory holds an image of a shooter marble.  It's only when you consider that a baby may be drinking 20oz on day 5 that this makes any sense.

As the studies show, the milk intake can vary massively from baby to baby.  A woman who has breastfed before, who had an uncomplicated birth, baby latches well and is feeding frequently may be producing significantly more milk in the first few days than a first time mother who had separation from baby after birth, is having problems with baby feeding, and/or there is infrequent feeding.  Birth weight will make a difference too.  A 9lb baby is going to have different energy requirements than a 6lb baby, and will therefore have different milk needs.  A 9lb baby may indeed be drinking 600ml of milk on day 5, and a 6lb baby may be drinking 500ml.  Both may be having their calorie needs met.  In contrast though a 7lb baby who hasn't been breastfeeding well and is drinking less than 500ml of milk on day 5 may be losing weight, or at least not gaining weight.

All of these factors can lead to very different pictures of weight loss and weight gain after birth.   We do expect babies to lose some weight after birth, due to using up fat stores.  They will also lose some weight due to fluids, and if a mother was given IV fluids during birth this may increase weight loss.  This is normal and expected and in breastfeeding forums I often see conversations about weight loss of up to 10% being ok.  This is both true and not true.  It's true that weight loss of over 10% requires intervention, but it's not true that weight loss of 9 or 10% would be considered average and therefore we shouldn't be concerned about it.  The average weight loss of a baby is 5% - 7% with the lowest weight occurring around day 3 or 4 - essentially just before "milk comes in".  According to the Academy of Breastfeeding Medicine:

"Although weight loss in the range of 8–10% may be within normal limits if all else is going well and the physical examination is normal, it is an indication for careful assessment and possible breastfeeding assistance. Weight loss in excess of this may be an indication of inadequate milk transfer or low milk production, but a thorough evaluation is required before automatically ordering supplementation"
Academy of Breastfeeding Medicine Clinical Protocol #3 [11]

Once milk comes in and babies are drinking larger volumes weight should start to increase.  This previous blog on weight gain discusses the expected pattern in detail, but in short a baby is expected to gain around 30g a day from this point, with 20g a day being the lower end of normal.  A baby who is gaining under 20g a day is also considered at need of intervention.  That intervention may be correcting positioning and attachment so that a baby gains better.  It may be feeding more frequently and/or swapping sides more frequently.  It may be expressing to increase milk supply and topping up feeds with the expresssed milk.  In some cases it may be using supplemental donor or formula milk temporarily while building up supply by feeding and expressing.


There were a few things that prompted this blog.  I've been mulling it over for a few months as I frequently find the same conversations popping up in breastfeeding forums.  Conversations where a HCP has suggested top ups (say 50ml) for a baby who isn't gaining as expected and some reply to say that babies have tiny stomachs and don't need this volume.  Others comment to say that giving that amount of top up will decrease her milk supply.  While both of these may be true in some situations, they are not in others.  A 2 day old won't need milk feeds of 50g.  Giving a 4 day old baby 50ml feeds of a milk other than mum's milk without building or sustaining her milk supply will impact milk production.  A one week old baby who is gaining 15g a day probably doesn't need 50g topups after each feed either - optimising breastfeeding would likely be enough to shift that baby into normal range.  On the other hand, a baby who is 10 days old, hasn't gained any weight since birth, is sleepy, is 11% below birth weight and a breastfeeding assessment shows very little milk transfer at the breast may need that much larger supplement while the breastfeeding problem is resolved and mum works on increasing milk production.  Each situation is very different and breastfeeding parents are often quite unaware of just how much milk their baby needs to regain birth weight or how quickly the volumes should increase.  I often see other conversations on forums or talk to parents who feel they have plenty of milk because they can express 30ml.  That 30ml expression may be a sign of great supply on day 3 or 4.  It may also be a good sign at 3 weeks immediately after a good effective breastfeed,  but is much less reassuring at 3 weeks if expressed 2-3 hours after the last feed/expression particularly in conjunction with a baby who is gaining perhaps 2 oz a week.

So I suppose the takeways I want to get across with this blog are these:
Yes colostrum is in very small quantities in the first day or 2 but it ramps up extremely quickly if all is going well, and consequently the amount that a baby drinks ramps up very quickly too.  We do expect a baby's weight to drop after birth, and it is by design, but by day 5 a baby should be gaining weight and ideally should gain at around 30g a day and to do this there needs to be significant milk intake.  The earlier and more frequently a baby breastfeeds in the early days the better this will be for milk production, which is why mothers are encouraged to start expressing early and often if their baby is not latching.  This blog is not meant to scare people about volumes.  I can understand why someone may be sitting in a hospital on day 1 reading this with a non latching baby, worried about only being able to express one ml at each expression session.  To you I want to extend reassurance.  Often parents are told to express and feed every 3 hours, but as I explored in a previous blog - this means at least every 3 hours.  If you express 1 ml every 3 hours you might get 8ml over the course of the day.  If you express every hour however, you may get closer to 24ml (remember the lower range found in the study above for day 1 was 7ml so it is also normal to have less).  The more you express, the better stimulation you provide and the better your milk volume will be on day 2 and day 3 etc.  Once your milk comes in around day 3, you will also likely find expressing much easier.
If your baby is at day 6 or 7 and isn't yet gaining weight you will likely be advised to start expressing in addition to breastfeeding to help raise your supply.  The volumes I have mentioned above of 600ml a day at 1 week may seem enormous when you look at your expressed milk.  The good news is that milk production really does ramp up extremely quickly when given the right stimulation.  If your baby didn't manage to get all the stimulation needed in the first few days then expressing can resolve that.  Hormones are primed for milk production in the first couple of weeks, and getting an expressing routine going can turn things around entirely in a few days.  Just as an effectively feeding baby can build milk production from a few mls to 600ml in a week, so can a pump.  The first 2-3 weeks are the easiest time to very quickly build milk supply to volumes that are needed, and sometimes expression is needed for a baby who didn't get the best start and isn't feeding effectively.  Raising supply through pumping can actually help a baby to feed better (bigger volumes flow more freely).

Babies do need significant quantities of milk in the latter part of first week and beyond, and weight gain is the best indicator of whether they are getting enough milk.  If everything is going well and all feeding is at the breast, you'll likely have no idea of the amazing volume your body is producing.  If weight gain isn't going well then your baby may need some help in getting your milk production built up as needed.  Now, there's no doubt that in some areas here in NI top ups are suggested far too quickly and it may be that far too large topups are suggested in some cases, but it's also true that sometimes supplemental milk is needed and the volumes may surprise you if you have been told that babies only need a few mls of milk.  Those who work in breastfeeding support walk a fine line when suggesting that more milk is needed.  We want babies to get the optimum amount of milk.  We want that to be at the breast.  We want mums to have a comfortable, enjoyable breastfeeding experience and to have an ample supply of milk.  If a baby is struggling with weight gain we want to find the best way to preserve breastfeeding, to build the milk supply while also giving baby adequate calories.  That involves the minimum amount of supplement needed, but enough to move weight gain into the normal range.  In some cases a comment on a forum telling a mum to feed more frequently rather than give a top up may be correct.  In other cases however that might cause a poorly feeding baby to expend more energy at the breast, further impact weight gain and not raise milk production.  A solution that worked for one mum, will not be the right solution for another who is in very different circumstances that may not have been described clearly on a forum post.  Encouraging a mother to Ignore suggestions to express and/or supplement can be damaging, as can not having good truthful support about when extra milk is needed.  Intervening to raise supply early is usually simple, whereas letting things run without intervening can lead to babies not having regained birthweight at 6, 7, 8, or even 9 weeks and this is when the outcome for breastfeeding is deeply impacted.  It is relatively easy to significantly increase supply with the right stimulation in the first 3 weeks.  It is much more difficult after 6 weeks, so getting early support with breastfeeding is key.

If you are concerned about milk intake, or your baby's weight gain ask for a breastfeeding assessment from your HCP or look for a local IBCLC (International Board Certified Lactation Consultant) or breastfeeding counselor to check if there is an issue which might need some extra support.  When there is a weight gain issue generally all that is needed is support around helping baby to feed better at the breast, and perhaps increasing the frequency of feeds.  If top ups are suggested discuss a plan with your caregiver.  The plan shouldn't just be about those top-ups, but should be about increasing supply so that you can then move back to exclusive breastfeeding.  Expressing and supplementing breastfeeds are almost always temporary if you have the right support.

When everything is going well with breastfeeding and you are feeding exclusively at the breast you will have no idea just how much milk your baby is drinking, but if our breasts were transparent or we had volume measurements we may be very surprised at just how generous our overflowing milk ducts are!                                                        

Further Reading

[1]  Walker, M. Breastfeeding Management for the Clinician: Jones & Bartlett Publishers, 2013 -
[2]  Neonatal stomach volume and physiology suggest feeding at 1-h intervals.  Nils J. Bergman Acta Paediatr. 2013 Aug; 102(8): 773–777. Published online 2013 Jun 3. doi: 10.1111/apa.12291
[3] Nutritional factors that affect the postnatal metabolic adaptation of full-term small- and large-for-gestational-age infants. Laura de Rooy, Jane Hawdon  Pediatrics. 2002 Mar; 109(3): E42.
[4] Controversies Regarding Definition of Neonatal Hypoglycemia: Suggested Operational Thresholds. Marvin Cornblath, Jane M. Hawdon, Anthony F. Williams, Albert Aynsley-Green, Martin P. Ward-Platt, Robert Schwartz,Satish C. Kalhan Pediatrics Special Article May 2000, VOLUME 105 / ISSUE 5 
[5] Hawdon JM, Ward Platt MP, Aynsley-Green A. Prevention and management of neonatal hypoglycaemia. Archives of Disease in Childhood Fetal and Neonatal edition. 1994;70(1):60-65.
[6] Mohrbacher, N. Breastfeeding Answers Made Simple: Hale Publishing, 2010
[7] Weight gain in the first week of life and overweight in adulthood: a cohort study of European American subjects fed infant formula. Nicolas Stettler, Virginia A. Stallings, Andrea B. Troxel, Jing Zhao, Rita Schinnar, Steven E. Nelson, Ekhard E. Ziegler, Brian L. Strom
Circulation. 2005 Apr 19; 111(15): 1897–1903. doi: 10.1161/01.CIR.0000161797.67671.A7
[8] Hester SN, Hustead DS, Mackey AD, Singhal A, Marriage BJ. Is the Macronutrient Intake of Formula-Fed Infants Greater Than Breast-Fed Infants in Early Infancy? Journal of Nutrition and Metabolism. 2012;2012:891201. doi:10.1155/2012/891201.
[9] Studies in human lactation: milk volumes in lactating women during the onset of lactation and full lactation. M. C. Neville, R. Keller, J. Seacat, V. Lutes, M. Neifert, C. Casey, J. Allen, P. Archer
Am J Clin Nutr. 1988 Dec; 48(6): 1375–1386.
[10] Comparison of milk output between mothers of preterm and term infants: the first 6 weeks after birth.  Pamela D. Hill, Jean C. Aldag, Robert T. Chatterton, Michael Zinaman J Hum Lact. 2005 Feb; 21(1): 22–30. doi: 10.1177/0890334404272407 
[11] Academy of Breastfeeding Medicine Clinical Protocol #3 -