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Fore milk and hind milk

- Julie Matheney

Is fore milk and hind milk really a thing? Many parents read or heard some where that “foremilk-hindmilk imbalance” is a thing they need to be concerned about. This confusion has led to so much unnecessary anxiety. Do I make 2 kinds of milk?  Does baby need to breastfeed for a specific number of minutes to make sure to get to the hindmilk?  How long do I need to feed before the hind milk starts flowing?

This term was coined related to human milk in a 1988 journal article that reported the experiences of a few mothers who breastfed by the clock, switching breasts after 10 minutes even though baby hadn’t finished on that side. The results have never been duplicated, and newer findings call into question this article’s conclusions.

This concept is also well known in the dairy industry related to cows.  A normal calf will nurse its mother 8-12 times per day in the first seven days of life and as calves get bigger, they will nurse larger volumes per meal and less frequently. By one month in age, calves will nurse approximately 4 times per day. Cows are follow mammals and the way a cow nurses and the fat content in her milk is different than in humans. Cows in the dairy industry, though, are only milked twice a day, every 12 hours, so the creamier, higher calorie milk, has had time to separate, and this fatty, thicker, "hind-milk" comes at the end of the milking session. The majority of the cream is in the hind milk, which is the last milk in the udder.

Cows make milk and store it in the udder for baby. This is the foremilk that is most often milked by dairy farmers and it is higher in lactose and lower in butterfat. When the calf is not satisfied by the available milk and continues to nurse, a more nutrient dense, higher butterfat hindmilk (cream) is made to meet baby's additional calorie needs. Cream is not made until stored milk is exhausted. If a cows let down is incomplete she will not give this higher butterfat milk that we call cream. When a cow has a calf to feed she often does not let her milk down completely for her human milker and when there is no more calf is more likely to let down completely including the hind milk. When being milked, a cow can refuse to let down milk entirely, let down just a bit, hold back the last milk, let down only from 1 or 2 quarters, etc. Their control is pretty amazing.  A cow with a calf on her will sometimes not let down all of her milk to a milking machine or human milker, wanting to save it for her own calf. Some cows are willing to let down completely for a milker even if they have a calf they are nursing. It really depends on the cow. This on demand feature allows calves to survive and flourish when the mother cow is also being milked for human consumption. A cow can not willfully withhold any component of her milk but rather the natural process allows us to have milk and the calf to still do well with only what the cow can produce on demand later.

With humans, when a mother nurses her baby frequently, every 1-3 hours, the milk actually stays mixed up.  In fact sometimes with frequent nursings the feeding can start with the creamy 'hind milk".  Dr. Hartman taught that mothers that nurse more often have higher calorie milk ALL THE TIME.  With humans it is usually when there is a longer stretch between breastfeeds, like at night,  that gives the fat time to separate and cling to the walls of the alveoli, that the difference between the fore and hind milk can be observed.  This is why many IBCLC lactation consultants are against sleep training where we are trying to get young babies to sleep longer than they naturally would in their own. this reduces time they would naturally spend at the breast which can drop supply.

There is a lot of misunderstanding of foremilk and hindmilk and I've had many mothers overly concerned because they have been told their babies doesn't nurse the prescribed amount of time to get to the hind milk or their baby isn’t gaining weight well and are told their milk isn’t fatty enough. If the baby is gaining properly and healthy, baby IS getting plenty of the calories needed. When in doubt, feed the baby more often at the breast  

Another concern of many parents is for having a foremilk/hindmilk imbalance. In reality this is usually lactose overload and not a fat imbalance.  Lactose is the primary sugar (carbohydrate) in human (and all mammals’) milk. It is a large molecule and the body has to break it down to be able to absorb it. It is broken down in the body by an enzyme called lactase. Your baby’s body naturally produces lactase until around 2-5 years old (the natural age of weaning from the breast). This enzyme is supposed to disappear and is also why many adults can become lactose intolerant later in life: they no longer have the enzyme to break down lactose effectively

Most healthy babies can break down lactose in normal volumes of breast milk. Fat slows down milk as it passes through your baby’s gut, giving the gut time to process and digest milk. If baby has a lot of breast milk that is relatively low in fat and higher in water concentration, it can rush through their digestive system more quickly than the lactose can be digested. This happens when baby drinks a very large amount of breastmilk – often when baby has gone a very long time between feedings, or because there is an oversupply of milk. The oversupply can be from many reasons: excessive pumping, using a Haakaa frequently during feeding, certain medications, baby with a tongue tie, etc  

Babies with lactose overload are often described as being really gassy with lots of pain while trying to relieve the gas. Parents also note green, foamy, frothy, or explosive poops. These are often regular, daily poops that happen multiple times a day as the milk they drink flushes rapidly through their system.  This is not the same as a cows milk protein allergy (CMPA) which typically presents as mucous or blood in the poop. But you can have both issues at the same time (CMPA AND lactose overload). Damage to a baby’s intestines, including inflammation caused by cow’s milk allergy and infection, can stop the production of sufficient amounts of lactase. This means milk isn’t digested as it moves through the intestine and instead ferments in the lower bowel causing pain, gas and green stools.

NOTE: green poops can be caused by other things other than just lactose overload or CMPA; sickness, certain medications, not drinking enough milk by volume and food allergies or intolerance can also change the color and consistency of baby’s poop. Healthy babies who are feeding well may occasionally have green poops. If baby only has occasional green poops, most likely everything is fine  

If your baby seems to be suffering with lactose overload try the following tips:

  • Check baby’s latch: a deeper latch can help baby manage the milk flow better. Usually the best way to get a deeper latch is to watch baby’s position at the breast. They should be completely touching your body, belly button touching you. Their chin contacts the breast first with their cheeks touching equally.  Address any known tongue or lip ties which prevent a deep latch. 
  • Try different positions: side lying and laid-back position, help baby manage faster milk flow by using gravity to slow the flow. Avoid additional pumping or Haakaa use to regulate supply down to what the baby needs. Feed the baby and not the freezer. 
  • Feed the baby until they are finished. There is no time limit for how long they may want to be on the breast. Finish the first side first before offering the second side. Some find block feeding helpful but this should be done under the direct care of an IBCLC lactation consultant. 
  • More frequent feeds: the best model of breastfeeding when there is suspected over supply or lactose overload is eat, play, eat, sleep. This helps reduce the volume baby gets at each feeding and increases the fat content of each of those feedings. 

Despite common advice, it is usually not necessary nor helpful to reduce the amount of dairy you consume in your diet to reduce the lactose content in your milk. The amount of lactose in your milk has nothing to do with your diet. Lactose is the number one sugar found in breast milk and your body makes it specifically for your baby. If you eliminate dairy from your diet and you see a reduction of symptoms in your baby, your baby was probably reacting to the proteins found in cow’s milk that can appear in your milk and not the lactose in your milk.

As always, if you’re concerned about your baby’s poops, your milk supply, or your diet, please consult the appropriate health care provider: pediatrician, specially trained IBCLC lactation consultant, maternal health dietician or allergist.

Breastfeeding as birth control

- Julie Matheney

Breastfeeding has historically been used as a method of birth control, called the lactational amenorrhea method (LAM). But 3 conditions must be met to make sure that it works:

  • Baby must younger than 6 months old. After your baby is 6 months old, your period is more likely to come back which means you can become pregnant again.
  • You must be exclusively breastfeeding your baby. This means no pumping, pacifiers, formula or other supplements. And you have to breastfeed for both day and night feeding, typically not going more than 4 hours between feedings during the day and no more than 6 hours between feedings at night.
  • You must not have a period (amenorrhea). When your periods start, use some other birth control method.

When these conditions are met, LAM has been shown to be about 98% effective. For many who exclusively breastfeed, they will have a light period before ovulating, but it is possible to ovulate and get pregnant before having your first postpartum period.

Pre and post breastfeeding weight check

- Julie Matheney

There are many factors that influence how many ounces a baby takes at the breast in a single; baby’s age and weight, how often they’re feeding, when the baby last fed and time of day, and the breast storage capacity of the mom. Many lactation consultants will do a pre and post feeding weight to see how much milk baby transfers at the breast in one feeding. This number is a snap shot in time that is a piece of the puzzle of how baby is feeding.

Feeding is a cumulative action. Some babies are snackers. They take smaller, more frequent feedings and may feed often over night. Some babies are bingers. They take larger, less frequent feedings and may sleep in longer stretches. And most fall some where in the middle. This is feeding. Sometimes baby wants a snack. Some times they want a drink. Some times they want a boob buffet. They move through waves of feeding like hummingbirds to feeding like baby sharks.

 

One single weighted feeding is just that. A single feeding. It’s helpful information that once we gather lots of data points can help us determine if what your baby is doing at the breast is normal for your baby or if it is something we should support. How your baby eats will be individual to your baby.

 

In general, if you have a pain free latch where your nipple goes in and out of baby’s mouth the same shape, where you hear baby swallowing, baby is making lots of wet and routine poops and gaining weight across time, keep going. If you’re concerned about how your baby is feeding, working with an IBCLC lactation consultant can be very reassuring.

Foods that increase breast milk supply

- Julie Matheney

Prolactin is hormone responsible for making breast milk. We know that when you’re breastfeeding, you need about 300-500 extra calories to supoort making nutrition for your baby. You’re still eating for two!! There are foods with phytoestrogens which help boost and support your natural prolactin levels.

There are several main classes of phytoestrogens. Lignans are part of plant cell walls and found in fiber-rich foods like berries, seeds (flaxseeds), grains, nuts, and fruits. Two other phytoestrogen classes are isoflavones and coumestans. Isoflavones are present in berries, grains, and nuts, but are most abundant in soybeans and other legumes. Coumestans are found in legumes like split peas, lima and pinto beans. Eating these will naturally increase prolactin which in turn helps support making milk

  • We all know oats are the go-to for increasing supply. They are rich in plant estrogens and beta-glucan. But other grains like brown rice, barley, and quinoa work as well!
  • Garlic! It will definitely flavor you milk, but research shows babies love the flavor and often suck more in response.
  • Fennel: Raw or cooked, fennel seeds can be added to a recipe, or drunk as a tea. There are also many lactation specific supplements that include fennel in pill form for a more concentrated dose
  • Dark Leafy greens like spinach, kale, collard greens, and broccoli. And yes, you can eat broccoli while breastfeeding.
  • Seeds: Sesame seeds, flax seeds, and chia seeds are all super boosters of making milk and can be added to baked goods and smoothies very easily
  • Berries: Get a phytoestrogen boost with fruits like strawberries, cranberries, and raspberries.
  • Nuts: Almonds are high in linoleic acid and known to be the most lactogenic nut. Packed with healthy fats and antioxidants, Vitamin E and omega-3, walnuts, cashews, and pistachios are all good choices. Snack on raw or roasted nuts, add them to cookies, smoothies, and salads.

Breast milk facts

- Julie Matheney

The main components of breast milk are water, fat, proteins, lactose (milk sugar) and minerals (salts). Milk also contains trace amounts of other substances such as pigments, enzymes, vitamins, growth hormones, and antibodies. It is normal for breast milk to separate (the fatty part of the milk rises to the top).

Other facts about human milk:

  • Fat content during a feed is determined by the fullness of the breast, not what you eat. The emptier the breast, the higher the fat content in the milk
  • The longer time between feeding or pumping, the lower the initial fat content at the start of the next feed. The fat level at the start of one feed may not be the same as the fat content at the start of the next.  The longer the gap between feeds, the higher the water content and lower the fat content.
  • Length of feed is irrelevant – some babies take a full feed in 5 minutes while others need 40 minutes to get the same amount. You can’t tell anything about fat content from the length of the feed.
  • There are millions of live cells in milk, including immune-boosting white blood cells and stem cells, which may help organs develop and heal.
  • Over a 1,000 proteins help baby grow and develop, activate the their immune system, and develop and protect brain neurons
  • More than 200 complex sugars act as prebiotics in your milk, feeding ‘good bacteria’ in baby’s gut
  • Enzymes are catalysts that speed up chemical reactions in the body. 40 different ones in your milk have jobs like helping baby’s digestion and immune system
  • Growth factors that support healthy development. These affect many parts of your baby’s body, including her intestines, blood vessels, nervous system, and her glands, which secrete hormones.
  • Hormones send messages between tissues and organs for them to work right. They help regulate baby’s appetite and sleep patterns
  • There are 5 basic forms of antibodies in your milk, protecting baby against illnesses and infections by neutralising bacteria and viruses.

Hormone swings with breastfeeding

- Julie Matheney

When the placenta is delivered, estrogen levels drop. While breastfeeding, periods may not return for several months because the hormone that causes you to make milk, prolactin, also stops you from ovulating and having your period. Breastfeeding, though, can cause hormonal fluctuations that can some times catalyze additional hormonal imbalance symptoms. Breastfeeding mimics menopause due to the production of the milk-producing hormone, prolactin, temporarily blocking estrogen production, which keeps your estrogen levels low and prevents your period from occurring. Around 2-3 months postpartum, hormones begin to reset to pre-pregnancy levels.

However, the stress hormone cortisol can increase, and in combination with lack of sleep, melatonin decreases (and, as a result, serotonin) and these hormone changes can negatively impact mood. For most, prolactin levels drop around 6 months postpartum as baby takes more solids and sleeps longer and periods may start again. These hormone shifts can have crazy symptoms. And if you've suffered from a hormone imbalance prior to pregnancy, there's a good chance it'll come back once this shift happens.

Some times just understanding the hormone shift can help you cope. Some times you’ll need to be seen by a health care provider to figure out your exact imbalance to work on strategies, therapies, nutrition or medications to bring you back to balance.

I think my baby has a breastfeeding aversion

- Julie Matheney

Aversion to feeding means screaming or crying when offered the breast or bottle, refusing to eat, or needing to be fed while moving or while drowsy/asleep. This is not a temporary nursing strike where baby refuses the breast/bottle for a few days because of periods returning, mom going back to work, teething, or illness, etc. The behaviors seen in baby are much more extreme for a true aversion. Most common causes:

👅Tongue tie: One of my biggest red flags for tongue tie is reflux and shutting down during breastfeeding (sleepy on the breast, popping on and off, refusing the breast and preferring the bottle but then shutting down on the bottle). Some babies with tongue or lip tie do fine for the first few months by compensating on a full milk supply. The aversion comes around 3-4 months when supply regulates. Address the ties and do oral motor exercises to strengthen the system and the refusal can go away.

🥛Intolerances/Allergy: This looks similar to reflux, but often with bowel issues as well (constipation, diarrhea, or mucousy/foamy poops). Babies who’s digestive tracts are uncomfortable don’t want to eat. They learn quickly to associate feeding with pain, so they shut down on feeding.

🤮Reflux: Easiest culprit to blame and mask with medication. The medication may mask the pain but won’t actually take the reflux away. Reflux is usually caused by food allergy/intolerance, gut issues, or tongue tie. Address the issue, resolve the reflux.

🥵Silent aspiration: Milk going into the lungs instead of to the stomach.

🤯Behavioral: The number one concern of parents is feeding the baby. When feeding isn’t going well, it causes extreme stress, which can causes parents to do extreme things to try to fix the problem. It’s easy to spiral out when you’ve tried everything and it’s not working out of stress and desperation. Occasionally the reason for the refusal is no longer there, but it was so stressful in the moment, the panic that it could happen again sets in and perpetuates the problem. Some times the root issue is still there, but you’ve compensated and it’s causing a behavioral manifestation in both you and the baby.

Breasts no longer feel full between feeding

- Julie Matheney

Breasts are made of a network of ducts, covered by a layer of fatty tissue. During pregnancy, estrogen and progesterone enlarge the milk ducts and multiply the glandular tissue that produces milk. After birth, estrogen and progesterone drop and prolactin and oxytocin rise. Prolactin makes milk production and oxytocin releases it into the ducts. Extra blood and fluid fill the breast just after birth to supoort your body adding hormone receptors in the breast to make milk. The blood and fluid surrounds the ducts and this extra pressure is what makes your breasts feel full between feeding. This blood and fluid reabsorb around 6-8 weeks once supply is established and you won’t feel that full/soft feeling except when you go a really long time between feeding or pumping.

Breasts go back to prepregnancy size when supply regulates around 11-14 weeks but continue to make milk. When you wean from breastfeeding, it can take several months for prolactin levels to return to baseline (which is why you may still see milk for months after weaning).

Once you stop breastfeeding, the milk making structures actually self-destruct – a process that involves massive cellular suicide, and the removal of the debris. Around 6 months after weaning, the milk-producing tissue is replaced with fatty tissue. If you return to your pre-pregnancy weight, your breasts most likely will return to the same size.

They may not be as “perky” because the skin is a bit more stretched and the connective and fatty tissues in the breasts often shifts during pregnancy and breastfeeding. While they may look smaller after weaning most of us can expect that our breasts will return to a similar size as they were pre-pregnancy. They’re just a little more lived in and well loved.

How many minutes should my breastfed baby feed for?

- Julie Matheney

Not every baby needs 15 minutes per side. Some babies take a full feeding in only a few minutes, and from just one breast per feeding. Other babies may feed for a few minutes off each side. Older, more distractible  babies are efficient eaters with more important things to do than state at your chest. They may graze at the boob a few minutes at a time or want to go back and forth from side to side.

In general, you know baby is getting enough breast milk when you have a pain free latch where the nipple goes in and out of baby’s mouth the same shape. You can hear baby swallow and don’t need to keep them awake at the breast for them to continue feeding. Baby should be making lots of heavy wet diapers and pooping daily or every other day. They also gain weight to their own curve and are a similar size of your unique family genetics.

If your baby typically latches for you, and feeds well, and refuses to latch, they most likely are done. Follow your baby’s lead and get to know their feeding habits. Trust your baby and trust your body. If you’re concerned about how your baby is feeding, schedule and appointment with a breastfeeding expert: an IBCLC lactation consultant.

How often should my breastfed baby poop?

- Julie Matheney

In the newborn stage, prior to 6 weeks, pooping tells us if baby is getting the appropriate volumes of milk from the breast. Many times when a newborn isn’t pooping, it’s a sign they’re not getting enough breast milk. As you increase milk volumes, baby starts to poop! Decreased milk intake can happen when baby has a tongue tie and can’t efficiently move milk from the breast, if feedings are scheduled or timed (waiting for every 3 hours, only feeding 15 minutes a side) or if baby is being sleep trained too early. Low milk supply can be caused by retained placenta, the impact of interventions during birth, medications, hormone based birth control, thyroid or hormone disorders, or when there is a breast surgical history like a reduction.

AFTER 6 weeks, it may be normal for SOME babies to poop less frequently. Baby should still make at least 6 wet diapers that have a mild smell. It can be normal for baby to have a massive yellow blow out every 1-7 days. As long as the poop is very soft or seedy/watery and they’re not in pain when passing

Constipation can have other root causes.

🧬For some, it may be that their digestive biome is not ideal... things like antibiotics given to mom during pregnancy/birth or antibiotics given to baby shortly after birth shift the biome where it doesn’t ideally absorb and process milk. Introduction of formula also changes the gut microbiome. Some babies may have difficulty digesting certain formulas and may struggle with pooping until the right one is found.

💃🏻Not getting enough movement, tummy time or being in one position for too long (sitting in positioning devices like a dockatot for hours a day) decreases movement through the gut. Allergies and intolerances are another culprit. 🦷Babies who are teething may have a temporary change and miss a day or two and then return to daily stooling.

🤢Illness, change of environment (maybe a holiday/ move of house), change of daily rhythm etc can all play a role, and temporary changes are to be expected.

Every person is unique and so there isn’t any “one size fits all” reason why an infant may be struggling with constipation/infrequent stooling. If you baby isn’t pooping regularly, an IBCLC can help figure out what may be going on and refer you to the right specialist as needed.