Fore milk and hind milk

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.