Why don't my breasts work at night?

Heather, a very dear friend, wrote to me asking if it was likely that she isn’t making enough milk at night because her baby fusses in the evening, won’t take the breast, and then takes 2 ounces of formula by bottle and falls asleep.  Her pediatrician suggested introducing solids as a means of solving the night time fussiness.  It got me thinking about this topic, and why that is such a terrible thing to do to mom.  Here is what I came up with in answer to her problem. 

The first thing we have to understand is that the breasts are an organ.  They work as well as the heart, the lungs, the kidneys, and the brain.  Even better, they are two mutually redundant organs so that one can compensate for the other if needed.  That redundancy is there for a reason, to help make sure that nothing bad will happen.  Breasts, like every other organ system, tend to work all the time.  They don’t function well from 9 am to noon and then suddenly and inexplicably fail for a few hours and then start back up again the next morning.  It is possible (but VERY unlikely) for them to slow down or even fail over time, but they wouldn’t work fine during the day and then fail at night.  As a matter of fact, we know that pregnancy, breasts, and infants are nocturnal.  They all work best at night, which is why contractions come from dinner to 2-3 AM, why babies are usually born in the early morning hours after a night of labor, and why babies are most awake from 9 pm to 3 am.  They aren’t hungry, they are alert and awake and frustrated that mom and dad want to sleep.  The problem isn’t the baby, it is the mom and dad that want to go to sleep and get frustrated because baby doesn’t want to go to sleep.  If you don’t want him to be awake all night, then don’t encourage him to take naps all day.  He has to sleep, but he won’t sleep 24/7.  Sooner or later he has to wake up.  I seriously doubt that night time fussiness has much to do with hunger.

Now, let’s talk about why a baby will always take a bottle.  Babies take bottles because gravity force feeds the baby and he has to take what is in the bottle, even if he doesn’t want it. They don't do it because they like it. Have you ever tasted formula? It is a rather nasty flavor and I seriously doubt a child will choose that over his mother’s breastmilk, which is incredibly sweet.  To help us figure this out, I’m going to pose a few questions that my families ask me all the time.

1) “Why do babies refuse the breast if they are hungry?”  First, I always say that if they refuse the breast, they are probably NOT hungry, they just want to suck.  You have to understand that babies are in charge of breastfeeding, they ONLY breastfeed when they are hungry.  That doesn’t mean that they won’t suckle at the breast if they aren’t hungry.  Any lactation consultant who practices pre and post weights knows that sometimes babies take the breast for 15-30 minutes and take almost no breastmilk at all, this is called “non-nutritive sucking”.   Babies suck for comfort and somehow control the flow of milk.  Another thing that babies will do is refuse the breast when the first let down happens.  They take the breasts, suck for a little bit and they pull away and cry.  Then they take the breast, suck for a bit, and pull away and cry.  It has always seemed to me that they realize that food is coming and they aren’t hungry, so they let go of the breast and cry because whatever is causing them to be uncomfortable is still there.  Their need to suckle hasn’t been met, so they cry.

 

2)  “But if they can refuse the breast, why can’t they refuse the bottle?”  Or “Why do they always take the bottle when I offer it?”  It goes back to infant development.  You may remember that all infants are born with a suck reflex.  It is instinctual, pleasurable, comforting, and helps to ensure survival.  Babies suckle EVERY TIME they are uncomfortable for any reason.  They suck when they are hungry, cold, lonely, frightened, frustrated, in pain, have a dirty diaper, they suckle EVERY TIME they are uncomfortable.  Suckling isn’t a “hunger sign” it is a “stress sign”.  Any time you put something long and hard in a baby’s mouth, they are forced to suck (fingers, pacifiers, bottles, breasts, etc...) so they will suck a pacifier or a bottle even if they aren't hungry, because it feels good, not because they are hungry.  But with a bottle filled with liquid, they have to drink because liquid is running out of it and into their mouth.

Let me explain, if you hold a bottle at more than a horizontal angle it will leak, and if you touch it the milk will squirt out all over the place.  Imagine what that does in his mouth? Let’s combine those two factors (the uncontrollable urge to suck and a readily flowing device) you get a baby who will over eat, even if he isn’t hungry.  Often he will simply push it back out and let the milk or formula drip down his chin, which is why you always need a cloth under his chin while bottle feeding to keep him from “making as mess”, but have you ever noticed that you don’t need to do that when you breastfeed?  Again, it is because he is in charge of the breastfeeding and can just let go if he isn’t interested.  But I digress, back to over eating.   When we over eat we fall asleep. This is why lions sleep on the Savannah after eating a zebra, why we sleep after our Thanksgiving feast, and why babies sleep when they are over fed. It has to do with the release of pleasurable and sedating hormones that comes with a full tummy (Gastrin and CCK, I think). 

3) “So what is the problem with over feeding him if it makes him stop crying and fall asleep?”  The real problem, is what it does to the mother, it is why this mother is writing to me in the first place.  She is convinced that SHE is the problem.  There could be no other explanation for why her baby is fussy at night.  Obviously her organ systems just intermittently stop working after dark and then start working again the next morning.  That is why her pediatrician suggested adding solid foods or offering a bottle….  REALLY PEDIATRICIAN?  REALLY?  It makes me angry to think that there is such ignorance out there coming from a health care provider.  What did her pediatrician do?  She took a mother who believes that fussiness is related to feeding and led her down the wrong path.  The mother has a baby who is fussy and offers the breast.  But if the baby isn't hungry, he won't take the breast for very long.  He suckles and then lets go and fusses, then suckles, and fusses, over and over again.  Mom, who is tired because it is 10 pm and she wants to sleep, gets frustrated and desperate.  Since her health care provider convinced her that she isn’t making enough milk (but only at night), and because people tend to trust physicians, mom offers a bottle and he drinks it and goes to sleep. What does that tell mom? It re-enforces the idea that he was obviously hungry and that she is just another inadequate mother who can’t do what her baby needs her to do.   

It is a terrible and frustrating myth that we in the health care field continue to spread every time we teach the mother “Hunger Signs”.  We don’t bother to explain newborn stress signs, we don’t teach a father that there is more to pleasing a baby than just feeding.  We simply suggest that every problem is a feeding problem and blame mom for not doing a good enough job.  Nonsense!  You are perfect, your breasts are perfect, your baby is perfect!  Have confidence in your body, it got you this far.  It amazes me that people, especially physicians, believe that the human body can take two cells, combine them, multiply them a couple billion times and create the most complex living system on the planet, and then for some inexplicable reason suddenly fail and not be capable of supporting that baby when they are born.  And for some reason, the fault is never the ignorant health care provider, but rather it is the helpless mother.  Okay, I have to stop or I will rant for another 100 pages. 

Hope that helps,

Sage Homme

Delayed Cord Clamping

I was recently asked to talk about delayed cord clamping (DCC) for a few friends who are due to deliver and want to know how to talk to their obstetrician about the subject.   I understand that this isn’t a breastfeeding topic, but I thought it was good information to share, so here goes. 

First, I think we should start with the professional opinion from the OB’s professional organization:

“Abstract: Delayed umbilical cord clamping appears to be beneficial for term and preterm infants.  In term infants, delayed umbilical cord clamping increases hemoglobin levels at birth and improves iron stores in the first several months of life, which may have a favorable effect on developmental outcomes.  There is a small increase in jaundice that requires phototherapy in this group of infants.  Consequently, health care providers adopting delayed umbilical cord clamping in term infants should ensure that mechanisms are in place to monitor for and treat neonatal jaundice.  In preterm infants, delayed umbilical cord clamping is associated with significant neonatal benefits, including improved transitional circulation, better establishment of red blood cell volume, decreased need for blood transfusion, and lower incidence of necrotizing enterocolitis and intraventricular hemorrhage.  Delayed umbilical cord clamping was not associated with an increased risk of postpartum hemorrhage or increased blood loss at deliver, nor was it associated with a difference in postpartum hemoglobin levels or the need for blood transfusion.  Given the benefits to most newborns and concordant with other professional organizations, the American College of Obstetricians and Gynecologists (ACOG) now recommends a delay in umbilical cord clamping in vigorous term and preterm infants for at least 30-60 seconds after birth.  The ability to provide delayed umbilical cord clamping may vary among institutions and settings; decisions in those circumstances are best made by the team caring for the mother-infant dyad. “  ACOG Committee Opinion # 684, January 2017.   

So what does that say?  First, I want to clear something up, it is actually, “normal cord clamping”, cutting immediately is an intervention started just before the Viet Nam War, but most OBs don’t know that.  OK, on with the show.  It says that DCC is good for almost all babies.  That it helps newborns transition from the womb to the outside world, that newborns who don’t get DCC are more likely to be anemic and suffer developmental problems (associated with newborn anemia).  It says that preterm infants are especially put at risk if you cut the cord immediately, and that there is no risk to mother or baby if you allow the cord to transfer blood to the baby after birth.  I should just stop there, but I feel like I need to help explain it to people, so here goes some physiology.

First, you should know that I wrote my master’s thesis on delayed cord clamping and that I was lucky enough to study under one of the world’s foremost experts on the topic, Dr. Judy Mercer CNM, when I was in midwifery school.  I know the concepts VERY well.  So here is how it happens.  In the uterus, the baby does not send much blood to the lungs, in fact, only 8% of the baby’s blood goes to the lungs before birth.  This is because the baby is not breathing air and doesn’t need his lungs yet.  There is just enough blood to help them grow and develop.  30% of term baby’s blood and 50% of the preterm baby’s blood is in the placenta at all times.  That amazing organ is actually an organ that is outside the baby’s body and it is where he gets his oxygen and his food, and where he sends his waste products for mom to get rid of.  At birth however, he has to start using his lungs and when he takes his first breath, the lungs require 40% of the cardiac output.   So when he is born, umbilical cord changes from a two-way street to a one-way street and begins to pump blood to the baby very quickly (8%+30%=38%, which is amazingly close to the 40% of his blood that he will need when he begins to breathe air).    

If the physician (I say physician because EVERY midwife learned this in school for the last 30 years and the doctors are incredibly far behind on this one), if the physician clamps and cuts the cord immediately, they do some horrible things to the baby.  First, they cut off that blood transfusion and force the baby to take the blood from their arms and legs.  Hello blue hands and feet!  If you took 30% of my blood away, I would also have blue hands and feet.  That means that baby no longer has the resources needed to do much and they sleep for the first day or two because a sudden and profound loss of blood volume will make you very tired.  Have you ever given blood?  Imagine you gave 4 times in 10 minutes, how would you feel?  How would you look? You would look like a newborn, exhausted, with blue hands and feet, pale face and red eyelids.  These babies also don’t breastfeed as well, partly because they don’t have the energy to eat. 

What is even worse than a pale baby is that when a baby doesn’t have enough blood he doesn’t have the ability to carry and use oxygen.  That means that well-meaning physicians who want to cut the cord and pass the baby to the waiting team to help the baby breath, have accidently made it worse.  When you leave 30% of his blood behind, all the oxygen in the world will be of little help, because without blood he can’t use the oxygen.  This is why immediate cord clamping is so very dangerous to preterm babies.  First, they lose 50% of their blood, and they are weak and vulnerable to begin with.  They really can’t afford to lose the blood, and shifting all that blood from the arms and legs to the heart and brain leads to brain bleeds (intraventricular hemorrhage), and loss of blood to the intestines causing them to dye (necrotizing enterocolitis). 

So why did physicians start doing it in the first place?  In the 50’s there was a high rate of baby’s having too many red blood cells (polycythemia).  The assumption was that the babies had too much blood, but they didn’t, they had too many red blood cells (there is a difference).  So the physicians assumed it was because blood was flowing into the baby after birth from the umbilical cord.  They were wrong and no one has asked why they were wrong, but that was what I wrote my thesis on, so I’ll tell you what it was.  In the 1960 census they reported 97% of women of childbearing age smoked >10 cigarettes a day.  We know that mothers who smoke cause polycythemia in their babies.  So, what actually happened, was that we had a VERY HIGH-RISK population, but no one knew it.  No one knew that smoking was bad for you back then, and so the scientists never thought to look at smoking as a cause of the problem.  As so often happens, they made an assumption (the wrong assumption), things got better, and they used that as evidence that they were right.  There weren’t, but then again, that happens all the time. 

Now there are times when immediate cord clamping may be a wise idea.  If the baby, God forbid, is born without a heartbeat, then there will be no transfer of blood to the baby after birth.  That baby needs immediate attention, and there is little value in waiting to start working on him.  That doesn’t mean every baby born in trouble, only the babies born without a heartbeat.  If a mother has high blood pressure, is diabetic, is a smoker, or a narcotic drug abuser, those babies have all had to compensate for those stresses, like the babies of the 50’s, they will probably benefit from immediate cord clamping. 

So there you have it.  Immediate cord clamping is bad for your baby, delayed cord clamping is the physiologic norm, and your physician should be told to read their professional policies and put them into practice.  Once in a while I get someone who tells me that their physician won’t practice delayed cord clamping.  I always say the same thing, FIRE THAT PROVIDER!!  Do you really want a physician caring for your baby when you know that they are 30 years behind the evidence?  Their own professional organization came out in 2012 and said it was most likely safe and effective, then 5 years later they put out the statement I quoted above.  If the provider is that far behind, what other things are they doing wrong?  I have no patience for health care providers who are not up to date on their own professional organization’s rules. 

Okay, that got a little harsher than I wanted it to get, and I’m sorry.  But I’m not going to change what I said.  I urge you to ask your physician about delayed cord clamping and ask them what their professional organization recommends on the topic.  If they won’t educate themselves, maybe they will listen to you?

Reference:

ACOG (2017) Committee Opinion #684.  Delayed Umbilical Cord Clamping after Birth.  Obstetrics and Gynecology; 129: e5-10. 

Foremilk and Hindmilk; Myth or fact and why should we care?

Lillian asked: “I learned in the CLC course that there is no such thing as foremilk and hindmilk for changes in nutritional content. I have also read and heard from IBCLCs that hind milk has a higher fat and calorie count with less lactose compared to foremilk. I am also aware that some cultures who nurse more frequently than the US culture of 8-12x/day would not necessarily “empty” the breast or access the hindmilk. These cultures still produce healthy and typical kids. The foremilk/hindmilk concept has come up regarding pumping mothers in the NICU where weight increase has been an issue at my place of work. However, the regiment an IBCLC recommended seemed very tedious. Additionally, I know the nutritional content of preterm breastmilk is different than term breastmilk and is baby specific for that feeding dyad. Would you be able to point me in a positive direction to further understand if foremilk and hindmilk differences exist and how this may impact the breastfeeding dyad or if this is a myth?”

So let’s dive right in with a discussion about the differences between foremilk and hind milk.  It is absolutely NOT A MYTH.  I am not surprised when I hear people tell me that they doubt there is a difference in breastmilk from the beginning to the end of the feeding, I used to say the same thing.  “What? Is there some kind of barrier that is removed half way through the feeding?”  I am a little embarrassed to admit I said that to many a patient over the early years of my career.  Well there is plenty of evidence to suggest that there is a difference between the milk released at the beginning of the feed and that released at the end of the feed.  The primary difference is in the fat content.  The difference is so very striking and predictable that it is a common scientific method of measuring the amount of milk remaining in the breast, the method is called “The Creamatocrit Method”.  The group that uses this method the most is the Hartmann group out of Australia.  If you pull any study from that group regarding milk volume you will find reference to that well documented phenomenon.  My favorite article on the basics is Kent, 2007 “How breastfeeding works” published in The Journal of Midwifery and Women’s Health 52(6).  It is older and doesn’t go into detail about the MER, but it is a straightforward discussion on most clinical breastfeeding questions.  It is easy to understand if you think of simple fluid dynamics.  If you mix sand and water in a pail allow it to settle and then start pouring, the first thing that will come out is the water, as you get to the end of the bucket you will get more sand and eventually, it will be wet sand that comes out and very little water.  The same is said for breast milk.  The first milk ejection (MER) reflex is almost entirely water and lactose, I describe it as “skim milk” or “fat free milk” It is approximately 4% fat.  The second MER is like whole fat milk, mostly water, but more fat.  The third MER is a milk shake, whole fat milk and high fat ice cream, and the last is almost entirely fatty ice cream, a little more than 12% fat.  In that study they cite another Hartmann lab study: “Kent JC, Mitoulas LR, Cregan MD, Ramsay DT, Doherty DA, Hartmann PE. Volume and frequency of breastfeeds and fat content of breast milk throughout the day. Pediatrics 2006;117:e387–95” here they document the findings specifically.  If you are interested in a full discussion, that is probably where you should start.  For reference values, Khan, Prime, Hartmann and few others did an interesting study looking at 24-hour nutrient intake for the Journal of Human lactation in 2013 (Volume 29(1)) where they used the fore milk and hind milk samples of mothers to extrapolate an average fat, lactose, and protein content of each feeding and the test weights of the infant and calculated the 24-hour intakes.  They, again demonstrated that the milk was lower in fat before the feeds (average 32 g/L) and higher after the feed at 56 g/L.  They found no difference in the lactose or the protein in the foremilk and hindmilk samples.   All that said, the authors also point out that the average baby tends to balance out feedings and that there is no real difference from feeding to feeding when you look at 24-hour intakes.  So you could say that there is very little clinical value in looking at foremilk/hindmilk as a phenomenon for the average baby.  Of course, it isn’t “the average baby” that a lactation consultant sees.  We are the experts of infant feeding and are usually only called on when there is a problem.  A baby who isn’t growing well, has green frothy poop, and eats for less than 10 minutes at a feeding, has all the hallmarks of a baby eating a low-fat diet due to inadequate time spent on the breast.  That is where a firm understanding of the difference between foremilk and hindmilk will be most valuable. 

As for feeding preterm infants.  I don’t have much experience in that topic, but what knowledge I do have comes from the excellent work of Paula Meier.  A decent review of breastfeeding management written by her is Meier, Write, and Engstrum (2013) Management of Breastfeeding During and after the Maternity Hospitalization for Late Preterm Infants. Clinics in Perinatology; 40, 689–705.  It is a good over view of the entire feeding problem for preterm infants.  While I was putting this note together, I also found a very promising review from Meier, Johnson, Patel, and Rossman, published in Clinics in Perinatology 2017; volume 44 (1) pg 1-22.   It is called “Evidence Based methods that promote human milk feeding of preterm infants: An expert review.  It looks very promising, but I don’t have time to read it before I send you this email.  I advise you to pull it and look into it. 

I hope that helps and answers a few questions for you.