Is Breastmilk Production Quantitative or Qualitative?

In Support of Demand-Feeding

**Note** In this article you will see several references to "PREP." This is referring to the Ezzos' class known as "Preparation for Parenting." (The Ezzos are also wrote the "Babywise" books.) For more information on this class, please see Steve and Kateri Rein's excellent page Concerns about the Ezzos' Preparation for Parenting Class.

This is not such an easy question to answer; and breastfeeding our babies can not be placed into such a cookie cutter approach as Prep/BabyWise would have us believe. There are myriad factors that go into breastfeeding; babies needs may differ from one baby to another; while mom's abilities will differ -- not only from one mom to another, but from one baby to another in the same mom.

Consider:

Mom's breast storage capacity. (Peter Hartmann's work) Some moms can store up to a liter of milk in their breasts. (1000 cc). If the baby could drink that much at one time, the mom would only have to breastfeed once a day. (This is VERY rare, believe me!). Many mothers cannot store more than 3 to 4 ounces at one time or milk supply begins to diminish. The emptier the breast is, the faster milk is synthesized. As the breast becomes fuller, the milk production becomes slower, until a point is reached in the breast in which production essentially stops and the alveoli (milk making apparatus) actually begin to involute, thus causing a decrease in supply overall (which is what happens when the mom begins to wean or tries to stretch out feedings artificially.

So, depending upon mom's own ability to store milk, it is true that in one mother who may be able to store 6 ounces of milk at a time (and baby is capable of taking that much), she may be able to breastfeed 6 times in 24 hours and the baby will essentially get 36 ounces (maybe, maybe not -- is isn't exact, but this will do for now). However, a mother who can only store 4 ounces will have to breastfeed 9 times to produce the same amount for her infant.

Now, if a mother who can only store 4 ounces is trying to feed 6 times in 24 hours, first of all, her baby will only get 24 ounces -- plus, her breasts, for her, will be overfull, so her milk supply will begin to diminish. How to get her milk supply back up again? Breastfeed more frequently, up to 8 to 9 times in 24 hours.

Consider:

The baby's stomach capacity. A newborn has a stomach about the size of a walnut. During intrauterine life, the baby drinks amniotic fluid at a pretty constant rate, a couple of ccs here -- 5 ccs there -- probably not ounces at a time every set number of hours. His tummy is used to having small amount in it at a time. Along we come, after birth, and tell our babies that they must have a large amount at set times during the day -- his tummy doesn't understand that -- for however many months in utero he's been doing it according to his own internal mechanisms, not according to a clock. It is important for a newborn to gradually move into spaced and larger feedings, not immediately.

Consider:

Caloric value of the milk, (Susan Carlson's work) which au contraire to popular opinion varies not only from mom to mom, but from feed to feed and month to month, and even within a feed itself. Formula is 20 calories per ounce regardless of the time of day, time of the feed, month of life, etc. etc. Over time, baby's energy needs decrease (from around 117 kcal/kg body weight/24 hours to 110, to 105, etc etc. So, volume of milk production also decreases as the baby gets older (or stays about the same) which also depends in part on the caloric value of mom's milk which isn't constant. Unfortunately, there hasn't been a lot of testing of mom's milk, and it is generally thought to be about 20 cal/ounce; same as cow's milk and goat's milk (21 cal/ounce), and which formula is modeled on. But, it does change.

Consider:

Babies go to the breast for hunger AND thirst -- not just hunger. And also for comfort. In the early days, they show the same cues for all three needs. The breast is not simply an attractive bottle -- it is not JUST a feeding mechanism. There is a reason why women who breastfeed only 3 to 4 months generally talk about "I breastfed my baby for 4 months" while women who breastfeed for extended periods (A year or more) talk about "I nursed my child for 18 months." Can you see the difference? One mom is only feeding her child -- the other is nursing the baby at the breast -- hunger, thirst and comfort. While breastfeeding is of paramount importance, I find the PREP series to completely discount the importance of nursing your baby.

Consider:

There are some babies that will do fine on a schedule of 3 to 4 hours. (Most not in the early days). Most mothers who limit the baby's feeds in the early days (note, I'm talking about the first 6 weeks or so) will not lay down enough prolactin receptors (DeCarvalho's work) in the breast to sustain long term breastfeeding when the breast moves from endocrine (hormonal) control to autocrine (self regulation) control. If a woman plans on breastfeeding for only 3 to 4 months and then switching to formula, she'll most likely have enough milk to sustain her for that long, but not enough to sustain long term breastfeeding. Again, these are all generalizations because as I first said, every mom is different, breast storage capacity is different, babies needs are different, stomach capacity is different, and so on. You cannot put ONE approach to ALL mother/baby dyads and say it is going to work.

Consider:

A baby who is made to wait to feed based on a clock is not going to "signal the breast to produce more" because he will suck more strongly. In fact, the opposite occurs. A baby who is made to wait will eventually shut down, and NOT breastfeed well. He may not take as much as he needs at a feed; and mom's milk production will slow. A newborn who is left to cry for even a few minutes (a baby of 2 to 3 weeks or less) becomes very disorganized and has a much more difficult time latching on and suckling correctly. Did any of you ever wonder why, in the hospital where there was no rooming in, the nurse would rush in with your baby, say, "He's really ready to eat, he's been crying for the last 10 minutes!" and as soon as you attempted to put him to breast, he would fall sound asleep and wouldn't eat? That's how newborns react when they are left to cry for what seems to be as little as 5 to 10 minutes. As babies get older, they can cry for longer periods without getting disorganized, but crying in a newborn also is like the valsalva maneuver in adults (straining at stool) -- it raises the baby's blood pressure, and temporarily can push him into fetal circulation. It also causes the sucking pressures to diminish..... bottom line is, a newborn left to cry for any length of time doesn't feel good! (Gene Cranston Anderson's research)

Also, newborns are unable to wake from a deep sleep and breastfeed. There is a reason why we look for feeding cues -- in fact, if you watch a newborn carefully, there is a systemetized mechanism in place -- when the baby is ready to eat, the breast, as a stimulus touches his cheek; his head turns slightly, and as it turns, the mouth opens and the tongue comes down and out, ready to latch on. If any of this is circumvented, such as attempting to feed the baby before he is ready, or waiting past those "golden moments" it simply won't work. Babies will shut down very quickly, and won't eat as told....this is again why it simply doesn't work (for the most part and in most babies) when the hospital staff says, "It's been 3 hours since he ate. Wake him up now and feed him." Any of us good nursery nurses (and I've been one) can MAKE a baby take a bottle on a schedule. However, I can't (and I'm a GOOD lactation consultant) MAKE a baby breastfeed -- either on a schedule or a set length of time at the breast. (Experience as 12 years as a lactation consultant; 25 years in maternal child health nursing)

Consider:

Physician's and dieticians have long decried the American way of eating 3 big meals a day. They have often said that 6 small meals would be much better for our digestive systems, growth and development. Why on earth are we trying to get our babies, who need to double their weight in 5 months & triple it in a year -- down to 4 feeds a day by 12 weeks?

Consider:

Adults have something in their mouths (unless they are actively dieting) on average of every 90 minutes during waking hours. Think of breakfast, lunch, dinner, coffee breaks, coffee, donuts, a piece of gum, a tic tac, hard candy, a soda, a glass of water. We snack. We get thirsty. We get a drink of water. Why must our babies wait for the clock? We don't. And we aren't trying to double our weight in a few months -- or even a year. Most adults will get up and go to the bathroom at least once, maybe twice during the night. Few sleep through the night. Often when they do that, they will be thirsty and get a drink of water on their way out of the bathroom. Some people still keep a carafe of water at their bedsides at night for those middle of the night thirsties. Why on earth are we denying our babies the right to do the same thing?

Consider:

I can give you references for virtually every statement in this. Can PREP do the same? Do a medline search for "metabolic chaos." Not there. Look for references that support the baby breastfeeding better if he is made to wait. Not there. Look for references that tell you that every baby will do fine if fed on the same schedule. Not available. There is no medical or scientific backup for the Ezzo's claim. Yes, there are some babies who will gain weight and do well physically on their program. There are some babies who will not do well. There are some mothers who will not produce enough milk on their program, who would produce plenty if encouraged to breastfeed their babies on cue. There are a very very few babies who will not signal their need to eat often enough -- who would rather sleep than eat, and who need to be prodded to eat in the early days. There are, au contraire to PREP, very few mothers who breastfeed their babies 15 to 20 times a day. If I have a mom who is breastfeeding that often, generally it is because there is something wrong, either with milk production or the baby's suck or latch, or a combination of both. The average number of feeds per day, is 8 to 10, going up to 12 to 14 during growth spurt periods or a time when a child might be exposed to some illness and needs to increase the antibodies and immune factors he is getting from his mother. (God's plan for breastfeeding is a miraculous design....babies know when they have been exposed to a virus/bacteria, and know when they need to breastfeed more frequently to get more immunities. See Katherine Dettwyler's work on this). A baby who is routinely breastfeeding less than 8 times in 24 hours during the first couple of months is a baby who, MOST LIKELY (not always), is going to be a slow weight gain infant. And a mother whose baby is not gaining weight and who refuses to increase the number of feeds because the schedule is more important than breastfeeding will start feeding formula to supplement the baby. Thus, breastfeeding (God's design for feeding our babies) becomes sacrificed on the altar of parental convenience and misguided parenting practices.

Jan Barger, RN, MA, IBCLC
Used by permission

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