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Foremilk and Hindmilk: In Quest of an Elusive Arbitrary Switch.

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Foremilk and Hindmilk: In Quest of an Elusive Arbitrary Switch.

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Explore common worries about milk quality and production

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Over the course of her breastfeeding journey, it is almost inevitable that a mother will encounter the terms "foremilk" and "hindmilk". There is certainly no shortage of confusing and conflicting advice on the concept, which has led to a lot of misunderstanding.

In The Breastfeeding Answer Book, "foremilk" and "hindmilk" were defined as follows:

"Foremilk" is the milk the baby receives when he begins breastfeeding, which is high in volume but low in fat (1).

"Hindmilk" is the milk near the end of the feeding, which is low in volume but high in fat (1).

Actually, the terms "foremilk" and "hindmilk" only really refer to samples of breastmilk taken right at the beginning of a feed ("foremilk") and samples of breastmilk taken right at the end of a feed ("hindmilk"). Even then, the advantage of using these terms is debatable. A photo on

Why?

Wikipedia "helpfully" shows two 25ml samples of human breastmilk: "foremilk" on the left and "hindmilk" on the right:

The problem with showing a sample of breastmilk from the start of a feed together with a sample of breastmilk from the end of a feed is that it tells us nothing about what happens to the breastmilk in between the two samples. Mothers end up mistakenly believing that their breasts make two different types of milk, and wonder how long they must feed for before the "foremilk" magically switches over into "hindmilk" (2).

So if the terms "foremilk" and "hindmilk" are misleading and there's no "magic switch" from one to the other, what really happens?

Since The Breastfeeding Answer Book was published in 2003, research in human lactation has advanced (2), so we now understand more about how breastmilk is produced:

Your breasts make just ONE type of milk

There is no magic switch between two different types of milk over the course of a feed. In fact, The answer lies in what happens to the
there is no sharp distinction between breastmilk at the start of a feed and breastmilk at the end of a feed (3). "Milk does indeed change consistency during a feed - but this happens gradually rather than suddenly" (4).

Why does the consistency of breastmilk change over the course of a feed?

fat in breastmilk when breastmilk is

Your breasts are continuously making just one type of milk, containing 'sticky' fat globules that tend to stick to each other and to the milk ducts in the breast as breastmilk is produced (2,3,5).

Breastmilk produced between feeds moves down towards the nipple and collects in the breast, leaving increasing amounts of fat globules 'stuck' together further up the milk ducts (3).

When let-down occurs, the milk ducts dilate (5) and the milk is ejected from the breast. The milk removed at the beginning of a feed may be lower in fat because the fat globules are still 'stuck' further up in the milk ducts (6). As the feed progresses, multiple milk ejections occur (5) and the breast is emptied, more and more fat globules become dislodged and the breastmilk increases in fat (3,6). This has the overall effect of a gradual increase in fat content of breastmilk in each breast independently as milk is removed.

How do we know that the increase in fat is gradual?

Studies involving several mothers have been conducted in which samples of breastmilk were taken at intervals over the course of a feed. The evidence from these studies suggests that the fat content of breastmilk increases gradually as the breast becomes progressively emptier over the course of a feed (7,8).

It's much easier to explain this gradual increase in fat content using pictures...

...so, revealing the crazy lengths I'm prepared to go to so I can prove a point, I visited The Countess of Chester Hospital, where several wonderful people enabled me to take consecutive small samples of breastmilk from one breast only over the course of one pumping session, and professionally photograph the results. The samples were then taken to the Cheshire and North Wales Human Milk Bank, where the fat content of each sample was analysed.

This is the snapshot we got of the gradual increase in fat content of my milk over the course of one pumping session:

Note the gradual colour change of each breastmilk sample. This is the gradual increase in fat content from the beginning of a feed (test tube 1) to the end of a feed (test tube 12).

Remove test tubes 2-11, and the result is a picture similar to the one on Wikipedia:

This shows a sharp contrast between the breastmilk at the When breastmilk is left to stand for a while, it separates into two layers. This very beginning and the breastmilk at the very end of a feed only - it tells us nothing about what happens to the breastmilk in between the two samples. Only the photo containing all 12 test tubes shows the complete picture: a gradual increase in fat content.

isn't the separation of "foremilk" from "hindmilk"; it is simply the fat in the milk rising to the top, not the separation of two different kinds of milk (4).
So what's that stuff that rises to the top of expressed breastmilk?

The reason this separation doesn't occur in a bottle of cow's or goat's milk you buy in a shop is that this milk has been homogenised. "

Whole homogenised milk is identical in fat and nutrient content to whole standardised milk however it has undergone a process known as "homogenisation" which breaks up the fat globules in the milk. This spreads the fat evenly throughout the milk and prevents a creamy layer forming at the top." (9)

After a while, the breastmilk in our test tubes separated into two layers (click on the image to open a larger version in a new window):

Again, removing test tubes 2-11 shows
Note that the breastmilk in test tube 1 does, in fact, contain a layer of fat.

Note also the increasing thickness of the fatty layer that collects at the top of the breastmilk from test tubes 1-12. This further demonstrates a gradual increase in fat content from the beginning of a feed (test tube 1) to the end of a feed (test tube 12).

only a sharp contrast between the thin fatty layer that rises to the top of the breastmilk at the very beginning, and the much thicker fatty layer that rises to the top of the breastmilk at the very end of a feed.

This photo tells us Before I continue, I must stress that this is just a snapshot of
nothing about what happens to the breastmilk in between the two samples. Remember: only the photo containing all 12 test tubes shows the complete picture: a gradual increase in fat content.

Showing us pretty pictures is nice, but how much fat did the breastmilk samples actually contain?

my breastmilk. It is unlikely that the results shown here will be an exact reflection of what happens to every mother's breastmilk. However, it does provide a rough idea of what happens, so here are the results of the analysis of each sample of my breastmilk:

If looking at raw data isn't your thing, here's a line
TS = Total Solids, ie. the bulk of the rest of the milk
Protein, carbohydrate, fat and TS values are in grammes per 100ml

graph showing the amount of protein, fat, carbohydrates and total solids present in each of my 12 breastmilk samples (fat content is shown in red).

The graph clearly shows there was a gradual (if slightly wobbly) increase in fat content as the breast is emptied. Quite plainly, there is no arbitrary "magic switch" between two different types of breastmilk during a feed.

Remember, though, that all of this is just a tiny piece in a vast breastfeeding jigsaw...

Although it is true that the fat content does gradually increase as the breast is emptied, it is important to understand that the difference in fat content between milk at the beginning of a feed and milk at the end of a feed can vary greatly from mother to mother. Not only this, but it can vary greatly over a 24 hour period, even among individual mothers (2). The difference in fat content can also depend to some degree on the amount of time elapsed between each feed (this is truer the younger the baby is) - another reason why it might not be a good idea to wait for your breasts to "fill up" before a feed.

the higher the fat content of the milk

the lower the difference in fat content between the breastmilk at the beginning and end of a feed (2,3)

This is not simply a case of the longer the feed, the higher the fat content: if there is a shorter gap between feeds (such as during periods of cluster feeding), the milk at the beginning of a feed may not necessarily be low in fat (2,10).

"Babies can show a wide variety of feeding patterns, suckling for varying lengths of time and at varying intervals over the course of a day, and maintain a healthy weight" (4,10)

Whilst fat is important, we can and do get far to preoccupied with the issue of fat content - take another look at the graph showing the amount of protein, fat, carbohydrates and total solids present in each of my 12 breastmilk samples:
The most important thing to remember is this:
In the vast majority of cases, as long as you are:

breastfeeding on cue

and allowing your baby to come away from the breast spontaneously at the end of a feed,

there is no need to worry about what's in the breastmilk your baby is getting. ALL of the components of breastmilk are essential for the growth and the physical and mental development of your baby, not just its fat content.

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If you liked this article, please consider making a small donation to Cheshire and North Wales Human Milk Bank (a charity which does a fantastic job of getting breastmilk to our most vulnerable babies), without whom this article could not have existed.

Lynda Coulter (Cheshire and North Wales Human Milk Bank) for very kindly agreeing to analyse the samples of my breastmilk.

Janet Beech and Linda Gendler (Cestrian Ward, The Countess of Chester Hospital) for entertaining my mad idea and helping to co-ordinate the experiment.
Becca Williamson (Bosom Buddy breastfeeding peer supporter) for being my extra pair of hands.

Jenni Ross (Medical Photography, The Countess of Chester Hospital) for taking such excellent photos of my breastmilk samples. This article has been republished as a guest blog on
_________________________________________________________

Acorn Pack
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Foremilk and Hindmilk: In Quest of an Elusive Arbitrary Switch.

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Over the course of her breastfeeding journey, it is almost inevitable that a mother will encounter the terms "foremilk" and "hindmilk". There is certainly no shortage of confusing and conflicting advice on the concept, which has led to a lot of misunderstanding.

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The Positive Breastfeeding Book by Amy Brown

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The Positive Breastfeeding Book by Amy Brown

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Detailed, upbeat handbook for breastfeeding

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'With its combination of straight talking, science-based information and reassuring advice from fellow mums and experts, the invaluable Positive Breastfeeding Book empowers new mums.' Mother & Baby

'I wish I'd had this splendid book a few months ago: warm, funny & accurate. For anyone who is making a choice about feeding or in the midst of it this will feel like a hug.' Chris van Tulleken

'A fantastic manual for new motherhood.' Saffia Farr, editor Juno magazine

'This book is the village of support and knowledge that all new parents need, but can be so difficult to find in our modern world.' Dr Natalie Shenker, cofounder, Hearts Milk Bank and Human Milk Foundation

'The beauty of this book is not only its accessibility but that it is informed by strong evidence and powerful voices of women.' Shereen Fisher, Chief Executive, Breastfeeding Network
How often does my baby really need to feed?
How do I know my baby is getting enough?
Is it normal for my baby to wake at night?
When you're expecting a new baby, suddenly everyone around you becomes an expert - particularly when it comes to how to feed them. It is easy to become overwhelmed by conflicting advice, myths and exaggerated stories. The Positive Breastfeeding Book cuts through the anecdotes, giving you clear, no-judgement, non-preachy, evidence-based information to help you make the right decisions for you and your baby. It will...

help you understand how breastfeeding works

give you tips for planning for your baby's arrival

help you cope with those early months

support you to make sure that whilst you're looking after the baby, you're getting taken care of too

point you to how to seek help if challenges come up

guide you through feeding in public, going back to work, and even rediscovering a glass of wine

You'll find plenty of real stories and guidance throughout from mothers and experts in supporting breastfeeding. There are handy chapters on formula and mixed feeding, which cut through advertising spiel and give you the facts you need to choose and use formula safely.

The Positive Breastfeeding Book doesn't promise to make it easy, nor will it get up in the middle of the night for you, but it will empower you with the knowledge and encouragement you need to feed your baby with confidence.

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the positive breastfeeding book: everything you need to feed your baby with confidence

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health & fitness / pregnancy & childbirth

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The Positive Breastfeeding Book: Everything you need to feed your baby with confidence

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Buy The Positive Breastfeeding Book: Everything you need to feed your baby with confidence by Amy Brown (ISBN: 9781780664606) from Amazon's Book Store. Everyday low prices and free delivery on eligible orders.

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Readable and friendly guide to breastfeeding

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you've got it in you: a positive guide to breastfeeding

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family & relationships / parenting / general

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family & relationships / parenting / motherhood

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You've Got It In You: A Positive Guide to Breastfeeding

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You may be worried about breastfeeding and worried that it might 'not work'. This is a common feeling when you live in a society where breastfeeding is often sabotaged by incorrect information, patchy support from a stretched health service and powerful messages from formula compani...

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by American breastfeeding supporter Nancy Mohrbacher

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As it describes, in the beginning, most nursing newborns bunch their feedings together during wakeful times or "cluster nurse." For this reason, it's not helpful to focus on when baby fed last. Whenever baby shows feeding cues (increased activity, rooting, mouthing), assume it's time to nurse again. Yes, even if it's only been 10 minutes. If baby seems hungry again soon after feeding, don't worry about overfeeding and don't consider it a reflection on your milk production. It's just what newborns do. This is how your baby helps you build a healthy milk supply.

There is no value whatsoever in trying to convince your baby to go for longer stretches between feeds. Newborns have no sense of time, and putting your baby off only adds stress to your life. If your baby seems interested in feeding or is fussy, try nursing first, and if that doesn't help, move on to other comfort techniques. As your baby grows and matures (and his stomach grows and can hold more milk), he will naturally become more regular in his feeding patterns. You don't have to do anything to make this happen.
How Long Is It Okay for a Newborn to Sleep?
Beginning on about second night after birth, don't be surprised if your newborn goes into a feeding frenzy just about the time you're thinking about going to bed. Most babies are born with their days and nights mixed up. That's why it's best for the sake of your own rest and recovery to sleep when your baby sleeps so that you're rested and ready for more feedings at night.

It's not uncommon for a brand-new baby to have one 4- to 5-hour sleep stretch, but it is often during the day. As long as your baby fits in at least 8 feedings every 24 hours and is gaining weight well (after Day 4, an average of about 1 oz. or 30 g per day), there's no reason to wake your baby to feed. (For more on this, see my post HERE.)

It usually takes a few weeks for your baby's body clock to get closer to yours. To speed up this process, try keeping stimulation to a minimum at night (lights low, sounds low, no diaper changes unless baby passes a stool). Make daytime full of light, sound, diaper changes, and before you know it, baby will be taking her longer sleep stretch at night.
Gaining Confidence in your Milk Production
Your baby's feeding patterns are not a reflection of your milk production. But there are other ways you will know that your baby is getting the milk she needs. Her stool color is one sign. If nursing is going well, your baby's stool will turn from black to green by about Day 3 and green to yellow by Day 4 or 5. Weight gain is the best way to gauge your baby's milk intake and your supply. Once baby reaches her low weight on Day 3 or 4, during the first 3 months, expect a weight gain of about 1 oz. or 30 g per day. Weight gain is the gold standard of healthy milk intake and milk production.

When it comes to nursing and the clock, keep in mind that nursing has been around much longer than clocks. In other words, you don't need a clock to make nursing work. Sometimes too much focus on the clock can even cause problems by shifting your focus away from what really matters.

Your baby will tell you everything you need to know. The American Academy of Pediatrics recommends nursing babies on cue rather than on a schedule. (See its 2012 policy statement HERE). Don't be distracted by the clock. Instead, watch (and trust) your baby.

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The Clock and Early Nursing - Nancy Mohrbacher

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The clock looms large in the lives of many nursing families.

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Feeding Your Baby – Is It Taking Too Much Time?

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Feeding Your Baby – Is It Taking Too Much Time?

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From the Australian website bellybelly

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It can feel reassuring to have specific instructions about when to feed your baby, especially when everything about caring for a baby is new and uncertain to you. However, when you are expected to time how many minutes you breastfeed, watch the hours between feeds or count how many feeds your baby has in a day, with the ultimate goal being how many hours you can make your baby sleep, you will soon see feeding your baby as a chore. As resentment brews about how much time your baby is taking up, it can seem an attractive option to prop your baby with a bottle in the hope that your life will become more efficient.

Despite claims by various people that a feeding schedule will positively influence your baby's sleep patterns, in most cases there are risks to be considered: some strict regimes have been associated with breast milk supply failure, poor infant weight gain and failing to thrive infants. Breastfeeding according to a schedule may seem to work at first but many women who use strict feeding schedules in the early weeks find that their milk supply dwindles and their baby may be weaned by about three months. By restricting feeds or repeatedly spacing them out with dummies, you may limit the development of the hormonal process that enhances ongoing milk production. This translates to: early and frequent breastfeeding will promote a continuing milk supply, which means that your baby will get lots of milk so he is less likely to wake up often to be fed.

The amount of breast milk you produce and how much your baby drinks is influenced by other factors including your baby's stomach size, and the milk storage capacity of your own breasts. At first, your baby's tummy is only the size of his tiny fist and breast milk is very quickly digested so your baby will need frequent feeds, at least in the early weeks. It is common for a breastfed baby to need feeding from several times in one hour to about every two hours at first. It is also common for babies to need a 'cluster' of feeds closer together in the evening.

Ultrasound studies by biochemist Dr Peter Hartmann and colleagues at the University of Western Australia have shown that breast milk storage capacity can vary up to three times as much between individual women (this is not necessarily related to breast size and doesn't influence milk production ability). This means that while some women who have a large milk storage capacity will be able to feed their babies enough milk to go three or four hours between feeds (providing their baby has a big enough stomach), other women will need to feed their babies more often. For women with a smaller milk storage capacity, a rigid feeding schedule could result in a hungry, unsettled baby and a mother who questions her ability to produce enough milk when really, it is the schedule that is inappropriate, not the mother's feeding ability.

Milk production and infant intake are also influenced by the fat content of your milk and the degree of breast emptying at any given feeding. According to Dr Hartmann's research, an empty breast will make milk more quickly while a full breast will make milk more slowly. This means that if your baby sucks vigorously and 'empties' your breasts (because you make milk continuously your breasts will never be completely empty), production speeds up and if he doesn't take much milk from the breast at a feeding, your breasts will get the message to make less milk. If your baby seems to go on a feeding binge at any time, this isn't an indicator that you are 'losing your milk' but that you will need to take it easy and feed your baby more frequently for a few days so your breasts get the message to produce more milk. By responding to your baby's signals, in a few days' time, he will space out his feeds again.

Babies regulate the type of milk they need by the way they suck. The first type (foremilk) will quench their thirst, which is why they often have short, frequent feeds on hot days, just as we sip from our water bottles. Hunger will be satisfied by longer sucking periods when baby gets the fatty hind milk which is squeezed down into your ducts by the reflex known as 'letdown'; this is usually felt as a 'tingly' sensation in your breasts and accompanied by leaking from the breast that your baby is not sucking from. Letting your baby decide how long he needs to feed and letting him finish the first breast before switching sides, rather than limiting him to an arbitrary number of minutes each side, will ensure he gets the rich fatty hind milk - and will satisfy him, so he sleeps longer.

There will be times when your baby has a growth spurt and will need to feed more often to match his increasing appetite. Babies who are unwell also often increase their feeding frequency. Researchers now believe that this not only provides comfort, but also increases the baby's intake of antibodies and immune factors through the mother's breast milk.

Bottle-feeding, whether you are giving your baby formula or expressed breast milk, can be as time-consuming as breastfeeding, especially if your baby feeds slowly as some very little babies do. The solution to a slow or sleepy feeding baby is not to force him to stay awake by brutal means such as sponging him with wet face washers or by cutting a bigger hole in the teat - this poses a choking risk and most certainly would cause discomfort and distress. Rather, follow your baby's lead and perhaps offer smaller, more frequent feeds. As he grows stronger, he will find it easier to stay awake and will become a more efficient feeder naturally.

Whether you are bottle or breastfeeding, by trying to see this time as an expression of your love for your baby, you will be able to appreciate the rewards of these intimate moments - breathing in your baby's delicious smell, stroking his silky skin as his warm little body snuggles against your own, and gazing into his trusting eyes as they meets yours - and you will cherish this precious time long after he has outgrown your lap.

More Great Breastfeeding Information?

For more fantastic breastfeeding information, check out Pinky's eBook, Breastfeeding Simply or check out BellyBelly's recommended breastfeeding books here.

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Feeding Your Baby - Is It Taking Too Much Time? | BellyBelly

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It can feel reassuring to have specific instructions about when to feed your baby, especially when everything about caring for a baby is new and uncertain to you.

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Breastfeeding: The dangerous obsession with the infant feeding interval

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Breastfeeding: The dangerous obsession with the infant feeding interval

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from the UNICEF Baby Friendly Initiative website

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This guest blog from breastfeeding counsellor Emma Pickett discusses the dangers of promoting a strict feeding schedule at the expense of responsive, flexible infant feeding.
Add your voice to Unicef UK's Change the Conversation campaign, calling on UK governments to take urgent action to protect, promote and support breastfeeding.
Somehow, somewhere, new mothers got the message that the gap between when a baby stops a breastfeed and the time they start to need another one matters a very very great deal. 24 hours a day.

It seems to matter beyond all logic and reason. They see this magic number - 90 minutes, 2 hours, 3 hours - as a measure of something sacred.

And it's crap.

There are mums sitting at home, relaxing and nesting with their gorgeous new baby. There's a disk from a box set in the DVD player, a cup of tea on the go, a recent chat with a friend. Breastfeeding is going well. Weight gain is fine. Baby is content. But when baby shows hunger cues after only 40 minutes instead of the hoped for 1 hr 30 minutes, their heart sinks and they feel a sense something is fundamentally wrong. They aren't 'doing it right'. Their friend's baby 'goes longer'. Doubts creep in.

As adults, we grab a cup of tea, a glass of water, a sweet, a snack. We respond to our personal cues and we're flexible depending on time of day, the temperature, our mood, our energy levels. Many go to bed with a glass of water or sip from a bottle throughout the day. I don't know any adults that look at their watch and say, "Only 30 minutes till my next sip of water or mint! Not long now". But yet we expect teeny growing babies to be governed by this artificial notion of time.

Basic misconceptions

I spoke to a new mother last week who was perfectly happy with her feeding routine but wondered if she should start to stretch her baby's intervals because 'that's what you do'. When I explained that it wasn't necessarily, she said she was more than happy to go on as she was.

Where do these ideas come from? They don't come from anyone with any breastfeeding education, nor antenatal classes with breastfeeding professionals, nor books written by those trained to support breastfeeding.

They come from popular baby care books and relatives and peers.

They seem to come from a fundamental misunderstanding of the science of breastfeeding and breastmilk production. Often they come from mid-20th century ideas based around the norms of formula-feeding and pseudo-science. And that's all incredibly dangerous.

There are still people out there, surrounded by breastfeeding, who believe that a baby who feeds after 4 hours rather than 3 hours will 'take more milk'. There are people who believe that you need to wait and hold a baby off to let your breasts 'refill'. There are people who believe that when a baby does want to return to the breast after only an hour that must reflect a 'problem' and perhaps the mother even has a supply issue.

It's scary and extremely frustrating that basic messages about how milk production works don't reach the people who need them.

Searching for "normal"

So what is normal? Well, how long have you got? Because there's a lot of normal. A newborn should feed a minimum of 8-12 times in 24 hours. That means some might be going every 3 hours and others will be feeding more frequently than 2 hourly. Some babies may feed every 10 minutes every hour. Some may feed for 10 minutes every 2 hours. Some may feed for 40 minutes every 2 hours. For periods in the day, a younger baby will often cluster feed and not be happy away from the breast for any longer than a few minutes at a time. This natural cluster feeding may dominate an evening.

A very common call to the National Breastfeeding Helpline goes like this: "My baby used to sleep in the evenings and now he's awake for 3-4 hours. The only thing that seems to settle him is the breast. I feel like I must not have enough milk as he's on there for ages. Surely there can't be anything there." As the baby swaps from breast to breast, getting small quantities of very high fat content milk and decompressing at the end of a long day, they know exactly what they are doing.

And soon their patterns will change again. Some babies will start to longer intervals in the day as the months go by. But not all will.

One of the most popular babycare books (which I better not name) gives a strong direction that while frequent feeding might be occasionally acceptable during growth spurts, this holy cow of the interval between feeds matters greatly. A 3 month old baby might be going 3 hourly intervals but if this isn't increasing at 4 months, then oh dear. This same writer believes a woman can measure her milk supply by doing a yield test and using a pump to extract milk which apparently will be the equivalent amount to what her baby extracts during a feed using an entirely different process. What this woman doesn't know about breastfeeding could fill an encyclopaedia.

What I find particularly dangerous about her message that longer intervals are 'better' and 'correct', is that is means new mothers doubt their milk supply with absolutely no justification. And I know from having spent time on the message boards associated with this writer, many mothers will end up supplementing with formula to try and reach these magic numbers of minutes.

Why?

Babies are no longer being exclusively breastfed and parents are not following Department of Health recommendations because of incorrect information in a baby care book.

There are parents who choose to use formula for a whole host of complex reasons. Some do so happily and some do so miserably. But to do so, merely because you have read a lie in a book, seems tragic to me.

Our knowledge about breasts has been transformed over the last 20 years. Much of the pioneering work has been done in Australia by scientists like Professor Peter Hartmann and Dr Donna Geddes, Steven Daly and their teams.

We used to think most women had a pretty similar number of milk ducts but the ultrasound research revealed there were less than previously thought and the range was big. One woman had 4 ducts at the nipple. One had 18.

But it's the findings about breast storage capacity that we need to talk about here. When a baby feeds, some milk is manufactured during the feed itself and some is taken from milk that has been stored in the breasts between feeds.

Ultrasound revealed that a mother's storage capacity cannot be guessed from breast size. Breast size is obviously not just about glandular tissue. The range in breast storage capacity was huge.

One mother was able to store about 2.6oz per breast. Another woman stored more than 20oz. That's not a typo.

Women with a smaller breast storage capacity had a healthy milk production over a 24 hr period and their babies had good weight gain. But their babies might need to feed more frequently to access this healthy milk production.

Is this a mother with a supply problem?

No, it is not.

Her baby may continue to feed 2 hourly or even more frequently for a few months during the day, cluster feed at certain points and perhaps continue to wake a couple of times hungry at night. Her friend's baby may settle into a pattern of feeding less frequently over a 24 hour period. This friend's baby may not be receiving more milk overall.

When breasts are fuller, milk production slows. When breasts are emptier, we make more milk. When babies feed more frequently and from emptier breasts, they receive milk with a higher fat content. Frequent feeding has value. And as human milk has a fat content of around 3-5% compared to some mammals who have a fat content of 40% +, it seems pretty clear we're designed as a species to need feeding more frequently.

But let's imagine the mother with the smaller breast storage capacity has read this baby care book. She might become distressed that her baby still wants to feed 2 hourly. She might even try and stretch the interval between feeds in the mistaken belief this will increase her baby's intake. And in doing so, her breasts spend longer at full storage capacity and their milk production slows and her breasts receive the signal to decrease milk supply.

So in her attempt to stretch between feeds as the advice she is reading suggests she does, she may actually be decreasing her overall milk production in 24 hours and be doing some actual harm.

So what should we suggest to this mum who never seems to be able to stretch her baby to longer intervals in the ways that her friends seem able?

First off, we should congratulate her for responding to her baby's cues. Thankfully she knew not to try and impose some routine early on and therefore her milk supply is at its maximum capacity. Let's check breastfeeding is otherwise going well: that feeds are comfortable for her, baby does settle for periods of contentment after a feed (though it may only be an hour or even less, rather than 3), weight gain and nappies are fine and latching and positioning is at maximum efficiency. If all this is true, and never reaching a magic 'interval' is her only concern, then we need to make sure she knows as much as possible about how milk production works. It is possible she is one of the mothers who has a minimal breast storage capacity and she will need to feed more in 24 hours to maximise the volume of milk her baby receives. And there might be nothing she can do about that. What happens next is about acceptance and support and attitude.

She has to keep that up for ideally around 6 months if her baby is going to get the full benefits of exclusive breastfeeding. She might need greater support with feeding outside the home - perhaps learning how to feed in a sling or experiment with different positions for different environments. It's possible she may be woken at night more than her friend with the longer intervals - though we would expect night time intervals to be longer and for her to get a block of longer rest. She may benefit from support on safe bed-sharing practices.

And it is just a matter of months. After solids have been established, patterns will change. It's surprising what we can cope with for just a few months. We have jars of pickle in our fridge significantly older than that. We may even have toothbrushes that are around that long. In terms of an adult lifetime, it's a blink of an eye.

What won't help these mothers is the relentless message that they just need to stretch their baby a little more. That if they leave him to cry for 15 minutes, magically he will take more milk and life will change. That just isn't what science tells us is true for all women.

Responsive feeding: So much more than milk

Of course breastfeeding isn't just about milk anyway. Apparently there are people who think that a baby comes to a breast primarily to get milk but I've not met a parent of a baby who thinks that's true. Just as we don't measure our sips of water, sweets and snacks, we also don't measure every time our family smiles warmly at us, communicates with us, looks for comfort, hugs us, checks in, helps us to feel safe. No smart phone app can measure all the complexities of our relationship with our baby and all the things that responsive feeding can do. You are trying to count and measure love.

And I'm talking about myself here, by the way. My children under 6 months never went longer than 2 hours between feeds in the day and not much longer at night. My red record book records me feeding at 3 months every 90 minutes or so. So I learnt to feed while babywearing. I went to friendly groups and friendly places and met up with people at home. I read about safe co-sleeping practices which I know beyond a shadow of a doubt saved my bacon. And thankfully, I never felt anything was 'wrong'. I just trusted my body. I trusted my baby and we worked as a beautiful team. I sat at home on the sofa and fed relatively frequently, enjoyed my box sets and my healthy and not-so-healthy snacks and that was OK.

It really wasn't for long. But the benefits of exclusive breastfeeding will be.

Why should a watch or clock tell me how to be a mother? I'd rather pay attention to my baby.
Sources

Anatomy of the lactating human breast redefined with ultrasound imaging. DT Ramsay, JC Kent, RA Hartmann, and PE Hartman. 2005.

The magic number and long-term milk production. Nancy Mohrbacher IBCLC

Studies on Human Lactation: Development of the computerized breast measurement system. D.B Cox, R.A Owens, Peter E. Hartmann

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Guest blog: Breastfeeding: The dangerous obsession with the infant feeding interval - Baby Friendly Initiative

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Advice that babies must follow a strict three-hourly breastfeeding routine is causing mothers distress and guilt,and reducing breastfeeding rates.

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The Importance of Dads and Grandmas to the Breastfeeding Mother

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The Importance of Dads and Grandmas to the Breastfeeding Mother

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Straightforward general text

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Warm and thoughtful book about baby-feeding, pressures and society

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Breastfeeding Uncovered:Who really decides how we feed our babies?

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The success or failure of breastfeeding should not be seen solely as the responsibility of the woman. Her ability to breastfeed is very much shaped by the support and the environment in which she lives. There is a broader responsibility of governments and society to support women through policies and programmes in the community.'

Dr Nigel Rollins, WHO, 2016

Across the Western world there continues to be a drive to improve breastfeeding rates. After all, breastfeeding protects the health of mothers and babies and saves economies many millions of pounds. The World Health Organisation therefore recommends exclusive breastfeeding for the first six months, with continued breastfeeding up to two years and beyond.

Levels of breastfeeding in the UK are however the lowest in the world. Yes the world. Only one in 200 mothers is breastfeeding at all by twelve months. Although four out of five mothers starts breastfeeding, less than half of babies are still exclusively breastfed by the end of their first week of life, with less than one in six exclusively breastfed at 12 weeks. Less than a third are breastfeeding at all by six months. Comparatively, in many Scandinavian countries three quarters are breastfeeding at six months.

But why? Medical issues that make breastfeeding impossible or ill advised do happen but they are very rare. Most likely affecting less than 1% of women. So what about everyone else? What's going on that we struggle with breastfeeding here, yet others don't? In a nutshell ... Society.
'The reasons why women avoid or stop breastfeeding range from the medical, cultural, and psychological, to physical discomfort and inconvenience. These matters are not trivial, and many mothers without support turn to a bottle of formula. Multiplied across populations and involving multinational commercial interests, this situation has catastrophic consequences on breastfeeding rates and the health of subsequent generations.'
http://www.thelancet.com/series/breastfeeding

Although the 'breast is best' message is heard on every corner, it often appears to just be lip service. Our society doesn't support breastfeeding. It doesn't accept it. Doesn't understand it. Doesn't protect it. We don't understand what breastfeeding is really like any more, and many mothers feel that they are doing something wrong and they need to stop.

Our 'normal' has become formula; more mums have experience of formula by the end of the first day than breastfeed even partially until six months. But breastfeeding and formula feeding are not the same. On the one hand we tell mums they must breastfeed ... but with the other place numerous barriers in their way.

Yes they must breastfeed but they must also think about how they look. Their job. Their relationship. Getting their life back. Whether they're causing anyone distress. And until we change that we won't increase breastfeeding rates. And we'll continue paying the health care costs of babies who were needlessly formula fed.

And you know who's responsible for that? Society. We all are. Unicef Baby Friendly sum this up perfectly in their recent call to action
'We need to change the conversation around breastfeeding by stopping laying the responsibility for this major public health issue in the laps of individual women and acknowledging the role that politics and society has to play at every level. The goal of our Call to Action is not to put pressure on women to breastfeed, but to remove the barriers that currently stop women who want to breastfeed from doing so.'
The aim of Breastfeeding Uncovered is to raise awareness of what breastfeeding is really like and to shine a light on the barriers we are placing in its way. Overall it aims to serve as a resource for information and support for breastfeeding mothers, but also those around them who have more power in affecting their feeding decisions than they realise.

It's time to make a change.

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Breastfeeding Uncovered:Who really decides how we feed our babies?

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The success or failure of breastfeeding should not be seen solely as the responsibility of the woman. Her ability to breastfeed is very much shaped by the support and the environment in which she lives. There is a broader responsibility of governments and society to support women through policies and programmes in the community.'

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A positive and encouraging read.

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The Positive Birth Book: A New Approach to Pregnancy, Birth and the Early Weeks

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Buy The Positive Birth Book: A New Approach to Pregnancy, Birth and the Early Weeks 1 by Milli Hill (ISBN: 9781780664309) from Amazon's Book Store. Everyday low prices and free delivery on eligible orders.

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Straightforward Information

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In the first few days, you and your baby will be getting to know each other. It may take time for both of you to get the hang of breastfeeding.
This happens faster for some women than others. But nearly all women produce enough milk for their baby.

Preparing to breastfeed before the birth

It's good to find out as much as you can about breastfeeding before you have your baby. It may help you feel more confident when you start breastfeeding your baby.

Antenatal classes usually cover the most important aspects of breastfeeding, such as positioning and attachment, expressing, and how to tackle common breastfeeding problems.

Find antenatal classes near you.

You can find out about breastfeeding from your midwife, family and friends, and useful helplines and websites.

There are lots of groups and drop-ins, some specially designed for pregnant women who want to know more about breastfeeding. You can find out more by asking your midwife, health visitor, local peer supporter or GP. Or visit your local Children's Centre.

Skin-to-skin contact

Having skin-to-skin contact with your baby straight after giving birth will help to keep them warm and calm and steady their breathing.

Skin-to-skin means holding your baby naked or dressed only in a nappy against your skin, usually under your top or under a blanket.

Skin-to-skin time can be a bonding experience for you and your baby. It's also a great time to have your first breastfeed. If you need any help, your midwife will support you with positioning and attachment.

Skin-to-skin contact is good at any time. It will help to comfort you and your baby over the first few days and weeks as you get to know each other. It also helps your baby attach to your breast using their natural crawling and latching-on reflexes.

You'll still be able to bond with and breastfeed your baby if skin-to-skin contact is delayed for some reason, for example if your baby needs to spend some time in special care.

If necessary, your midwife will show you how to express your breast milk until your baby is ready to breastfeed. They can also help you have skin-to-skin contact with your baby as soon as it's possible.

Skin-to-skin after a caesarean

If your baby is delivered by caesarean, you should still be able to have skin-to-skin contact with your baby straight after delivery.

Colostrum: your first milk

The fluid your breasts produce in the first few days after birth is called colostrum. It's thick and usually a golden yellow colour. It's a very concentrated food, so your baby will only need a small amount, about a teaspoonful, at each feed.

Your baby may want to feed quite often, perhaps every hour to begin with. They'll begin to have fewer, but longer feeds once your breasts start to produce more "mature" milk after a few days.

The more you breastfeed, the more your baby's sucking will stimulate your supply and the more milk you'll make.

Your let-down reflex

Your baby's sucking causes muscles in your breasts to squeeze milk towards your nipples. This is called the let-down reflex.

Some women get a tingling feeling, which can be quite strong. Others feel nothing at all.

You'll see your baby respond when your milk lets down. Their quick sucks will change to deep rhythmic swallows as the milk begins to flow. Babies often pause after the initial quick sucks while they wait for more milk to be delivered.

Occasionally this let-down reflex can be so strong that your baby coughs and splutters. Your midwife, health visitor or breastfeeding supporter can help with this, or see some tips for when you have too much breast milk.

If your baby seems to be falling asleep before the deep swallowing stage of feeds, they may not be properly attached to the breast. Ask your midwife, health visitor or breastfeeding supporter to check your baby's positioning and attachment.

Sometimes you'll notice your milk letting down in response to your baby crying or when you have a warm bath or shower. This is normal.

How often should I feed my baby?

In the first week, your baby may want to feed very often. It could be every hour in the first few days.

Feed your baby as often as they want and for as long as they want. They'll begin to have fewer, but longer feeds after a few days.

As a very rough guide, your baby should feed at least 8 to 12 times, or more, every 24 hours during the first few weeks.

It's fine to feed your baby whenever they are hungry, when your breasts feel full or if you just want to have a cuddle.

It's not possible to overfeed a breastfed baby.

When your baby is hungry they may:

get restless

suck their fist or fingers

make murmuring sounds

turn their head and open their mouth (rooting)

It's best to try and feed your baby during these early feeding cues as a crying baby is difficult to feed.

Building up your milk supply

Around 2 to 4 days after birth you may notice that your breasts become fuller. This is often referred to as your milk "coming in".

Your milk will vary according to your baby's needs. Each time your baby feeds, your body knows to make more milk for the next feed. The amount of milk you make will increase or decrease depending on how often your baby feeds.

Feed your baby as often as they want and for as long as they want. This is called responsive feeding. In other words, responding to your baby's needs. It's also known as on-demand or baby-led feeding.

In the beginning, it can feel like you're doing nothing but feeding. But gradually you and your baby will get into a pattern and the amount of milk you produce will settle down.

It's important to breastfeed at night because this is when you produce more hormones (prolactin) to build up your milk supply.

In the early weeks, before you and your baby have become comfortable with breastfeeding, "topping up" with formula milk or giving your baby a dummy can lower your milk supply.

Speak to a midwife or health visitor if you are worried about breastfeeding or you think your baby is not getting enough milk.

They might suggest giving your baby some expressed breast milk along with breastfeeding.

Find out more about how to tell if your baby is getting enough milk and tips for building up your milk supply.

Dealing with leaking breasts

Sometimes, breast milk may leak unexpectedly from your nipples.

Wearing breast pads will stop your clothes becoming wet with breast milk. Remember to change them frequently to prevent an infection.

Expressing some milk may also help. Only express enough to feel comfortable as you do not want to overstimulate your supply.

If your baby has not fed recently, you could offer them a feed as breastfeeding is also about you being comfortable.

Help and support for breastfeeding

Find out more about positioning and attachment, including how to get comfortable and make sure your baby is properly attached.

If you are having difficulties with breastfeeding, take a look at breastfeeding problems.

Ask a midwife or health visitor for help. They can also tell you about other breastfeeding support available near you.

Search online for breastfeeding support in your area.

Call the National Breastfeeding Helpline on 0300 100 0212 (9.30am to 9.30pm daily).

Got a breastfeeding question?

Use the Start4Life Breastfeeding Friend chatbot for fast, friendly, trusted NHS advice anytime, day or night.

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