by Melissa Clark Vickers       MEd, IBCLC Lactation Consultant

Question:

My son is 7 weeks old and I am breastfeeding only. At about 4 weeks old he started to spit up more (he normally spit up a little after each feeding). About once a day or every other day he began to spit up just about everything that he ate (I would be covered in it as would he). This only happens after one feeding a day, not each one. He has been wanting to eat more often and I am wondering if feeding him too often could be the problem. It seems to happen when I feed him closer than two and a half hours apart. He also seems to be having a lot of trouble with painful gas. Could this be a problem with my milk? He is gaining weight. At 7 weeks he weighs a little over 11 pounds. (His birth weight was 7 pounds, 9 ounces.)

Answer:

As different as the problems of spitting up and gas sound initially, I suspect they may both be related to the same cause, both based on the composition of the milk.

Your Milk Changes Throughout a Feeding
Unlike formula, the composition of your milk changes to suit the needs of your baby -- over the course of the entire breastfeeding experience, and even throughout a single feeding. At the beginning of a feeding, your milk is basically like skim milk. Foremilk is low in fat and calories, but high in volume. It is initially satisfying for a hungry and thirsty baby. As your baby continues to feed from that breast, the milk composition gradually changes to be more like whole milk, and eventually, by the end of the feeding, your hindmilk is more like cheesecake -- high in fat and calories and low in volume. It's all the same milk, it just gradually changes throughout the feeding.

Now, babies are pretty smart. They will try to nurse until they get the calories they need. If most of the milk they get is the earlier "skim" milk, it will take more to fill them up than if they get both the first milk and the "cheesecake" at the end. Not only does a meal of mostly foremilk set them up for an overly full tummy (and therefore more likely to trigger a fountain of spit-up), but it also means that baby will want to eat sooner than he might if he got more fat in one meal.

Your breasts determine how much milk to make based on how much milk is removed from them. If baby removes a lot of milk from your breasts (in an effort to get those calories), the breasts respond by making lots more to replace that milk. That can cause a major letdown, which can be difficult for baby to cope with -- it's like trying to nurse from a fire hydrant!

Foremilk-hindmilk Imbalance
The foremilk-hindmilk imbalance, as it is sometimes called, can trigger yet another related problem. While the fat content changes throughout the feeding, the milk sugar, lactose, stays pretty constant. Babies naturally have enough of the enzyme lactase to digest the lactose they get from your milk. However, if baby is getting tanked up on a lot of foremilk to get the calories his body needs, he's also getting an extra dose of the lactose. This may well be more than he has lactase to handle. This sets up something like an artificial lactose intolerance symptoms.

If you are lactose intolerant, or know someone who is, you know that eating more milk products than you have the lactase to digest can cause a major tummy ache! Babies who get more lactose than they have lactase for typically have lots of gas pains, and can be pretty miserable. The added sugar can cause food to move through the gut very quickly as well, and so these babies often have green, frothy stools.

What You Can Do About It
So how can you ensure that your baby gets a full meal of both the foremilk and the hindmilk? And why is this a problem for so many moms?

The reason this problem is pretty common is that many moms are taught to rely on clocks and symmetry to nurse their babies! Conventional wisdom has taught new moms to feed from the first breast for 10 minutes or so, and then switch to the second breast for as long as baby wants to nurse. This means that baby gets a double dose of the low-fat skim milk from both breasts, and probably won't have room for the fattier hindmilk. This is backwards! Throw out the clock, and look instead to your baby!

Offer the first breast to your baby and let him nurse as long as he wants to on that breast. He may go through cycles of actively nursing and swallowing, interspersed with short rest periods. Then he'll start the quick nursing that will trigger more milk to be letdown. It's those later letdowns that help get the fattier hindmilk to baby.

When baby's had enough, chances are he will come off the breast by himself -- often with that wonderful "drunken sailor" look! There's no mistake that this baby has gotten what he wants and needs! You can then burp him, change him, and offer the other side. If he takes it, that's fine. Regardless, start the next meal on the second breast.

This is a much more natural way to nurse, and is much easier than dealing with clocks!

The Results
When you nurse this way, let's look at what happens as a result. First of all, baby gets a complete meal from start to finish. He gets the calories he needs in a smaller volume of milk -- a volume he can comfortably handle. He has enough of the enzyme lactase to digest the lactose he's gotten. He may even go longer between feedings because he's gotten more calories (and most likely spit up less, too!).

Because a smaller volume of milk is removed from your breast, the breast will respond by making less milk -- enough for what your baby needs, but not so much as to trigger major letdowns that cause baby to sputter and choke. You may find that you leak much less as well.

One final note. Some women seem to have a greater difference in fat content between the foremilk and the hindmilk. For the women who have little difference, it doesn't really matter how they nurse. And the greater the difference, the more likely this "finish the first breast first" approach will help both mom and baby. You need to find the approach that works best for you and your baby!