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A test for lactation success
A TEST FOR LACTATION SUCCESS A Preliminary Report MICHAEL (From
the
Gynecean Hospital and Gynecology,
NEWTON,
M.D., PHILADEWHIA,
FA.
Institute of Gynecologic Research, Department Hospital of the University of Pennsylonnia)
of
Obstr+ric!s
T
HE object of this study was to find a simple laboratory test which could be used to predict a nursing mother’s ability to produce an adequate supply of milk. Wailer’s report? indicated that among women in whom lactation was well established the increase in the fat content of milk during a single nursing was due to a draught or let-down reflex. Newton and Newton’ showed success in early lactation to be related to the function of this reflex. When proper let-down occurs, fat-rich milk is expelled from t,he alveoli of the breast into the larger ducts to become available at the nipple, With normal function. later samples of milk should contain considerably more fat, while with subnormal function little or no increase in the fat, cont,ent should occur. The difference in the fat content of the milk before and after nursing might therefore be used in early lactation to appraise the function of t,hc let-down reflex and to predict the successof lactation.
Miterial and Methods A group of 25 mothers in the Maternity Ward of the Hospital of the University of Pennsylvania were used in this study. These patients were selected inasmuch as they had experienced uncomplicated antepartum courses, spontaneous or simple instrumental deliveries, and normal postpartum courses. The breasts and nipples of all were grossly normal and the babies were mature and healthy. At the time of this study, the breast feeding practice in use at the hospital consisted of scheduled feedings which permitted liberal sucking. Mothers were strongly urged to breast feed their babies. The babies were brought to the mothers every 4 hours, for 30 to 45 minutes, starting 24 hours after birth. For the first few feedings the time of sucking was somewhat limited and thereafter it was permitted for the whole time during which t,he baby was with the mother. Tests for milk fat were performed in all cases on the fourth postpartum ~2 day, i.e., at an average of 98 hours (range 80 to 110 hours) after delivery. specimen of milk (3 to 5 c.c.) was obtained from one breast by means of an electric breast pump at the regular nursing time just before the baby was brought in. The baby was then allowed to nurse until he was satisfied or refused to continue, usually 30 to 45 minutes, starting on the side from which the specimen had been taken. As soon as possible thereafter, 3 to 5 C.C. of milk were taken as before from the same breast. The babies were weighed before and after all feedings on the fourth postpartum day, including the test feeding, and the average amount of milk obtained at a fourth-day feeding was computed. In addition, the mothers were 397
questioned concerning symptoms suggestive of function of the let-clown relies3 I)ot,h at previous feedings at~d during the test feeding. These symptoms were : (d) uterine pain tluring nursil~g, (2) dripping of milk before the baby was put to the breast, (3) drilq)ing of milk from the opposite breast, (4j cessation of nipple pain during nursing. Th(l significance of these symptoms has been discussed in a previous publication.’ The specimens of milk which were obtained before and after nursing were analyzed for fat by a modification of’ the Leffmann-Beam method.” After the sample had been mixed, 2.5 c.c. were placed in a special tube.” One cc. of a mixture of equal pa.rts of amyl alcohol and concentrated hydrochloric acid was added ant1 the tube was filled with 75 per cent sulfuric acid to just above the graduated marks on the narrow neck. The tube was then centrifuged for fire minutes at approximately 1,500 r.p.m. and the percentage of fat in the sample was read off front the graduated scale. The resultant figure was bhen rloublecl since 2.5 C.C. instead of 5 C.C. (as originally described) were used. Readings were made with confidence to 0.1 per cent (0.2 per cent after correction) and repeated determinations on the same sample of milk agreed satisfactorily.
Results The difference in the fat conteut of the two specimens in successful and unsuccessful breast feeders is seen in Tables I and II. The mean initial fat content of the milk was approximately the same in the two groups: 2.8 per cent in the successful and 2.9 per cent in the unsuccessful group. The difference in the mean increase, however, was quite definite: 2.0 per cent in the successful and only 0.2 per cent in the unsuccessful group. This difference is statisticaliy significant (p less than 0.05 j. Of the 15 successful breast feeders, only 3 gave an increase of under 1 per cent. Of those who were unsuccessful, 10 in number, only 2 gave an increase of over 1 per cent. TABLE
I.
DIFFERENCES
IN
FAT CONTENT OF HUMAN MILK IN 15 SUCCESSFUL* BREAST
--.__
up--
-.--I_
FAT BEFORE
NURSING
70
FEEDERS
-
I
CONTENT
AFTER
OF MI1.K
%YRSING --_ 1.1.0 9.0
%
DIFFERENCE
I
k
--
-
7.8
5.4
3.2
3.2 2.2 1.8 0.4 3.0 2 4.0 2.8 2.8 2.4 2.4 Mean 2.8 *A successful breast feeder was defined as one whose baby was fed entirely on the flfth postpartum day.
by breast
The increase in fat content showed a positive correlation with the amount of milk taken by the baby at the test feeding and a greater but not significant positive correlation with the average amount of miIk given at a fourth-day *Manufactured
by the A. H. Thomas Co., Philadelphia,
Pa.
feeding. The successful mothers gave a mean of 76 Gm. of milk during an average fourth-day feeding while the unsuccessful mothers gave a mean of only 34 Gm. The difference between the two groups is highly significant (1) less than 0.01). TABLE
11.
DIFFERENCES
IN
FAT CONTENT OF HUMAN MILK IN 10 U?;SIY:CLSSI"I:I.+ BREAST
FEEDERS -_--I__
-__~-_-FAT -
I___^_
REFORE
Mean on
the
*An fifth
NURSING
7%
CONTENT
AFTER
I
OF
NURSING
4.2 1.2 1.6 1.6 3.0 3.n 4.4 2.4
6.8 2.4 2. 0 2.0 3.0 3.0 4.0 1.8
2.0 5.6
1.2
2.9
3.1
-
MILK c/r
r. ..___..
breast day.
feeder
was
;
--...
-_
70
PIFFERENCE
-.--. 2.6 1.2 0.4 0.4 0.0 0.0 -4.4
4.6 -0.S
4.6
unsuccessful postpartum
-7x.z
1.0 0.2
--___---.-
one whose
baby
required
.___.
a supplementary
formula
The relat,ion between the let-down symptoms and the increase in fat content of the milk is seen in Table III. When the four symptoms of let-down were totaled they occurred more frequently in mothers who had an increase in fat of more than 1.3 per cent than in those who had an increase of less than 1.3 per cent. This difference was slight before the test nursing but significant (p less than 0.05) during the test nursing. Differences were most marked in “milk dripping before nursing” and in L‘milk dripping from opposite breast during nursing. ’ ’ The slight differences in the other two symptoms may be explained by the low over-all incidence of “uterine pain” on the fourth postpartum day and the relatively small number of cases in the “cessation of nipple pain ” group.
__-..~-
_---.__-.-___MOTHERS
-.--__
WITH BEFORE
SYMPTOMS TEST
FAT INCREASE 31ORl? THAN
Nl’RSING
Uterine pain while Milk dripping while Milk dripping from site breast while Cessation of nipple while nursing All symptoms t *1.3 per cent nIpI&
tOccasiona1 pain.
ssro
represents
78% mean
symptoms
of all
unclassifiable,
FAT I?*‘CREASF. IIESS THAN
1.3%
1.3%
62'/'0 467%
73%
100%
ti2%
100%
100%
lOl1f,i
siyc
-._____71%
CASES)
73% 91%
the
TEST
increases e.g.,
home
(11
_ .
_____._~.. NI’RSlNG
cases~ -----18% x3'%
( 14
6@7'c
were
I~I.‘RlK:O
FAT INCREASE --___-_____--------MORE TH.IN
1.3 ‘$7
CASES)
nursing nursing opponursing pain
_____-
/ FAT INCILEASE LESS THAN
1.3%X (11
PRESENT
-.__.
in
fat mothrrs
content stated
, 14 CASES ~-. --.....23 '>i "3'5
- -----
------... 48%
during that
1
,-- -~ .-
nursing. they
harl
n
Comment The fat difference adequacy of lactation.
test is the newest of several methods of judging the No test is as good as the continued health and weight
gain of the baby. T‘)uriog early lact.ation, however, other tests are neede({, among which are the clinical est,ima.tion of the baby’s ability to take the breast and weighing before and after nursing. The former may be very helpful hut is necessarily inexact. Test weighing (repeated rather than single) has been the most reliable guide to the adequilcy of lactation up to the present. It is, Furtherhowever, a nuisance to the nursing staff and may upset the mother. more, both the caloric content of the human milk and the individual caloric requirement of the baby may vary. Measurement of the quantity ingest,ed does not take such variations into account. The fat difference test is a T-aluable adjunct to other methods and it may permit a decisive opinion reasonably early in the breast feeding trial. It is simple and requires only 15 minutes to perform. Only one feeding need be disturbed for the test and the sample of milk required is so small that it does not appreciably lessen the quantit.y available to the baby. This test can also be used as N measure of let-down reflex function. Previously this was evaluated by the presence or absence of symptoms of letdown and by measurement of the proportion of milk left in the breast after nursing by inducing artificial let-down by the injection of Pitocin (Pitocin percentage) .2 The disadvantage of using these symptoms is that they are subjective and are based upon abnormal sensations, such as pain. The determination of Pitocin percentage is difficult in the presence of severe engorgement, ,just when it is most needed. The fat. difference test is not, subjective, it, is applicable to all mothers, and appears to give a reasonably good indica.tion of let-down reflex function. While the clinica value of this test is not proved, it seems to have definite promise. In many mothers, knowledge of their attitude toward breast feeding4 and observation of their early attempts to lactate will indicate without furthe? study the likelihood of success or failure. There are some whose attitudes are doubtful and in whom the onset of lactation is precarious and difficult. It. would seem worth while in such individuals to perform the fat difference test on the third or fourth postpartum day in addition to test weighing. If the fa.t increase is less than 1 per cent the outlook is not good but the effort to brea.st feed should not be aba.ndonecl. All possible measures should be instituted to forestall lactation failure. Such measures include : 1. Sympathetic encouragement of the mot.her with a simple explanation of the physiological mechanisms that, are involved. 2. Privacy during nursing. 3. Relief of nervous tension by giving mild sedatives throughout the day. 4. The assurance of relaxation and freedom from pain during nursing by giving mild analgesics or alcohol prior to nursing. 5. Provision for adequate sucking stimulation by allowing eight feedings or more a day, and by instructing the mother to empty her breasts manually a,ft,er the baby has nursed. 6. lmmecliatc at,tention to sore or damaged nipples. These measures are particularly important at the present time when the postpartum stay in the hospital has become shorter and the mother has barely time to establish lactation before she is faced with the difficult physical and emotional transition from the hospital to the home. This test may enable the medical adviser to predict the success of continued breast feeding and to advise his patients prior to their discharge from the hospital. Further work is being done to substantiate the validity of the deductions that are based upon this study. Its promise justifies a preliminary report in the hope that its clinical value will be tested by others.
Volume Number
TEST
64 ?
FOR
LACTATION
401
SUCCESS
Summary 1. The fat content of human milk was determined before and after nursing on the fourth postpartum day in 25 mothers at the Hospital of the Universit.y of Pennsylvania. 2. A modification of the Leffmann-Beam method, employing 2.5 cc, of milk, was used for determining fat. 3. Mothers who lactated successfully during their hospital stay showed a great,er increase in the fat content of their milk than those who were unsuccessful. 4. Symptoms of function of the let-down reflex were present more frequently in those mothers who showed a greater increase in fat than in those who showed a smaller increase. 5. The clinical application of this test was discussed, References 1. Waller, H. 3. Newton, N. 3. Leffmann, 1905, 4. Newton, N.
Ii.: R., H., P. R.!
Lancet 1: 69, 1943. and Newton, M.: Pediatrics 5: 726, 1950. and Beam, W.: Select Methods in Food Blakiston’s Son & Co. and Newton, M.: Pediatrics 5: 869, 1950.
Analysis,
ed. 3, Philadelphia,
the
Gynecean Hospital and Gynecology,
NEWTON,
M.D., PHILADEWHIA,
FA.
Institute of Gynecologic Research, Department Hospital of the University of Pennsylonnia)
of
Obstr+ric!s
T
HE object of this study was to find a simple laboratory test which could be used to predict a nursing mother’s ability to produce an adequate supply of milk. Wailer’s report? indicated that among women in whom lactation was well established the increase in the fat content of milk during a single nursing was due to a draught or let-down reflex. Newton and Newton’ showed success in early lactation to be related to the function of this reflex. When proper let-down occurs, fat-rich milk is expelled from t,he alveoli of the breast into the larger ducts to become available at the nipple, With normal function. later samples of milk should contain considerably more fat, while with subnormal function little or no increase in the fat, cont,ent should occur. The difference in the fat content of the milk before and after nursing might therefore be used in early lactation to appraise the function of t,hc let-down reflex and to predict the successof lactation.
Miterial and Methods A group of 25 mothers in the Maternity Ward of the Hospital of the University of Pennsylvania were used in this study. These patients were selected inasmuch as they had experienced uncomplicated antepartum courses, spontaneous or simple instrumental deliveries, and normal postpartum courses. The breasts and nipples of all were grossly normal and the babies were mature and healthy. At the time of this study, the breast feeding practice in use at the hospital consisted of scheduled feedings which permitted liberal sucking. Mothers were strongly urged to breast feed their babies. The babies were brought to the mothers every 4 hours, for 30 to 45 minutes, starting 24 hours after birth. For the first few feedings the time of sucking was somewhat limited and thereafter it was permitted for the whole time during which t,he baby was with the mother. Tests for milk fat were performed in all cases on the fourth postpartum ~2 day, i.e., at an average of 98 hours (range 80 to 110 hours) after delivery. specimen of milk (3 to 5 c.c.) was obtained from one breast by means of an electric breast pump at the regular nursing time just before the baby was brought in. The baby was then allowed to nurse until he was satisfied or refused to continue, usually 30 to 45 minutes, starting on the side from which the specimen had been taken. As soon as possible thereafter, 3 to 5 C.C. of milk were taken as before from the same breast. The babies were weighed before and after all feedings on the fourth postpartum day, including the test feeding, and the average amount of milk obtained at a fourth-day feeding was computed. In addition, the mothers were 397
questioned concerning symptoms suggestive of function of the let-clown relies3 I)ot,h at previous feedings at~d during the test feeding. These symptoms were : (d) uterine pain tluring nursil~g, (2) dripping of milk before the baby was put to the breast, (3) drilq)ing of milk from the opposite breast, (4j cessation of nipple pain during nursing. Th(l significance of these symptoms has been discussed in a previous publication.’ The specimens of milk which were obtained before and after nursing were analyzed for fat by a modification of’ the Leffmann-Beam method.” After the sample had been mixed, 2.5 c.c. were placed in a special tube.” One cc. of a mixture of equal pa.rts of amyl alcohol and concentrated hydrochloric acid was added ant1 the tube was filled with 75 per cent sulfuric acid to just above the graduated marks on the narrow neck. The tube was then centrifuged for fire minutes at approximately 1,500 r.p.m. and the percentage of fat in the sample was read off front the graduated scale. The resultant figure was bhen rloublecl since 2.5 C.C. instead of 5 C.C. (as originally described) were used. Readings were made with confidence to 0.1 per cent (0.2 per cent after correction) and repeated determinations on the same sample of milk agreed satisfactorily.
Results The difference in the fat conteut of the two specimens in successful and unsuccessful breast feeders is seen in Tables I and II. The mean initial fat content of the milk was approximately the same in the two groups: 2.8 per cent in the successful and 2.9 per cent in the unsuccessful group. The difference in the mean increase, however, was quite definite: 2.0 per cent in the successful and only 0.2 per cent in the unsuccessful group. This difference is statisticaliy significant (p less than 0.05 j. Of the 15 successful breast feeders, only 3 gave an increase of under 1 per cent. Of those who were unsuccessful, 10 in number, only 2 gave an increase of over 1 per cent. TABLE
I.
DIFFERENCES
IN
FAT CONTENT OF HUMAN MILK IN 15 SUCCESSFUL* BREAST
--.__
up--
-.--I_
FAT BEFORE
NURSING
70
FEEDERS
-
I
CONTENT
AFTER
OF MI1.K
%YRSING --_ 1.1.0 9.0
%
DIFFERENCE
I
k
--
-
7.8
5.4
3.2
3.2 2.2 1.8 0.4 3.0 2 4.0 2.8 2.8 2.4 2.4 Mean 2.8 *A successful breast feeder was defined as one whose baby was fed entirely on the flfth postpartum day.
by breast
The increase in fat content showed a positive correlation with the amount of milk taken by the baby at the test feeding and a greater but not significant positive correlation with the average amount of miIk given at a fourth-day *Manufactured
by the A. H. Thomas Co., Philadelphia,
Pa.
feeding. The successful mothers gave a mean of 76 Gm. of milk during an average fourth-day feeding while the unsuccessful mothers gave a mean of only 34 Gm. The difference between the two groups is highly significant (1) less than 0.01). TABLE
11.
DIFFERENCES
IN
FAT CONTENT OF HUMAN MILK IN 10 U?;SIY:CLSSI"I:I.+ BREAST
FEEDERS -_--I__
-__~-_-FAT -
I___^_
REFORE
Mean on
the
*An fifth
NURSING
7%
CONTENT
AFTER
I
OF
NURSING
4.2 1.2 1.6 1.6 3.0 3.n 4.4 2.4
6.8 2.4 2. 0 2.0 3.0 3.0 4.0 1.8
2.0 5.6
1.2
2.9
3.1
-
MILK c/r
r. ..___..
breast day.
feeder
was
;
--...
-_
70
PIFFERENCE
-.--. 2.6 1.2 0.4 0.4 0.0 0.0 -4.4
4.6 -0.S
4.6
unsuccessful postpartum
-7x.z
1.0 0.2
--___---.-
one whose
baby
required
.___.
a supplementary
formula
The relat,ion between the let-down symptoms and the increase in fat content of the milk is seen in Table III. When the four symptoms of let-down were totaled they occurred more frequently in mothers who had an increase in fat of more than 1.3 per cent than in those who had an increase of less than 1.3 per cent. This difference was slight before the test nursing but significant (p less than 0.05) during the test nursing. Differences were most marked in “milk dripping before nursing” and in L‘milk dripping from opposite breast during nursing. ’ ’ The slight differences in the other two symptoms may be explained by the low over-all incidence of “uterine pain” on the fourth postpartum day and the relatively small number of cases in the “cessation of nipple pain ” group.
__-..~-
_---.__-.-___MOTHERS
-.--__
WITH BEFORE
SYMPTOMS TEST
FAT INCREASE 31ORl? THAN
Nl’RSING
Uterine pain while Milk dripping while Milk dripping from site breast while Cessation of nipple while nursing All symptoms t *1.3 per cent nIpI&
tOccasiona1 pain.
ssro
represents
78% mean
symptoms
of all
unclassifiable,
FAT I?*‘CREASF. IIESS THAN
1.3%
1.3%
62'/'0 467%
73%
100%
ti2%
100%
100%
lOl1f,i
siyc
-._____71%
CASES)
73% 91%
the
TEST
increases e.g.,
home
(11
_ .
_____._~.. NI’RSlNG
cases~ -----18% x3'%
( 14
6@7'c
were
I~I.‘RlK:O
FAT INCREASE --___-_____--------MORE TH.IN
1.3 ‘$7
CASES)
nursing nursing opponursing pain
_____-
/ FAT INCILEASE LESS THAN
1.3%X (11
PRESENT
-.__.
in
fat mothrrs
content stated
, 14 CASES ~-. --.....23 '>i "3'5
- -----
------... 48%
during that
1
,-- -~ .-
nursing. they
harl
n
Comment The fat difference adequacy of lactation.
test is the newest of several methods of judging the No test is as good as the continued health and weight
gain of the baby. T‘)uriog early lact.ation, however, other tests are neede({, among which are the clinical est,ima.tion of the baby’s ability to take the breast and weighing before and after nursing. The former may be very helpful hut is necessarily inexact. Test weighing (repeated rather than single) has been the most reliable guide to the adequilcy of lactation up to the present. It is, Furtherhowever, a nuisance to the nursing staff and may upset the mother. more, both the caloric content of the human milk and the individual caloric requirement of the baby may vary. Measurement of the quantity ingest,ed does not take such variations into account. The fat difference test is a T-aluable adjunct to other methods and it may permit a decisive opinion reasonably early in the breast feeding trial. It is simple and requires only 15 minutes to perform. Only one feeding need be disturbed for the test and the sample of milk required is so small that it does not appreciably lessen the quantit.y available to the baby. This test can also be used as N measure of let-down reflex function. Previously this was evaluated by the presence or absence of symptoms of letdown and by measurement of the proportion of milk left in the breast after nursing by inducing artificial let-down by the injection of Pitocin (Pitocin percentage) .2 The disadvantage of using these symptoms is that they are subjective and are based upon abnormal sensations, such as pain. The determination of Pitocin percentage is difficult in the presence of severe engorgement, ,just when it is most needed. The fat. difference test is not, subjective, it, is applicable to all mothers, and appears to give a reasonably good indica.tion of let-down reflex function. While the clinica value of this test is not proved, it seems to have definite promise. In many mothers, knowledge of their attitude toward breast feeding4 and observation of their early attempts to lactate will indicate without furthe? study the likelihood of success or failure. There are some whose attitudes are doubtful and in whom the onset of lactation is precarious and difficult. It. would seem worth while in such individuals to perform the fat difference test on the third or fourth postpartum day in addition to test weighing. If the fa.t increase is less than 1 per cent the outlook is not good but the effort to brea.st feed should not be aba.ndonecl. All possible measures should be instituted to forestall lactation failure. Such measures include : 1. Sympathetic encouragement of the mot.her with a simple explanation of the physiological mechanisms that, are involved. 2. Privacy during nursing. 3. Relief of nervous tension by giving mild sedatives throughout the day. 4. The assurance of relaxation and freedom from pain during nursing by giving mild analgesics or alcohol prior to nursing. 5. Provision for adequate sucking stimulation by allowing eight feedings or more a day, and by instructing the mother to empty her breasts manually a,ft,er the baby has nursed. 6. lmmecliatc at,tention to sore or damaged nipples. These measures are particularly important at the present time when the postpartum stay in the hospital has become shorter and the mother has barely time to establish lactation before she is faced with the difficult physical and emotional transition from the hospital to the home. This test may enable the medical adviser to predict the success of continued breast feeding and to advise his patients prior to their discharge from the hospital. Further work is being done to substantiate the validity of the deductions that are based upon this study. Its promise justifies a preliminary report in the hope that its clinical value will be tested by others.
Volume Number
TEST
64 ?
FOR
LACTATION
401
SUCCESS
Summary 1. The fat content of human milk was determined before and after nursing on the fourth postpartum day in 25 mothers at the Hospital of the Universit.y of Pennsylvania. 2. A modification of the Leffmann-Beam method, employing 2.5 cc, of milk, was used for determining fat. 3. Mothers who lactated successfully during their hospital stay showed a great,er increase in the fat content of their milk than those who were unsuccessful. 4. Symptoms of function of the let-down reflex were present more frequently in those mothers who showed a greater increase in fat than in those who showed a smaller increase. 5. The clinical application of this test was discussed, References 1. Waller, H. 3. Newton, N. 3. Leffmann, 1905, 4. Newton, N.
Ii.: R., H., P. R.!
Lancet 1: 69, 1943. and Newton, M.: Pediatrics 5: 726, 1950. and Beam, W.: Select Methods in Food Blakiston’s Son & Co. and Newton, M.: Pediatrics 5: 869, 1950.
Analysis,
ed. 3, Philadelphia,