Breastfeeding Science

Pharmaceuticals From Breast Milk

Creating New Medications Based on Human Breast Milk Components

Previously, I've written about the possibility of making therapeutics directly from donor breastmilk, such as Prolacta's HMF (the need for HMF has been discussed in the comments of another post about Prolacta).  But what about individual breast milk components being recreated in a lab for use in medicinal products?  In my first post on this topic I focused on the irreproducibility of breast milk, but what about the individual components that are reproducible - the ones that can be made in a lab?

This topic, though related to the question of how breast milk might be used by those who collect it (in this case, for research), spreads out into questions about biological patents and intellectual property (IP).  True to being a bench scientist, I know little about patents, IP, business, money, etc. That's how they get us to work as postdocs to work for almost nothing.

What I do know is that if a biomolecule like the antimicrobial lactoferrin can be identified and characterized through the study of breast milk and used to prevent illness, I'm in (lactoferrin was brought up in a comment).  If what we can learn from breast milk increases our understanding of human biology and allows us to develop effective medications and therapeutics, I support that.

Creating medicines based on the intricate, elegant molecules made by living organisms (as opposed to the relying on the random luck of screens or using sledgehammer drugs with global affects on the body) is tricky work. It's something we have been struggling to do this century because it is finally becoming possible through the sequencing of DNA (genomics) and study of it's gene products (proteomics). 

As we move forward, we will be able to create more effective medications with fewer side effects than traditional drugs. Stories like this one about the drug PLX4032, which was created through research and understanding of the biomolecule B-RAF, show how the process works.  Medications created like this are the future of treating cancer, cardiovascular disease, altzheimers, autism, HIV and other ailments that lead to human suffering.

If biomolecules discovered in human breast milk (and made in a lab) can be part of that and lead to therapies that improve outcomes for babies in the NICU or even adult patients suffering from something totally unrelated, I think that's great. 

What inspires individuals and organizations to do the kind of difficult, expensive research it takes to develop these medications? Three things, really: a desire to help people, a desire for academic prestige and glory, and a desire for money. The individuals tend to focus on helping people and getting glory while the larger, more powerful organizations tend to focus on the money. 

The current system for rewarding successful research with money is through patents.  Patents allow those who generate new, useful ideas and information to limit anyone else from using them to make money for some period of time.  Patents, especially biological patents can get very complicated in how they are issued and legally enforced.  Of course, there's lots of controversy and deviousness that goes on around patents, like anything else that involves a lot of money.  Valerie McClain, who has commented here, addresses more issues related to this in her blog.  Incidentally, the academic glory reward system isn't perfect either, so to be a happy scientist you really have to work on something you believe will contribute to the common good. 

In another life, I walked straight from the Cornell Chemistry Department over to the Law School the day after getting my Master's and became a patent lawyer instead of a PhD.  In that life, I make way more money than I do now and know all about biological patents.  As it is, I know only the basics, but I can still see that there are flaws in the system.  Maybe we will find a better system someday.  For now, we have patents, and to get them big companies spend about a billion dollars each bringing medications to market.

If some of those medications are designed based on therapeutic components of breast milk and created and delivered to the people who need them (a big "if" in the current US healthcare system), that's a good thing.  However clumsily, we will have used our ingenuity to alleviate human suffering and to help or even (dare I say) cure the sick.  That gives me hope, the only truly reliable reward for good biomedical research.

What About Formula?

Of course this all brings up another, much more breastfeeding-centric question: What about using this kind of research to make "better" formula? Is that a good thing or a bad thing? Although I don't  see how any company could afford to use donor breast milk in the manufacture of formula, they could use what they learn from the research of breast milk to identify components (like DHA and ARA) that can be added to formula.  Perhaps more important additives could be included to make formula a little less unhealthy.  The question is, do we want unhealthy formula - to keep moms from seeing it as a suitable substitutre, or more healthy formula - to improve the health of those babies forced to drink it? What do you think?

Execs in Desperate Need of Donor Breast Milk (part 4)

Part 4: Milk Money

Will informing donors about the manufacture of costly therapeutics from their milk mean paying them, too?
This question is hard to answer. First, because I have no idea whether Prolacta has far more milk than they need or just enough to squeak by. Of course, if the donor milk supply is exceedingly high, there will never be any need to pay donors.

How much milk?
So, how much breast milk does Prolacta currently have in its possession? For that matter, how much total milk is collected in the US every year? What percentage of that milk is processed and sold back to hospitals at cost by non-profits and what percentage goes to the development and manufacture of Prolacta products? If anyone out there has access to these numbers, I'd love to know them.  I can only find the odd report here and there - nothing comprehensive.

One number I can find is on the IBMP website, which says they've collected 262,682 oz. of milk for Africa. If the milk split described on their How It Works / Donation Process page holds true (25% to Africa and 75% to "critically ill babies in the US," aka Prolacta), than that particular bank has provided Prolacta with 788,046 oz (=6,156 gallons =22,305 L) of breast milk. Add to that 100% of the milk collected at all the other Prolacta milk Banks, and that could be a lot. Or maybe it's barely enough?

How will donors feel?
The next question is - how will donors feel about giving milk to a for-profit enterprise that is also a life-saving one? This is hard to predict. I hold to my statement in Part 2 of this post:  For every mom who wants her milk to be non-profit all the way, there will be others who don't really care as long as they are helping someone with their extra milk (probably the majority of moms) and still others who want to see as many lifesaving medications developed from human breast milk as possible.

Will the milk river dry up if moms learn more about where it's been flowing? I think there would likely still be plenty of donor milk forthcoming. Let's assume, however, that if Prolacta milk banks started being called just that (with little displays of Prolacta products inside and "Prolacta Bioscience" T-shirts and totebags for all the donor moms) that the moms would stop giving milk without compensation. Would it be so bad?

Can Prolacta afford to compensate donors?
Would it really hurt Prolacta to compensate donors? I'm sure they've invested a lot in establishing so many milk banks across the US. With this milk collection infrastructure already in place, it would seem the cost of compensating donors, if necessary, wouldn't break the bank. And what about those T-shirts? Wouldn't Prolcata benefit greatly from being out in the open, happily marketing their brand and making donor moms feel like part of the Prolacta team? If the fear of paying for milk (as other for-profit "bioscience" companies pay for human plasma) is what’s keeping Prolacta in the closet, it hardly seems worth all the hiding.

A recent study published in The Journal of Pediatrics shows the valid medical benefit Prolacta's HMF has for severely premature babies. This paper, paired with their recent agreement with Abbott Nutrition (makers of the Similac cow-milk HMF) will make hiding in the shadows of their milk banks not only wrong but also exceedingly difficult for Prolacta.

Other issues related to compensating donors
Of course, there are more important issues than money when it comes to paying breast milk donors. One is the concern that non-profit milk banks will never see another ounce after donors hear about the awesome deal down the road. I don't think this would be a major problem because many moms feel strongly about giving milk as a charitable donation. Many women in the US who currently breastfeed are well-educated, fairly well-off, and in a position and a mind-set to make this kind of charitable donation.

The non-breastfeeding community
Now let's consider the women in the US who aren't breastfeeding (the majority of mothers), and the general public. Sadly, unscrupulous members of the food industry have been very successful in portraying breastmilk as a questionable, cheap, and even gross alternative to the gold standard of formula to many of these people.

Maybe Prolacta paying moms for milk, because it can be used to make valuable, life-saving medical treatments, would help to change that.  Maybe the only force powerful enough to fully stomp out the bad image of breastfeeding perpetuated by the corporate powers-that-be will come from the corporate powers-that-are-coming - like Zeus defeating Cronus.  It's not ideal, but it's practical.

Placing a monetary (and medical) value on breast milk would have a positive impact on how "Joe Public" regards breastfeeding. Mothers who now consider formula an expensive but worthwhile investment in their child's health (and there are lots of moms like this) may start to think twice when they hear the news that breastmilk is valued at some dollar amount per ounce and used to make medicinal products.

Some of these same moms may also benefit from the extra income their own extra breastmilk could earn. Paid milk donation would then doubly encourage these moms to work hard at establishing and continuing breastfeeding their own children, not only to have highly-valued, premium nutrition for their babies but also to be able to donate milk for extra income. Whatever the motivator is, the numerous benefits of breastfeeding will be enjoyed by each new mom willing to try (and her baby).

Would moms sell their milk and feed formula?
The argument that moms who would have breastfed otherwise will instead sell all their breastmilk and feed formula doesn't make sense. Why would they spend an enormous amount on formula when they can make more breastmilk, which they know is superior, for free. A strict screening process for paid donors and limits to the volume a donor can provide could also be imposed to ensure that this is not a problem.

Other Issues related to compensated donation of human fluids
The arguments against compensation of blood donors don't seem to apply here either - these are the possibilities of over-donation causing severe bodily harm and payment attracting a disproportionate number of desperate, diseased drug addicts.

First of all, moms can't risk their lives by over-donating milk as a blood donor could, and with only one company in this business it would be easy to impose and enforce the limits and pre-screening mentioned above. Milk donation is certainly less physically taxing and risky than blood plasma donation, which is legally compensated by many plasma banks. 

The plasma collection process takes only part of a donor's blood, and it occurs both with compensation (when given to for-profits) and without (when given to non-profits) in the US. Interestingly, the collection of both plasma and blood products without compensation by the Red Cross has also come under fire – demonstrating on a much bigger and more complicated scale how unhappy donors are to find that their donations are being used in an undisclosed or poorly disclosed way to turn a profit. My thanks to a commenter (Lindsay) for bringing this up.

It’s also easier to prevent the spread of pathogens through breast milk (which is naturally safer and can be pasteurized) than through blood. Although I might worry about desperate souls selling off their blood, I find it hard to envision the same people hatching a plan to become pregnant and bear a child for some limited amount of milk money.

Bankers - breast milk bankers, that is
So although I wince a bit at the phrase "corporate breast milk bank," I realize they are already out there. At the same time, I see the potential for positive outcomes from these banks and the company behind them.  Run properly, they could help reshape the way many in our culture view breastmilk and breastfeeding and possibly improve breastfeeding rates, not to mention develop important therapeutics from breast milk both now and in the future.

I just hope that Prolacta is dedicated to biotherapeutics. I hate to think of a future with very expensive formulas made from processed human milk - like a wet nurse in a can (with many key components long since destroyed during processing, plus an unhealthy dose of can-liner chemicals).

If this ever did move away from therapeutics and toward food products, I hope moms would realize that they can make real "liquid gold" far superior to anything processed in a plant. Remember that Prolacata, or any company making pasteurized, processed human milk products still cannot keep many of the critical antimicrobial biomolecules (which our mammary glands originally evolved to deliver) viable and active through processing.

Execs in Desperate Need of Donor Breast Milk (part 3)

Part 3. The Haiti Milk Mix-up

What happened to all the milk donated for Haiti?
Soon after I started this blog and got a Twitter account, I saw a flurry of requests for donor milk to save Haitian orphans (this was shortly after the earthquake).  A press release asking for milk  was "going viral" in the breastfeeding community - one from some very trustworthy sources, including La Leche League, HMBANA, and the ILCA.  Like many, I was really moved by these requests and sorry that since my youngest is two and nurses mostly for comfort, I don't make enough milk to donate. 

Later on, I started to see reports that donor milk might not actually be able to get to Haiti.  After that, I read this great article in the Sustainable Mothering blog about why donated breastmilk may not be the best way to help Haiti - for numerous reasons: Haiti, Hell, Good Intentions, and Breast Milk Donations.  So there was a big misunderstanding, it seems.  That total disconnect is described in an article from MSNBC excerpted below:

from Call for breast milk donations in Haiti goes bust

“Tell them not to send it,” said Eric Porterfield, a spokesman for the American Red Cross. “I’m 100 percent sure we didn’t ask for that.”

The international Emergency Nutrition Network has asked one group, the Human Milk Banking Association of North America, to retract a press release this week that issued an “urgent call” for breast milk for orphaned and premature infants in Haiti, saying the donations contradict best practices for babies in emergencies.

Such donations pose problems of transportation, screening, supply and storage and create an “unfeasible and unsafe intervention,” according to a statement from the Office of U.S. Foreign Disaster Assistance, or OFDA.

Simply trying to fill a need
Pauline Sakamoto, executive director of HMBANA, said the group was simply trying to help fill a need, if not in Haiti, then elsewhere. Donated milk that doesn't make it to Haitian babies will be diverted for use in the U.S. and Canada, she said.

“We don’t want to waste an ounce of milk. It’s very precious,” she said, adding.

The confusion started earlier this week when the milk bank group and several organizations — including heavy hitters like La Leche League International — urged nursing mothers to donate milk. While representatives for aid agencies such as the American Red Cross, Doctors Without Borders and World Vision said there never was a need for donated milk, some agencies said they heard from workers at orphanages in Haiti who indicated that babies were going hungry.

“This was very grass roots,” said Amanda Nickerson, executive director of the International Breast Milk Project.

So maybe this was all just a big misunderstanding. Or maybe the visceral reaction a nursing mother has to the type of horrific images of human suffering caused by the earthquake in Haiti was seen as an opportunity to stock up on milk (a point raised by blogger Valerie McClain).  I trust the organizations who signed off on the original press release had the earnest intent of helping Haitian orphans.  But who got that release underway?  Was it really "very grass roots," as the director of the Prolacta-partnered IMBP stated? Perhaps it was. It certainly was a big misunderstanding.

My concern is that the breastfeeding institutions and banks involved should have made more detailed plans and policy agreements with those on the ground in Haiti before sounding the call-to-boobs.  The thing that really bothers me is the idea that - hey, no big deal because "donated milk that doesn't make it to Haitian babies will be diverted for use in the U.S. and Canada." 

That's the same type of thinking behind showing donors pictures of needy children (in Africa or in the NICU) and then using their milk to make an unmentioned product that's sold by an unmentioned company (see the previous post, Part 2).   

Potential milk donors should not be told whatever it takes to get them in the door (or on the pump).  They should be respected as valued members of the process that brings breast milk or breast milk-derived therapeutics to those in need. 

This means banks should do their homework and provide a complete description about where the milk is going.  Fully inform and include breastmilk donors and the public- don't just show them pictures of sick babies and call it a day.  This applies to the Haiti solicitation, to Prolacta collection banks, and to any milk banks. Women who donate breastmilk are handing over liquid gold (see Part 1), and they don't need to be tricked or manipulated, they need to be respected. 

Next, Part 4: Will informing breast milk donors about the manufacture of costly therapeutics from their milk mean paying them as well?

Execs in Desperate Need of Donor Breast Milk (part 2)

Part 2: The Prolacta Milk Bank Story Recap

Breastfeeding moms planning to donate milk to Prolacta (including those who donate to the National Milk Bank, Milkbanking.net  banks, and 75% from those who donate to the IBMP) generally only read that their milk goes to "critically ill babies in the US" or to "severely premature babies."  On most of these sites for these banks (Milkin' Mamas being a notable exception) , no mention is made that the milk is processed into a specific line of products (HMFs) and sold by a very specific company (Prolacta) and provided to "critically ill babies" whose parents are lucky enough to be able to afford and have access to Prolacta's HMF products.

This is not a new story - Prolacta was in the news a lot when they began collecting milk in 2006 and in 2007 after the fact they collect 75% of the milk donated to the International Breast Milk Project (IBMP) came under scrutiny.

10/20/06   Blisstree.com Milk Donors Beware – Choose a Milk Bank Carefully!
05/22/07   The Lactivist    Is The International Breast Milk Project a Scam?
09/02/07   Breastfeedingsymbol.org  Thinking of Donating Your Breastmilk? Read This First.

Recently, Prolacata has been in the news again, both for research that shows the benefits of human breast milk HMF and for their business partnership with Abbott Nutrition, makers of Similac.  I learned about Prolacta from this on from The Motherwear Breastfeeding Blog: Formula maker to sell human milk product.  I also found a post by blogger Valerie W. McClain Human Milk Patent Pending and some discussion at the Mothering Magazine forums about Prolacta.

Now, I understand that the profitability of Prolacta allows them to do more research and help more premature babies.  I also understand that the more breast milk Prolacta gets, the more HMF products they will be able to supply for premature babies.  For severely premature babies, a system for increasing the caloric density of their mother's milk without exposing them to cow milk or soy proteins can make a critical difference.  For them, HMF is not a formula supplement - it's a biotherapeutic medication. 

So why does Prolacta think they need to hide behind the curtain and hand-wave about where the milk goes?  Why is there no mention of Prolacta or HMF or developing breastmilk-based biotherapeutics on the National Milk Bank website?  Why does the IBMP speak so hesitantly and defensively about their relationship with Prolacta? 

Breastfeeding moms tend to be well-educated women who are very capable about making decisions based on complete information. Who decided these women can't handle the facts and instead should know nothing more that the milk goes somewhere that "helps babies" (now run along, ladies, it's time for man-talk)?  It's not like the milk is being turned into high priced hand-cream or something.

Biotherapeutics from breast milk make sense.  Some smart people looked at the amazing medical treatments that can be made from human blood and realized that breast milk could also have important medicinal properties.  They invested a lot of time and money into researching whether medically relevant therapeutics could be derived from human breast milk.  They found that yes, this is the case. They made those products.  They charge money for these products, just like all companies who develop and manufacture medical treatments do.  Why are they afraid of making their mission a clearly stated goal of the many milk banks they run? 

The only answers that make sense are

A. They think that breastfeeding moms will stop giving them milk
B. They don't want to have to pay donors for breastmilk

Option A: Yes - some women may choose to provide milk to a non-profit bank instead, like the HMBANA which provides breast milk (in milk form) to babies in need.  Others may choose to provide milk to a company interested in developing biotherapeutics. For every mom who wants her milk to be non-profit all the way, there will be others who don't really care as long as they are helping someone with their extra milk (probably the majority) and still others who want to see as many lifesaving medications developed from human breast milk as possible.  The point is, Prolacta milk banks should be called Prolacta milk banks.  All of this "processing partner" stuff is ridiculous.  

Option B: I'll discuss this in my final post on this topic. 

My next post will be more about how the earthquake in Haiti inspired a great call to arms (or boobs).  The subsequent news - that the donor milk flowing in could not get to Haiti and might not be as helpful as we'd thought - has made me (and others) question the great hue and cry for milk donations to help third world orphans from institutions who know most of the donated milk will never get to them. 
 

Executives in desperate need of donor breastmilk (Part 1)

Part 1: The complex evolution of breastmilk

Human breast milk is not reproducible, but can be collected from donors.
Breast milk is full of active proteins and other complex biomolecules.  As a scientist who struggles to purify stable, soluble, biologically active proteins (or even small fragments of them), I know how difficult and expensive it is to do this.  Figuring out how to produce even one milligram of one protein that is still folded (shaped properly) and active (able to work like a tiny machine) can take a year.

The protein content listed on a formula label refers to what's left of once-active proteins that are now unfolded, inactive, and simply a source of amino acids.  Formula provides protein as well as carbohydrate and fat for food calories, it's cheap and easy to produce, and it's nothing like breast milk.

Breast milk actually evolved as part of the immune system, not as a method for feeding.  It started as an antimicrobial fluid, not a food.  This ancestral substance was composed primarily of complex immune-related proteins and biomolecules and acted then as it does today - as a system for properly establishing the immune system of a newborn under the direct guidance of the parental immune system.  Mammals now produce breastmilk that also contains lactose and lipids, which provide sustenance (a later evolutionary flourish).

Infant formula is not synthetic breastmilk.  Creating synthetic breastmilk would be a feat comparable to making synthetic blood.  Anyone who considers the problem will quickly realize that, like blood, there is only one way to get breast milk - from a donor. 

Since breast milk is such a precious, useful substance I wasn't surprised to learn that, like Telacris and CSL Behring, companies that make therapeutics from blood plasma, another company has figured out what a commerical goldmine donor breast milk - processed and sold as a biotherapeutic - could be. 

Enter Prolacta, a company that has spent an enormous amount of time and effort researching human breastmilk - what's in it, why it's medically important, how it can be effectively collected, safety checked, pasteurized, processed, and sold at a profit. 

The work Prolacta does is good for breastfeeding science, and for the image of breast milk. Prolacta supports an excellent charity (the IMBP).  It also helps a lot of severely premature babies, because they sell a breast milk version of human milk fortifier (HMF) - an additive that boosts the calories in milk fed to those babies in the NICU.   Unfortunately, the way they get the milk is pretty devious.  

Next:

Part 2. The Prolacta/IMBP Controversy Recap (this story broke in 2007) - preview this Lactivist article

Part 3. How much breastmilk donated for Haiti will actaully make it to Haiti?

Part 4. Paying moms for breastmilk (shudder) - could there be a silver lining?

Clogged Ducts are The Enemy...

… here's how I knock out my nemesis,
GI Jane style.

By Jen Humberson, MD

I am writing this as a mother of two boys whom I nursed for one year each. I’m also a pediatrician, but I’m writing this as a mom. Some of my thoughts below might not be ones I’d share gracefully in the office.

So in two years of nursing I probably had clogged ducts 15 times. I have no idea if this is average, but I certainly know friends who’ve had 5 or so. I got to where I could tell when one was starting and begin my routine ASAP to keep it from getting worse. One thing I DID know from my medical experience: clogged ducts can lead to mastitis, and I do not ever want to have mastitis. I’ve seen lots of people in lots of pain, but none of it compares to the women I’ve seen with untreated mastitis.

How do you know if you have a clogged duct? Well read good sources of information. My signs? A vague feeling like one section (think pie slice) of one breast wasn’t emptied at the end of a feeding, and the same area feeling more so a feeding or two or three later. Or feeling a lumpy firm area (again, sometimes like a pie slice, sometimes like a rock) in my breast that became increasingly tender. Sometimes the area was starting to pink up, and sometimes the veins in that area would become a little bluer, a little more noticeable. Only once did I have the “little white spot on the end of the nipple” that some resources describe.

What to do? Simple. Get the area unclogged. How to do that? Not always easy. I would do a few things, alternating between them, until I got it completely unclogged (when the whole breast is soft, there’s little to no more milk coming, and the pain is pretty much gone about 12 hours later, save for some bruising if you had to cause some… read on.)

1.  Nurse, nurse, nurse. Let your baby drink as much as s/he wants as often as s/he wants while you’re trying to get unclogged. While nursing, as much as possible, massage (with your hand) the firm and tender part of your breast. How hard? Not as hard as you can take it- Harder than that. This is the not-fun part, but it is ABSOLUTELY worth it when you get it unclogged and you avoid further problems. Frankly, nursing alone only solved my clogged ducts once or twice

2.  Take two to four ibuprofen, ie Motrin or Advil (400mg to 800mg) with your doctor’s okay. It will make the next part more bearable.

3.  Pump, pump, pump. Find a good t.v. show, brew some tea, and pump the affected breast (you can pump both if you want to) and, with your hand, massage the tender firm area like it’s a bear about to mawl your baby. You can start gentle, but you will likely have to use a good bit of pressure (read: a heck of a lot) to get the milk to get through. Also increase the strength of the pump to the highest you can stand without harming your nipples. You will know when it really starts releasing as there is a flood of more milk (sometimes yellowish or reddish- don’t be alarmed) and the area slowly turns softer. KEEP GOING until the whole breast feels soft and there’s pretty much no more milk coming. This method worked for about 75% of my clogged ducts. The worst ones took 2 or 3 pumping sessions, usually about 30 minutes long each (one time was 45 minutes but finally worked).

4.  Shower Power. Basically, you use your hands to massage and somewhat manually pump the affected breast. I used this method more after I realized how well it worked with my second child. After trying the first two, if the area is still partially or completely clogged, turn on a steamy shower, as warm as you can take it, and step in and massage the firm tender area more firmly than you can take and use the fingers of your other hand to express some milk.

In my experience, it often took 5 to 15 minutes, and occasionally two showers, but then the area unclogged and I was able to manually express the milk until the whole breast was soft.

Re-clogging: The same area will be sore and slightly swollen for a day or two, and is also at risk of re-clogging. So try to make sure your breasts get completely emptied with every feeding or pumping over the next few days.

Be Proactive: The sooner you start trying to clear a clogged duct, the easier it will be. The longer you wait, the harder it will be (and the more you’ll regret waiting- you might get to the point where you can’t tolerate even the slightest touch to the area).

If your pain is severe, you get a fever, or your baby isn’t eating well or seems ill, call your doctor. I was able to treat all mine at home, but I was aggressive and I knew the signs of when I should call my doctor.

This post might highlight some of the rougher parts of breastfeeding, but the VAST majority of my nursing times were some of the most intimate, cozy, beautiful times I’ve had with my children.

I hope this helps if you ever have clogged ducts. Please write any other things that worked for your clogged ducts in the comments!

How much milk should I be making?

This short post comes from my response to a question in the comments of the Pumping Sucks post (thanks Kelly).  

The amount of milk you make and how much fat and calories it contains will vary a lot from person to person (and from day-to-day and hour-to-hour in the same person).  This article from the journal Pediatrics provides an interesting overview of what 71 "normal" moms produced:

Volume and Frequency of Breastfeedings and Fat Content of Breast Milk Throughout the Day

The paper is thorough - it even describes the output of "the more productive breast" versus "the less productive breast."  Ah, the poor, "less productive breast" all it ever hears is "Marcia, Marcia, Marcia."

They observed a per day milk output of 440-1220g, which translates roughly to 15-41 oz. (only two women fell outside this range, both on the high side). The mothers have infants from 1-6 months old.  This data is consistent with the kellymom discussion of this topic, which gives 25 oz. as the average milk consumed per day by a breastfed baby 6 months and older.  If you are on the low end - you may just make more caloric milk.  As long as your baby is gaining weight, don't worry! 

After around  6-7 months, breastmilk consumption and production plateau as you start adding to the menu mashed-up, breastmilk-added versions of all the super healthy foods they'll snub in pre-school. Milk production may even decrease a little after that, but that doesn't always mean less nursing since the boob is an all around comfort station for breastfed babies and toddlers.  

Breastfeeding continues to provide key nutrition and immune support as you add new foods, which is why it's encouraged for at least a year or two by most medical and health organizations and as much longer than that as possible by most toddlers.  

Vitamin D and Breastfeeding

All breastfeeding moms should be knowledgeable about Vitamin D, and this reading this review is a great way to learn:  

Vitamin D: An Evidence-Based Review

Read the full article

Jump directly to the section "Vitamin D Supplementation for Infants and Breastfeeding Mothers"

Vitamin D deficiency can be a negative health consequence of breastfeeding when either you or your infant are not properly supplemented.  Don't ignore this common problem that can be solved safely and easily!  Some feel that any discussion of Vitamin D deficiency (or anything else that nursing moms should be warned about) is somehow insulting to breastmilk.  Others bristle at the word "supplement," but remember that you can take Vitamin D yourself if you feel uncomfortable giving it to your infant directly.  

Why is the problem of Vitamin D deficiency getting worse?  Our bodies depend on UVB rays in sunlight to make Vitamin D.  People spend a lot less time in the sun these days than we used to because we spend more time indoors and protect our skin when we do go out (for good reason).  To make up for this lack of UVB exposure, we must rely on dietary sources and/or vitamin supplements.  

Unless you just love herring or spend lots of time tanning, you may not be getting the 2000 IU of Vitamin D recommended for breastfeeding mothers by the Canadian Pediatric Society.  The American Association of Pediatrics recommends supplementing your infant directly with 400 IU, typically in the form of drops from birth to age 1.  Whichever you decide to do, know your Vitamin D levels and your baby's.  As clearly demonstrated in the above review from JABFM, making sure that your baby has adequate Vitamin D intake won't just spare them from rickets (the sad consequence of severe Vitamin D deficiency) - it will also help them to avoid other health problems throughout life including cancer, Alzheimer's, multiple sclerosis (MS), cardiovascular disease, and diabetes. 

Lactation Basics (how your breasts make and release milk)

Learn the Basics

Before you begin to breastfeed, take some time to learn the basics of how it works. Lactation is unlike any other bodily process, and knowing more about it will allow you to better understand how to do it properly and how to avoid (or at least be ready for) some common problems like a shrinking supply or clogged milk duct. Wikipedia has a decent lactation entry. Other informative descriptions of lactation come from Kellymom and the La Leche League. One of the better discussions I have found online is by pediatrician Carol Wagner and available here on the emedicine blog from WebMD. The basic biology and key terms are described here.

Making Milk

Your body prepares to make milk late in pregnancy. Your breast cells become more specialized and prepare to make large amounts of the characteristic components of breastmilk, such as lactose and immunoglobulins. This phase is referred to as Lactogenesis I. You begin producing milk after your baby is delivered. The sharp decrease in pregnancy hormones (namely progesterone) after birth initiates your milk production. Once this process begins, it requires 2-3 days for your breasts to feel full. This initial feeling of fullness and build up of milk is what women refer to as their milk "coming in." It is important to note that giving birth stimulates this phase, Lactogenesis II, not nursing. Your breast will make milk at this point whether you nurse or not. Please remember that just because your milk comes in quickly and/or copiously does NOT mean that your baby is latching and nursing well (and vice versa). Keep a close eye on your production as this "automatic milk" produced after birth goes away and your supply begins to depend on nursing properly. Once your body has become accustomed to the cycle of producing and releasing milk, you have reached the phase known as Galactopoiesis - this is kind of like finishing a marathon - congratulations!

Releasing Milk (let down)

You produce the components of breastmilk in specialized mammary cells. It is released from these cells into small ducts that gather into larger ducts. These ducts carry milk to about 20 openings at the tip of your nipple. As your breast releases milk, the milk sprays out from these openings. It is important to remember that milk flows from your breast into your baby's mouth not so much because it is pulled out by sucking, but more because it is pushed out by contracting breast cells. When these cells contract, milk flows, or even sprays forcefully, through your nipple. This is referred to as "let down." Let down does depend on nursing. That spraying milk is a response to signals from the brain (primarily the hormones oxytocin and prolactin) produced in response to your baby's sucking (or a breast pump, if necessary). To keep making milk from this point on, you must either nurse or pump at regular intervals. Feedback inhibition, a biological system for halting production of things that buildup to a certain level, is another important factor. This keeps full breasts from making more milk, so it is important both to stimulate milk release and to empty the breast.

Observing the Process

A good breast pump, which is helpful in numerous ways throughout breastfeeding, will allow you to see clearly how this works. Initially, milk dribbles gradually - drawn out by the sucking pull of the pump then, after a minute or two, you will begin to feel your breast contract as let down begins. Milk then sprays out in many directions from your nipple. The let down response is more extreme in the new mother. This can cause your bra/shirt to be soaked during feedings by the unnursed boob, unless you wear a breastpad - especially early on. If too much milk (enough to soak a breastpad) is lost, it may be useful to use a catch to collect the the milk. This will help you ensure the milk goes to the baby and isn't soaked up in the breastpads!

Take home summary

Having a baby will initiate milk production. This initial production, however good, will dwindle and stop without stimulation of the newly active breast by a baby or a breastpump. Nursing your baby (or pumping with a high quality motorized pump) does not simply draw milk out, it stimulates your brain to produce key hormones that cause the breast cells to contract and spray milk. Effective nursing will stimulate milk release and empty the breast so that more milk will be produced. If your baby has trouble nursing in the first days or weeks, a pump can help (see Pumping Sucks).

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