by Anne Smith, IBCLC
Nearly all nursing mothers worry at one time or another about whether their babies are getting enough milk. Since we can't measure breastmilk intake the way we can formula intake, it is easy to be insecure about the adequacy of our milk supplies. The "perception" of insufficient breastmilk production is the most common reason mothers give for weaning or early introduction of solids or supplements. Although there is a very small percentage of women who can't produce enough milk no matter what they do, this is very rare.
The first thing to determine is whether your supply is really low or not. Some mothers have unrealistic expectations, and feel that if their baby isn't on a three-hour schedule, or sleeping through the night by six weeks, they must not have enough milk. There is a tendency for a nursing mother to blame everything on her breastmilk -- for example, if your baby spits up or is gassy, it must be something you ate; if he has a day when he feeds more often than usual, it must be because you don't have enough milk. Be careful not to get into the habit of attributing everything your baby does to nursing. All babies, formula or breastfed, have laid back, easy, and fussy days.
Often mothers worry about their milk supply if:
• The baby nurses often, or seems hungry soon after being fed. Remember it is normal for babies to feed often. They have a strong need to suck, and love to be held close. Breastmilk digests faster than formula, so nursing babies tend to eat more often. Nursing 10-12 times or more in 24 hours is not unusual. In fact, we lactation consultants worry a lot more about the baby who is sleeping long stretches than we do about the baby who wants to nurse "all the time". Growth spurts commonly occur at around 10 days to 2 weeks, at 3 weeks, at 6 weeks, at 3 months, and again at 6 months. The baby will nurse more frequently during a time of rapid growth and not seem satisfied. After nursing frequently on demand for a few days, most babies will level off and go back to their old schedule. Also, many babies will "cluster feed" in the evenings before going to sleep. This is a normal pattern for a breastfed babies. Formula fed babies also have fussy periods in the evening, but their mothers don't have a built-in way to comfort them, so they cry more.
• The baby spends less time at the breast (maybe 5-10 minutes rather than 15-20), he takes one breast rather than both at a feeding, or your breasts feel softer and don't leak as much as they did in the early weeks of nursing. These changes are normal and just mean that your body is adjusting your supply to meet your baby's needs.
• You compare your baby's nursing patterns, weight gain, or sleep habits to other people's babies, or even your previous baby. Remember that each baby is an individual, and the same rules don't apply to everyone, just as the same rules don't apply to formula-fed and breastfed babies.
To determine if you really do need to increase your supply, see the article on How To Tell If Your Baby Is Getting Enough Milk. If your baby is losing weight or not gaining rapidly enough, you need to determine why your milk supply is low, and take steps to increase it.
The following factors can contribute to an inadequate milk supply:
• Not getting enough sucking stimulation. A sleepy, ill or jaundiced baby may not nurse vigorously enough to empty your breasts adequately. Even a baby who nurses often may not give you the stimulation you need if he is sucking weakly or ineffectively.
• Being separated from your baby or scheduling feedings too rigidly can interfere with the supply and demand system of milk production. Nursing often is the best way to increase your supply.
• Limiting the amount of time your baby spends at the breast can cause your baby to get more of the lower calorie foremilk and less of the higher fat content hindmilk. Usually babies need to spend from 20-45 minutes nursing during the newborn period in order to get enough milk. Offer both breasts at a feeding during the early weeks in order to receive adequate stimulation. While some babies can get plenty of milk from one breast, and after nursing only a few minutes, usually this happens after the milk supply is well established, and not in the early stages of breastfeeding.
• If you are ill or under a lot of stress, your milk supply may be low. Hormonal disorders such as thyroid or pituitary imbalances or retained placental fragments can cause problems. Many mothers find that their supply goes down when they have a cold, or when they return to work.
• Using formula supplements or pacifiers regularly can decrease your supply. Babies who are full of formula will nurse less often, and some babies are willing to meet their sucking needs with a pacifier rather than spending time at the breast. If you need to supplement with formula, try to pump after feedings to give your breasts extra stimulation. If you use a pacifier, make sure that it isn't used as a supplement for nutritive sucking.
• If your nipples are very sore, pain may inhibit your letdown reflex, and you may also tend to delay feedings because they are so unpleasant. See the article on Sore Nipples for causes and treatment. Often careful attention to positioning will correct the problem.
• Previous breast surgery can cause a low milk supply. Anytime you have breast surgery, there is a risk of breastfeeding problems, especially if milk ducts have been damaged. Generally, breast implants or breast biopsies cause fewer problems than breast reduction surgery.
• Taking combination birth control pills (those containing both estrogen and progesterone) and getting pregnant while nursing can alter your hormone levels and cause a decrease in your supply. Smoking heavily, and taking certain medications can also adversely affect your supply (see article on "Drugs and Breastfeeding").
If your milk supply is low, here are some suggestions on how to increase it:
• Monitor your baby's weight often, especially in the early days and weeks. In general, the longer your supply has been low, the longer it will take to build it back up. Get help early, before weight gain becomes a big concern.
• Take care of yourself. Try to eat well and drink enough fluids. You don't need to force fluids -- if you are drinking enough to keep your urine clear, and you aren't constipated, then you're probably getting enough. Drink to thirst, usually 6-8 glasses a day. Your diet doesn't have to be perfect, but you do need to eat enough to keep yourself from being tired all the time. It is easy to get so overwhelmed with baby care that you forget to eat and drink enough. Don't try to diet while you are nursing, especially in the beginning while you are establishing your supply. You need a minimum of 1800 calories each day while you are lactating, and if you eat high quality foods and limit fats and sweets, you will usually lose weight more easily than a mother who is formula feeding, even without depriving yourself. (See article on "Nutrition, Weight Loss & Exercise")
• Nurse frequently for as long as your baby will nurse. Try to get in a minimum of 8 feedings in 24 hours, and more if possible. If your baby is sleepy, see article on "Waking A Sleepy Baby".
• Offer both breasts at each feeding. Try "switch nursing". Watch your baby as he nurses. He will nurse vigorously for a few minutes, then start slowing down and swallowing less often. He may continue this lazy sucking for a long time, then be too tired to take the other breast when you try to switch sides. Try switching him to the other breast as soon as his sucking slows down, even if it has only been a couple of minutes. Do the same thing on the other breast until you have offered each breast twice, then let him nurse as long as he wants to. This switch nursing will ensure that he receives more of the higher calorie hindmilk, while also ensuring that both breasts receive adequate stimulation.
• Try massaging the breast gently as you nurse. This can help the rich, higher calorie hindmilk let down more efficiently.
• Make sure that you are using proper breastfeeding techniques. Check your positioning to make sure that he is latching on properly. If the areola is not far enough back in his mouth, he may not be able to compress the milk sinuses effectively in order to release the milk. (See article on "Sore Nipples" for tips on positioning).
• Avoid bottles (if possible) and pacifiers. You want your baby's sucking needs to be met at the breast. If your baby needs to be supplemented, try to use a cup, syringe, or tube feeding system, especially in the very beginning (babies under 2 weeks old). This is less of a concern with older babies who are well established with breastfeeding, as they are much less likely to have trouble switching back and forth between breast and bottle.
• If you want to increase your supply quickly, consider renting a hospital-grade breast pump for a few days, unless you have a good quality double pump at home. The best way to increase your supply is to double pump for 5-10 minutes after you nurse your baby, or a least 8 times in 24 hours. Try to set the pump on maximum unless your nipples are very sore. Most pumps work better on the higher suction settings. Minimum is kind of like the baby sucking in his sleep toward the end of the feeding, and maximum is more like the vigorous sucking he does for the first few minutes of the feeding. If you live in the Winston-Salem area, call me and I can provide you with a hospital grade pump for a few days while you are building your supply. For all other areas, call Medela at 1-800-TELL-YOU to find a rental outlet in your area.
• There are certain food supplements as well as prescription medications that may increase your milk supply. Before using any of these, it is important to rule out other problems such as illness in mother or baby. Many herbal supplements have been used for many years to increase milk production, with the most popular being Fenugreek, Blessed Thistle, and Red Raspberry. Brewers Yeast (containing B vitamins) is another commonly recommended treatment for low milk supply. I usually recommend that mothers try Fenugreek capsules (2-3 capsules taken 3 times daily) along with Blessed Thistle tablets (same dosage). You many want to add Brewers Yeast tablets (3 tablets taken with meals, 3 times per day) and Red Raspberry tea or capsules several times each day. I know that seems like a lot of capsules to take, but if you don't want to take them all, the Fenugreek seems to be the most effective. Fenugreek is rated GRAS (generally regarded as safe), but when taken in large doses may cause lowered blood sugar, so should be used with caution by diabetics. It is in the same family with peanuts and chickpeas, and may cause an allergic reaction in moms who are allergic to them. It may cause a maple syrup odor in urine and sweat. For the majority of mothers, it causes no problems, and can be very effective. It has not been known to cause any problems for the babies of the mothers who take it. Contact Mechell Turner, IBCLC & herbalist.
There is one prescription medication available in the US that is often used to increase milk supply. It is usually reserved for cases where all other factors have been ruled out, and other treatments have failed. It is often used for mothers who are nursing premature infants who are hospitalized for long periods of time, and who are under a great deal of stress. Metoclopramide (Reglan) is most commonly prescribed to treat reflux in infants, and to prevent nausea in mothers after a cesarean birth. When given to lactating women, it stimulates prolaction production and will usually increase milk output. Many studies have shown an increase of 66 to 100% in milk production, depending on the dose given and how much milk the mother was producing before taking the drug. A dose of 30-45 mg per day seems to be most effective, with the average dose being 10 mgs taken 3 times a day. If a mother responds to Reglan, she will usually see an increase in her supply within 2-3 days. Once she stops taking it, her supply will usually drop off again. If you are taking Reglan, you should also work on addressing the cause of the problem, by correcting positioning or pumping frequently, or your supply will drop back to previous levels when you discontinue it. Tapering off the dose over a period of several weeks is generally better than discontinuing it abruptly.
Reglan is commonly used in pediatric patients, and no adverse side effects have been noted in nursing infants. Mothers may experience cramping and diarrhea, and long-term use (more than four weeks) has been associated with depression.
The most important thing to consider when dealing with an infant who is not gaining weight is your baby's welfare. You need to work closely with his doctor, and monitor his weight carefully. It is often necessary to supplement with formula while you are working to increase your supply. Don't have the feeling that giving formula is the "kiss of death" for breastfeeding. Often, supplementing with formula is just what you need to put weight on the baby quickly so that he can nurse more vigorously and effectively. Ask your doctor what formula he recommends, and get it into your baby however you can. If syringe-feeding, cup-feeding, tube-feeding at the breast or finger-feeding works for you, that's great. However, sometimes bottle-feeding is the most efficient way to get milk in a baby, and that is what takes priority over everything else. Many babies switch back and forth from breast to bottle with no problems, and if nipple confusion does develop, you can deal with it then. Once your baby is gaining weight appropriately, you can go back to nursing totally at the breast again. Don't be afraid to use a bottle or supplement with formula if that is what works for you and your baby.
If you are one of those women who fall into the small group of those who can't produce enough milk no matter what you do, you can always combine breast and formula feedings. Any amount of breastmilk that your baby receives provides nutritional and immunological benefits, and the special closeness that you feel while nursing your baby is not dependent on how many times a day he nurses.
Anne Smith, IBCLC has breastfed a total of six children (three boys, three girls). She feels that her first hand experience plus her more than twenty years experience of counseling nursing mothers are among her most important credentials. Anne has been a La Leche Leader since 1978 and IBCLC since 1990. As a nursing mother, LLL Leader, and IBCLC, Anne has worked in many areas over the years. She has led support group meetings, taught breastfeeding classes, trained breastfeeding peer counselors to work with low income mothers, worked one-on-one with mothers to solve breastfeeding problems, helped thousands of mothers with breastfeeding questions over the phone, held workshops for health professionals on various breastfeeding topics, taught OB, Pediatric, and Family Practice Residents breastfeeding at Bowman Gray School of Medicine, and run a breast pump rental station with over 100 pumps, scales, and nursing bras for the past eleven years. We invite you to visit Anne's website.
Copyright © Anne Smith. Permission to publish granted to Pregnancy.org, LLC.