by Jack Newman, MD, FRCPC
Most mothers have lots of milk or could have had lots of milk if they had gotten off to a good start and had good hands-on help. The problem is often that the baby is not getting the milk that is available. Sometimes mothers seem to have a lot of milk which flows very quickly at the beginning of a feeding, but the baby fusses or falls asleep when the flow slows down later in the feeding. Although the following symptoms are not necessarily due to the baby's not getting enough milk flow from the breast, this Protocol can be used to help resolve concerns about:
- The sleepy or "lazy" baby. Babies are not lazy, incidentally. They respond to milk flow and if flow is slow, they tend to sleep at the breast especially if they are under a few weeks of age. Babies also seem to want to "use the mother as a pacifier." Yes, sucking is pleasurable for the baby, but if the baby gets better milk flow and is truly "full" often the baby won't want to just suck at the breast.
- The baby who pulls or fusses at the breast.
- The baby who is fussy or "colicky" (see also the information sheet on Colic in the Breastfed Baby).
- Frequent or long feedings or the baby who does not seem to wake up for feedings.
- Jaundice (see also the information sheet on Jaundice & Breastfeeding).
- A too-rapid milk flow, "Over-active letdown," babies choking or coughing at the breast or breasts that don't seem to drain adequately.
To Ensure the Baby Drinks as Well as Possible
1. Get the best latch possible. In order to accomplish this it is best to get help from someone who knows how to help mothers with breastfeeding. Anyone can look at the baby at the breast and say the latch looks good. We tend to teach the latch differently from most others. Naturally we think our approach is very effective and often is.
A baby latched on well is on the breast asymmetrically, covering more of the areola with his lower lip than his upper lip, with his chin in the breast but not his nose, and his head is slightly tipped backwards compared to the rest of his body. When the baby is latched on well, the mother has no pain, and the baby gets milk well from the breast. See the information sheet When Latching and the video clips at the website nbci.ca. Get good "hands-on" help.
2. Know how to know a baby is getting milk. When a baby is getting milk, he will have an open mouth wide -- pause -- close mouth type of suck. He is not getting milk just because he has the breast in his mouth and is making sucking movements. When he is sucking and not getting milk his chin moves down and up rapidly with no pausing of the chin at the maximum opening -- this means "I am not getting milk flow into my mouth."
If you wish to demonstrate this to yourself, put your index finger into your mouth and suck as if you were sucking on a straw. As you draw in, your chin drops and stays down as long as you are drawing in. When you stop drawing in, your chin will come back up.
This pause that is visible at the baby's chin represents a mouthful of milk when the baby does it at the breast. Actually the baby does this pause when he gets milk from finger feeding or a bottle, too. The longer the pause, the more milk the baby got, so it is obvious that the frequently advised "feed the baby 20 minutes on each side" makes no sense. A baby who drinks very well (as opposed to sucking without drinking) for say, 20 minutes straight, will likely not take the other side. A baby who nibbles (doesn't drink) for 20 hours will come off the breast hungry. You can see video clips of babies drinking (or not) at the website nbci.ca.
Note that when baby stops sucking, "taking a break," this is not the pause we are referring to. Note also that it is normal for babies not to suck continuously without a break. Just ensure that when he begins to suck again he is also drinking.
3. Compressions. Once the baby is sucking without drinking, use the technique of breast compression to increase the flow of milk to the baby. Babies react in two ways to slow flow. They either fall asleep at the breast or they pull at the breast. Some babies do one thing at one feeding and another at another feeding. Some will both fall asleep and pull at different times during a single feeding.
When the baby is sucking without drinking, start compression, but be sure to do them while the baby is sucking but not drinking. Keep the baby on the first breast until he doesn't drink even with compressions (so that there is no pausing-type of suck even when you compress). See the information sheet Breast Compression. You can also see a mother using breast compression at the website nbci.ca.
4. Switch sides. When the baby no longer drinks even with compression, switch sides and repeat the process. Keep going back and forth as long as the baby gets reasonable amounts of milk. Of course once the baby has fed well, there is no harm in letting him "nibble" at the breast until he pulls off.
When the above techniques don't work well enough...
5. Herbs. Take fenugreek and blessed thistle. These two herbs seem to increase milk supply and increase the rate of milk flow, which is actually more important. Because herbs are not standardized, we recommend mothers take enough fenugreek that she notices its scent on her skin. Often 3 capsules each of fenugreek and blessed thistle (or 20 drops of the tincture) taken 3 times daily will help and should work within 24-72 hours. If they have not worked by 72 hours and the mother smells of fenugreek, they probably won't work. For other herbs that may help increase milk supply, see the information sheet Herbal Remedies for Milk Supply.
6. Lying down to breastfeed. In the evening, when babies often want to be at the breast frequently and/or for long periods of time, get help to position the baby so that you can feed him lying down. (Note: mothers have less milk in the evenings, but less does not necessarily mean "not enough"). Let the baby breastfeed and maybe you will fall asleep. Babies who fuss at the breast when the flow is slower in the evening may be content to suckle at the breast when lying side by side with the mother. Or rent videos and let the baby breastfeed while you watch. See the information sheet Safe Co-sleeping.
Still having difficulty?
7. Domperidone. This is a medication that increases the rate of milk flow to the baby by increasing the milk supply. It is not a magic bullet and won't cure all problems. It must be used in conjunction with the other steps in this Protocol. Sometimes it can be useful even if your milk supply is already substantial (as when the baby does not yet know how to latch on). See the information sheets on Domperidone -- Part 1 and Part 2.
8. Supplementation. It is not always easy to decide if a baby needs supplementation. Sometimes applying this Protocol for a few days and continuing with it will get the baby gaining more rapidly. Sometimes more rapid growth is necessary and it may not be possible without supplementation.
If practical, get banked breastmilk to use as a supplement (for more information see the HMBANA Website). If not available, infant formula may be necessary.
However, sometimes slow but steady growth is acceptable. The main reason to worry about growth is that standard growth is a sign of good health. A baby who grows well is usually in good health, but not necessarily so. Neither is a baby who grows slowly necessarily in poor health, but physicians worry about a baby growing more slowly than average.
Growth charts are, however, frequently interpreted poorly. A baby who follows the 10th percentile is growing normally and as he should. Too many people, and surprisingly even some physicians, believe that only babies on the 50th percentile and above are growing normally. This couldn't be more false. Growth charts were developed on information gathered on normal babies. Somebody has to be smaller than 90% of all other babies (on the 10th percentile) -- somebody normal.
9. Lactation aid. If it is decided that supplementing is necessary, the best way to do it, even if you are supplementing with breastmilk, is with a lactation aid at the breast. Our lactation aid is made with a #5 French, 36 inch or 93 cm long feeding tube leading from a bottle of supplement and it is used once the baby has fed only after doing steps #3 and #4 above and the baby has fed on at least both sides. Why is a lactation aid better than a bottle, cup, syringe, or spoon?
- Babies learn to breastfeed by breastfeeding.
- Mothers learn to breastfeed by breastfeeding.
- The baby continues to get milk from the breast thus helping to increase the milk supply.
- The baby won't reject the breast.
- There is more to breastfeeding than breastmilk.
10. Solids. If the baby is older than about 3 or 4 months and supplementation appears to be necessary, formula is not necessary and extra calories can be given to the baby as solid foods. Yes, you can give solids to a baby of 3 or 4 months of age. The statement by Health Canada, the Canadian Paediatric Society, the American Academy of Pediatrics, UNICEF, the World Health Organization, and almost all paediatric societies around the world encourage exclusive breastfeeding to about 6 months.
This means that if the baby needs extra calories and is also getting formula he is still not exclusively breastfed. Formula is basically a liquefied solid. But it's not the formula that is the biggest problem. It's the bottle. If the baby gets bottles when the milk flow from the breast has slowed because of a decreased supply, he will figure out pretty quickly where the food comes from and start rejecting the breast.
Bonding is important, but hunger comes first. So formula can be given, but mixed with the baby's solids. This works fine. First solids can include mashed banana, mashed avocado, mashed potato or sweet potato, etc -- as much as the baby will take without forcing.
Note however, that giving the baby solids at 3 or 4 months of age when everything is going well and the baby is gaining well is not recommended. Solids should normally be started when the baby is showing a definite interest in eating solids (usually around 6 months of age, but not always, sometimes this occurs before six months and sometimes after). See the information sheet Starting Solid Foods.
11. Late onset slow weight gain. If your baby was gaining weight well for a few months and no longer is, see the information sheet Slow Weight Gain After Early Good Weight Gain. Reasons for a decreased milk supply are listed there. Fix what interfering factors fit your situation and follow this Protocol
Questions? Get Dr. Jack Newman's book The Ultimate Breastfeeding Book of Answers.
Jack Newman graduated from the University of Toronto medical school as a pediatrician in 1970. He started the first hospital-based breastfeeding clinic in Canada in 1984 at Toronto's Hospital for Sick Children. He has been a consultant with UNICEF for the Baby Friendly Hospital Initiative in Africa, and has published articles on the subject of breastfeeding in Scientific American and several medical journals. Dr. Newman has practiced as a physician in Canada, New Zealand, and South Africa.
Protocol to Manage Milk Intake, 2009©
Written & revised (under other names) by Jack Newman, MD, FRCPC, 1995-2005©
Revised by Jack Newman MD, FRCPC, IBCLC & Edith Kernerman, IBCLC, 2008, 2009©