Low milk supply 101

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This is a very important place to start. Please bear with me. I don’t mean to doubt your situation but it’s crucial to note that the MAJORITY of new mothers who fear they have low milk supply DO NOT. The majority of women who start to use formula because they worry they aren’t making enough or baby isn’t getting enough DO NOT HAVE A PROBLEM.

I cannot emphasise this enough. Apologies for the capital letters. Every day mothers panic and end breastfeeding or start using formula and there is not an underlying problem with their milk supply. But of course – once they start using formula without correct support, they often will start to send signals to their breasts to really reduce supply.

• You do not have low milk supply just because your baby won’t go the X number of hours between feeds that the book on your coffee table tells you they should. Or your mother-in- law. Or the X number of hours your friend’s baby is going between feeds. A normal happy healthy baby who has a gorgeous mummy with a normal healthy milk supply might get hungry an hour after the last feed, or 90 minutes, or 45 minutes or two hours. They might be cluster feeding and hardly want to come off the breast at all. They might be having a growth spurt and feed every hour for a day.
• You do not have low milk supply because your breasts have stopped leaking. Some mothers leak less than others. MOST mothers notice that leaking reduces at the weeks go by and the teeny tiny sphincter muscles responsible tighten.
• You do not have low milk supply because your breasts feel softer than they used to. The excessive fullness we experience in the early days of breastfeeding is about vascular engorgement (blood and lymph) and it’s about the body inefficiently storing unnecessary amounts of milk between feeds. As time goes by, the breasts get cleverer at storage (don’t forget milk is also made while a baby is actually feeding). There is also less blood and lymph needed in the breasts as breast tissue growth slows down. At the beginning, it’s often very obvious which breast is going to be fed from next. That feeling goes. And many mothers mistakenly connect it with a reduction in milk supply. We are not all supposed to continue feeling heavy and full throughout our breastfeeding experience. Don’t ever think ‘I’ll wait to let my breasts fill up!’ Noooooo. This shows a misunderstanding of how lactation works to a spectacular degree. When breasts are fuller, milk production slows down. When breasts are emptier, milk production increases. Emptier softer breasts may well be making a heap more milk in a 24 hour period than the engorged full versions.
• You do not have low milk supply because your baby feeds for a short time. Plenty of babies get everything they need in under ten minutes. Probably not five – but sometimes a feed might even be five minutes long. Lots of babies use their tongue and jaw muscles super efficiently and gulp and glug and slow down as the milk gets fattier and thicker and then come off happy. It might take them nine minutes or nineteen. A baby might start off life needing 30 minutes to drain a breast (when we say ‘drain’, breasts are never completelyempty, it just means the baby has taken out all the milk they usefully want to). As a baby gets older, this can dramatically reduce. It doesn’t mean less milk is going in. If a small sleepy jaundiced baby falls asleep very quickly at the breast without some solid minutes of good swallowing, that’s a different story. Overall however, a longer feed does not always mean a better one.

• You do not have low milk supply because you have small breasts. Large breasts are a combination of fatty tissue and glandular tissue. You cannot tell much about someone’s milk production by the size of the breasts. If you are really worried your breasts don’t ‘look right’, we’ll come back to this later.
• You do not have low milk supply just because your baby wakes up a lot. Plenty of young babies feed with similar intervals day and night. Plenty continue waking every 2-3 hours for a while.
• You do not have low milk supply because your baby won’t ‘go down’ after a feed. So you feed your baby and they drop off to sleep on the breast. You move them to the Moses basket and they wake up as if you just placed them on a sheet of molten lead. And they seem to be rooting again. This happens because being next to you skin-to-skin was nice and cosy and relaxing and warm and it smelt good. The Moses basket is cold and NOT YOU. You probably triggered the Moro startle reflex when you moved them. You probably moved them about 15-30 minutes after a feed when the hormone cholecystokinin had dropped in their blood stream causing them to be more wakeful. Your teeny primate mammal baby finds the breast a lovely place to be. They like to suck to relax themselves. Babies like second helpings. This does not mean you are not making enough milk.
• You do not have low milk supply because your baby will take milk out of a bottle after a feed. Put a teat against a young baby’s palate and you trigger that baby’s sucking reflex. Babies will usually continue to take milk beyond the point that they need it. This is one of the reasons we see links between bottlefeeding and obesity.
• You do not have low milk supply because you don’t pump very much milk. Pumping and breastfeeding are surprisingly unrelated. Your baby removes milk in a completely different way. Plenty of women with healthy milk supplies fail to pump much at all. Their bodies can’t be tricked into eliciting the milk ejection reflex (or ‘letdown’). Plus pumps don’t always work. Suction goes as valves get old.

These are the things that REALLY tell you a mother might have low milk supply:

• Weight gain problems. A newborn is born and then loses weight. They regain birth weight at around two weeks. They then put on about 150-200g a week after that. That slows down after around four months. If your newborn loses more than 10% of their body weight, we might pay attention but we’ll also want to look at things like your birth. Did you have a drip in labour that filled you and your baby with fluid? Did your gorgeous newborn look a wee bit like the Stay Puft marshmallow man in their first photos? That fluid elevated the birth weight and as it comes out again in the first few days, we might see more of a weight drop. That doesn’t necessarily mean feeding or supply is a problem. However wouldn’t want your baby to lose weight after about day five or lose weight a second time. It might take some babies three weeks to get back up to birth weight.

Have a look at the chart in your red book. Notice how we have birth weight line and then a space where the curvy lines don’t go and they start again at week two. Just because your baby was born on the 75th percentile, that doesn’t mean we would expect them to definitely re-start on the 75th after that two week gap. That’s why the lines don’t continue. That’s why we have that space. We start again at two weeks. Your baby might be on the 50th then. They then ideally will roughly stick in the same vicinity. But babies wobble around a bit. They might dip below. They might get close to the 25th. And then they might bob back up again. We don’t expect all babies to hug a line exactly. This chart is a guide. It’s about averages. It’s not about mathematical certainties.

• Nappies. In the early days (first four weeks), we look at poo and pee. After your milk has come in (around day two to five), we’d expect to see six wet nappies in 24 hours and three poos the size of a £2 coin or bigger. After week four, some babies poo rate can slow right down. This doesn’t mean anything is wrong. Some babies can skip several days between poos and this isn’t anything to do with milk transfer or supply. However if someone tells you it’s OK for a ten day old baby not to poo for a few days, don’t believe them. We’d need to investigate that situation. Only later on do we relax.

Weight gain and nappies. That’s it. Those are the only things that tell us about milk supply. You may hear people say that ‘babies should be settled after a feed’ but some babies get wind or need to poo or have reflux or wake up and want second helpings. Let’s be careful about even saying that. Let’s look at weight gain and nappies.

So let’s now assume you do have low milk supply. How many of you are still with me? I’m sorry if you are. I’m sorry if your baby only put on 60g last week and 90g or less or nothing the week before that and they are slipping down the percentiles. I’m sorry because I know how scary that can feel. Nothing feels like it matters more. There are things we can do.

1. Find people. Find people who know about breastfeeding. Someone who tells you just to use formula in this situation is not who you need. If that’s all they can offer you, they don’t know about breastfeeding and you need someone else. You need someone who understands how lactation works. These people may actually still tell you to use some formula in some situations (or donor breastmilk) but they will do so alongside telling you how to protect and develop your milk supply. You also need people close to you to look after you. If you are going to do all the other stuff on this list, you need to have people who love you who will cook your dinner and run you a bath sometimes. And text you just before the weigh-in clinic next week to say they are thinking of you.

2. Breastfeeding M.O.T.
   Someone like a breastfeeding counsellor or IBCLC (lactation consultant) should check your latch. You might not be sore and your nipples might not be misshapen after a feed but something still might be going wrong. Your latch needs checking. Is baby’s chin deep into the breast? Is baby’s body close to yours? Is baby’s ear/ shoulder/ hip in a line?
   They shouldn’t just check your latch but look at your breastfeeding management. Are you feeding enough? Maybe your baby doesn’t show cues very strongly and someone told you to wait for them and you’re sometimes going four hours between feeds? Maybe you need to feed more frequently?
   When are you changing sides? Too quickly? (and baby is missing the fatty milk). OR did someone tell you to stick on one side forever to get that ‘hind milk’ and the baby is on 45 minutes without doing a heck of a lot? Maybe you need to change sides at 20-30 minutes instead and get baby a greater volume of milk overall and fatty milk overall. Both of these habits can cause weight gain problems. Get someone to help you recognise what swallowing looks like so you’ll know when to change sides and when good feeding has finished.
3. Google ‘breast compressions’. You’ll get to a video and handout from Dr Jack Newman. You can finish a feed with breast compressions and get an extra dose of fatty milk into baby.
4. You have 3 sides and 4 sides. This is ‘switch nursing’. Try and go back to the first side. There will be milk there. The more breastfeeding you do, the more milk you will make. The second time you return to that breast, the milk will be fattier and richer and you’ll send great signals to your body to make more.
5. Find time. If you are going to build up your supply, get help. You can’t devote time to switch nursing and skin-to-skin when you have to go to Tesco to buy milk and pick up another child from school. If this is ‘Operation Milk supply’, who can help you? You’ll read people talking about a ‘babymoon’. Go to bed, they say. Just you and the baby. Feed lots. If that sounds appealing, go for it. Personally my babymoon would involve the sofa and box sets and crisps. However there’s no point in babymoooning until next Christmas if your latch and breastfeeding management are the issues. Get that checked first.
6. Using a pump. Baby feeding effectively is first choice but pumps can be useful. You can pump on an emptier breast to send even more signals to your milk supply. But we’re not going to take a baby off the breast do be able to pump. You don’t need to wash and sterilize a pump every time you use it. Pop it in a plastic bag and put it back into the fridge between pumping sessions. 10 minutes is ample. If you are pumping for 30 minutes and ‘nothing is coming’ out, you are not getting a letdown and you are not doing yourself any favours. Use hand expression before and after (google ‘Marmet hand expression’) and prepare the breasts with warm compresses and massage if you can.

You can take an hour and do some ‘cluster pumping’ or ‘power pumping’. Pretend to be a baby having a cluster feed. Pump for ten minutes. Break for five. Pump again and repeat. Just check your pump is the best one available. If it’s second hand or you have had it a while, it might need servicing or replacement parts. You also might want to consider hiring a hospital grade double electric pump from someone like www.ardobreastpumps.co.uk to give yourself the opportunity to pump both sides together as effectively as possible.

Pumping shouldn’t hurt. Make sure your flanges are the right size – that means they are the right diameter for the size of your nipple. Don’t think that cranking up the suction will automatically do better things. And don’t think, “I don’t want to pump because I will empty my breasts and baby will have less milk.” Certainly they might be less appreciative if you pump just before a feed is due and you leave them with an emptier breast full of thicker fattier milk but pumping overall will increase milk supply and stimulate milk production. You are not ‘taking their milk away’.

You might also be someone who always gets better results with just using hand expression so stick with that. Of course, you might not want to pump at all and just focus on feeding baby more effectively and frequently.

7. Galactagogues. Taking herbs and medication that increase milk supply. Not right for everyone but some women really feel they helped. You need to read about side effects and dosage on sites like kellymom.com. Fenugreek, blessed thistle and goat’s rue are popular. Some doctors prescribe domperidone in certain situations. These are never a substitute for good breast emptying and a breastfeeding MOT.
8. The science part. In a book, this bit would be under a little flap as we’re only talking to a small group of people.
   Did you have breast surgery?
   Are your breasts very widely-spaced or asymmetrical, or very tubular with a bulging areola? Did they not really change much in pregnancy (or puberty)?

Do you have PCOS? Some women with PCOS (not all) have a reduced milk supply.
These are times when it’s worth finding an IBCLC and getting technical.
Some doctors will do hormonal testing for you. There are medications that can help develop breast tissue especially in pregnancy.

What about your thyroid levels? This is something relevant for more people than you might realise. If you are trying everything and low milk supply continues to be a problem, ask your doctor to check your thyroid levels. There are sometimes medical reasons mothers have a low milk supply and doctors and lactation consultants may be able to help you. These are not the most common reasons why people have low milk supply by a long shot. Hence the need for the flap.

Most people who genuinely have low milk supply got themselves into a pickle with using artificial nipples or not breastfeeding enough or breastfeeding ineffectively. And it can almost always be reversed.

Also remember that just because you had low milk supply in your first breastfeeding experience, it doesn’t mean a subsequent lactation will also be a struggle. The development of all that breast tissue first time round often helps.

Hold in your mind the fact that women can relactate after not breastfeeding at all for several weeks. We CAN send signals to increase supply again in the vast majority of cases. There are tons of us in real life and online who want to support you.

Article written by IBCLC and ABM BFC Emma Pickett