Low Milk Supply
Low Milk Supply
Low milk supply is the most common reason women report weaning sooner than they'd hoped. (The second most common reason is pain.) There are entire books and countless medical journal articles devoted to the topic. In this article, we will scratch the surface of the topic and look at the aspects of milk production that are most relevant to the women I work with. When I was first trained in the field of lactation in 2011, we were taught that most of these cases were "perceived" low milk supply. This is a polite way to say that many women think their milk supply is low when really it may be sufficient. In my private practice, when women tell me they are worried about their milk supply it is usually a legitimate concern, and not "all in their head." If you have concerns, please read this article and then reach out for help. My passion is to help you find solutions and answers for your difficulties. First, let's define normal milk production before we dive into low milk supply.
A "full" milk supply is defined as producing 25-30oz of breastmilk per 24 hours. This is a very objective way of measuring and describing how much milk a woman should be able to produce in order to support a thriving, growing baby. When our bodies work the way they are supposed to, women will reach this peak of 25-30oz within a few weeks of delivery. After the first month, a woman simply has to maintain this level of milk production until her baby is well established on solid foods and the quantity slowly decreases. Babies do not consume more breastmilk as they get older. An infant's metabolism slows over the course of the first year, causing their total milk intake to plateau. The good news is that if you can do the hard work to bring in a full milk supply during the first month, all you'll have to do is maintain it after that.
Perceptions vs Reality
The debate over perceived vs real low milk supply is often due to the challenge of measuring milk production when a woman is directly breastfeeding. Obviously, if you are exclusively pumping its possible to keep track and know how much you're expressing each day. For women directly breastfeeding, calculating milk production is a bit trickier. The most reliable indicator of a healthy milk supply for an exclusively breastfed baby over 2 months is to plot their growth on the World Health Organization's growth chart. A baby who is maintaining his percentile (growth curve) over time is getting enough milk to grow well and thus we know mother is producing a full milk supply. A baby who is dropping more than 5% per month off his growth curve may not be getting enough milk. Using WHO growth charts is the gold standard, objective way to determine if there is a problem with the amount of milk baby is getting. You can easily create a growth chart at home for your baby using Apple or Android apps. If your baby is less than 2 months old its harder to see trends on a growth chart, so we might use the WHO's growth standards instead, which indicate most babies should be gaining around 1 oz per day during the first two months.
Another reliable tool is to use a sensitive scale designed for lactation consultants to weigh baby before and after breastfeeding to measure intake. This is not quite as simple as it seems because babies don't take the same size feeding at each breastfeed. However, a highly trained lactation consultant can use a single feed measurement in the context of other clues (baby's feeding patterns, time since last feed, time of day, duration of feed, etc) to reliably estimate total milk production. For example, if in a lactation consult after taking a thorough history and observing a feeding I determine that baby's average intake at breast is about 3 1/2 oz and the baby usually nurses 8 times in each 24 hour period then this equals 28oz...a full milk supply. On the other hand if baby transfers 21/2 oz and mother reports baby nurses 6 times per day then we know there is at least a 10 oz shortfall. This was essentially the feeding pattern of the baby whose growth chart is pictured as poor growth pattern.
Less reliable ways to gauge milk supply are baby's diaper output (only helpful in the first week), baby's feeding patterns, and baby's temperament. These three factors can be highly variable in either direction and have to be interpreted carefully in the context of objective tools. For example, an older baby who poops infrequently, wants to nurse all the time, and is fussy is not necessarily behaving this way due to low milk supply. On the other end of the spectrum, some of the worst failure to thrive cases I have seen were babies who wet 6 diapers a day, seemed happy, and the mothers thought baby was feeding normally. The growth charts proved otherwise, as these babies were dangerously underfed. As I partnered with these families to develop a custom Care Plan to increase milk supply and baby's intake, their growth took off and these babies blossomed in every area - physically, emotionally and developmentally. Mothers often can see the difference in retrospect but not in the day to day fog of normal life. Solving these puzzles takes someone skilled in lactation and infant behavior to put the pieces together and parse out the real issues. If you are worried about milk supply, have already started supplementing or if your baby is not following his growth curve (percentiles) on the World Health Organization growth chart, schedule an appointment right away with a lactation consultant. The sooner you get help the easier it is to correct.
Producing Milk vs Transferring Milk
Let's come back to this idea that women can produce enough milk (25-30oz/day) but it doesn't necessarily guarantee baby is drinking (transferring) that much milk. Quite often, when women come to my practice due to concerns about baby's growth or their milk supply, it turns out that the mother is producing sufficient quantities of milk but baby is not transferring enough of what she is making. This is actually far more common than mother not being able to produce enough milk. The top two explanations? Infrequent feeding and tongue-tie. Let's tackle these one at a time.
Infrequent Feeding (<8 times per 24 hours)
Breastfed babies have this wonderful inborn mechanism where they naturally stop feeding when their tummy feels full, which is often around 31/2 ounces for an exclusively breastfed baby. When their tummies start to feel full, they switch to a comfort suck that doesn't draw milk. Mother may have 6oz available in her breasts, but an exclusively breastfed baby will almost never drink that much milk even if it's available. The normal range for a breastfed baby is 21/2 - 5 oz per feeding. This is a good thing because it helps to prevent unhealthy stomach stretching that leads to childhood obesity. (Bottle-fed babies on the other hand have a hard time regulating their intake because even a comfort suck draws milk from a bottle and perpetuates the feeding.) If you think about the fact that most breastfed babies will stop eating once they've consumed around 31/2 oz at each feeding, and they have to reach 25-30oz per day to grow, then it starts to become clear why its so important for breastfed babies to be offered the breast at least 8-10 times per 24 hours. Frequency of feeding is the most important driver of both milk production AND infant intake. If a baby isn't offered both breasts frequently and encouraged to keep nursing until she is full she won't take in enough total milk each day even if mother is producing enough milk overall. Over time, baby not transferring enough each day will lead to mother's supply decreasing and create true low milk supply. If your baby is not growing well and is feeding less than 8 times per 24 hours, the first solution is quite simple: offer more frequently regardless of your baby's age. In addition to responding to your baby's feeding cues, also take initiative to offer both breasts 8-12 times per 24 hours. For information on normal feeding patterns, see my article on the topic.
Tongue-tie affects about 10% of babies. It occurs when baby's lingual frenulum (see picture) is restricting the mobility and function of the tongue. Tongue-tie makes it difficult for babies to get the milk out from mother's breasts unless mother has a naturally fast and easy milk flow. Mother may be producing sufficient milk, but baby can have a hard time removing it when tongue-tie is limiting his oral-motor abilities. Like the infrequently fed baby, this eventually will lead to low milk production. Its important to treat tongue-tie once its been identified so that baby can feed efficiently and to prevent many other symptoms down the road. Click here to read my handout on tongue-tie and explore its symptoms, evaluation and treatment. In addition to tongue-tie, other less common causes of oral motor problems that can be limiting baby's transfer include low muscle tone, birth injuries and neurological issues. Until baby is breastfeeding efficiently, mother may need to pump after breastfeeding to ensure her milk supply is protected.
Causes & Solutions for True Low Milk Supply
To effectively target treatment for low milk supply, you first have to understand how milk production works what caused it to be low. Milk supply is primarily driven by the frequency of effective milk removal. Sometimes we refer to this as "supply and demand." Frequency of milk removal directly affects a mother's hormone levels and sends signals within her breasts to speed or slow the rate of milk production. The "magic number" of milk removals needed per day depends primarily on a woman's milk storage capacity. A woman's milk storage capacity is how much breastmilk her body can comfortably fit/store within her milk glands between feeds before her body starts to signal to decrease milk production. The normal range is to be able to store/fit 21/2 - 5 oz of breastmilk combined between both breasts. A lactation consultant can gauge this by looking at baby's feeding patterns, transfer, and mother's typical pumping output. Because each woman has such a different milk storage capacity, the frequency with which she will need to empty her breasts (breastfeeding/pumping) to maintain production will vary widely. The average range is 6-10 times per 24 hours with 8 being the most common magic number.
Infrequent Breast Emptying
As we discussed earlier, infrequent feeding (or only offering one breast each feed) explains why a mother with normal milk production could still have a baby who is not growing well. However, infrequent feeding (or pumping) is also the most common explanation for true low milk supply. Many women who start off with a high milk supply in the first week or two postpartum will develop a low supply later if they decrease how often they are breastfeeding or pumping. In my practice, the number one reason for late onset low milk supply is baby sleeping through the night. For most women, if they go longer than 5 hours at night without nursing or pumping, their body will signal to decrease milk production. Its also very difficult to hit the magic number of 8 breastfeeds/pumps per day if you are going longer than 5 hours at night without emptying your breasts. This kind of low milk supply is sneaky and insidious. It sets in gradually over a few weeks of reduced breast stimulation. If you started with a great milk supply but are now experiencing low supply, the most likely reason is you've dropped your number of milk removals each day below your magic number. Thankfully this is the easiest kind of low milk supply to fix. Simply increase milk removals again to 8-12 times per 24 hours, with no longer than a 5 hour stretch at night, and your milk supply should rebound quickly. Some herbal blends can help you rebound more quickly, but no herb can create full milk production in absence of frequent milk removals.
Pump Related Problems
For women that rely on pumping to express milk for their babies, low milk supply may be caused by issues with their pump or how they go about pumping. Sufficient milk removals each day are needed as described above. Additionally, the flanges on the pump need to be fitted correctly. Old or low quality pumps may not have sufficient motor strength to remove milk thoroughly and stimulate milk production. A new, high quality pump should be obtained with each birth of a baby if baby is going to be bottle-fed breastmilk. If you pump frequently the membranes/valves on your pump should be replaced every 2-3 months. To increase milk supply while pumping, first be sure your pump is in good condition and fit properly. Pump or breastfeed often (8-12 times per 24 hours, no longer than a 5 hour stretch at night), pump both breasts at the same time (this increases your hormone levels better than pumping one breast at a time), use breast massage and compression while pumping, and try to use visualization and relaxation techniques to improve milk flow. Pump both breasts at the same time for 20 minutes or until you have expressed the amount of milk your baby drinks in a bottle (21/2 - 5 oz). If you are pumping after breastfeeding to improve milk supply, pump both breasts for 10 minutes using breast massage and compression. Average output when pumping after breastfeeding is about 1 oz.
Insufficient Glandular Tissue
About 2% of mothers are thought to have insufficient glandular tissue (IGT) which means that they cannot fit/store very much milk within their breasts. One of the hallmarks of this condition is that mother's milk never seems to "come in" during the first week postpartum or is only present in very small quantities. (By the way, this can also happen to women who experienced severe hemorrhage during delivery). If a woman cannot store at least 21/2 oz combined in her breasts she will have a difficult time exclusively breastfeeding. Our knowledge about the causes of IGT is limited, but its been noticed more often in women with other endocrine (hormone) disrupting conditions such as eating disorders during adolescence, low progesterone, Polycystic Ovarian Syndrome, and insulin resistance. Lactation consultants are trained to assess for IGT markers and may be able to help you determine if IGT could be the cause of your low milk supply. Certain herbs and medications can help maximize glandular development to improve milk production, but most women with IGT will need to supplement baby in addition to breastfeeding. Metformin or domperidone are sometimes recommended for women with IGT who are trying to improve their breastmilk production. Legendairy's Liquid Gold supplement has a blend of herbs including goat's rue thought to help stimulate glandular function. If you have been diagnosed with low progesterone (common with recurrent miscarriage), taking progesterone during the first trimester of your next pregnancy may help improve glandular tissue development. Talk to your OBGYN or lactation consultant about options available to you.
Other Health Conditions
Hypothyroidism, anemia and dehydration are three of the other potential causes of true low milk supply. Dehydration sometimes occurs after gastrointestinal illness or intense exercise and needs to be corrected with electrolyte enhanced hydration (not just water). Severe anxiety and stress can indirectly affect milk supply by making it harder for a woman's milk to "let down" (flow) when breastfeeding or pumping; if milk flow is frequently impaired by a woman's stress/anxiety levels, it will eventually affect her milk supply because of the reduced milk removal. Thankfully with all of these conditions, proper treatment can help improve milk supply. Subclinical health conditions may be alleviated by herbal blends that improve milk production.
If you are worried about your milk supply or baby's intake, get help. It can be confusing and overwhelming to try to solve it on your own. At Lake Norman Breastfeeding Solutions, we are committed to offering you respectful, compassionate care that is focused on helping you achieve your personal goals. Each woman has unique needs that deserve a custom feeding plan.