Nearly all nursing mothers worry at one time or another about whether their babies are getting enough milk. Since we can’t measure breast milk intake the way we can formula intake, it is easy to be insecure about the adequacy of our milk supplies. The “perception” of insufficient breast milk 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 extremely rare. It is even more unusual for a mother not to be able to produce any milk at all. Mothers can almost always produce some milk to give their babies, even if they have to supplement with formula.
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 their breast milk – for example, if the baby spits up or is gassy, it must be something she ate…if he has a day when he feeds more often than usual, it must be because she doesn’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 some laid back, easy days, and some fussy and cranky days. Often, your baby’s behavior is not related to breastfeeding at all.
Mothers often 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. Breast milk is digested 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 (okay, all the time) for a few days, your supply will increase to meet the demand, and most babies will level off and go back to a more predictable schedule. Also, many babies will ‘cluster feed’ in the evenings before going to sleep. This is a normal pattern for a breastfed baby. 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), takes one breast rather than both at a feeding, or mom’s 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.
- They compare their baby’s nursing patterns, weight gain, or sleep habits to other people’s babies, or even their 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.
Most pediatricians have now switched to the new revised growth charts that replace the old ones from the 1950s, that were based on fat formula-fed babies. Based on these outdated charts, many breastfed babies were considered to be gaining weight too slowly, when they were actually gaining weight at the normal rate for breastfed babies. Make sure your pediatrician is using the updated charts: http://www.cdc.gov/growthcharts/who_charts.htm If your baby is losing weight or not gaining rapidly enough, consult your doctor and make sure your baby is healthy, and that a medical problem is not causing the low weight gain. If your healthy baby is losing weight, or not gaining 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 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. Keeping your baby close, day and night, and nursing often is the best way to boost your milk production.
- Many mothers find that their milk production decreases when they return to work. Being separated from their baby for long periods of time, as well as the stress associated with re-entering the work force can make it difficult for moms to maintain their supply. The article Returning to Work has information about how to deal with these challenges.
- 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. Typically, 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, 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 sick 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 other illness. Hormonal birth control methods containing estrogen may decrease your supply as well.
- 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. Often careful attention to positioning will correct the problem.
- Medical conditions like Tongue-Tie, Yeast Infections, and Flat or Inverted Nipples can cause nipple soreness and make it difficult for the baby to get the milk he needs. Correcting the problem so that nursing doesn’t hurt can help you increase the let-down and frequency of putting the baby on the breast, and that can result in increasing your milk supply.
- 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.
- Moms who have a Cesarean birth may need some extra time to recover before they physically feel like holding and nursing their new baby. This may cause a slight delay in the milk coming in, but once it does, moms who deliver via C-section produce just as much milk as the mothers who deliver vaginally.
- Taking combination birth control pills – those containing both estrogen and progesterone (see article Breastfeeding and Birth Control) and getting pregnant while nursing (Nursing During Pregnancy and Tandem 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 Drugs and Breastfeeding)
Be aware of the fact that it’s normal for your baby to lose some weight in the first couple of days after birth. Babies are born with extra fluid in their tissues to ‘hold them over’ until mom’s milk comes in. They typically lose 5-7 % of their weight in the first couple of days as their bodies excrete the extra fluid. For the average baby, this is close to a half a pound weight loss (often more for larger babies). You need to ask what your baby’s discharge weight is when leaving the hospital, because that is the figure you will be calculating his weight gain from, not from his birth weight.
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. In almost all cases, once a healthy baby starts gaining weight, he won’t suddenly start losing it unless there is an underlying medical problem with mom or baby.
- 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 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 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. Using breast compression is an simple, easy, and effective way to help your baby get more milk. Newborn babies will often fall asleep at the breast when the flow of milk slows down, even if they haven’t gotten enough to eat. Breast compression helps to continue the flow of milk once the baby starts falling asleep at the breast, so the baby gets more hindmilk. This video shows Dr. Jack Newman helping a mom use breast compression to help a baby get more milk as he nurses.
- 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 Establishing Your Milk Supply).
- Avoid bottles and pacifiers if possible. 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.
- Consider renting a hospital-grade breast pump for a few days, unless you have a good quality double pump at home. Hospital grade pumps have stronger, more powerful motors, and are the most efficient pumps you can use. They are bigger and heavier, so they aren’t as portable as other pumps. They are made for multiple users, as long as each mom has her own collection kit. Because they are so heavy duty and expensive, most hospitals have them available for moms to use in the hospital. They are very expensive to buy – some sell for over $1,000 – so most moms will rent them instead. The hospital, a La Leche League Leader, or your childbirth educator should be able to provide you information you need to find a breast pump rental station, and also how to contact an IBCLC if you have further questions about increasing your milk production. The article Pumping and Storing Breastmilk has more information.
- The best way to increase your supply by using a pump 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.
- There are certain food supplements 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. Some herbal supplements have been used for many years to increase milk production, with the most popular being Fenugreek, Blessed Thistle, Red Raspberry, and Brewers Yeast (containing B vitamins). None of these herbal remedies have been proven scientifically to increase milk supply, but they’ve been used by moms for hundred of years with varying degrees of success. In over thirty years of experience, I have seldom seen any dramatic change in milk production in moms who used these herbs. However, many moms do see somewhat of an increase, and these herbs are generally considered safe, so I recommend that moms try them along with other methods if they want to, but to have realistic expectations about the results. 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, so 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 has not been known to cause any problems for the babies of the mothers who take it, but shouldn’t be used by pregnant women because it may cause uterine contractions. If the Fenugreek is going to help, moms usually notice an increase in one to three days. Fenugreek is used in artificial maple flavorings, and may cause a maple-syrup odor in a mother or baby’s sweat. That just means that enough of it is in your system to be effective.
One thing that I don’t suggest is spending money on so- called “lactogenic” supplements that claim to increase milk supply.
If you Google “increase milk supply” or “how to make more milk”, hundreds of websites will come up, with many of them selling products that make outrageous claims and seldom work. I found one website that made this statement: “Breastfeeding is supposed to be easy but for the majority of mothers…it isn’t. You aren’t alone if you don’t feel like you’re producing enough milk. An overwhelming majority of first-time mothers (74%) have issues producing milk.” This is one of the most negative, discouraging ways to present breastfeeding that I’ve ever heard. It’s a sleazy, but too often used, sales technique that uses negativity to play on mother’s fears that they won’t have enough milk for their babies. What are they thinking? Define “issues” here. Surely they don’t really believe that three out of four nursing moms aren’t able to produce enough milk for their babies. How would the human race have survived this long if this were the case? Could they be talking about other “issues” like learning to use a pump, or sore nipples, or leaking, etc? And could they be more discouraging and negative? They’re trying to sell you stuff by making claims like this: “Studies show that Fenugreek can increase milk production up to 900%.” Say WHAT? Was that a misprint?
“Mamatini can help you produce a healthy supply of breast milk for your baby, while giving you the energy to breeze through your day.” I don’t know what you think about this, but if anyone ever comes up with a product that lets new moms ‘breeze through their day’, it’s going to make a billion dollars. “Mothers who ate Malunggay (whatever that is) produced 228% more milk than mothers who didn’t.” Obviously another misprint. Apparently this amazing product is “100% vegan using premium Malunggay leaves”, and “produced in an ISO-certified facility”. Whatever that means. My point is, don’t waste your money. These products don’t work, unless there is some sort of placebo effect. Greedy manufacturers take advantage of the fact that nursing moms are so worried about having enough milk that they will try anything. Don’t fall for these outrageous claims. There is no product out there than can increase your milk supply the way they claim. They just want your money.
Oatmeal is often used by women as a galactagogue. There is no scientific evidence to show that this is the case, and I’ve never personally seen a mom’s supply increase due to her oatmeal intake, but some mothers swear by it. Again, you have to wonder about the placebo effect. It’s a good thing to try – it’s cheap, it’s good for you, and it doesn’t have any side effects. Just don’t expect a dramatic increase in your supply when you eat oatmeal cookies. If increasing milk production was that easy, every nursing mom would weigh a ton, and no one would need articles like this.
The latest fad in galactagogues is ‘placenta encapsulation’. Mothers ingest their placenta, usually by drying it, grinding it up, and putting it in capsules. The people who promote this practice and profit from it claim that it has all sorts of benefits, including reducing postpartum depression and increasing milk supply. However, there is no evidence that ingesting your placenta has any health benefits, but there may be a placebo effect. I’ve never heard of a mother having any side effects from eating her placenta, so if it trips your trigger, try it. You can Google ‘placenta recipes’ and find out how to make everything from placenta pizza to placenta smoothies.
If all other methods of increasing milk production haven’t worked, there are two prescription medications available that may be used to increase milk supply: Metroclopromide and domperidone. 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 these medications. Metoclopramide (Reglan, or Maxeran), has been used in infants for years to treat reflux, and is also given to moms who’ve had a c-section to help prevent nausea. When it’s taken by a lactating woman, it stimulates prolaction production and will nearly always increase milk output within 2-3 days. A dose of 30-45 mg per day seems to be most effective. If you are taking Reglan, you should also work on addressing the cause of the low supply by correcting positioning or pumping frequently, or your supply will drop back to previous levels when you discontinue taking it. Even though Reglan is considered a very safe medication for moms and babies, it has frequent side effects for moms like fatigue, irritability, and depression which have made its use for many nursing mothers unacceptable.
There is another safer and more effective drug that works even better than Reglan at increasing milk production. Like Reglan, it is also used to treat gastrointestinal disorders in infants as well as adults, and has the same side effect of increasing prolaction production by the pituitary gland. Domeperidone (Motillium) has been used in Canada and other countries for decades, and has been shown to be a very safe and effective medication that significantly increases breast milk production. Domperidone has fewer side effects than Reglan because it does not enter the brain tissue in significant amounts. It does not pass the blood-brain barrier that keeps medication from passing into the milk the way that Reglan does. In some countries, it is available OTC (without a prescription). There is a controversy over use of domperidone, and – you guessed it – the FDA is at the bottom of it. IMO, they’re using scare tactics to keep moms from using a drug proven to be safe and effective, because they are so liability oriented that it’s ridiculous. This isn’t some experimental drug. It’s been used for years, given directly to tiny babies, and can make the difference between continuing to nurse your baby or not. This article will give you detailed information from Dr. Jack Newman about domperidone: http://www.breastfeedinginc.ca/content.php?pagename=doc-DGS. You’ll find the information and facts that you need to make your own informed decision about whether you want to consider use this prescription medication to increase your supply.
There is good information about metoclopramide versus domperidone, the FDA controversy, and how to obtain domperidone in the US if you decide to try it. In my thirty plus years of experience, I have worked with many mothers who used it. All of them had significant increases in their milk supply, and few if any side effects. Over the last few months, USLCA has been working in conjunction with Dr. Thomas Hale from the Infant Risk Center at Texas Tech University towards obtaining approval from the Food and Drug Administration (FDA) for the use of domperidone for breastfeeding mothers experiencing problems with insufficient breast milk production. Clinicians in the US have long been unable to offer this option with great difficulty, if at all, to mothers experiencing insufficient milk production.
The most important thing to consider when dealing with an infant who is not gaining weight is the baby’s welfare. You need to work closely with his doctor, and monitor his weight carefully.
It’s often necessary to supplement with formula while you are working to increase your supply. Don’t make the mistake of thinking 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 alternate feeding methods like 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 and least stressful 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. (See article Introducing Bottles and Pacifiers to the Breastfed Baby). 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 best for you and your baby. If you are one of those women who fall into the very 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 breast milk 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, or how much milk you produce.
Anne Smith, IBCLC
(Updated October 2013)