In the United States, we are doing a great job promoting breastfeeding. Most women in the U.S. want to breastfeed their babies and more than 80% initiate breastfeeding immediately after birth.4 A lot of pressure is put on mothers to breastfeed. It’s tough then for a mother who is unable to continue to breastfeed despite her best intentions and efforts, to constantly see and hear this message, “breast is best”. It may lead her to believe she has failed.
However, in most parts of our country, adequate support and protection are not in place to help the majority of mothers achieve the goal of breastfeeding for at least a year, or even six months.16,20 I am referring to education, available lactation counselors, warm lines, support groups, peer counseling, state and federal laws and workplace policies. For more details, please refer to the Surgeon General’s Call to Action to Support Breastfeeding Mothers. In other countries with higher rates of extended breastfeeding, the difference is equal attention given to promotion, support, and protection.c1,23
The number one reason women report for giving up breastfeeding is inadequate milk supply.7,15 If women weren’t able to make enough milk for their babies, most of us wouldn’t be alive today. Women have been breastfeeding their babies since humans began walking the Earth. Our bodies are designed to feed our babies exactly what they need to thrive. Somewhere along the way, women have lost confidence in this ability.9 Your body can and will make enough milk! Your body is AMAZING! You grew a whole human being inside your uterus and your breasts are going to make just the right amount of milk to feed your precious baby.
Here are some important steps you can take to ensure that your body makes enough milk after the birth of your baby:
- Place your baby on your belly or chest skin-to-skin for at least an hour immediately after birth. If your baby is born by cesarean section many hospitals are allowing skin to skin immediately after birth. This is called a “Gentle Cesarean” or “Family-Centered Cesarean”. Research shows that immediate or early skin to skin is one of the most powerful steps in influencing positive breastfeeding outcomes.1,7,8,18,21,22 If a mother and baby cannot do skin to skin right away, initiate this as soon as possible, even if it is several hours later. Have the father do skin to skin if necessary.
- Encourage early feeding (within the first 2 hours of birth)7,8. Hormone receptors in your milk making cells (alveoli) are ready to receive prolactin (milk producing hormone) as soon as the placenta is released. Prolactin is released when the baby stimulates their mother’s nipples. The sooner a baby breastfeeds, the more likely those receptors will be filled with prolactin. If a feeding is delayed for too long, some receptors may shut down and less milk will be made moving forward.c1,t1
- Seek out help from a lactation counselor to ensure your baby has a good latch! This will eliminate possible issues down the road that can lead to lower milk supply. Breastfeeding should never hurt.c1,t1 This is a tough one for women to believe. If it hurts, get help!
- Learn your baby’s feeding cues! You may have been taught to feed your baby when they are rooting, sucking on their hands, or crying. Actually, you want to try and feed baby before they get to that point. The optimal time to latch your baby on for a feeding, is when they are quiet but alert, or in a state of light sleep with rapid eye movement (REM).c1,t1
- Feed your newborn on demand and OFTEN to maintain a sufficient milk supply, avoid feeding your baby by the clock. Also avoid spacing out your newborn’s feedings. Women sometimes say they want a more predictable schedule, mainly for convenience or sanity. Think about your own eating patterns. Most people don’t eat strictly by the clock. If you are thirsty, you might have a small drink. I am also willing to bet you eat small snacks between meals. Babies are like us! They may want a sip or a snack between meals, and that’s normal! You should be feeding your baby 10-12 times in a 24 hour period.1,c1,t1 Prolactin is released when your nipples are stimulated by a baby suckling.t1 When your baby stops breastfeeding, prolactin levels slowly drop. If you begin a new feeding before your prolactin levels drop to the baseline level, it has the effect of raising prolactin even higher than at the previous feeding. If you then feed your baby yet again before prolactin drops too far, levels will rise even higher and so on. The higher the prolactin levels, the more milk you will make.t1 In other words: Let’s say two women both feed their babies for 140 minutes each in 24 hours. Mom #1 feeds her baby 12 times and mom #2 feeds her baby 8 times. Even though they both feed their babies for the same total number of minutes, the mom who fed her baby 12 times will make more milk.c1, t1
- Avoid or limit the use of a pacifier.3,6,7,8 This will likely space out your feedings and decrease the amount of time your baby is at the breast, which will in turn decrease your supply.
- Avoid the use of a nipple shield.7, 17,c1 This will teach your baby a different way of latching and also lessens nipple stimulation, which in turn decreases prolactin production, which will effect your milk supply. Get help from a lactation counselor early to get a good latch so you will not need the nipple shield.
- Don’t supplement with formula.1,5,7,8, 12 Some pediatricians will still suggest supplementing despite all of this information. It often takes several years for medical professionals to change their practice when new evidence based information is presented. Lactation counselors typically have the most recent research-based knowledge in the area of breastfeeding. If you suspect your baby isn’t getting enough breastmilk, call your pediatrician. The only way to truly know if your baby is getting enough breastmilk is by checking their weight gain. Breastfeeding is a supply and demand system. If your baby is not at your breast stimulating release of prolactin, then you are not going to make as much milk.1,6,7,12 Feeding your little one more often will increase your supply.1 Supplementing with formula will decrease your supply5,6,7,12 (and also alter the biome in your baby’s gut, but that topic is for another blog post)2,c1 if you are not also pumping each time a supplementary feeding is given. Again, the closer together the feedings, the higher your prolactin levels will rise.
- If your supply is already lowered and you would like to increase it quickly, in addition to feeding your baby more frequently, try something called Power Pumping.c1 The best way to get prolactin levels up high for an extended period of time is to pump for 5 minutes, stop for 5-10 minutes, then pump again for 5 minutes and stop again, and repeat. A good way to do it is to watch a 30 minute show and pump during the commercials. This will increase your supply more than pumping for 15 consecutive minutes.
Keep in mind that your baby will go through growth spurts and will nurse more frequently during these times. That doesn’t mean there is anything wrong with your milk. They are just trying to increase your milk production to meet their new growth pattern.t1 Some babies may nurse more frequently just to calm themselves, soothe teething pain10 and discomfort, and it doesn’t necessarily mean they aren’t getting enough milk.
While there are many myths about why some women may experience a low milk supply, the following list are the only reasons that can negatively impact your milk supply. Some are easily corrected, while others may require mothers to work closely with their doctor, pediatrician, and/or lactation professional to ensure their baby is getting what they need. In some cases, formula will be the best option for mother and baby, and that’s okay!
Possible reasons for low milk supply include:
- Long spacing between feedings1,c1
- Decreased nipple stimulation (from poor latch, nipple shield, infrequent feeding)c1, 7,17
- Use of pacifiers (increases spacing between feedings and decreases total feedings/day)3,6,7
- Excessive pressure on the breast (from engorgement, restrictive clothing, or breast implants)14,c1
- Suboptimal anatomical differences (breast reduction surgery, breast injury, hypoplastic breast, inverted nipples,)1,6, c1
- Iron Deficiency Anemia11
- Women who have had postpartum hemorrhage (Sheehan’s syndrome)1
- Maternal obesity (can delay onset of milk production in the first 7 days)6,19
- Hormone imbalance (thyroid disorders, Polycystic Ovarian Syndrome (PCOS), insulin dysregulation (pre-diabetes))c1
- Use of certain drugs (Sudafed and betamethasone)c1
- Retained placenta 1
- Cigarette smoking13
- Many times, even with a medical reason for low milk supply, a mother can still produce enough milk with the right support. There are very few things that will lower a mother’s milk supply that are not within our control to change. Trust your intuition and get help from a professional if you are having any difficulties or doubts. Know that whatever you decide, the most important thing is to feed your baby, whether that is breastmilk OR formula. Only you and your medical provider can make the decision for what is best for you and your baby. Have confidence in your body, but also have confidence in yourself.
- ABM Protocol Committee. (2009a). ABM Clinical Protocol #3. Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009. Breastfeeding Medicine: The Official Journal of the Academy of Breastfeeding Medicine, 4(3), 175-182
- Backhed, F., Roswall, J., Peng, Y., Feng, Q., Jia, H., Kovatcheva-Datchary, P., …Jun, W. (2015). Dynamics and Stabilization of the Human Gut Microbiome during the First Year of Life. Cell Host & Microbe, 17(5), 690-703.
- Binns, C. W., & Scott, J. A. (2002). Using Pacifiers: what are breastfeeding mothers doing? Breastfeeding Review: Professional Publication of the Nursing Mothers’ Association of Australia, 10(2), 21-25
- Centers for Disease Control and Prevention. (2014, Aug 1). Breastfeeding: Data: Report Card 2014| DNPAO | CDC. Retrieved August 1, 2014 from http://www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf
- Chantry, C.J., Dewey, K. G., Peerson, J. M., Wagner, E. A., & Nommsen-Rivers, L. A. (2014). In hospital formula use increases early breastfeeding cessation among first-time mothers intending to exclusively breastfeed. The Journal of Pediatrics, 164(6), 1339-1345.e5.
- Dewey, K. G., Nommsen-Rivers, L. A., Heinig, M. J. & Cohen, R. J. (2003). Risk Factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics, 112(3 pt 1), 607-619
- Difrisco, E., Goodman, K. E., Budin, W. C., Lilienthal, M. W., Kleinman, A., & Holmes, B. (2011). Factors associated with exclusive breastfeeding 2 to 4 weeks following discharge from a large, urban, academic medical center striving for baby-friendly designation. The Journal of Perinatal Education, 20(1), 28-35.
- DiGirolamo, A. M., Grummer-Strawn, L. M., & Fein, S. B. (2008). Effect of maternity care practices on breastfeeding. Pediatrics, 122 Suppl 2, S43-49.
- Ertem, I. O., Votto, N., & Leventhal, J. M. (2001). The timing and predictors of the early termination of breastfeeding. Pediatrics, 107(3), 543-548.
- Gray, L., Watt, L., & Blass, E. M. (2000). Breastfeeding is analgesic in healthy newborns. Pediatrics, 109(4), 590-593.
- Henleym S. J., Anderson, C. M., Avery, M. D., Hills-Bonczyk, S. G., Potter, S., & Duckett, L. J. (1995). Anemia and insufficient milk in first time mothers. Birth (Berkley, Calif.), 22(2), 86-92.
- Hill, P. D., Humenick, S. S., Brennan, M. L., & Wooley, D., (1997). Does early supplementation affect long-term breastfeeding? Clinical Pediatrics, 36(6), 345-350.
- Horta, B. L., Kramer, M. S., & Platt, R. W. (2001). Maternal smoking and the risk of early weaning. A meta-analysis. American Journal of Public Health, 91(2), 304-307.
- Hurst, N. M., (1996). Lactation after augmentation, mammoplasty. Obstetrics and Gynecology, 87(1), 30-34.
- Li, R., Fein, S. B., Chen, J., & Grummer-Strawn, L. M. (2008). Why mothers stop breastfeeding: mothers’ self-reported reasons for stopping during the first year. Pediatrics, 122 suppl 2, S69-76.
- McInnes, R. J., & Chambers, J. A. (2008). Supporting breastfeeding mothers: qualitative synthesis. Journal of Advanced Nursing, 62(4), 407-427.
- McKechnie, A. C., & Eglash, A. (2010). Nipple Shields: a review of the literature. Breastfeeding Medicine: The Official Journal of the Academy of Breastfeeding Medicine, 5(6), 309-314.
- Moore, E. R., Anderson, G. C., Bergman, N., & Dowswell, T. (2012). Early skin to skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews (Online), 5, CD003519
- Nommsen-Rivers, L. A., Chantry, C. J., Peerson, J. M., Cohen, R. J., & Dewey, K. G. (2010). Delayed onset of lactogenesis among first time mothers is related to maternal obesity and factors associated with ineffective breastfeeding. The American Journal of Clinical Nutrition, 92(3), 574-584.
- Renfrew, M. J., McCormick, F. M., Wade A., Quinn, B., & Dowswell, T. (2012). Support for healthy breastfeeding mothers with healthy term babies. The Cochrane Database of Systematic Reviews, 5, CD001141.
- Rowe-Murray, H. J., & Fisher, J. R. W. (2002). Baby friendly hospital practices: cesearean section is a persistent barrier to early initiation of breastfeeding. Birth (Berkley, Calif), 29(2), 124-131.
- Stevens, J., Schmied, V., Burns, E., & Dahlen, H. (2014). Immediate or early skin to skin contact after a Cesarean section: a review of the literature. Maternal & Child Nutrition.
- UNICEF/WHO (1990, August 1). Innocenti Declaration on the Protection, Promotion, and Support of Breastfeeding. UNICEF. Retrieved from http://unicef.org/programme/breastfeeding/innocenti.htm
- U.S. Department of Health and Human Services. (2011). The Surgeon General’s Call to Action to Support Breastfeeding. U. S. Department of Health and Human Services, Office of the Surgeon General. Retrieved from: http://www.surgeongeneral.gov/library/calls/breastfeeding/calltoactiontosupportbreastfeeding.pdf
T1. Wambach, K., & Riordan, J. (2014). Breastfeeding and Human Lactation. Burlington, MA: Jones and Bartlett Learning.
C1. Cadwell, K., & Turner-Maffei, C. (2015). The Lactation Counselor Training Course Notebook, 2015-2016 Ed. East Sandwich, Massachusetts, USA: Healthy Children Project, Inc.