Got Milk? How to increase your supply

When your milk comes in, you may feel awe that your body is capable of making this life-sustaining fluid. But how much milk is a full supply? When baby is nursing, there are lots of clues that he is getting "enough." Many parents are doing a combination of both nursing and pumping, when milk is delayed or volume is low. If you're worried about your supply, you're not alone...it's the #1 biggest concern of new moms.

How much is enough?

A full supply, expected by 2-3 weeks post-delivery, is 24-32 ounces in 24 hours. If you are exclusively pumping, 8 times a day, you'll be getting at least 3 ounces (90 mls) total each time. If you are directly breastfeeding your baby, good signs that your supply is plentiful are: By Day 5, baby is having 5-6 wet diapers and at least 3 stools a day. He will be back to birth weight by at least 2 weeks of age, and begin gaining in most cases, 5-8 ounces per week or more. A baby who wants to nurse all the time, and cluster feed at certain times of day, is NOT itself a sign of low supply. This is typical, even crucial for your supply and baby's weight gain.

Risk Factors

First of all, let's discuss reasons why mature milk does not arrive when baby needs it, usually by about 72 hours post delivery. There are some risk factors for delayed onset of mature milk, that you want to have on your radar. Unfairly, these can hit you before you're even out of the gate! By the time you're nursing your baby, these are basically pre-existing conditions that are not actionable, but they do offer an explanation as to why, despite enough stimulation, your milk volume has not increased by Day 3-5. Here they are:

• History of infertility or use of reproductive technology

• Polycystic Ovarian Syndrome

• Diabetes/Gestational Diabetes

• Hypertension

• Stressful or prolonged labor and birth

• C-Section

• Postpartum hemorrhage

• Body mass index greater than 30

• Prior breast surgery

• Exposure to Chemotherapy/Radiation

Remember that these factors might be a strike, but not a death blow! If your mature milk production is late, it doesn't necessarily mean that when it finally arrives, your supply will be low. Plenty of moms with some or many of the above risk factors, go on to successfully breastfeed and make plenty of milk. But with the knowledge that you have a risk factor, you'll want to watch carefully for signs of adequate intake, and have an expert assess a breastfeeding session. If your mature milk is in fact delayed, you'll be ready to employ the necessary strategies to make sure baby is fed while you work on giving yourself added stimulation, likely with a breast pump. If your outputs are not increasing as expected, even given some extra time, then we need to rule out medical issues. Here are some additional problems that can affect your supply:

• Retained placenta - when the placenta fully detaches from the uterine wall, hormonal signals are sent that result in the production of mature milk within a few days. So if a piece of the placenta remains in place, called a retained placenta, your progesterone levels will not plummet sufficiently to activate prolactin. This will prevent your milk from coming in. If you had a C/S, it' s unlikely that you have a retained placenta. They got a good look directly into your uterus during the surgery. If you delivered vaginally, your provider will have inspected your placenta to make sure that it was whole. Still, this can be missed in some instances, and if it was, you're likely having abnormally heavy postpartum bleeding. Talk to your OB if you suspect this cause.

• Anemia - if you were anemic during pregnancy, or lost an excessive amount of blood during delivery, you could easily be anemic. Symptoms of iron deficient anemia are fatigue, weakness, pale skin, cold hands and feet, fast heartbeat, shortness of breath, headache or light-headedness, poor appetite, and craving ice or non-edible substances such as dirt. Focus on boosting those iron levels through your diet, and talk to your doctor about iron supplements.

• Thyroid disorder - many women aren't aware their thyroid is out of whack until they have their thyroid function checked by a blood test. Symptoms of low thyroid are fatigue, weight gain, muscle weakness, hair falling out, constipation, memory issues, cold intolerance. Since fatigue and hair loss are common in the early postpartum months, the symptoms of hypothyroidism can easily be missed.

• Insufficient glandular tissue or IGT - True IGT is not very common. IGT means that the milk-making equipment in your breasts, the milk sacs and the ductal tissue, is lacking, due to a hormonal disruption during your fetal development or adolescence. Women with true IGT may have certain characteristics to their breasts, such as very small breasts that are wide-spaced and have a disproportionately large or bulbous nipple, asymmetry between breasts, and more of a tubular shape than rounded. Women with IGT usually do not report significant breast changes during pregnancy. For women with this condition, galactagogues might be helpful, like Goat's Rue, which is thought to build more mammary tissue. If IGT is accompanied by low prolactin levels, then a prescription medication called Domperidone could increase production. For more insight into the condition of IGT, here is a great article that contains a video (with balloons!) to help explain the physiology, and is overall very encouraging: https://www.genuinelactation.com/blog-for-breastfeeding-families/understanding-insufficient-glandular-tissue-igt-a-guide-for-low-supply-moms?rq=igt

The most COMMON REASON supply is low

Medical stuff aside, now let's tackle THE most common reason that your milk supply is low. It is also, happily, the easiest to fix, if you catch it early. The reason is: insufficient emptying of your breasts. Many new parents don't realize how frequently newborns need to nurse, and are only offering the breast at 3 hr intervals, with a pacifier in between feedings to help baby "self-soothe." New families are prime targets and extremely vulnerable to pressure from social media and "sleep experts" to schedule feedings every three hours, and utilize the "eat, play, sleep" model in order to develop "good sleeping habits." If your baby isn't gaining weight well, consider throwing all that out the window and nurse your baby on cue, 10-14 times a day. Your supply will respond! See tips below.

In other cases, families truly are doing a fantastic job offering the breast on cue, but baby isn't quite carrying his share of the load. In the beginning days, colostrum production is automatic. But once your mature milk comes in, production becomes completely dependent on frequent removal. Your lactating breasts are like a production line, and if the demand isn't there, the assembly line comes to a screeching halt. So if baby is having difficulty latching, or sleepy at breast, you may be offering the breast every hour, but baby is not sucking actively enough to turn on the faucet and drain your breasts, so your breasts don't register a demand. Yet another common scenario is that your baby is unable to nurse, and you are reliant on a pump to establish your milk supply. In some cases, the pump is not emptying your breasts well, possibly because your flanges don't fit, or because you are using the wrong type of pump. More on that below.

So, here are tips to address these situations and increase milk supply:

1. Get off to a good start! This is easier said than done, especially given all the complications that can arise. If possible: 1) initiate breastfeeding in the first hour after birth, 2) get professional help with latching to ensure that your positioning is good and baby is nutritively nursing instead of just passively latched, 3) room-in with baby 24/7 so you don't miss any feeding cues, 4) practice hand expression in the early days to entice baby at breast, 5) spend time skin-to-skin with your baby, and 6) avoid pacifier use or supplements that aren't medically recommended. These practices will all put you on the road to success!

2. Take advantage of the "window of opportunity" When your milk starts to transition from colostrum to mature milk, your breasts may feel fuller or heavier. You may notice the color of your milk is changing and appears more white. This is a crucial time to provide plenty of stimulation, to send the signal to your body that you want to keep increasing production. Your supply is now 100% dependent on demand. Make sure your baby is up to the task, or get the breast pump involved! Once this window closes, it is more challenging to get your supply back.

3. Nurse on demand /cue and wake baby if he is sleeping past three hours. Even if you aren't offering a pacifier, you may still be trying to limit feedings to every 3 hours around the clock, and then you are only meeting the bare minimum # of feedings/pumping sessions that is recommended. Most babies who are breastfeeding and gaining weight well without supplements, are nursing 10-14 times in 24 hrs. During the day, you can offer the breast every two hours if you're trying to plump up your baby. At night, you can allow three hours, but many babies are night owls. Let him cluster feed if he is inclined to do that, because it helps him get efficient, and it keeps your prolactin levels from returning to baseline. High prolactin is great for making more milk.

4. If baby's weight loss is excessive, then a supplement may be necessary. Have a lactation consultant guide you so that you can offer the supplement in a way that supports breastfeeding. If baby has begun gaining weight but it's inadequate or slow, then you'll need to identify how efficient he is at breast by conducting a weighted feed. You'll need a sensitive scale, one that measures grams. If he is not taking weight-gaining amounts from the breast, you'll need to start Triple Feeding. (see my Triple Feeding article where that program is detailed.) Nursing, pumping, and supplementing at each feeding will improve baby's skill at breast, boost supply by increasing demand, and put weight on baby, which helps him to nurse more vigorously.

5. Avoid long intervals in between nursing or pumping sessions. I know it's life changing to sleep for 4 hours, but it's terrible for a low supply. Don't let your breasts sit full for longer than 3 hours, especially at night when your prolactin levels are high, priming you for high production. Thoroughly emptying your breasts 8X per 24 hours provides the minimum amount of stimulation that your supply needs. If you are exhausted, take a daytime nap! It's the only way to survive, really. You won't get all the sleep you need at night.

6. Try wearing a Haakaa or other passive milk collector on the opposite side while baby nurses. This tells your body at each nursing session, to make more milk than baby is removing. It also collects milk during a baby-triggered let-down. And those can be more powerful than pump-triggered let-downs. If the haakaa takes a turn and then the baby follows and is frustrated because there's no milk left, then only wear the Haakaa on the breast that baby is finished with. In many cases though, the Haakaa removes a little milk but not all, and there is still plenty left for baby, minus the first let-down. Even if your breasts do not leak, routinely wearing the Haakaa (or Boon Trove) will usually begin to collect milk after 1-2 days.

7. Use breast massage. This is a proven way to increase the amount that baby transfers during the feeding. You'll need to grow a third arm. But seriously, use a breastfeeding support pillow and see if you can sneak a hand away from baby or underneath your breast, and use it to gently rub your breast toward baby's mouth. You can also hand express after pumping. I worked with one mom who hated her pump and never felt like it emptied her, but she could hand express another ounce after pumping, and this is how she increased her supply!

8. For those moms who are reliant on the pump for stimulation, try a power pumping session once a day, to simulate cluster feeding. The basic principle here is to pump 3 times inside of one hour, with short breaks in between. There are different recipes and it doesn't really matter which one you choose. One example: Pump for 15", rest for 15", pump for 10", rest for 10'', and then pump for another 10".

9. Optimize your pump, if your supply is dependent upon it. Make sure your flanges fit your nipples, meaning your nipples are being pulled into the tunnels in a smooth and non-chafing manner, without your areola being pulled in as well and becoming swollen after the session. Pumping should not hurt. Turn down the suction or try another flange size if you experience pain while pumping. Lubricate your nipples prior to pumping. (coconut oil is a good choice) Replace old pump parts, and make sure you're using the correct type of pump for the job that you're asking it to do. For example, don't expect your wearable pump, or worse, a manual pump, to establish a milk supply when baby isn't nursing effectively. To bring in a full milk supply without baby's help, you need a hospital grade, double electric pump that plugs into the wall. (You can rent them; also a Spectra is hospital grade)

10. Ditch the pacifier and make sure that all of baby's sucking is at breast. I cannot stress enough how much damage a little pacifier can do, because it prevents baby from cluster-feeding, and it masks hunger cues. In many instances parents are unaware that their baby is consuming inadequate amounts of milk, because they put a pacifier in his mouth when he cries, and then he sucks on it contentedly instead of consuming more weight-gaining calories. Meanwhile, the breasts miss out on that sucking that triggers ample production. It's a horrible cycle of slow weight gain and low supply. A pacifier is only recommended after baby is above birth weight and gaining an ounce per day by exclusively nursing. The baby who is struggling to gain weight and nurse efficiently cannot afford to waste his sucking energy on a dummy. (that's what they call pacifiers outside of the U.S.) If he is inconsolable without a pacifier, then he is hungry. Feed him by whatever means! Sidenote: the AAP recommends offering a pacifier to baby once they are a month old and established at breast. They specifically recommend offering it at bedtime for baby to suck on as he sleeps. This may keep baby in a lighter sleep pattern, which is protective against SIDS. They do NOT recommend early pacifier use for the breastfed baby, or using the pacifier in a way that limits breastfeeding sessions. Fun Fact: breastfeeding is protective against SIDS!

11. Make sure you're getting enough calories. If you are already thin, you really need to make a dedicated effort to eat every few hours. Make sure that you're snacking in between meals, and eating foods that have complex carbohydrates and fat. Lactation requires at least 300 extra calories a day, and it you're thin, it's more like 600.

12. Maintain hydration.  In most cases, keeping water with you at all times and drinking when thirsty is going to get the job done. You can't water board yourself into becoming a Dairy Queen, so there's no need to force fluids. Moms swear by Body Armor drinks and Gatorade, and they certainly can't hurt, but there is no evidence other than anecdotal, to support the claim that these electrolyte drinks increase supply.

13. Fix your sore nipples. Pain can negatively impact your supply. This generally involves having baby's latch evaluated by a lactation consultant. If the latch improves, then APNO cream to heal nipples can help, and so can Nifedipine if the problem is a vasospasm. Nipples that become discolored, often white, during the feeding or pumping session, should be evaluated for vasospasm/Raynaud's syndrome.

14. Avoid smoking, severe weight loss diets, and excessive alcohol. These habits are associated with low supply, and aren't good for you anyway!

15. Use a Nursing Supplementer System. Medela makes a good SNS, or supplemental nursing system. Basically, this system allows supplemental milk, which can be either formula, pumped milk, or donor milk, to be given to baby while he is latched and sucking at the breast. It works like this: milk is poured into a container that mom wears around her neck, and a small tube comes out of the container and is threaded into baby's mouth while he nurses. By avoiding a bottle-feed, baby is not given the opportunity to begin preferring that method, which could cause his breastfeeding skills to deteriorate. When receiving a supplement at the breast, breastfeeding is protected and baby may suck longer and stronger, because the constant flow from the SNS is an incentive. This type of nutritive sucking is great stimulation for supply, so that's a bonus. If you had been triple feeding, and you get into a groove with the SNS, now you've replaced three steps, with one! You might still choose to pump afterward if you are using expressed milk, but it is still a valuable multi-tasking feat to be able to practice breastfeeding while providing a supplement at the same time.

16. Try a galactagogue. Galactagogues are medications or supplements that increase supply. However, they are not a magic bullet - they only work if you are also emptying your breasts frequently. Additionally, most of them aim to increase prolactin levels, so if your levels are already in the normal range for lactation, a galactagogue might not have much to offer you. One of the most effective prescription medications is Domperidone, which sounds like a fancy champagne, but it's not! Also called Motilium, and originally developed as a stomach drug, its action is to block dopamine receptors, which allows the release of prolactin, the milk-making hormone. Unfortunately Domperidone is challenging to obtain in the U.S. because it isn't approved by the FDA. It's a shame because the FDA-approved alternative is Metoclopramide, or Reglan, which has more side effects than Domperidone. Because mood changes are common on Reglan, you should not take it if you have any history of depression. It's prescribed for a maximum of 7-14 days, because the incidence of side effects increases the longer it is used. You'll want to discuss with your doctor to see if it's a good fit for you. Meanwhile, obtaining Domperidone is possible, even if you live outside of Canada, where it's widely used. Here's an excellent website that can educate and guide you through the process of obtaining Domperidone, and determine if you are a good candidate for this drug: https://www.alyssaschnellibclc.com/domhub. It's a trustworthy site based in the U.S., but there is a membership fee of $14 per month/$49 per year to access the detailed information and international pharmacy resources. Although your U.S. provider cannot prescribe Domperidone, they may be willing to monitor you while you use this drug therapy. (Do not take Domperidone if you have cardiac disease/arrhythmias; see complete exclusion list in website above.) Another prescription that can be considered is Metformin, which lowers blood sugar and may be helpful in moms with insulin resistance. Non-prescription galactagogues include Fenugreek, Goat's Rue, blessed thistle, and fennel. You can get all these supplements in one pill if you take "More Milk Plus" by Mother Love. If you have small breasts, I would get the special blend version for the added goat's rue, which is associated with an increase in mammary tissue. Fenugreek should not be taken with thyroid medication, insulin, or warfarin, because of adverse drug interactions. It also makes you smell like maple syrup, so don't be surprised if your sweat and urine develop an unusual odor! The maximum dose may also cause loose stools, and be warned - in a minority of moms, fenugreek DECREASES supply.

17. Facilitate the Milk-Ejection Reflex. If you are past the engorgement phase, and your breasts still feel full after nursing or pumping, there could be a problem with milk ejection or "let-down," which requires a release of the hormone oxytocin. This is more common in women who have had breast surgery that interfered with the innervation leading to their nipple. Oxytocin nasal spray could be helpful in these instances. It's cheap and available, but not as commonly prescribed as it once was. Talk to a lactation consultant if you think this is your issue, and then contact your OB, who can prescribe it. Slow or reluctant let-down can also occur when moms are stressed or rushed. Finding ways to relax, like guided imagery or meditation, could work wonders. It's common for moms who have just returned to work, to find themselves with low pumping outputs, and stress may be the culprit. Stress hormones like adrenaline OPPOSE oxytocin, so you have to find a way to enter a Zen state while pumping!

18. Avoid certain medications that can decrease supply such as hormonal birth control, (EVEN progesterone only in sensitive individuals) decongestants like pseudoephedrine, antihistamines like Benadryl, ergotamine, (for migraines) bromocriptine, (sometimes given to lower blood sugar in Type 2 diabetes) cabergoline, and diuretics (often prescribed for high blood pressure and/or excessive swelling, so not always negotiable.) You'll also want to avoid certain herbs that are known to decrease supply: sage, spearmint, peppermint, and possibly also parsley, oregano, lemon balm, jasmine and hops. You may have heard that beer is good for your supply, but only to the extent that it may relax you if you're feeling very anxious. Excessive alcohol inhibits let-down and can decrease production.

19. For more on the topic of milk production, and to take a deep dive into what causes low production and how to address it, I recommend the book "Making More Milk," by Lisa Marasco and Diana West.

I hope this article has provided you with some insight into your milk supply, as well as some suggestions for increasing your production. Remember that ANY amount of milk you are providing to your little one, is beneficial. There are a million live components in just one milliliter of human milk! Most importantly, if you find that despite your best efforts, you are needing to permanently supplement with formula, lose the guilt. Formula provides volume and nutrition, and if your baby needs it, give it. Feel good about it! Not everyone is swimming in breastmilk, and there are some things about your body that you can't change. Your baby is going to be grateful for every ounce of sweet milk that you offer, and will fall in love with you from the business end of a bottle, as well.