If a mother complain not having enough breast milk what to do

1. Insufficient Milk Syndrome
DR. D. Gunasingh MD DCH FIAP
Professor of pediatrics
SRM Medical College Hospital & Research
Centre

2. Over view
 Perceived/real Insufficient Milk
 Situations of not enough milk
 Confidence building
 Breast Pumps
 Galactogogues
 Supplemental milk

3. Optimal infant and young child
feeding
is defined as
initiation of breast feeding
within one hour, exclusive
breastfeeding, from birth
to six months of age, and
thereafter continued
breastfeeding for two years
or beyond, with adequate,
safe and proper additional
foods and liquid, to meet
the nutritional needs of a
young child.

4. NFHS 4

5. 2004.6.5
Preventive intervention
Deaths
averted
(in '000s)
Percent (of
total deaths)
Breastfeeding 373 16%
Complementary feeding 125 5%
Clean delivery 123 5%
Hib vaccine 107 4%
Clean water, sanitation, hygiene 106 4%
Zinc 101 4%
Vitamin A 84 3%
Antenatal steroids 72 3%
Newborn temperature management 62 3%
Tetanus toxoid 43 2%
Antibiotics for premature rupture of membranes 36 1%
Measles vaccine 14 1%
Nivirapine and replacement feeding 10 0%
Insecticide-treated materials 2 0%
Antimalarial IPT in pregnancy 0 0%
Under-5 deaths preventable through universal
coverage with individual interventions (2000)

6. Insufficient Milk Syndrome
The term insufficient milk syndrome refers to real
as well as perceived inadequate breast milk. This
term does not qualify whether the mother failed to
produce adequate milk or the infant is unable to
extract available milk by breast-feeding.
One of the important barriers for exclusive
breastfeeding from birth to six months of age is
the mother’s feeling that she does not have
enough breast milk

7. Why optimal feeding
 and almost 90% of the
mothers switched to mixed
feeding as they believed
that they did not have
enough milk.
 Malnourished
 Prone for infections
 risk of death is increased.
 Stunted
 Brain development
affected
 Lower IQ

8. Solution to Insufficient milk
syndrome
 . Formula is widely viewed by mothers and
doctors alike as the solution to breastfeeding
problems rather than a cause or contributor to
breastfeeding problems.

9. Reliable Indicators of the Baby Getting
Enough Milk:
 Adequate weight gain: Reaching birth weight by 2
weeks. Weight gain 500 grams or more per month
during the first 6 months of life. Use Growth Charts to
monitor.
 Passing light-colored urine about 6 times or more per
day by 4 days of age, if the child is exclusively breast-
fed.

10. Possible signs that indicate the baby is
not getting enough milk:
 The baby is not satisfied and is crying after feeds.
 Wants frequent feeds (more than 12 feeds).
 Short feeds(less than 5 mts) or prolonged feeds (more
than 30 mts).
 Having infrequent stools and hard dry or green stools.

11. Up to 3to 4 days the urine output and number of stools are less because the
baby is getting only small quantity of colostrum. The change of stool colour to
yellow by 4 to 5 days is a sign of adequate breast feeding.

12. The newborn baby
 Can sleep for up to 24 hours
 Does not need other liquids then mothers milk up to 48
hours
 Has a tiny little stomach
 Stomach size on day 1 - 3 about 1.5cm in diameter (5-
7ml approx.)
 Stomach size on day 3 - 5 about 2.5cm in diameter (10-
15ml approx.)
 Stomach size on day 7 - 10 about 3.7cm in diameter (15-
20ml approx.)
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Day 1 - 3
1.5cm
Stomach wall stiff
Day 3 - 5
2.5cm
Day 7 - 10
3.7cm

13. Meconium:day 0-4 Changing: day 4-8
Infant stools
05/08/2019
B. Wilson-Clay, K. Hoover, Breastfeeding Atlas
13

14. Stools can be watery Look like bird seedOR
Breastfeeding Stools
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B. Wilson-Clay, K. Hoover, Breastfeeding Atlas
14

15. Good to know about
breastfeeding
Stages of breast milk
 colostrum
 transitional milk
 mature milk
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16. Primary Insufficient Lactation
 Hypoplasia of breast,
 Retained placenta
 Surgical reduction or augmentation of breast.
 Only minimal or no breast enlargement after delivery
is more likely to have inadequate milk.

17. Secondary Insufficient Lactation
REASONS WHY A BABY MAY NOT GET ENOUGH BREASTMILK

18. Pain and nipple damage
Breastmilk not removed effectively
Apparent poor milk supply
Milk production declines
Soreness
Cracks
Engorgement
Stasis of milk
Baby unsatisfied,
wants to feed often
Baby frustrated, refuses to
suckle
Baby fails to gain weight
Cascade to early weaning
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20. Management
 Health care provider who is dealing with breast feeding problems
should have undergone formal training and should have
experience
 Assessment of Attachment and periodic Weight monitoring
 Confidence building measures
 Give practical help.
 Tell the mother to breast-feed at least 8 times a day and a
minimum 2 night feeds
 Minimum 5 minutes and maximum 30 minutes suckling at each
breast
 After complete emptying of one breast only she should go to the
next breast so that the baby gets both foremilk and hind milk.
 If the child is already on non-breast-milk / complementary feeds
help her to reduce them without compromising on the weight
gain of the baby

21.  Beginning of Bottle feeding is may be the end of
breastfeeding. Stop bottle feeding use only
paladai/cup/spoon to feed.
 Mother should be taught to how to comfort a crying child,
namely, placing over the forearm or shoulder with pressure
on the abdomen.
 Tell the mother about the advantages of breast-feeding and
the dangers of artificial feeding
 The mother should be reviewed periodically at least once a
week to give confidence. The baby also should be
monitored for weight gain. It is better to use weight chart

22.  Demand feeding is advised in a healthy term child.
Schedule feeding with EBM is advised in a pre-term /
LBW / sick child whose sucking may not be effective.
 Audio- Visual aids may be used for more effective
Counseling. I use it for teaching attachment and
expressing breast milk.
 The pediatrician may give contact number to call for
help in breastfeeding problems.

23. In the new born period:
 Immediately after delivery the newborn should be given
uninterrupted skin- to- skin contact by the mother and
initiate breast feeding immediately or at least within one
hour
 Triple Feeding Technique:
 If there is an abnormal weight loss in the first week or
failure to gain weight after a week triple feeding technique
is advised.
 Direct breast feeding 5-10 mts per side then supplement
with ad libitum(giving milk as long as child wants)
Expressed Breast Milk followed by pumping of residual
milk until breasts are empty . This should be continued till
the child get adequate weight gain

24. In preterm delivery
 Pumping with an electric pump should be initiated
within 6to 12 hours and continued 8 to 12 times per
day until the milk is well established.

25. Galactogogues: (Recommendation by The
Academy of Breastfeeding Medicine)
 If increased frequency of breastfeeding or
pumping or expression has not been successful one
may try galactogogues. Domperidone is the only
galactogogue evaluated in a randomized controlled
trial and shown to be safe and effective in increasing
breast milk production. The usual dosage is 10 to 20
mg three to four times per day taken for 3 to 8 weeks.
Most women respond within 3 to 4 days, but some
women respond in 24 hours, and some require 2 to 3
weeks to get maximum effect

26. Case scenarios 1
 B/O Meena 10 weeks old weighing 5.6 kgs come for
vaccination and complaints that the child is crying
excessively. She googled and found out that the
crying is often due to not enough breast milk. So she is
giving formula by using bottle whenever the child is
crying excessively.She is of complaining of sore nipple.
Weight at 6 weeks is 4.5 How will you approach?

27. Case scenarios-2
 B/O Dhanya IDM just born, You have given the baby
to the mother for breast feeding. Mother says there is
no milk and the baby also crying and not sucking and
wants you to advise some formula feeds till she gets
enough milk. The CBG is 40mg.

28. Case scenarios-3
 B/O Valli born Preterm 34 Weeks come for review at 7
days , exclusively breastfed.Birth weight is 1.5 Kg, now
weighing 1 kg Mother says she does not have any
problem with breast feeding . You find attachment is
ok. How will you approach?

29. Prevention:
 Pre-natal counseling which includes breast-feeding
counseling and breast examination.
 Help mother to initiate breastfeeding within one hour
 If there are any mother or infant risk factors intervene
early to maximize milk production
 When the infant is unable to extract milk regularly and
effectively the mother should express the residual milk
either manually or by electric breast pumps. This EBM
may be used to supplement the infant.

30.  Allow uninterrupted skin to skin contact and never
separate mother and baby
 Follow-up visits on Days 3, 7, 14, and 28 days and assess
weight loss, weight gain and frequency and duration of
feeding.
 All maternity hospitals should follow the 10 steps in
BFHI(Baby Friendly Hospital Initiative)


31.  Increasing the frequency of breastfeeding and
complete emptying will augment breast milk
supply
 Perceived insufficient milk is more common
 Real insufficient milk is uncommon
 Secondary insufficient milk is more common than
primary
 Weight gain and the frequency of urination are the
only reliable indicators of enough breast-milk

32.  Approach not enough milk rationally and manage
appropriately
 Irrational prescription of supplemental feeding will do
more harm
 Supplemental feeding may be necessary in a rare
situation
 Most pre-term and low-birth-weight babies can grow
appropriately on exclusive breast-feeding.

33. Happy breast feeding….