This document discusses concerns about low milk supply in mothers and strategies to address this issue. It covers normal breastfeeding and infant growth patterns, factors that influence milk production, signs of inadequate milk intake in infants, and interventions to improve milk supply and transfer. These include ensuring proper latch and frequent, on-demand feedings to stimulate milk production as well as monitoring mothers and infants to identify and address supply issues. The goal is to provide appropriate support to establish and maintain a sufficient milk supply through education and early intervention.

1. Session 9

2. 1. Discuss concerns about “Not enough milk”
with mothers. 10 minutes
2. Describe normal growth patterns of infants.
3. Describe how to improve milk intake/transfer
and milk production.
4. Discuss a case study of “not enough milk”.

3. Under optimal conditions, mothers
produce adequate milk for their babies.
Complete delivery of the placenta causes
drop in progesterone levels, initiating
Lactogenesis II.
Mismanagement of feeding routines is
highly related to insufficient milk.

4.  Suckling and emptying the breast are essential to
adequate milk production. Regulation of milk
production in full lactation is based primarily on
infant demand.
 Maternal age, nutrition, fluid intake, body
composition and parity are of little significance in
milk production.
 Maternal malnutrition does not seem to have an
effect on total volume produced.

5. When there is sufficient milk, baby
appears healthy, gains weight and
feeds frequently.
Exclusive breastfeeding supports
adequate growth in the first six
months.

6.  Normal growth patterns in breastfed babies show
that breastfed babies grow more rapidly in the first
several months compared to formula fed infants.
 After the first three to four months the velocity
(speed) of growth slows down in the breastfed
infant, while the formula fed infant continues to
grow at a higher velocity.
 With old growth charts frequently it looked like
breastfed babies were abnormal and slow to gain
because of a change in growth velocity.

7.  New growth charts adopted for the US on 9/10/10.
 Based on WHO growth studies and charts (2006).
 Created from high quality study designed specifically to examine
growth of healthy children in optimal conditions for growth.
 Breastfed babies predominantly breastfed for at least 4 months and
who were still breastfeeding at 12 months.
Establishes the breastfed baby as the norm for
infant growth.

8.  WHO standards provide a better description of
physiological growth in infancy.
 Typical growth patterns seen in the US on old charts may
not be ideal growth patterns
 New charts available at:
http://www.cdc.gov/growthcharts
 Training tools for clinicians being developed and will
be posted at the same web site.

9. A weight loss of more than 7% in the first 72
hours should trigger breastfeeding
assessment of mother and baby.
Weight loss of 10% from birth weight is
maximum for a breastfed infant and requires
close observation and support.

10. “Formal evaluation of breastfeeding
performance should be undertaken by trained
caregivers at least twice daily and fully
documented in the record during each day in
the hospital after birth…” (p. 499)

11. “All breastfeeding newborn infants should be
seen by a pediatrician or other knowledgeable
and experienced health care professional at 3
to 5 days of age.” (p. 499)

12. Observe baby at breast. Does baby grasp the
breast well and suck vigorously?
Question the mother about:
 breastfeeding patterns
 use of gadgets such as nipple shields, pacifiers
 sleep patterns
 smoking, drug and medication intake, etc.

13.  Consider the following possible contributors:
 maternal infection, anemia
 thyroid disease
 poor release of milk (let-down reflex)
 anatomical anomalies of mother or baby
 incomplete delivery of the placenta
 poor sucking

14. If the milk is not removed, less milk is made.
Factors include:
 infrequent feeds
 scheduled feeds
 short feeds
 poor suckling
 poor attachment
Stress, lack of confidence, or overwhelmed
mother leads to ineffective feeding practices

15. The baby is poorly attached to the breast and not
suckling effectively. The baby may seem restless
during a breastfeed and may pull away or tug at
the breast.
 Breastfeeds are short and hurried or infrequent.
 The baby is removed from one breast too soon,
and does not receive enough hindmilk.
The baby is ill or premature and not able to suck
strongly and for long enough to obtain the milk
the baby needs.

16. Interventions should be appropriate to the
identified cause(s) of problem.
Increased nipple stimulation through
improved suckling, massage and
expression, and/or pumping, may help
increase supply.
Treatment plans should include frequent
feedings and frequent follow-up contacts.

17.  Listen to the mother and ask relevant questions.
 Look at the baby - alertness, appearance, behaviour, and
weight chart if available.
 Observe a breastfeed, using the Breastfeed Observation Aid.
 Respond to the mother and tell her what you are finding. Use
positive words and avoid criticism or judgments.
 Give relevant information using suitable language.
 Offer suggestions that may improve the situation and discuss
whether the suggestions seem possible to the mother.
 Build the mother’s confidence.
 Help her to find support for breastfeeding and mothering.

18.  40 - 80% of women who wean during the first 6
months of life cite inadequate milk supply as the
reason for weaning.
 Mother’s perception of inadequate milk may not
indicate an actual supply problem, but rather a
misreading of infant behavior.
 Teaching mothers to understand infant feeding
and fullness cues helps support optimal milk
supply and build maternal confidence.

19. Infant growth in length and weight can
offer reassurance that milk transfer is
occurring.
Infants of mothers who report concerns
about milk supply tend to weigh less at
birth, be fussier and poorer feeders.
Babies who are calorically deprived may
sleep more and give fewer feeding cues.

20.  When a mother perceives she has insufficient milk
she may stop breastfeeding altogether or give the
baby formula. Both of these behaviors may result in
early cessation of breastfeeding.
 Understanding feeding cues, especially that crying is
a late feeding cue, may help the mother feed more
frequently and make the feedings more satisfying.
 Lack of confidence with breastfeeding may be
countered with teaching and support for the mother.

21. Signs of milk ejection may include:
 Change in suck/swallow pattern of baby to 1:1 or 2:1 with
audible swallowing
 Longer, slower sucks replace faster more shallow sucks
 Leakage from opposite breast during nursing
 Uterine cramping in early postpartum period
 “Tingling” sensations (not experienced by all mothers)
 Thirst
 Feeling of relaxation or peacefulness

22.  Early, on-going skin to skin contact
 Early, frequent feedings - unlimited by the clock
 Night feedings
 Water or formula supplementation for medical indications
only
 24 hour rooming-in with frequent feedings on cue
 Teaching mother about infant behavior and milk
production
 Educating staff about advantages and management of
breastfeeding

23.  Improve birthing routines to facilitate earliest and
most frequent breastfeeding with correct latch
and optimal milk transfer.
 Increase mothers’ knowledge about breastfeeding
and skill in reading newborn behavior cues.
 Establish community support networks which
identify problems with milk supply early and
provide appropriate intervention.

24.  Follow-up the mother and baby to check that the milk
production/milk transfer is improving.
 Monitoring means to look for signs of improvement that you
can point out to the mother – increased alertness, less crying,
stronger suck, more urine and stooling, and changes in her
breasts such as fullness and leaking.
 Monitoring also gives you an opportunity to talk with the
mother and see how the changes are working. Build her
confidence and encourage things that she is doing well.
 If the baby’s weight was very low and supplements were
needed, reduce supplements as the situation improves.
Continue to monitor the baby for a few weeks after
supplements have stopped to ensure milk supply is sufficient.