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Monday, September 5, 2016

Over and Under Supply of Breast Milk

New moms often worry that they won't have enough milk for baby. Most moms have plenty of milk, but working with nurses or doctors who have been trained to help with lactation and following weights of your baby is important until breastfeeding is well established. In some instances we also check blood sugars and other indicators of hydration. I always try to support breastfeeding, but there are some instances where a baby will require a supplemental formula to avoid further medical complications.

photo source: Shutterstock


It is normal to lose weight the first week of life. Babies are born with excess water weight, making them look a bit puffy, but this allows them to stay hydrated until milk comes in. Most babies lose between 6 and 8% of their birth weight, but there are normal variances. A great resource to see if they are within the acceptable weight loss is the Newborn Weight Tool. Once they start gaining, they tend to gain 15-30 grams per day until about 4 months of age.

How much milk is there?


Once milk supply is established, it is constantly being made. The breasts are never completely empty. It is common for one breast to make more milk than the other. This does not indicate over or under supply as long as the combined amount is sufficient for baby to grow. In general the more a baby feeds, the more milk is made. It is not recommended to wait longer between feedings to have more milk per feed. This actually backfires because your breasts sense that baby doesn't need to eat as much, so will make less overall milk.

Initially there is only a few milliliters of colostrum for each feed. Once milk comes in, there will be a couple ounces total. This increases as baby feeds more, such as during growth spurts. Your body should respond to baby's needs.

Peeing and pooping


We monitor urine to be sure babies stay hydrated. I use the 1, 2, 3 rule.

  • 1. The first 24 hours of life baby should pee once. 
  • 2. The 2nd 24 hours baby should pee twice.
  • 3. The 3rd 24 hours baby should pee three times.
  • By the 4th day milk should come in and the wet diapers will increase. Most babies will need to be changed with each feeding.
  • Disposable diapers have super absorbent gel that make it really difficult to see small amounts of urine. (When older babies have a soaked diaper you might notice these gels look like crystals - some parents worry about kidney stones when they see these. Nope. Just super absorbent gel crystals that escape the diaper!) If you're having a hard time telling if there is urine in the diaper during the first few days, put a piece of toilet paper in the diaper. Don't count on the color indicator strip (found on some diapers) to know if the diaper is wet or dirty - there's often not enough wetness to make these work initially. 
Stools change quite a bit during the first week of life and then again over the initial months.
  • Meconium (thick, black tar like stools) is common the first few days. If baby doesn't have a meconium stool within the first 24 hours of life talk to baby's doctor.
  • Once all the meconium is out, some babies don't poop for a day or two. It takes time for the milk to go through. This is fine as long as breastfeeding is otherwise going well!
  • Green stools are common during the transition from meconium to breastfeeding stools.
  • Breastfeeding stools look like yellow cottage cheese - watery with flecks of solid pieces (this is why they are called seedy). Many parents think it looks like diarrhea, but it's normal. 
  • Breast fed babies often stool multiple times a day initially, but then can develop a pattern that they only stool once a week (sometimes even less often). As long as the stools are soft when they come out, it is okay. 
  • Most babies grunt and groan during bowel movements. Some even get red in the face. This is not constipation. They are just learning to bear down and poop. 


Engorgement


When milk first comes in the breasts often feel hard and swollen. This is normal and typically improves over time. It does not indicate that there is too much milk. Breasts must adjust to milk production, so can feel very full when they are not. You can get relief from warm compresses for 5 minutes before each feed, feeding frequently, changing baby's position with each feed, and massaging breast tissue during feeds. Some women like to use cold compresses between feeds for 20 minutes at a time. You can also take ibuprofen for pain. Briefly hand expressing milk or pumping before breastfeeding can be helpful. Excessive pumping can lead to more milk production, so use this only to soften the tissues to allow for a better latch when feeding unless you're trying to increase milk supply or begin storing milk.

Is it normal to feed so often?


Most newborns will feed 8-12 times in a 24 hour period. Since feedings and the associated diaper changes, burping, and everything else can take an hour or so initially, it does seem like they are constantly feeding. Many babies will cluster feed, which is when they stack feedings closely together at a particular time of day. This is often in the evening and can help them sleep longer stretches at night. 

How do I know when milk comes in?


The first few days there is colustrum to nourish baby. This is usually sufficient until milk comes in, typically when baby is 3-5 days old.

When milk comes in some mother's feel their breasts harden and swell, but not all mothers feel this. You might feel baby sucking and hear swallowing in a different pattern once milk comes in. The amount of urine baby makes will increase when milk is in, both in the number of wet diapers and the volume in each diaper.

Nipple Confusion


A lot of lactation experts warn about nipple confusion, but I don't find that it causes problems in most babies if they use artificial nipples, especially pacifiers.

Pacifiers, AKA binkies, can help soothe a fussy baby between feeds. They have been shown to reduce the risk of SIDS, though it is not known how. Studies are inconclusive as to whether or not they affect breastfeeding success. The suck on a pacifier and the suck on mother's nipples are very different, but I have not seen many babies get confused when offered both. If baby has a good latch and breastfeeds effectively, there is no reason to avoid pacifiers in my opinion - which is shared by others. (This differs from the American Academy of Pediatrics position to wait until 3-4 weeks of age.) Babies are seen to suck on fingers and arms while still in the womb... if they need to suck, it is okay for them to suck. If a pacifier helps between feeds to give mom's nipples a break, great! I actually find that this break helps mom want to breastfeed and not give up as easily. Don't use the pacifier to delay a feed though - if baby's hungry, feed him! Of course, if the use of a pacifier seems to affect their feedings, then stop their use until breastfeeding is well established.

Bottles are a means of nutrition. Most breastfeeding babies won't need to take a bottle until breastfeeding is established, but if a baby is failing to get sufficient hydration or nutrition from the breast supplemental nutrition is important. I do see some issues with latch and biting if baby gets used to biting on a bottle's nipple, though not every baby has problems. Many can go back and forth from breast to bottle easily. If you're worried about nipple confusion and your baby needs supplemental nutrition, you can spoon feed or use a syringe to put the milk into baby's mouth. Some mother's will use a supplemental nursing system provided by a lactation nurse. If you are using a bottle for nutrition, it is important to pump so that the breasts are stimulated to make milk for baby.

On the flip side, if breastfeeding is going well, don't forget to start a bottle between 3 and 6 weeks. Mothers who wait longer often find that baby won't take a bottle at all, which makes returning to work or leaving baby for more than an hour or two difficult.

Overproduction of Milk


I always say that too much breast milk is a good problem to have. It's good because it's often easier to handle than too little milk, but it's still a problem.

Too much milk can lead to baby not emptying the breast sufficiently, which can lead to clogged milk ducts and mastitis. You might notice a firm area in the breast that didn't empty during a feed. If this becomes red, painful, or is accompanied with fever or flu like symptoms, see your doctor.

It can also allow them to fill up on fore milk, which is lower in fat than hind milk (which means fewer calories per ounce), so baby can be well hydrated but under nourished.

There also can be increased lactose in fore milk, which can lead to gas, fussiness, and even more watery than normal stools. Many people see more green in the stool, but stool color can also vary with mother's diet.

These babies often only need to feed for a short period of time, but more often than other babies because they fill up quickly, but the low calorie content of the milk leaves them hungry in a short period of time.

Because there is oversupply, these babies may choke when feeding if the milk comes out fast. They may pull off or clamp down. To help with this, try side lying position of feeding or sit in a reclined position during feeds.

Working with your pediatrician and a lactation specialist to ensure adequate weight gain is important with overproduction because baby is feeding well and satisfied after each feeding so it is difficult to be sure the calories he is getting is sufficient. 

Tips and tricks used:

  • Express 1/2-1 oz of milk before the feed to allow baby to get some hind milk. (Store this in the freezer for future use!)
  • Feed only from one breast per feed to decrease overall supply. Usually within a week supply will begin to decrease, and you might need to feed the second side if baby shows hunger cues after eating from the first side.
  • Pumping about an hour before the next feeding can remove some of the excess milk. 
  • Sometimes hormone therapy (birth control pills) or other medicines are used to decrease supply.

Low Milk Supply


It is very common for mothers to worry about not having enough milk for their baby. The first few days most babies only need a teaspoon or so of colostrum per feed. Most babies do not need to supplement with formula until milk comes in. 

Breastfeeding 8-12 times per 24 hours will help establish healthy milk supply. Feed from one breast completely before changing to the other side, and alternate which side you start each feeding. The more you feed (or stimulate the breast with pumping), the more milk you'll make. You can pump between feedings or for 5 minutes after each feed. Feed baby anything you pump if he's still hungry after breastfeeding! See "Nipple Confusion" section above for information on giving expressed milk.

Milk supply can be affected if you have had medical complications of pregnancy, are excessively tired, are not properly nourished, start hormonal birth control or have certain medical conditions. Some medications (especially for cough and cold)  and some herbs can decrease milk supply. Talk with both your obstetrician and baby's pediatrician about any milk production concerns. 

In general you will need about 500 calories per day more than your baseline to make milk. You will also need to drink plenty of water -- keep your urine pale, not too yellow! 

Sleep helps! I know it is difficult to get enough sleep when baby eats every 2 hours, but nap throughout the day as much as possible. 

Galactagogues are compounds that boost milk supply. Many are sold over the counter but should only be used if other means of increasing milk have not worked well enough. Talk with your OB and pediatrician if you are using any of these:

  • Fenugreek (do not use if diabetic or allergic to chick peas or peanuts): 
  • Tea - 1 cup three times daily
  • Capsules 1500- 2000 mg three times daily 

  • Blessed thistle or Milk thistle (can be used with fenugreek but is very bitter)
  • Tea - 1-2 tsp in cup of tea three times daily
  • Capsules 800-1000 mg three times daily

  •  Alfalfa  
  • Tea - 1-2 tsp in cup of tea three times daily
  • Capsules 2000 mg three times daily

  •  Anise
  • Tea - 1-2 tsp in cup of tea three times daily

  • Oats (you can do this one regardless of milk production since it can be part of a healthy breakfast)
  • One bowl oatmeal a day (avoid the little packets with added sugars)

  •  Goat's Rue


  • Tea - 1 tsp in cup of tea three times daily





    • For more information:


      Kelly Mom is a fantastic breastfeeding resource. You might have noticed that I linked several of their pages above.