Low Milk Supply 101

By Emma Pickett, IBCLC

Forgive me for asking but…

Do you REALLY have low milk supply?

This is a very important place to start. Please bear with me. I don’t mean to doubt your situation and be annoying patronising lactation consultant woman but it’s crucial to note that the MAJORITY of new mothers who fear they have low milk supply DO NOT.

The majority of women who start to use formula because they worry they aren’t making enough or baby isn’t getting enough DO NOT HAVE A PROBLEM.

I cannot emphasise this enough.

Every day mothers panic and end breastfeeding or start using formula and there is not an underlying problem with their milk supply. But of course – once they start using formula without correct support, they often will start to send signals to their breasts to really reduce supply.

• You do not have low milk supply just because your baby won’t go the X number of hours between feeds that the book on your coffee table tells you they should. Or your mother-in-law. Or the X number of hours your friend’s baby is going between feeds.
  A normal happy healthy baby who has a gorgeous mummy with a normal healthy milk supply might get hungry an hour after the last feed, or 90 minutes, or 45 minutes or two hours. They might be cluster feeding and hardly want to come off the breast at all. They might be having a growth spurt and feed every hour for a day.
• You do not have low milk supply because your breasts have stopped leaking. Some mothers leak less than others. MOST mothers notice that leaking reduces at the weeks go by and the teeny tiny sphincter muscles responsible tighten.
• You do not have low milk supply because your breasts feel softer than they used to. The excessive fullness we experience in the early days of breastfeeding is about vascular engorgement (blood and lymph) and it’s about the body inefficiently storing unnecessary amounts of milk between feeds. As time goes by, the breasts get cleverer at storage (don’t forget milk is also made while a baby is actually feeding). There is also less blood and lymph needed in the breasts as breast tissue growth slows down. At the beginning, it’s often very obvious which breast is going to be fed from next. That feeling goes. And many mothers mistakenly connect it with a reduction in milk supply. We are not all supposed to continue feeling heavy and full throughout our breastfeeding experience. Don’t ever think ‘I’ll wait to let my breasts fill up!’ Noooooo. This shows a misunderstanding of how lactation works to a spectacular degree. When breasts are fuller, milk production slows down. When breasts are emptier, milk production increases. Emptier softer breasts may well be making a heap more milk in a 24 hour period than the engorged full versions.

As time goes by, the breasts get cleverer at storage (don’t forget milk is also made while a baby is actually feeding).

• You do not have low milk supply because your baby feeds for a short time. Plenty of babies get everything they need in under ten minutes. Probably not five – but sometimes a feed might even be five minutes long. Lots of babies use their tongue and jaw muscles super efficiently and gulp and glug and slow down as the milk gets fattier and thicker and then come off happy. It might take them nine minutes or nineteen. A baby might start off life needing 30 minutes to drain a breast (when we say ‘drain’, breasts are never completely empty, it just means the baby has taken out all the milk they usefully want to). As a baby gets older, this can dramatically reduce. It doesn’t mean less milk is going in. If a small sleepy jaundiced baby falls asleep very quickly at the breast without some solid minutes of good swallowing, that’s a different story. Overall however, a longer feed does not always mean a better one.
• You do not have low milk supply because you have small breasts. Large breasts are a combination of fatty tissue and glandular tissue. You cannot tell much about someone’s milk production by the size of the breasts. If you are really worried your breasts don’t ‘look right’, we’ll come back to this later.
• You do not have low milk supply just because your baby wakes up a lot. Plenty of young babies feed with similar intervals day and night. Plenty continue waking every 2-3 hours for a while.
• You do not have low milk supply because your baby won’t ‘go down’ after a feed. So you feed your baby and they drop off to sleep on the breast. You move them to the Moses basket and they wake up as if you just placed them on a sheet of molten lead. And they seem to be rooting again. This happens because being next to you skin-to-skin was nice and cosy and relaxing and warm and it smelt good. The Moses basket is cold and NOT YOU. You probably triggered the Moro startle reflex when you moved them. You probably moved them about 15-30 minutes after a feed when the hormone cholecystokinin had dropped in their blood stream causing them to be more wakeful. Your teeny primate mammal baby finds the breast a lovely place to be. They like to suck to relax themselves. Babies like second helpings. This does not mean you are not making enough milk.
• You do not have low milk supply because your baby will take milk out of a bottle after a feed. Put a teat against a young baby’s palate and you trigger that baby’s sucking reflex. Babies will usually continue to take milk beyond the point that they need it. This is one of the reasons we see links between bottlefeeding and obesity.
• You do not have low milk supply if you cannot feel your ‘letdown’ reflex (milk ejection reflex). Some women feel an electrical tingle at the point the milk lets down. Some don’t. Crucially, some feel it for the first few weeks and then it fades. This fading sometimes worries people. It does not mean anything has changed with your milk supply and it is perfectly normal for the sensation to go.
• You do not have low milk supply because you don’t pump very much milk. Pumping and breastfeeding are surprisingly unrelated. Your baby removes milk in a completely different way. Plenty of women with healthy milk supplies fail to pump much at all. Their bodies can’t be tricked into eliciting the milk ejection reflex (or ‘letdown’). Plus pumps don’t always work. Suction goes as valves get old.

Your teeny primate mammal baby finds the breast a lovely place to be. They like to suck to relax themselves. Babies like second helpings. This does not mean you are not making enough milk.

These are the things that REALLY tell you a mother might have low milk supply:

• Weight gain problems. A newborn is born and then loses weight. They regain birth weight at around two weeks. They then put on about 150-200g a week after that. That slows down after around four months. If your newborn loses more than 10% of their body weight, we might pay attention but we’ll also want to look at things like your birth. Did you have a drip in labour that filled you and your baby with fluid? Did your gorgeous newborn look a wee bit like the Stay Puft marshmallow man in their first photos? That fluid elevated the birth weight and as it comes out again in the first few days, we might see more of a weight drop. That doesn’t necessarily mean feeding or supply is a problem. However we wouldn’t want your baby to lose weight after about day five or lose weight a second time. It might take some babies three weeks to get back up to birth weight.
  Have a look at the chart in your red book. Notice how we have birth weight line and then a space where the curvy lines don’t go and they start again at week two. Just because your baby was born on the 75th percentile, that doesn’t mean we would expect them to definitely re-start on the 75th after that two week gap. That’s why the lines don’t continue. That’s why we have that space. We start again at two weeks. Your baby might be on the 50th then. They then ideally will roughly stick in the same vicinity. But babies wobble around a bit. They might dip below. They might get close to the 25th. And then they might bob back up again. We don’t expect all babies to hug a line exactly. This chart is a guide. It’s about averages. It’s not about mathematical certainties.
• Nappies. In the early days (first four weeks), we look at poo and pee. After your milk has come in (around day two to five), we’d expect to see six wet nappies in 24 hours and three poos the size of a £2 coin or bigger. After week four, some babies’ poo rate can slow right down. This doesn’t mean anything is wrong. Some babies can skip several days between poos and this isn’t anything to do with milk transfer or supply. However if someone tells you it’s OK for a ten day old baby not to poo for a few days, don’t believe them. We’d need to investigate that situation. Only later on do we relax.

Weight gain and nappies. That’s it. Those are the only things that tell us about milk supply. You may hear people say that ‘babies should be settled after a feed’ but some babies get wind or need to poo or have reflux or wake up and want second helpings. Let’s be careful about even saying that. Let’s look at weight gain and nappies.

So let’s now assume you do have low milk supply. How many of you are still with me? I’m sorry if you are. I’m sorry if your baby only put on 60g last week and 90g or less or nothing the week before that and they are slipping down the percentiles. I’m sorry because I know how scary that can feel. Nothing feels like it matters more. There are things we can do.

See next page for what to do if you DO have low supply…