Low Milk Supply: Beyond the Basic Causes September 16, 2014 16:28
Written By Michelle Roth, BA, LCCE, IBCLC
Your milk supply is driven by how much milk is removed from the breast. The more often your baby nurses, the emptier your breasts get, the more milk you make. If the breast isn’t stimulated and emptied often, your hormones signal that it’s time to slow production.
Most often, low milk supply can be remedied by nursing your baby more frequently. Milk supply issues tend to be related to mistaken impressions of how often or how long a baby should nurse. It’s a product of our bottle feeding culture – we imagine a baby eating every 4 hours and taking a certain number of ounces. But nursing is much more fluid than this – and once moms start using babies’ cues and nursing more often, things improve. Sometimes you need to pump to increase the emptying of the breast in addition to feeding more often. If you have tried both of these methods – nursing more and adding pumping – and your supply is still faltering, here are five questions to consider:
- Could it be related to the birth? It may take longer than normal for your milk to “come-in” if you have had a cesarean birth. Colostrum – your first milk – is the perfect food for your baby during this time, and your baby does not necessarily need supplements. Continue nursing often to build the receptors necessary for a full supply when your milk does come in. While labor pain medications don’t necessarily directly impact your milk supply, they can make baby sleepy in the early days, meaning less frequent feedings. Waking these babies and getting them to the breast more often is the solution. If you’ve had IV fluids for the birth, you may be extra swollen for the first couple of days, which can make breastfeeding more challenging. Baby may have a shallower latch, and may not be able to remove much milk, laying the groundwork for the low supply spiral. If you experienced postpartum hemorrhage, especially if you have Sheehan’s syndrome, your milk supply may be adversely affected. If you have even a very small piece of placenta left in your uterus, it may be producing just enough pregnancy hormones that your body doesn’t realize it’s time to make milk instead.
- Is it a breastfeeding management issue? If you are giving your baby any supplements – expressed breastmilk or formula – by bottle, these are replacing breast stimulation and can decrease supply quickly. The same with scheduled feedings – your body isn’t getting enough stimulation to keep milk-making up. If your baby is using a pacifier, it’s possible that you are missing hunger cues, or that your baby is soothed when that suckling should in fact be at the breast. A baby who is missing feedings gets sleepier – not enough calories equals sleep to conserve energy. Also, if you are trying to get your baby to sleep through the night, or to take extended daytime naps, it’s likely that you’re both missing some feedings. Have you started solids and are you replacing breastfeeding with them? Early solids should be complementary to breastfeeding rather than in place of nursing. All of these breastfeeding management issues are easily resolved by nursing more often or stopping whatever it is you’re doing that is interrupting unrestricted feeding at the breast.
- Are you taking any medications or have you recently been ill? Cold medications – especially those containing pseudoephedrine – have the potential to dry up your milk supply. If you are ill and need medication, it’s always best to check with a Lactation Consultant (or checking for yourself on LactMed or the InfantRisk Center) before taking anything – whether prescription or over-the-counter. Another category of drug that could impact milk supply is hormonal birth control. Birth control methods containing estrogen are the most damaging to milk supply, even if you have a strong supply and you’ve been nursing for months. Progestin-only contraceptives, such as the ‘mini-pill’ or DepoProvera injection, may be a better choice for breastfeeding moms; but, they shouldn’t be started until 6-8 weeks after the birth. Before that time, they can wreak havoc with milk supply for some moms. If you have recently been ill, your supply may have decreased due to lack of appetite, dehydration, and infrequent nursing.
- Could it be hormonal? Is there a chance you are pregnant again? If so, the hormones to support pregnancy may cause a sharp decrease in supply. Sometimes a mother has an undiagnosed hormonal imbalance that impacts her ability to make milk. Such was the case with a retained placental fragment discussed above. If you had infertility issues before becoming pregnant with this baby, there is a chance that hormones played a part and will impact breastfeeding as well. Moms who have a history of polycystic ovary syndrome (PCOS) often report low milk supply – some of the hormones for milk making and breast growth are suppressed by other hormones in mom’s body. Low thyroid hormone levels can also cause low milk supply. This usually rebound to a normal supply once thyroid replacement therapy is started. These are only a few of the many hormonal imbalances that can affect milk production - so a thorough health history and wide-ranging laboratory tests can confirm deficiencies.
- Could it be structural? Insufficient glandular tissue is rare, but can cause low supply – there just aren’t enough milk making glands to support lactation. If you have a history of breast surgery (whether augmentation, reduction or biopsy), there’s a chance that glands, nerves or ducts were disturbed. Working closely with a lactation consultant and your baby’s doctor will ensure you maximize your milk production and your baby gains weight adequately. A mom with inverted nipples may have problems with latch in the beginning, but keep in mind babies ‘breast’feed, not ‘nipple’feed. But improper latch due to inversion, or lack of milk transfer because baby can’t use the nipple normally, can lead to low milk supply. Structural problems for baby that can impact supply include tongue tie, cleft palate, low muscle tone, cardiac issues, and more. Anything that reduces the amount of milk baby actually transfers will work negatively on milk supply.
In addition to all of these potential factors that could affect your supply, lifestyle factors can inhibit your let-down reflex which will eventually limit your milk supply. Caffeine and alcohol have been known to inhibit “let-down,” making it likely that your baby isn’t able to transfer as much milk. The same with stress and fatigue. Mothers who smoke also report low supply more often, and these babies tend to have weight gain issues. Sudden maternal weight loss or extreme calorie restriction can also decrease supply.
As you are working on milk supply issues, it’s good to have the support of someone knowledgeable about normal breastfeeding. Consider working with a board-certified lactation consultant (IBCLC) or a trained breastfeeding counselor (such as a CLC, La Leche League Leader, Breastfeeding USA counselor, or WIC peer counselor). The help of these professionals may be instrumental to your success. Most of all, keep an eye on your baby. As you are working on increasing your milk supply, make sure your baby is having plenty of wet and dirty diapers, and gaining weight well. You may need to supplement with expressed breastmilk (or formula), but working to increase your supply is well worth the effort.
Mohrbacher, N. (2010). Breastfeeding answers made simple: A guide for helping mothers. Amarillo, TX: Hale Publishing, L.P.
Riordan, J., & Wambach, K. (2010). Breastfeeding and human lactation. Sudbury, Mass: Jones and Bartlett Publishers.
West, D., & Marasco, L. (2009). The breastfeeding mother's guide to making more milk. New York: McGraw-Hill.