Most mothers have lots of milk or perhaps, better said, could have had lots of milk if they had gotten off to a good start and had good hands-on help. The problem is usually that the baby is not getting the milk that is available and thus, with time the production of milk will decrease.
Sometimes mothers seem to have a lot of milk which flows very quickly at the beginning of a feeding, but the baby fusses or falls asleep when the flow slows down later in the feeding. Although the following symptoms are not necessarily due to the baby’s not getting enough milk flow from the breast, this Protocol can be used to help resolve concerns about:
1. Get the best latch possible.In order to accomplish this, it is best to get help from someone who is experienced and knows how to help mothers with breastfeeding. Anyone can look at the baby at the breast and say the latch looks good.
We tend to teach the latch differently from most others. Naturally, we think our approach is very effective and often is. A baby latched on well is on the breast asymmetrically, covering more of the areola with his lower lip than his upper lip, with his chin in the breast but not his nose, and his head is slightly tipped backwards compared to the rest of his body. When the baby is latched on well, the mother has no pain, and the baby gets milk well from the breast. See this video clip showing a good latch and good drinking .
2. Know how to know a baby is getting milk.When a baby is getting milk, he will have an open mouth wide – pause – close mouth type of suck. S/he is not getting milk just because he has the breast in his mouth and is making sucking movements. When s/he is sucking and not getting milk his chin moves down and up rapidly with no pausing of the chin at the maximum opening—this means “I am not getting milk flow into my mouth”.
If you wish to demonstrate this to yourself, put your index finger into your mouth and suck as if you were sucking on a straw. As you draw in, your chin drops and stays down as long as you are drawing in. When you stop drawing in, your chin will come back up. This pause that is visible at the baby’s chin when the baby does it at the breast represents a mouthful of milk. Watch the videos in the previous paragraph.
In fact, the baby does this pause when he gets milk from finger feeding. The longer the pause, the more milk the baby got, so it is obvious that the frequently advised “feed the baby 20 minutes on each side” makes no sense. A baby who drinks very well (as opposed to sucking without drinking) for say, 20 minutes straight, will likely not take the other side. A baby who nibbles (doesn’t drink) for 20 hours will come off the breast hungry. You can see video clips of babies drinking (or not) above .
Note that when baby stops sucking, “taking a break”, this is not the pause we are referring to. Note also that it is normal for babies not to suck continuously without a break. Just ensure that when he begins to suck again he is also drinking.
3. Breast compressions.Once the baby is sucking without drinking, use the technique of breast compression to increase the flow of milk to the baby. Babies react in two ways to slow flow. They either fall asleep at the breast or they pull at the breast. Some babies do one thing at one feeding and another at another feeding. Some will both fall asleep and pull at different times during a single feeding. When the baby is sucking without drinking, start compression, but be sure to do them while the baby is sucking but not drinking. Keep the baby on the first breast until he doesn’t drink even with compressions (so that there is no pausing-type of suck even when you compress). See the blog Breast Compression.
4. Switch sides.There is a trend to advise mothers to feed on only one breast at each feeding to ensure that the baby receives the high fat hindmilk. Here is the reason that does not work a lot of the time: if the baby is not drinking, the baby is not getting hindmilk because the baby is getting no milk. See this video of a baby sucking but not getting any milk. When the baby no longer drinks even with compression, offer the other side and repeat the process. Keep going back and forth as long as the baby gets reasonable amounts of milk. Of course once the baby has fed well, there is no harm in letting him “nibble” at the breast until s/he pulls off.
5. Herbs.Fenugreek and blessed thistle. These two herbs seem to increase the rate of milk flow.. Because herbs are not standardized, we recommend mothers take enough fenugreek that she notices its scent on her skin. Often 3 capsules each of fenugreek and blessed thistle (or 20 drops of the tincture) taken 3 times daily may help and should work within 24-72 hours. If they have not worked by 72 hours and the mother smells of fenugreek, they probably won’t help. For other herbs that may help increase milk supply, see the information sheet Herbal Remedies for Milk Supply.
Please note that there is no good studies showing that the various herbal remedies actually increase milk supply and flow of milk to the baby. If there does not seem to be an improvement in the baby’s drinking at the breast by a week after starting the herbs, domperidone is more likely to help.
6. Lying down to breastfeed.In the evening, when babies often want to be at the breast frequently and/or for long periods of time, get help to position the baby so that you can feed the baby lying down. (Note: mothers seem to have less milk in the evenings, but less does not necessarily mean “not enough”). Let the baby breastfeed and maybe you will fall asleep. Babies who fuss at the breast when the flow is slower in the evening may be content to suckle at the breast when lying side by side with the mother. Or rent videos and let the baby breastfeed while you watch. See the information sheet (Dr James McKenna’s) Safe Co-sleeping as well as our blog.
7. Domperidone. This is a medication that increases the rate of milk flow to the baby by increasing the milk supply. It is not a magic bullet and won’t cure all problems. It must be used in conjunction with the other steps in this Protocol. Sometimes it can be useful even if your milk supply is already substantial (as when the baby does not yet know how to latch on). See the blog on Domperidone, the FDA (Federal Drug Administration) and domperidone, and Health Canada and domperidone.
8. Supplementation.It is not always easy to decide if a baby needs supplementation. Sometimes applying this Protocol for a few days and continuing with it will get the baby gaining more rapidly.
Sometimes more rapid growth is necessary, and it may not be possible without supplementation, especially if help for the mother and baby is delayed. If practical, get banked breastmilk to use as a supplement (for more information see www.hmbana.org). If not available, milk sharing is a possibility also. See this website which is supportive of mother to mother milk sharing, but is a very full and long discussion. Check websites in your geographical area, though “official” websites such as public health units will usually discourage informal milk sharing. Still with proper precautions, safe milk sharing is possible and practical.
If none of the above are possible, infant formula may be necessary. However, sometimes slow but steady growth is acceptable. The main reason to worry about growth is that standard growth is a sign of good health. A baby who grows well is usually in good health, but not necessarily so. Neither is a baby who grows slowly necessarily in poor health, but physicians worry about a baby growing more slowly than average.
Growth charts are, however, frequently interpreted poorly. A baby who follows the 10th percentile is growing normally and as he should. Too many people, and surprisingly even some physicians, believe that only babies on the 50th percentile and above are growing normally. This could not be more false. Growth charts were developed on information gathered on normal babies. Somebody has to be smaller than 90% of all other babies (those on the 10th percentile)—somebody normal.
9. Lactation aid.If it is decided that supplementing is necessary, the best way to do it, even if you are supplementing with breastmilk, is with a lactation aid at the breast. Our lactation aid is made with a #5 French, 36 inch or 93 cm long feeding tube leading from a bottle of supplement, and it is used once the baby has fed only after doing steps #3 and #4 above and the baby has fed on at least both sides. Why is a lactation aid better than a bottle, cup, syringe, or spoon?
10. Food. If the baby is older than about 3 or 4 months and supplementation appears to be necessary, formula can be avoided and extra calories can be given to the baby as solid foods.
Yes, you can give solids to a baby of 3 or 4 months of age. The statement by Health Canada, the Canadian Paediatric Society, the American Academy of Pediatrics, UNICEF, the World Health Organization, and almost all paediatric societies around the world encourage exclusive breastfeeding to 6 months. This means that if the baby needs extra calories and is also getting formula he is still not exclusively breastfed. Formula is basically a liquefied solid. But it is not the formula that is the biggest problem. It is the bottle. If the baby gets bottles when the milk flow from the breast has slowed because of a decreased supply, s/he will figure out pretty quickly where the milk comes from and start rejecting the breast. Bonding is important, but hunger comes first.
So formula can be given, but mixed with the baby’s solids. This works fine. First solids can include mashed banana, mashed avocado, mashed potato or sweet potato etc—as much as the baby will take as often as the baby will take the solids without forcing.
Note however, that giving the baby solids at 3 or 4 months of age when everything is going well with breastfeeding and the baby is gaining well is not recommended. Solids should normally be started when the baby is showing a definite interest in eating solids (usually around 6 months of age, but not always, sometimes this occurs before six months and sometimes after). See the blog Starting Solid Foods.
11. Late onset slow weight gain.If your baby was gaining weight well for a few months and no longer is, see the blog on late onset decreasing milk supply and flow. Reasons for a decreased milk supply are listed there. Fix what interfering factors fit your situation and follow this Protocol
The information presented here is general and not a substitute for personalized treatment from an International Board Certified Lactation Consultant (IBCLC) or other qualified medical professionals.
This information sheet may be copied and distributed without further permission on the condition that it is not used in any context that violates the WHO International Code on the Marketing of Breastmilk Substitutes (1981) and subsequent World Health Assembly resolutions. If you don’t know what this means, please email us to ask!
©IBC, updated July 2009, 2021
Questions or concerns? Email Dr. Jack Newman (read the page carefully, and answer the listed questions).