Is my baby getting enough milk? (Part 1)

 

Why would a baby not be getting enough breastmilk?  Almost always, the most important reason is that the baby is not latched on as well as he could be.  If the baby is not latched on well, he does not stimulate the breast as well as he could and thus the milk does not flow from the mother to the baby (note that mothers transfer milk, not babies).

 

And why would a baby not be latched on as well as he could be?

 

Because of:

 

1. How the baby is positioned and latched on and also the chapter on what is a good latch, from my book Dr Jack Newman’s Guide to breastfeeding (HarperCollins 2014).

 

2. Using artificial nipples such as bottles, pacifiers and nipple shields. It is unfortunate that the first thing many mothers are advised to do when there are problems with breastfeeding is to give the baby formula, usually with a bottle, which only serves to increase the weight, but does not address the real issue and very often makes the breastfeeding go downhill. When it is determined that the baby truly needs supplementation, a lactation aid at the breast is a far better way to supplement a baby (not an SNS), but its use needs to be shown properly. The baby’s latch needs to be as good as possible and the tube of the lactation aid needs to be placed well.

 

3. The baby has a tongue tie.  Some tongue ties are obvious, but many tongue ties are more subtle and require an evaluation that goes farther than just looking, but includes feeling under the baby’s tongue as well, assessing the upward mobility of the tongue and knowing what to feel for.  Unfortunately, few health professionals, including lactation consultants, know how to evaluate whether or not the baby has a tongue tie. As well, not all health professionals know how to release a tongue tie properly.

 

4. Decreased milk supply, (which does not mean “not enough milk” but rather a decrease in milk supply relative to what the baby was used to) can lead to even more decrease in the milk supply. Late onset decreased milk supply is not uncommon. And when the milk flow slows, the baby tends to slip down on the nipple and the latch becomes even worse, so that decreased milk supply itself can lead to more decrease in milk flow. As this happens, in response to the slow flow of milk, the baby stays on the breast drinking for shorter and shorter periods of time which contributes to the milk supply decreasing even further. And this may also result in sore nipples. For more information on late onset decreased milk supply. And click these links Really good drinking with English text, Twelve day old nibbling, English Text, “Borderline” drinking for video clips showing babies drinking well at the breast, or not.  Watch the videos, read the texts and then watch the videos again.

 

The first few days

 

It is commonly believed that there is not enough milk for the baby in the first few days.  This is bizarre thinking, imagining that babies can get dehydrated and even die because there is not enough milk.  But the problem is not that there is not enough milk; in fact, there almost always is enough.  Breastmilk has been produced in the breasts since about 16 weeks gestation.  The usual problem is that the baby does not receive the milk that is available to him.

 

And why does a baby not get the milk that is available to him?  Basically, because the baby is not latched on well.  How a baby latches on determines how well he gets milk from the breast. The problem is that the importance of how a baby latches on is ignored in general. And even if the health professional knows that the latch is important, few really know how to help the baby latch on well. It is not a routine part of postpartum care to observe the baby at the breast and to help the mother with the latching on should it be necessary.

 

And most are not aware how difficult it can be for a baby to latch on well when the mother’s nipples and areolas are swollen from the intravenous fluids given to the mother during labour and birth.  Mothers are often told that they have “flat nipples” and thus won’t be able to breastfeed. When we see such mothers in the breastfeeding clinic, they do not have “flat nipples”, they have normal nipples, as do the vast majority of mothers.  The nipples had looked flat because of swelling. Telling the mother her nipples are “flat” is wrong and undermines her confidence to breastfeeding and too often leads to the use of nipple shields.

 

Swelling of breast, nipple and areola due to overhydration

Photo 1: This mother has swelling of the breast, the nipple and the areola, due to retention of fluid. This makes it difficult for the baby to latch on. The result? The baby does not get milk well and the mother’s nipples are sore.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Furthermore, because the mother and baby have been overloaded with fluid, because the baby does not latch on well, because of these factors and others, babies are supplemented, very often without any attempt to help the baby get milk from the breast by improving the latching on, the mother is thus convinced, by the “information” from the nurse, physician and lactation consultant, that she does not have enough milk.  Too often this becomes a self-fulfilling prophecy.

 

The mother then continues the supplements, usually by bottle, which interferes with the baby’s latch, which results in the baby getting less milk and as a result, more bottles and more formula. And often, that is the end of breastfeeding, sooner or later, usually sooner than later.

 

This baby is 24 hours old and is drinking lots of milk from the breast.  How do we know?  Because of the pause in the chin as he opens his mouth wide to the maximum. The longer the pause, the more milk the baby received. 

 

After the first few days

 

Are there truly women who cannot produce enough milk?  Of course, this has always been and likely always will be.  Probably, in tribal societies, when a baby is obviously not thriving, the baby would be shared around and fed by other nursing mothers. Just as with any other part of the human body, things can go wrong through no fault of the person affected.

 

Once humans started domesticating cattle and sheep, babies were still shared around but they might have also received cow, sheep, mule, camel or mare milk.  And many would have died from infection or quite possibly electrolyte imbalances if they were fed only animal milk.  But even many of these babies usually did survive, because they received unpasteurized milk, sometimes directly from the animal. The milk would have contained immune factors, though immune factors appropriate for the animal.

 

Feeding at the teat of a mule

Photo 2. In 19th century France, orphans for whom a wet nurse could not be found, were often fed directly at the teat of a domesticated animal, in this case, a mule.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

But, until mothers and babies get the help they need to establish and continue breastfeeding, there will always be far more mothers who believe they are incapable of breastfeeding exclusively than actually exist.

 

Why might a baby not get all the breastmilk that is available?

 

1. Mothers are still being told that the baby should be feeding a limited amount of time on the breast (say, 10 or 15 minutes on each breast) which might result in the baby not getting enough milk from the breast. There are some health professionals who believe that 10 minutes on the breast is enough because the baby gets 90% of the milk in that time.

 

2. Feeding on schedule. Limiting when the baby can go the breast and having the baby wait until being breastfed so that the baby feeds only every 3 hours, say, can cause the baby not to get enough milk. Babies should be breastfed whenever they show signs of readiness to feed before they begin to cry.

 

3. The use of pacifiers can both result in decrease of milk supply and can be a consequence of a decrease in milk supply when the mother uses a pacifiers to calm a baby who would actually need to go to the breast instead.

 

4. Feeding only one breast per feeding. The idea, apparently, is that the baby would get high fat milk. If the baby is not getting milk from the breast, he is not getting high fat milk. A baby is not necessary getting milk simply because he is making sucking motions on the breast.

 

 

Most mothers whose babies are not getting enough milk from the breast, are not getting enough because of a cascade of events that include birth interventions, separation of mother and baby after birth, early and unnecessary use of artificial nipples, postpartum practices and bad breastfeeding advice and thus most causes of “insufficient milk supply” are preventable. 

 

 

Other causes of “insufficient milk supply”

 

1. Women who have had breast reduction surgery, which is most often done with an incision around the areola, usually do not produce enough milk. However, there are definitely exceptions. We have seen mothers in our clinic who have had breast reduction and who do produce all the milk the baby needs. We even have had one mother with breast reduction who breastfed twins exclusively to 6 months of age.  It should be mentioned that any surgery on the breast with an incision made around the areola, will decrease the mother’s capacity to make milk.  The more complete the incision (breast reduction usually involves an incision completely around the areola), the greater the negative effect on milk production.

 

Photo 3: This mother has had breast reduction surgery. As a result, it has been difficult for her to produce enough milk for her baby.

Photo 3: This mother has had breast reduction surgery. As a result, it has been difficult for her to produce enough milk for her baby.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. It should be mentioned that simply looking at a woman’s breast is not a good way to determine whether she can produce enough milk or not. Some breasts are sometimes described as having “insufficient glandular tissue” (IGT). I do not like this term because it is essentially saying the mother will never produce enough milk, and this is not true. This diagnosis is not helpful because it may cause the mother to feel insecure and it does not change how we would help the mother with breastfeeding.

 

 

Photo 4: A mother with the typical signs of “Insufficient glandular tissue”. Her other breast also showed signs of “insufficient glandular tissue” but the baby gained well. Be careful about making this diagnosis.

Photo 4: A mother with the typical signs of “Insufficient glandular tissue”. Her other breast also showed signs of “insufficient glandular tissue” but the baby gained well. Be careful about making this diagnosis.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Women who induce lactation to feed an adopted baby or a baby born with a surrogate often do not produce all the milk the baby needs. But some do.

 

4. And there are some mothers who do not produce enough milk for reasons that are uncommon or unknown. Some of these uncommon causes include women who have had surgical removal of or damage to their pituitary gland or bilateral mastectomies.

 

Can these mothers breastfeed?

 

Of course, but they may not be able to breastfeed exclusively. Part 2 of this article will discuss a practical approach to helping mothers breastfeed their babies as exclusively as possible. It is important to know, however, that breastfeeding is much more than just making milk for the baby.

 

 

 

Need help with breastfeeding? Make an appointment with the International Breastfeeding Centre

 

Copyright: Jack Newman, MD, FRCPC, 2017

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