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?
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 serves only 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 the mother needs to be shown how to use it so that it works. The baby’s latch needs to be as good as possible and the tube of the lactation aid needs to be placed well. One without the other makes the use of the lactation aid at the breast difficult.
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. Evaluation requires feeling under the baby’s tongue as well, assessing the upward mobility of the tongue and, of course, 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. Too often, partial release may not really help much.
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 the mother developing a new onset of 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 receive 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 and this is particularly important when there are not large volumes of milk as in the first 3 or 4 days. The problem is that the importance of how a baby latches on is ignored in general unless the mother has sore nipples, and even when mothers have sore nipples the mother is often told the latch is just fine. (Secret: if the mother has nipple pain while breastfeeding, the latch is not good no matter who says otherwise). And even if the health professional knows that the latch is important, few really know how to help the baby latch on well. Unfortunately, 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 and unfortunately, far too often, the “treatment” of “flat nipples” is a nipple shield. 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 due to the intravenous fluids. 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.
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, without showing the mother breast compression to help the baby get more milk. As a result, the mother is 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 continues to undermine 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, not rarely sooner rather 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 as well as the mother herself. 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, goats 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.
But, until mothers and babies get the help they need to establish and continue breastfeeding, there will always be far more mothers who incorrectly believe they are incapable of breastfeeding exclusively than actually exist.
Why might a baby not get all the breastmilk that is available?
1. Restricting time on the breast. 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 still seem to believe that 10 minutes on the breast is enough because the baby gets 90% of the milk in that time. I really have no idea where this notion arose (that the baby gets 90% of the milk in the first 10 minutes of suckling).
2. Feeding on schedule. Many health professionals tell mothers that the baby should be offered the breast only every 3 hours or even 4 hours. Feeding only every three or four hours can cause the baby not to get enough milk and eventually for the mother’s milk production to decrease. Most babies are showing signs of hunger well before 3 or 4 hours. If the mother believes the “rule”, the baby may be offered a pacifier instead of the breast. Babies should be breastfed whenever they show signs of readiness to feed and they show readiness to feed well before they begin to cry.
3. The use of pacifiers can result both in a decrease of milk production and their use can also be a consequence of a decrease in milk production when the mother uses a pacifier to calm a baby who would actually need to go to the breast instead. The baby seems hungry well before he “is supposed to”, so a pacifier is offered. The baby sucks on a pacifier instead of breastfeeding, and so milk production decreases, and the baby “needs” the pacifier even more. Eventually, the mother is advised by the baby’s physician that the baby is not gaining enough, and she should supplement the baby with bottles of formula. We see a lot of recent onset pacifier use in babies whose mothers have had late onset decreased milk supply.
4. Feeding only one breast per feeding. The idea, apparently, is that the baby would get high fat milk. However, 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, including use of medications in the epidurals, separation of mother and baby after birth, early and unnecessary use of artificial nipples, postpartum practices and bad breastfeeding advice. Thus, most causes of “insufficient milk supply” are preventable and potentially reversible if good help is begun early.
Other causes of “insufficient milk supply”
1. Women who have had breast reduction surgery, 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 breast surgery done 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.
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. Sometimes breasts are 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.
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. And mothers who wish to relactate, 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. There is much more to breastfeeding than breastmilk. Breastfeeding is not just bottle feeding with a softer bottle. It is a close, intimate physical and emotional relationship between two (or more) people who are generally in love with each other.
Need help with breastfeeding? Make an appointment with the International Breastfeeding Centre
Copyright: Jack Newman, MD, FRCPC, Andrea Polokova 2017, 2018, 2020