“I don’t make enough milk, now what do I do?”

I was recently contacted via Facebook about my opinions on supplementing at birth when mother’s milk “doesn’t come in right away”.  I thought you might be interested in my response. The first several paragraphs are the background anatomy and physiology of early breastfeeding. Below are the questions I was sent as well as my responses. Enjoy!

Breastfeeding is a natural process that has become misunderstood by the general public as it became hidden from the community. I believe when mothers actually understand the process of breastfeeding, it can help then understand what is going on in their newborn. Prenatal breastfeeding classes are essential for this. At 10-14 weeks of gestation, every mothers breast begins to fill with colostrum, a high protein milk which acts as a laxative. It’d why their breast change size during pregnancy. Mothers already have the first milk in the breast that their babies need for birth. It is in a small volume because babies are born constipated and fluid overloaded from the womb. In a natural, uncomplicated delivery, a newborn has a high need to suck because of this constipation. Sucking causes peristalsis (a wave like movement) to travel through the esophagus through the stomach to the intestines to push out the poop. It takes approximately three days for all the meconium to be pooped out (which is exactly how long it takes for colostrum to change over to mature milk!!) Nature designed the breast to feed the need of the baby in perfect balance to allow baby to become unconstipated so the gut would be ready for nature milk at the right time. Breast milk actually doesn’t “come in”. It’s already there in the form of colostrum. The first few days are controlled by the autonomic system. You’re pregnant so you will produce colotrum and your body will think you’re feeding a baby. You need your baby to suck at birth to lay down hormone receptors in the breast for prolactin, the milk making hormone. The more your baby simulates your breast in the first few days after birth, the more hormone receptors are activated to make milk for your baby. After the first few days, you switch from the autonomic system to the demand a supply model that continues for the duration of breastfeeding. The more the baby demands, the more mama makes.

Unfortunately in the modern world of medicine, we have tampered with the natural process of birth and thereby impacting breastfeeding. With IV fluids, the epidural, and other medications used in birth, we’re changing how newborns interact with the world and how hormones in mom are being produced. The epidural rate in hospitals in LA County is over 80%, with many hospitals over 90%! It actually causes sleepy babies that do not do as well at the breast (Richard and Alade, 1990, https://youtu.be/4eQdQ1Ww9-k) Cesarean births also significantly delay the Natural switch from colostrum to mature milk for obvious reasons based on the above information. Babies really need to be skin to skin and at the breast with no interruption for the first few days of life or until mature milk had come in. Skin to skin contact promotes physiologic stability in the baby (including regulation temperature ebooks sugar) while promoting free access to the breast to facilitate the process described above. If hospitals encouraged mothers in Birthing a more natural and unmedicated way, we would actually see a significant drop in the need for supplementation and in breastfeeding issues.

The Baby-friendly Hospital Initiative (BFHI) was launched by WHO and UNICEF in 1991, following the Innocenti Declaration of 1990. The initiative is a global effort to implement practices that protect, promote and support breastfeeding. Formula fed babies have a 50% higher risk of dying of SIDS at all ages of infancy with even higher rates in other developing nations due to unsafe water and lack of finances for parents to afford formula. Baby friendly hospitals in the US understand the importance of breastfeeding but aren’t the best at communicating why. Breastfeeding is better for babies for a laundry list of reasons.

One of my newest clients.

What should expectant parents look for when searching for a lactation consultant? They need to find someone who is skilled and trained. An IBCLC is always the gold standard because of the extensive training we go through. Facebook forums are horrible for information because there is a lot of poor information floating around. Yelp is great for reviews of local consultants. If they suspect a tongue tie, they need to find a lactation consultant specifically trained in it. Not every one is.

How are lactation consultants accredited and are their different professional organizations? http://blog.mothersboutique.com/whats-the-difference-between-lc-ibclc-cle-etc/


What is generally the maximum amount of time a mother should wait for milk to come in before offering formula? For instance, after a c-section when it can take longer. This is a loaded question because every story is different. In the hospital it’s always based on bilirubin numbers and the risk for jaundice. In my practice, if a baby has not has the recommended number of wet diapers by day three we’re supplementing at the breast using an SNS at the very least.

What are the guidelines when it comes to (temporarily) supplementing with formula for newborns? Unfortunately there are no guidelines and every practitioner comes from their own experience and setting. There are no rules and it’s a case by case basis which should be based on parents breastfeeding goals, but unfortunately is not always an option.

When waiting for milk to come in, what amount of weight loss would be a red flag? 10% is normal weight loss for all infants. Birth weight needs to be regained by 2 weeks. And we need to know WHY. Is there a tongue tie? Does the mother have a hormone issue? Does the baby have birth trauma or tortícolis? Is there a metabolic issue or heart defect? Is it simply a poor latch or improper position? Did the baby have poor oral skills? These all can relate to weight loss. At what point would you advise a breastfeeding mother to offer formula? If baby gets adequate skin to skin time and constant access to the breast, most of these issues resolve on their own. If a baby is lethargic, sleeping more than 4 hours multiple times in a row, or not making enough wet and dirty diapers by 48-72 hours, I’m all about supplementing. But that’s me coming from a hospital background. I don’t mess around with the risk of jaundice. I also always prefer supplementing at the breast with an SNS and with donor breast milk when possible. Stimulate the breast for increased production while getting the baby fed and used to the breast at the same time.

Do you feel the threat of “nipple confusion,” supply issues, or a mother “giving up” breastfeeding are valid reasons for avoiding formula when milk hasn’t come in? Are there other reasons to avoid temporary supplementing? This is another misconception. There really isn’t “nipple confusion”. It’s actually flow confusion. At the breast, babies need to stimulate milk flow at the beginning of a feeding with active suckling. It can take one to two minutes of suckling for let down to happen. Breasts can flow at different rates and even flow different during a single feeding. Bottles, however, are instant and constant. It’s much easier to feed from a bottle, so some babies “prefer” this from having to work at getting their milk. A lactation consultant can help with any issue of flow at the breast to help with this. Opinions vary in the introduction of a bottle. Some say no sooner than 2-3 weeks or when breastfeeding is well established. Die hard lactation consultants say no sooner than 6 weeks. In NICU where I work, we use bottles from day one and babies easily transition back and forth between breast and bottle. We use and teach paced bottle feedings and use of a slow flow nipple to try to replicate breast flow from a bottle.

What do you think is the biggest benefit to enlisting lactation consultants’ help in breastfeeding? The earlier you get help, statistics show, the longer mothers will breastfeed. If breastfeeding is your goal, get help in the first 72-96 hours. Enlisting help give mothers the confidence in knowing subtle changes in positioning and latch that can make a world of difference. An LC can also identify if there is something wrong, like a tongue tie, inverted nipple, swelling of the breast from fluids at birth, etc that is impacting feeding.

Do you feel pediatricians are being pulled in different directions when it comes to supplementing? For instance, they are promoting breastfeeding because of the proven health benefits, but also want to be able to offer formula because sometimes it’s needed? Pediatricians get a 45 minute lecture on breastfeeding on medium school if there lucky. It depends on their training and setting. They are mostly concerned about weight and usually have no problems supplementing outside the hospital setting. In the hospital, if it is baby friendly, there are guidelines for when formula can be introduced.

What are your thoughts on the “fed is best” campaign? I strongly disagree with it. But I’m in the profession of breastfeeding. The risks of not breastfeeding far outweigh the benefits of formula feeding. There are obviously cases when supplementation is absolutely necessary and mothers should never be shamed of needing to supplement. They should also be encouraged to get professional help as soon as possible to facilitate breastfeeding from the beginning. So many issues can be prevented before they’re a problem.

Do you feel that there is too much pressure to breastfeed currently? Whether from society, lactation consultants, media, doctors, etc. I believe we don’t have enough proper education on breastfeeding. With good quality education of the risks of not breastfeeding and the benefits to the mother, baby, partnrr and community, as well as having adequate postnatal support, I believe more families would actually choose breastfeeding.

In your opinion, is there anything that can be done to prevent instances where babies or starving or losing too much weight while waiting for milk to come in? The best practice after a normal delivery is keeping babies skin to skin on mom and with free access to nurse on demand. Babies should not be swaddled in isolettes away from their mothers. They should be allowed to sleep with skin to skin contact for the first few days of life. If a baby is not making enough wet and dirty diapers by 48 hours, they need to be evaluated for a tongue tie or other oral motor issues by a therapist in the hospital or a skilled/trained lactation consultant who is trained in oral motor which may be impacting the ability to drain the breast this causing the cycle of not enough milk taken in by baby and the breast not being stimulated by baby to produce more milk.

If not, do you think more breastfeeding mothers should be informed of this scenario before labor? I believe every mother needs to attend a high quality breastfeeding class before birth and breastfeeding support groups after birth. So many mothers don’t get education because they think it’s going to be natural and easy. But we’ve lost the communal/tribal living where we breastfeed with other women and learn about breastfeeding from childhood. There is so much misinformation on social media it perpetuates problems. But I also believe we should be educating mothers about the real impact of epidurals, medications, and induction on breastfeeding so mothers can understand how it will impact breastfeeding.

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