Low Milk Supply

There are people that will struggle to or never make a full milk supply. From 1 month to 1 year, exclusively breastfed babies average 25oz of breast milk per day. True low supply means making less than this when the breasts are stimulated at least 8 times in 24 hours. Chronic low milk supply is linked to either a greater health concern or something out of your control which you cannot change or fix with cookies, teas or even medications and pumping. 

🗝Low milk supply that can be increased with time and support:

  • 💡Taking certain prescription medications with a side effect of dropping milk (Sudafed, Benadryl, antibiotics)
  • 💡Baby not feeding efficiently from lack of oral motor skill or tongue tie
  • 💡Taking certain prescription medications with a side effect of dropping milk (Sudafed, Benadryl, antibiotics)
  • 💡Not feeding or pumping enough, especially over night
  • 💡Scheduled feedings or over use of a pacifier
  • 💡Birth. Many medications designed to help you labor and deliver actually inhibit baby from latching and feeding effectively for hours to days after birth. Hemorrhage or birth trauma can also cause low supply in the beginning
  • 💡Supplementing, especially in the two weeks after birth

🗝Reasons for chronic low milk supply that may NOT increase even with maximal support:

  • 💡Breast or nipple surgery, augmentation, reduction, trauma
  • 💡Insufficient glandular tissue (IGT). Breasts never developed during puberty and look tubular or widely spaced. Signs of IGT include breasts did not grow in puberty, or increase in size during pregnancy. No engorgement in the week after birth
  • 💡Uncontrolled or undiagnosed thyroid disorder
  • 💡Uncontrolled diabetes
  • 💡Hormone or endocrine disorders, including severe PCOS
  • 💡Hormonal birth control placed/used too soon after delivery
  • 💡Nipple piercing that scars shut instead of staying open

There is a mistaken belief that prescription galactagogues, teas, or herbs can cure ANY chronic low milk supply. Before self-prescribing or taking Domperidone, Reglan, fenugreek, or any other lactation supplement, consider having your serum prolactin levels tested and a full evaluation by a skilled lactation consultant. Continue to follow @lalactation in Instagram or see my videos on YouTube for strategies of breastfeeding with chronic low milk supply.

Do I need to give my breastfeeding toddler cow’s milk or switch to cow’s milk when they turn one?

If you’re still breastfeeding into toddlerhood, no. The World Health Organization recommends breastfeeding until 2 years old. After 2, you can wean to water and table foods or to any kind of milk per your family’s choice. If you’ve decided to wean between 1-2 years, yes and no. Cow’s milk provides a convenient source of a lot of nutrients, including calcium, protein, potassium and vitamin D that are important for building bone and brain development. But if your toddler won’t drink it, has an allergy or intolerance, or your family follows a vegan lifestyle, a well-planned diet can provide these nutrients too. According to the USDA, children ages 2-3 need two servings of dairy per day (milk, yogurt, cheese, or calcium-fortified non-dairy beverage), children age 4-8 need two and a half, and kids 9+ need three. Can you use a milk alternative such as soy, almond or oat? Yes, but they’re not one-for-one swaps. For instance, almond and rice milk have only 1 gram of protein per serving, compared to 8 grams in cow’s.

When choosing a non-dairy milk, make sure it’s fortified with calcium and vitamin D. Homemade versions won’t have this fortification. Shake milk substitutes well before serving, the calcium settles on the bottom. Look for varieties labeled “unsweetened” as many milk alternatives contain lots of added sugar! If you’re choosing not to offer your toddler cow’s milk, make sure they’re getting a wide variety of fruits, vegetables, beans, grains and protein to get them the vitamins, minerals, fats and protein they need for growth. When in doubt, discuss nutrition with a pediatric dietician

Milk is a very convenient source of calcium, but not essential. It is recommended that a 1-3 year old child have 700mg (2-3 servings) of calcium per day. Eating a diet rich in beans, tofu, spinach, kale, broccoli, kiwi, figs, brown rice, oatmeal and certain fish such as salmon can give your child just as much calcium as drinking milk. No one ever “has” to drink milk. Human milk contains less calcium than cow’s milk, but the calcium in human milk has over twice the bioavailability of the calcium in cow’s milk. Increasing your calcium intake does not increase the calcium in your milk – your milk always has the right amount of calcium for your baby. Getting adequate calcium in your diet is recommended because if you’re not getting enough, your body will take calcium from your bones to provide to your baby, making you more prone to bone fractures. However as soon as you wean, your body regains bone mass and your bones will actually be stronger than before. 

Human milk averages 5.9-10.1 mg/oz calcium. 67% of this calcium is absorbed by the body. 

Whole milk contains 36.4 mg/oz calcium. 25-30% of cow’s milk is absorbed by the body.

Infant formulas contain 15.6 mg/oz calcium; toddler formulas contain 24-27 mg/oz calcium. Extra calcium is added to infant formulas because of the lower bioavailability of the calcium from formulas as compared to human milk (they aim for baby to absorb the same amount of calcium as would be absorbed from breastmilk).

Toddler formulas have come on the market in recent years touting that they’re great nutrition for the 12+ month group. In reality, it’s all clever marketing. If you supplement baby with formula, there’s no need to switch to a toddler formula at 12+ months. In the second year of life, growth slows. Your toddler doesn’t gain weight or length as quickly as they did right after birth.

If you’re still breastfeeding, your milk adjusts to this based on how toddler nurses; how the breast is emptied tells your body what kind of milk to make. When breast milk is the primary diet, like in the first 6 months, your milk is made for growth and immunity. When your toddler is taking lots of table foods and nursing, your milk is made for development and immunity.

At 1 you don’t need a fancy toddler formula or cow’s milk. If you’re exclusively formula feeding, switching to whole cow’s milk is fine. While cow’s milk is a convenient source of calcium, protein, fats, and vitamin D, there’s no need to switch to that, either. As long as your child takes a wide variety in their diet and has a good source of calcium (yogurt, cheese, dark leafy greens like spinach, fortified cereals or juice, soybeans, etc), just choose what you offer your child wisely. If you’re still breastfeeding, know your child is getting good nutrition from your milk suited to their growing needs. If you’re concerned about your toddlers diet or they don’t eat a wide variety, consult your pediatrician or a pediatric nutritionist for advice and help.

Sudden breast milk supply drop

Breastfeeding going well and all of a sudden you feel like your milk is gone? Go pee on a stick. A drastic drop in milk supply when breastfeeding has been going well can be a sign of pregnancy, even if your period hasn’t come back yet. Research shows it is safe to continue breastfeeding while pregnant and does not increase the risk of miscarriage. So there no reason to wean unless you’re a high risk pregnancy (if you are told by your health care provider that you can’t have sex, you shouldn’t breastfeed. If it’s safe to have sex, it’s safe to continue breastfeeding.) If so you are not alone—far from it.

Key points to remember when breastfeeding and pregnant:

• Milk will shift from mature milk back to colostrum around 14-20 weeks of your pregnancy to prepare for the birth. Babies under 6 months may not get enough milk from the breast alone while toddler eating solids may do fine. Monitor weight gain for babies under 1 year

• Colostrum is saltier than mature milk. Some nurslings are fine with the taste shift and others may self wean

• Aim for a total of about 600 to 800 extra calories — 300 for the fetus and 300 to 500 for milk production.

• Nipples may become extremely tender during pregnancy, especially at the beginning, due to hormone changes

• Breastfeeding aversion while pregnant is normal (feelings of stress or anxiety or wanting to stop breastfeeding)

• If your toddler always nurses to sleep, you may want to find other sleep routines to make putting older one to sleep easier when you have the new baby.

• As your belly grows, you may need to experiment with new breastfeeding positions.

Empty breasts make milk faster than full breasts

FULL/EMPTY BREASTS

While it seems counterintuitive, the emptier your breasts are, the faster they make milk. A full bread has no place to store or hold the milk, so milk production slows to prevent plugged ducts and breast discomfort. Cluster feeding on an emptier breast actually tells the body to make more milk at a faster rate!! Some incorrectly assume you have to wait for the breast to “fill up” before feeding your baby or for pumping while at work. This will eventually lead to less milk, as a fuller breast tells your body baby isn’t eating very often and to slow milk production. The more frequent you empty the breast, the higher the fat content in that milk and the faster milk is made. The longer often you wait and the fuller the breast, the higher the water content in that milk and the slower your body will make milk overall.

W atch the baby, not the clock. Breasts may feel really full between feedings in the first few weeks after birth, but they’re also not supposed to stay engorged. There will come a time when they stay soft and don’t feel full between feedings or pumping, so waiting for that as a cue to feed will also sabotage your supply. Don’t be alarmed when your breasts no longer feel full between feeding. You’re entering a new stage where you’ll still make plenty of milk for your baby as long as you’re routinely emptying that milk. Trust your body. Trust your baby.

The science vs the art of breastfeeding

SCIENCE AND ART

Breastfeeding is the perfect blend of science and art. There are basic principles that apply, but within those principles is a lot of variation

🔬Science says you should switch which breast you start with at each feeding to keep milk supply balanced

🎨Art says this mom always starts left to try to increase supply on the slacker boob while that mom only feeds one breast per feeding. This mom needs to block feed and that mom offers whatever breast passes the boob shake fullness test

🔬Science says babies should poop at least once a day

🎨Art says some babies poop every time they sit in the car seat and others in the bathtub🤷🏽‍♀️ Some babies poop after every feeding and others have just one a day (or every other day)

🔬Science says eat whatever you want

🎨Art says one can eat dairy without a problem for baby and for another it causes a rash and digestive upset in baby

🔬Science says having baby in a good position will get you a deep latch.

🎨Art says you over here love koala hold a rolled up wash cloth supporting your breast to help reduce reflux. While you over there do better in cross cradle sitting up.

🔬Science says as baby ages they can sleep in longer stretches at night

🎨Art says many babies still wake up 1-3 times a night to nurse until 18 months and need help from an adult to transition back to sleep

🔬By understanding the science behind breastfeeding, we can understand typical patterns of behavior which helps guide us when things aren’t going well.

🎨By appreciating the art of breastfeeding, we can celebrate the unique differences of every feeding baby within its own family dynamic.

🔬If you’re struggling with the science of breastfeeding, find help.

🎨If breastfeeding is going well, appreciate the art of your own masterpiece that you’re creating with your little one.

My baby won’t breastfeed I think there’s a tongue tie

As an SLP/IBCLC, I look at three things when doing an assessment on infants: what does the tongue look like, what can the tongue do, what symptoms is it causing. The tongue needs full range of motion (in and out, side to side, and up and down ) for feeding, dental hygiene and to some extent speech. You can have a frenulum can still have good range of motion. A frenulum is considered tied when the tongue can’t move in all directions and it’s causing symptoms because it’s not functioning correctly.

Symptoms to watch out for are:

👅Can not grasp and hold a nipple for breast or bottle feeding

👅Pops on and off the breast/unable to latch or maintain the latch

👅Leaks milk from breast or bottle

👅Fatigues easily from tension on the tongue and jaw/“sleepy” at the breast

👅Wants to feed all the time and never seems satisfied

👅Causes nipple pain and damage when latched

👅Pinches the nipple when feeding causing recurrent plugged ducts and mastitis

👅Doesn’t empty the breast well causing low milk supply

👅Tongue constantly in a “stimulation” mode instead of efficient sucking at the breast, causing an over supply of milk with fast let down

👅Cannot create the vacuum needed to draw breast milk and makes a clicking or loss of suction sound at the breast

👅Poor weight gain

👅Chokes and gags during feeding

👅Fussy at the breast

👅Swallows air while feeding causing reflux, gassiness or colic

When range of motion is restricted, or is causing symptoms, I will refer to a pediatric dentist who also looks at how the frenulum is impacting structure: is it pulling on the structures of the floor of the mouth and the jaw? Is it putting tension on the bone? In those cases, when function is restricted and it is currently causing symptoms, a revision is warranted. I never recommend revision to avoid symptoms down the road. It’s not ethical.

Nursing aversions and breastfeeding strikes

NURSING AVERSION

My baby won’t take the breast and is completely refusing to eat. What do I do? I see cases like these occasionally and I feel like they’re some of my most challenging (and most rewarding) cases. If your infant under 6 months is displaying aversion to feeding, we need to figure out why. Aversion to feeding means screaming or crying when even offered the breast, taking very little from the breast, refusing to eat, or needing to be fed while moving or while drowsy/asleep. This is not a temporary nursing strike where baby refuses the breast/bottle for a few days because of periods returning, mom going back to work, teething, or illness, etc. A nursing strike that isn’t managed well can turn into a feeding aversion, though. The behaviors seen in baby are much more extreme for a true aversion. Here is my list of the most common culprits to a true breast aversion in order of most common cause in my experience.

👅Tongue tie/oral motor: Is there a visible tongue or lip tie? One of my biggest red flags for tongue tie is reflux and shutting down during breastfeeding (sleepy baby on the breast, popping on and off, refusing the breast and preferring the bottle but then shutting down on the bottle). Some babies with tongue or lip tie do fine for the first few months as they’re compensating from a full milk supply. The aversion comes around 3-4 months when moms supply regulates and is dictated by the efficiency and responsibility of baby removing milk from the breast. If there is no tie, what’s the baby’s sucking pattern like? Do they have an immature or disorganized suck? How is their latch? Are they possibly taking in too much air with poor latch causing discomfort? Would a different bottle nipple shape or pacing be more appropriate? Do they struggle at the breast but take a bottle occasionally? Address the ties and do oral motor exercises to strengthen and coordinate the system and the refusal goes away.

🥛Intolerances/Allergy: This can look similar to reflux, but there is often a component of bowel issues involved as well (constipation with uncomfortable bowel movements, diarrhea, or mucousy/foamy poops). Look for patterns with formula changes- sometimes parents will say one formula works better than another, and if we look at the formula ingredients we might understand which ingredients baby is sensitive to. Babies who’s digestive tracts are uncomfortable don’t want to eat. They learn really quickly to associate feeding with pain, so they shut down on feeding. Finding the allergens clears the gut and makes feeding pleasant again.

🤮Reflux: Easiest culprit to blame and mask with medication. To be honest, putting baby on reflux meds rarely makes a difference. The medication may mask the pain but won’t actually take the reflux away. Don’t get me wrong, for some babies it can make a big difference, but let’s get to the root of the reflux. And medications should always be a last resort. Is the baby spitting up (doesn’t always happen with reflux)? Is there pain associated with the spit up? Is it projectile and frequent? Does the refusal stop once the bottle is removed or are there signs of discomfort even after the bottle is removed? Wanting small, frequent feedings is my classic tell tale of reflux. Continually swallowing helps keep acid in the stomach and reduces the pain. True reflux is usually caused by food allergy/intolerance, gut issues, or tongue tie. Address the issue, resolve the reflux.

🥵Aspiration: Milk going into the lungs instead of to the stomach. Is the baby stressed during feeding? Do their nostrils flare and their body get stiff or arch? Do the cough and choke throughout the feeding and not just during let down? Do they have noising breathing or feeding? Do you need to be super careful with position change/flow rate changes? Do they have a respiratory history (not just pneumonia- does the baby take long periods to get over any illness)? Further assessment by a speech pathologist is always needed.

🤯Behavioral: I’m not sure if “behavioral” is the correct word, but it’s the best way to describe it. The number one concern of parents is feeding the baby. When feeding isn’t going well, it causes extreme stress, which can cause us as parents to do extreme things to try to fix the problem. It’s easy to spiral out when you’ve tried everything and it’s not working out of stress and desperation (or not being able to figure out the why in the first place). Occasionally the reason for the refusal is not longer there, but it was so stressful in the moment, the panic that it could happen again sets in and perpetuates the problem unnecessarily. Some times the root issue is still there, but you’ve compensated and it’s causing a behavioral manifestation in both you and the baby. Are you just trying to push past baby’s stress signs due to your own stress with trying to get baby fed? Are you just trying a bunch of different things to see what works? Are you trying to feed based off of old information? You are just trying to do your best and are scared for baby, but sometimes the compensatory things we do can cause more problems or cause it to persist. Having an outside observer come in to help see what’s going on can help bring everyone back to baseline.

When trying to figure out which of these culprits is the cause of the aversion, know that you don’t have to figure it out alone. Finding a trained lactation consultant (🙋🏽‍♀️) can help ask the right questions to get to the root of the issue and get feeding back on track.

Does breast shape impact making milk?

We come in all different shapes and sizes, and so do our breasts/chests. They can be large, petite, round, tubular, wide, narrow, symmetrical, uneven, teardrop shaped, or droopy. All of these types of breasts/chest are normal.

The size of your breasts/chest is based upon the amount of fatty tissue in it. Those with smaller breasts have less fatty tissue, and those with larger breasts have more fatty tissue. The fatty tissue doesn’t make breast milk. Glandular tissue inside the fatty tissue produces the breast milk.

Unlike fat, the amount of milk-making tissue in your breasts is not necessarily related to the size of your breasts. People with all different breast sizes are fully capable of producing a healthy supply of breast milk for their babies.

Smaller breasts does not necessarily mean smaller milk supply. As long as the small size is not related to hypoplastic breasts (not enough glandular tissue), there shouldn’t be an issue. While you may have to breastfeed more often due to the amount of breast milk that your breasts can hold, you can still successfully produce enough milk.

Breastfeeding with large breasts has its own unique challenges, usually related to position and how to hold or support the breast. Side lying or rolling a towel to put underneath the breast to lift it can be very helpful. Some worry that their breasts will block baby’s nose. Pulling baby in the opposite direction of the breast and compressing the breast from the back can help pop baby’s nose up off the breast. If your baby’s nose gets blocked while nursing, they will open their mouth and let go of the breast so they can breathe.

If you were told your breasts were too big or too small to breastfeed, I am so sorry. Your body is perfect just the way it is.

If you’re concerned that you’re not producing enough milk, pay attention to your baby’s wet diapers and bowel movements. Generally, small infrequent bowel movements or less than six wet diapers a day, are cause for concern. Contact a lactation consultant (🙋🏽‍♀️)right away.

Why does my breast milk supply drop during my period?

Did you know that many of us will notice a supply drop right before our period is going to start and lasts through the period? This is caused by hormone shifts in your body. As supply dips, the milk flow slows. Research shows that the composition of breast milk changes around ovulation (mid-cycle). The levels of sodium and chloride in the milk go up while lactose (milk sugar) and potassium go down. So, the breast milk becomes saltier and less sweet during this time. Some babies become frustrated with this change. They may grab the nipple with their mouth and shake their head back and forth. Pop on and off the breast. Knead or beat the breast with their hands or become extra fussy at the breast. They may even cluster feed and act as if they’re still hungry. They’re trying all the strategies to get your milk to flow how they prefer.

Also around the time of ovulation and just before the start of your period, estrogen and progesterone levels change which can affect your breasts and your breast milk. When estrogen and progesterone levels go up, it can make your breasts feel full and tender.

Higher estrogen levels can also interfere with milk production. Studies also show that calcium levels in the blood go down after ovulation. The lower level of calcium may also contribute to the drop in the milk supply. Lower levels of calcium may also cause your nipples to feel sore, making breastfeeding during your period uncomfortable or sometimes painful.

This is a temporary dip but can be surprising the first time it happens. Remember: this dip can happen once or twice before you actually have a period as your hormones are shifting back into baby making mode. If your baby is older than 6 months and eating lots of solids, you may not notice a difference. The strongest behaviors are seen under 6 months when babies need an exclusive milk diet. You may also notice the dip if you’re a pumper.

Having your period start again may not have any effect on your baby or your milk supply. Some babies continue to breastfeed well. Others will not like the taste of the breast milk or the drop in the amount of breast milk that can happen when your period returns. Your baby may:

  • Become fussier than normal
  • Want to breastfeed more due to the lower milk supply
  • Breastfeed less because there is less breast milk and it tastes different
  • Nursing strike

What can you do about it? Knowing it can happen is the first step. Stay well hydrated and eat quality nutrition. Many find adding in a calcium/magnesium supplement (1000mg of calcium/500mg magnesium per day split into 3-4 “doses”) can help combat the drop. Others find adding in lactation specific herbs or supportive foods help. Iron rich foods like dark leafy greens and red meat and milk making foods like oatmeal, almonds and fennel can really help. Keep offering the breast or pumping frequently. It will get better and your supply will come back up as soon as your hormones shift again after your period. It usually only lasts a few days.

Word to the wise: You can release an egg from your ovary (ovulate) before your period returns. If you’re involved in an intimate relationship, and you’re not using birth control, you can get pregnant again without ever getting your first period even while you’re breastfeeding. If you notice a very drastic drop in milk supply, consider taking a pregnancy test.

Maternal vaccines and breastfeeding

Did you know babies routinely get antibodies to anything you’ve been vaccinate against? Babies get temporary disease protection from you in this way. When you are vaccinated, your body has an immune response that makes antibodies to what you were vaccinated against. Antibodies are then secreted in breast milk to your baby. The type and quantity of these antibodies, and whether they provide any protection for baby after they are swallowed, are dependent on the vaccine received and maternal factors that influence immune system function such as genes, age and health.

Antibodies in breast milk have not been shown to reduce baby’s response to their own immunizations. However, some studies suggest that breast milk may improve baby’s immune response to some of the vaccines they receive.

If you do decide to be vaccinated while breastfeeding, there is no need to pump and dump your milk. Or to stop breastfeeding for any amount of time. When considering the vaccine, or any medication, most want to know whether a dangerous amount of a substance will be filtered into our milk and cause harm to our baby. For most drugs, so little gets to the baby that there’s really very little theoretical risk. Even if a drug or vaccine does end up in breastmilk, anything that goes through breastmilk also then has to go through baby’s gut before reaching baby’s bloodstream. The mRNA molecules in the Pfizer or Moderna vaccines, if they made it into your milk, would have to survive baby’s stomach acid first.

While breastfeeding, it is highly unlikely that an intact lipid from the vaccine would enter your blood stream and be passed directly into your milk. If it does, it is even less likely that either the intact nanoparticle or mRNA could be transferred into your milk. In the unlikely event that mRNA is present in your milk, it would first go through baby’s digestive system and would be unlikely to have any biological effects. The vaccine is supposed to trigger an immune response in your body. It helps your body recognize the virus when you’re exposed and fights the virus early, reducing the severity and length of illness. Once your immune system recognizes the SARS-CoV-2, the virus that causes Covid-19, antibodies are made to protect you and those antibodies may pass into the breastmilk. Researchers have already found Covid antibodies in the breastmilk of previously infected women, though they don’t know yet how much protection these antibodies give babies.

Choosing to be vaccinated is a personal risk/benefit decision to be made between you and your health care providers. If you do chose to be vaccinated with the COVID vaccines, there is no need to pump and dump for concerns of your milk harming your baby.