All questions are so very very important. Especially breastfeeding questions! Never, ever do I hear a “stupid” question, although many new moms could feel like their questions may be silly or stupid and are then are afraid to ask.  As a Health Care Professional (HCP) and Certified Lactation Counselor, I want you to know that the very questions moms or dads ask are the ones which help me learn how to help them best, what their true concern is, or realize how to be clearer in my answers so they really understand. Many times I’ve learned that the first question a mom asks may not be what she really wants to ask. To help define a mother’s actual concern, I must first listen carefully to what she is asking and ask her a few more questions. Then I try to provide her with the information she wants in a non judgmental way so she can make the best informed decisions possible for her own breastfeeding situation. My goal is always to support the mother.

I hope I can meet with your expectations and answer some of your questions in this new forum! Don’t be afraid to ask! Please keep in mind that since each actual mother-baby breastfeeding relationship is unique, some specific questions or situations are not easily answered unless the mother/baby are physically observed, examined, or seen in person. In this format, it’s best to answer questions which are more general in nature. As always, check with your health care provider for specific concerns about your baby’s or your own health.

Questions about Milk Supply

@notdiyheather “ How do you help moms understand that their bodies WILL make the milk needed? I hear that all the time re: no milk supply”

Excellent question!! I take this as a question from someone who may help other moms so I’ll approach it that way. This type of milk supply question goes hand in hand with what is perhaps the number one question new mothers have: “How do I know the baby is getting enough milk?”

Helping new moms understand how to evaluate the adequacy of feedings and teach them to look at the overall picture, a 24 hr day and general health of the baby, is of the utmost importance. Most moms will make the needed amount of milk, given proper management.

Many times, concerns about inadequate milk supply are based on a mother’s perception that she doesn’t have enough or can’t make enough milk. This is fairly common due to a multitude of issues, but mainly lack of proper education. Sometimes her friend’s and or family’s comments spark this concern.

I have learned that in most breastfeeding situations, whatever the concern, I try to expect that the situation and the answer will most likely be simple. It can be a simple correction of breastfeeding management practices or techniques. Mothers need to know the basic foundation: Proper latch, quality feeding activity and frequency, producing adequate output, and weight gain for a thriving healthy baby. When you see a deviation from the simple, normal or common, then further exploration is needed to actually identify the root or cause of the situation.

All questions about milk supply concerns should be taken seriously and not be given a “standard” answer until we determine that the baby is indeed feeding adequately with good milk transfer and the milk supply is adequate. Sometimes at first glance or from a distance, many situations of the perception of insufficient milk versus actual insufficient milk can look similar.

When the mother says she is afraid she doesn’t have enough milk or asks how she can know the baby is getting enough milk I do the following:

• I always start with telling her she is not alone. She is asking the #1 question new parents ask!
• Rule-out any actual problems of supply issues by trying to determine the adequacy of feeding and milk transfer:
  • What causes your concern about not making enough milk?
  • Right from the start, colostrum (the “newborn milk”) is the ideal food and adequate for the baby.
  • Does your baby feed with good energy at least (minimum) 8 times in 24 hours? More often is common and encouraged especially in those early days.
  • Do you see bursts of rhythmic sucking/drinking with swallowing at each feed?
  • Do you see expected output patterns for age? (according to the AAP 2005) ~3–5 urines and 3–4 stools per day by 3–5 days of age; 4–6 urines and 3–6 stools per day by 5–7 days of age~ with urines continuing to be lighter, clearer and increasing volume. The stools should be mostly yellowish in color by the 4^th to 5^th day.
  • The baby’s weight should be down no more than 7% from birth and regained before 2 weeks of age.  Then there should be a weight gain of at least ½ to 1 ounce per day in the early months (most healthy breastfed babies gain more than that daily on average).
  • These are safe parameters or guides … if the baby is outside these ranges; an observational evaluation should be made by a Lactation professional.
• Once established that baby and mom are within the normal ranges, find out what she knows about and help her understand the keys to breastfeeding success and the process and science behind milk production. Simplify these as best you can for the mother.
  • Early and frequent removal of milk from breasts.
  • Lots of skin to skin time right from birth.
  • Infant feeding cues – state of readiness – best motor coordination (crying is a late sign of hunger).
  • Adequate comfortable asymmetrical latch with good seal/good suction.
  • Nipple stretch. It is important that the nipple lengthens to maximize release of oxytocin.
  • Adequate sucking rhythm: 2 sucks to 1 swallow or 1 suck to 1 swallow
  • Milk transfer speed. The faster milk is removed from breast and transferred to baby, the higher the fat content is in milk. There is a faster short-term milk synthesis and faster wash down of fat globules.
  • Satisfaction signs in baby (drunk on milk).
  • Adequate stools. Urine output indicates hydration and stool output is a better tool or indicator of adequate calories from milk, especially in the early days and weeks.
  • Encourage a weight check visit even if only for her piece of mind….  Once I suggested that to a mom who was certain she did NOT have enough milk at one week. Her baby was already 9 oz over birth weight!!
• If her milk supply is indeed below what it should be, there is a lot of good information out there to help guide the mother, the first being an evaluation by a Lactation professional and visit to the baby’s HCP and possibly the mother’s HCP.

• As I always say, give the mother proper information and then support her decisions. Allow her to make her own decisions about which solutions she may choose to work on based on her situation.

• Never underestimate a mother’s desire to breastfeed her infant
• Never overestimate a mother’s desire to breastfeed her infant
• Support the mother, support the mother and most of all… support the mother

Bear with me as I am going to tie in the next question because a lot of the same information applies about evaluating normal, perceived inadequate and an actual problem. There is also a correlation between proper breastfeeding management from the beginning (described above) to help avoid this situation.

@Trevieness “So many people I know say their milk hasn’t come in? I always wonder if that’s really true but why would they if it’s not?”

Another excellent question! It is possible that some of these friends or people you are helping never noticed their milk “coming in.” This is many times true if the mother pays attention to the baby’s feeding needs only, nurses very frequently and her breasts do not have the occasion to become noticeably full.  This is especially true with second and third time lactating moms. Of course this is looking at the situation from a simple/normal angle provided all the above parameters are met.

On the other hand, there can be a delay in lactogenesis (actually Lactogenesis II, the onset of copious milk secretion) for various reasons. This should happen by the 4^th postpartum day and sometimes a little later if there was a delay in stimulation and infrequent removal of colostrum from the breast. This may be due to poor breastfeeding management advice, an unidentified/unresolved inadequate feeding pattern, giving the baby formula, or the baby is sick and not able to feed, accompanied by lack of pumping/expressing in place of those missed feeds. There have also been reports of very stressful deliveries, or uncontrolled/poorly controlled diabetes playing a role. (These are usually accompanied by the above, not to mention feeding formula for hypoglycemia). There is also the possibility of retained placental fragments inhibiting lactogenesis. These situations have been listed from most often to least often seen in my experience.  There may be additional factors depending on the mother’s (hormonal imbalances) or babies health. There is the rarer situation of true Insufficient Glandular Tissue (IGT),however, I doubt you are talking about that since you said “so many people I know.”

Thanks so much for this opportunity! I look forward to more questions!

Melissa Yetter RN CLC is an experienced OB/L&D/Newborn nurse since the 70′s. She started her specialized lactation career in 1988, became a CLC in 1991, and an IBCLC in 1993. In 2003, due to unforseen circimstances, opted not to sit for the required 10 year IBCLC recertication exam but maintained LC status. She recently recertified for CLC (Certified Lactation Counselor) in 2008. She blogs at “Stork Stories… Birth & Breastfeeding” about her experiences as a maternity nurse and lactation professional from the 1970′s to present.

References:

Cadwell, Turner-Maffei:  Pocket Guide for Lactation Management; Jones and Bartlett, MA. 2008

AAP, Section on Breastfeeding:  Breastfeeding and the Use of Human Milk ; Policy Statement 2005 PEDIATRICS Vol. 115 No. 2 February 2005, pp. 496-506

Neville, Morton: Physiology and Endocrine Changes Underlying Human Lactogenesis II; J. Nutr. 131:3005S-3008S, November 2001