Breastfeeding: supply issues and solutions

Midwife and lactation consultant, Stephanie Callaghan-Armstrong takes an in-depth look at the complexity of supply issues and discusses solutions. 

Indeed, it is nothing short of spectacular how a baby is born, and by day three postpartum, many new mums suddenly have more than enough milk to feed their growing baby. Some joke they could feed a village, others however, feel like they never have enough or wonder if their milk ever properly 'came in'.

Many of us know the catch phrase in breastfeeding of ‘supply and demand’, which is loosely understood to mean if you breastfeed when baby asks for it, there will be the right amount of milk for baby, right?

The answer is very often effortlessly yes, but for many this is not the case. One of the most common reasons new mums give up breastfeeding or start partial feeding (adding in milk supplements) is having a low, or 'perceived low', milk supply. Equally, an oversupply can be very challenging for mum and baby too.

Let’s look at a 'normal' breast milk supply for context and then the issues of having an ‘under’ and an ‘over' supply, and what you can do to get it right for you and baby…

Firstly, here's how it works – I always say that the human breast is pretty much another wonder of the world. How do breasts actually make milk?

GETTING READY TO MAKE MILK

In puberty and then pregnancy, the tiniest changes in a young woman’s hormones help prepare her breasts with growing ducts and milk sacs to make milk; like a tree growing branches and leaves. The Montgomery glands, or little bumps by the nipples and breast veins become more pronounced and colostrum often leaks or is able to be expressed in the third trimester, a good sign they’re ready!

While less obvious breast development in pregnancy can be an indicator of low milk supply in some women, it is not a reason to worry. When baby is born, after the placenta is delivered, the pregnancy hormones oestrogen and progesterone fall rapidly and the breastfeeding hormones prolactin and oxytocin kick in.

Your colostrum is baby’s first milk that is filled with rich antibody protection, proteins, and sugars. It’s the best of the best superfood to kick-start their life. Feeding baby every few hours gives them a constant supply of this 'liquid gold' and also increases your prolactin levels by breast stimulation, sending messages to the brain to make milk.

ESTABLISHING SUPPLY

For a milk supply that is just right for your baby (yes, it's tailor-made and even adjusts in composition for prematurity and climate), how you start out with breastfeeding matters a lot. It’s good to also know what the goals are for an established, good milk supply – the evidence of this will be in your breastfeeding and with baby.

Uninterrupted skin-to-skin contact with mum straight from birth, then a latched on breastfeed (ideally in the first hour of life) is the most ideal plan. Baby staying right by mama for demand feeding, or waking baby for feeds if they are sleepy, so there are no big stretches between feeds in the first few days of life is key to establishing the blueprint for your milk supply.

❧  Emptying the breasts sends a message to the brain to make milk

❧  Full breasts sends a message to hold fire on making more

If there is a separation situation of mum and baby, this naturally interrupts baby being put to the breast every few hours. Making sure you express milk by hand or pumping in these circumstances is vital. Not removing milk regularly can also result in severe engorgement of the breasts which can be very painful and can also result in a low supply as the milk initiation process is interrupted.

MILK MAKING

A normal/ideal milk supply and breastfeeding initiation process looks like this:

+  Breasts increasingly feel full and the milk 'comes in’ around day three postpartum

+  Baby latches correctly and non-painfully for mum, suckles well with the jaw moving back to baby’s ear with audible rhythmic swallows and increased gulps during the let-downs. The let-down is the milk ejection reflex power squirting through the milk ducts into baby’s mouth and may happen several times per feed while mum’s milk supply is establishing

+  By a week old, baby typically has 6-10 wet nappies a day, and stools the size of their fist are mustard yellow with ‘seeds’ in them and sweet to smell (I get asked a lot what these seeds are. They're the milk curds, and are a sign of normal, healthy digestion of breast milk). Breastfed babies in the first six weeks of life usually poop after most feeds and after six weeks the saying goes that they can pass stools ‘seven times a day or up to every seven days’. This is pretty much true because of the breast milk's reabsorbability by the gut, some babies go infrequently but when they go, they really go! One of my daughters was the queen of doing this once she was put in her car seat, just as I was heading somewhere in a rush!

+  Breasts may feel softer after feeds and firmer before feeds

+  Baby weight gain is approximately 25 grams a day, more during growth spurt times (roughly around three weeks, six weeks, three months and six months). Babies often have a greater demand for feeds for 24 to 48 hours to naturally increase your supply during this time. Sometimes women can mistake this for not having enough milk supply. If supplementation with formula happens at these times, the natural milk supply never has a chance to increase on its own, so it’s important to trust your body and baby.  Spend a quiet few days tucked up on the couch or in bed with lots of skin-to-skin and regular feeding, your breasts will catch up with demand! 

+  Baby usually settles to sleep after feeds and looks a bit ‘milk drunk’, sleepy and full. You often see milk still in baby’s mouth at the end of the feed

+  If you were to skip a feed and use a good breast pump you would find you have enough milk for a breastfeed. Expressing is not always an accurate measure of milk supply though. Some mums find their let-down is best when directly breastfeeding. Performance anxiety with pumping is a thing! 

Using what is a ‘normal’ supply as a baseline, we can now explore what an undersupply and over supply of breast milk is and how to resolve this...

UNDERSUPPLY

An under or low supply of breast milk is a very real thing, although in some cases it is what we call ‘perceived’. This is when a woman does in fact have enough milk, but other issues are making baby appear unsatisfied. It can be really tricky to try and navigate this conundrum.

There may have been engorgement and fullness initially in the first days or weeks after birth, but once the breasts have softened, baby may often seem hungry after feeding and become fussy on the breast, pulling off as if they’re not getting what they want.

Baby may not settle to sleep well, and cry and be rooting around with their mouth or looking for the breast in-between feeds. This may well be due to not having enough milk, but if baby’s weight gain is adequate, it’s likely something else. It could be wind or reflux or an intolerance to foods that you may have eaten. As your breast is also a source of comfort, sometimes baby wants to keep latching to try and relieve their discomfort rather than being hungry. 

Signs you may have a true low supply is baby not having enough wet or dirty nappies, and stools may be very scant or greenish. Weight gain may not be adequate and subsequently baby may be too sleepy to latch and suckle on the breast properly.

UNDERSUPPLY PLAN

Go back to basics. Strip off and have some skin-to-skin contact to increase the oxytocin (feel-good hormones) to help you make more milk. Stimulation of the nipple correctly is key (it shouldn’t be painful).

Breastfeed regularly (2-3 hourly), with correct latching, plus express with a good pump afterwards for up to 10 minutes. If your supply is very low, pumping helps reset the message to the brain about supply and demand.

Have a midwife or lactation consultant assess your baby’s feeding if you have difficulty latching. Getting your latch right is key and maybe even small tweaks of technique and position can help increase the amount of areola baby suckles. Diagnosing and correcting other issues such as a tongue tie, could also help immensely. 

A cranial osteopath who specialises in babies may also help baby to latch and suckle better.

Galactagogues or milk-making supplements are beneficial to help boost milk supply. These include ‘nursing teas,’ blessed thistle capsules, brewers yeast, and milk-making cookies. Increasing protein and low GI carbs into your diet is important for a good milk supply boost. A nutrient-dense smoothie or a handful of nuts in the afternoon before cluster feeding in the evening can help build up your supply too.

Your lead maternity carer (LMC) or doctor may also consider prescribing a medicine that increases your supply. They will take into account your medical history and what has gone on since baby was born, however it is never a first line treatment.

Some new mums never experience the usual breast development in pregnancy or maybe have hypoplastic breasts from underdevelopment in their teen years. After a trial of natural breastfeeding, they may need medical intervention to kick-start or boost their supply.

Your LMC or doctor may send you for blood tests to rule out other reasons for low milk supply such as obesity, diabetes, or hypothyroidism. Smoking and vaping can also negatively affect milk supply.

Iron deficiency (anaemia) can cause a low milk supply so it’s beneficial in pregnancy to have your iron stores checked and if need, to increase iron-rich foods in your diet and take supplements. Occasionally it’s recommended for a mum-to-be to have an iron infusion for anaemia if their iron levels are low enough.

Avoid cold and flu medications and also contraceptive pills containing oestrogen, because both have the side effect of of inhibiting milk supply. I always say, there are very few mums who would be unable to provide at least some breast milk for their baby, even those with severe latching difficulties or a true undersupply.

Consider sourcing donor milk over formula so baby gets the benefits of breast milk for as long as possible. There are so many women out there with too much milk donating to various places to help others. One of my own babies received breast milk from a friend for months while I was on a medication that meant I couldn’t breastfeed. I pumped and dumped and took domperidone to increase my supply when it was time to re-latch and then exclusively breastfed again until she was nearly three!

 OVERSUPPLY

Oversupply of breast milk (sometimes called hyperlactation or hypergalactia - sounds like a Star Wars scene, I know!) is when some mothers find they're ‘blessed’ with way more milk than they need. It sounds like a good thing and yes, it’s often preferable to work with too much milk rather than too little, but it can make breastfeeding very difficult and stressful.

I also have first-hand experience with this and remember the midwives at the hospital putting me in a ‘binder’ with cabbage leaves to soften the engorgement. Even after it settled, it seemed there was so much milk, I felt too full and had difficulty latching my baby. 

If your ‘oversupply' is in the early stages postpartum, take heart that it should naturally resolve on its own and is a temporary situation, your breasts should settle and your milk supply will hopefully regulate.

A genuine lactation oversupply however, may not resolve without intervention so it's good to recognize the signs and put steps in place to reduce and manage it before it gets too challenging to continue feeding. After the initial time of establishing breastfeeding (6-12 weeks), oversupply may present in ways such as this:

+  Your breasts may feel full or extremely uncomfortable much or all of the time even after feeding, and expressing is needed to relieve the pressure

+  Breastfeeding is literally a slip and slide show of milk everywhere, difficulty latching, fullness and excess milk flow

+  You may have to use breast pads for moderate to extreme leaking

+  Baby may have continual high levels of weight gain (double or more than the normal), and on the growth curve be heading off the charts, not following the curve

+  Baby may gulp, pull off the breast, start to refuse, cry or clamp on the nipple during let-downs in an attempt to modify the fast flow. It can lead to breast refusal and become a negative, stressful experience

+  Baby has excessive wet and dirty nappies, they may be green and frothy or explosive

+  Baby may be unsettled after feeds – crying, bringing knees up, spilling milk, not sleeping, or even wanting to excessively feed (for comfort)

+  Your nipples may be tender from difficulty stabilising your latch due to full breasts

+  You may have experienced recurrent breast infections, painful breasts or blocked ducts due to inefficient emptying

OVERSUPPLY PLAN

Feed in a position that helps baby control and cope with an excess milk supply and often a more forceful let-down while the issue is resolved. The traditional cradle hold position is not the best for oversupply as during a let-down it pours milk into baby’s mouth. Try positions like the biological hold AKA the laid back hold (you are the one laid back, with baby lying on top of you, tummy-to- tummy). Another position where the flow is uphill rather than downhill is the ‘sitting up football hold’. Again, baby can pull off and cope with the gulps and let-down better being more upright.

Baby passing green, explosive stools can be caused by too much foremilk going through the gut fast, rather than the richer hindmilk that is more residual in the milk sacs. For an increased hindmilk feed, massage your breasts for about a minute before feeding. There is research that shows this can release the fat content into the milk more freely – worth a try! Feeding off one breast for a whole feed at a time may help too, just express the other for comfort and to reduce the risk of getting mastitis or blocked ducts.

Think ‘opposites’ when it comes to slowing your milk supply. Your milk contains a clever protein called  Feedback Inhibitor Hormone (FIL) that signals when the breasts are full, to slow milk-making down. When you want to increase milk supply, the breasts need to be regularly emptied, but alternatively allowing them to be full is the key so there is increased FIL sending a red light/stop-making-milk signal to the brain. Feeding off only one side per feed can help slow the milk production down, and expressing the other only for comfort to relieve the pressure, if you’re in the habit of taking milk off to soften the breasts. Reduce time spent pumping if you do that regularly (a known cause of creating oversupply because your brain thinks it's providing for another baby, no doubt), this will decrease the demand, which should lower the supply. Watch for signs of mastitis and blocked ducts during this process – these include  sore, red patches, lumps, fever or flu like symptoms. In this case, express for comfort, take high doses of vitamin C and use massage. See your doctor if infection needs to be treated with antibiotics.  

In cases where your oversupply is still resistant to decreasing, try ‘block feeding’ – a technique where the breasts are emptied fully by a pump and then only feed off one breast at a time for 4-6 hour blocks. This helps the other breast fill with milk and therefore a high level of FIL to slow supply. Only use this method for a maximum of a few days and again, watch for signs of breast infection.

Avoid taking galactagogues. It sounds obvious, but lactation supplements and teas do often get taken for ‘nutrition’, yet also work to boost supply and this can add to the oversupply issue.

There are natural milk-decreasing treatments such as herbs like sage, parsley, and jasmine taken in teas, as well as peppermint oil. Cold and flu treatments containing pseudoephedrine and phenylephrine may also reduce milk supply and are sometimes used under medical guidance for this purpose.

If you do have too much milk you could also consider donating to a milk bank to our undersupply mums out there.

Well done, beautiful mamas! Breastfeeding can have its challenges but the benefits for your baby for their lifelong health and development, and yours too, are so so worth it. 

Stephanie Callaghan Armstrong is a mum of five, experienced Lead Maternity Carer, Midwife & Lactation Consultant and runs a breast pump rental and sales business with husband, Dr Mikey from The Barnstead in Coatesville. Find her at babymed.co.nz, and @babylove.midwife.life & @babymednz on Instagram. 

PHOTOGRAPHY: Catherine Smith