Low milk supply

Low milk supply is when you are not producing enough milk to meet your baby’s normal growth and development needs. Low milk supply is usually a temporary situation that will improve with appropriate breastfeeding support and management. Making more milk is all about supply and demand — the more milk is removed from the breast, the more milk is made. The less milk removed, the less made.

Many mothers worry about their milk supply, especially in the early stages of breastfeeding. In fact, women who have stopped breastfeeding will most commonly say it was because they ‘didn’t have enough milk’. However, most mothers do produce enough milk for their babies. In fact, most women make one-third more breast milk than their babies typically drink. If your breast milk supply is genuinely low it is usually a temporary situation and can be improved with appropriate support. If you are concerned about your milk supply it is important to seek advice from your doctor, a lactation consultant, Nursing Moms (https://nursingmoms.net) or Breastfeeding USA (https://breastfeedingusa.org).

A newborn’s tummy is very small, especially in the early days. At birth, the baby’s stomach can comfortably digest what would fit in a hazelnut (about 1 to 2 teaspoons). By around 10 days, the baby’s stomach grows to hold about 2 ounces, or what would fit in a walnut. Once breastfeeding is established, exclusively breastfed babies who are 1 to 6 months old take in between 19 and 30 ounces of breastmilk each day ¹. If you breastfeed your baby eight times a day, your baby will get around 3 ounces per feeding. But every baby is a little different.

There are some common reasons why you may think your milk supply is low.

• Your baby feeds too often. Babies naturally feed frequently (normally 8 to 12 times in 24 hours), and in the early days babies can be very unsettled. This does not mean that there is not enough milk. In fact, frequent feeding is necessary to establish a good breast milk supply.
• Your breasts feel soft. When your milk supply adjusts to your baby’s needs your breasts may not feel as full (this may occur anywhere between 3 to 12 weeks following birth). As long as your baby continues to feed well, your breasts will produce enough milk for your baby.
• Your baby has suddenly started to feed more frequently. Your baby may want to feed more during a ‘growth spurt’, but this increased feeding over a couple of days will help you to increase your supply.
• Your baby only feeds for a short time. This is no cause for concern as long as your baby continues to grow. After two or three months your baby becomes more efficient at feeding and therefore will take less time at the breast.

There may be times when you think your supply is low, but it is actually just fine:

• When your baby is around 6 weeks to 2 months old, your breasts may no longer feel full. This is normal. At the same time, your baby may nurse for only five minutes at a time. This can mean that you and your baby are just getting used to breastfeeding — and getting good at it!
• Growth spurts can make your baby nurse longer and more often. These growth spurts often happen around 2 to 3 weeks, 6 weeks, and 3 months of age. Growth spurts can also happen at any time. Don’t be worried that your supply is too low to satisfy your baby. Follow your baby’s lead. Nursing more and more often will help increase your milk supply. Once your supply increases, you will probably be back to your usual routine.

There are many signs you can watch for to see if your baby is getting enough milk. Signs your baby is getting enough milk:

After the first week following birth, your baby should:

• Your baby wakes for feeds by themselves
• Your baby settles between most feeds
• Your baby have at least 6 to 8 soaked nappies (4 to 5 heavy disposable nappies) in 24 hours
• Your baby passes a soft yellow stool (poo) at least once a day.
• Your baby passes enough clear or pale yellow urine (see the Table 1 below). The urine is not deep yellow or orange.
• Your baby has enough bowel movements (see the Table 1 below).
• Your baby switches between short sleeping periods and wakeful, alert periods.
• Your baby is satisfied and content after feedings.
• Your baby releases on his/her own from your breast or falls asleep and releases
• Your breasts may feel softer (not hard) after feeding.
• Your baby’s cheeks are full while feeding rather than sucked in
• Your baby seems happy and content after feeding
• You may feel sleepy after feedings
• You can see/hear your baby swallowing during feeding.

Your baby should be back to birth weight by approximately two weeks of age and gaining an average of 150 grams or more per week for the first three months of life.

From birth to 3 months old, a baby usually will gain up to 1 ounce of weight each day. Keep in mind that many babies lose a small amount of weight in the first days after birth. Your baby’s doctor will check your baby’s weight at your first doctor visit after you leave the hospital. Make sure to visit your baby’s doctor for a checkup within three to five days after birth and then again when the baby is 2 to 3 weeks old.

Keep in mind that babies may request to feed many times throughout each day – this may cause you to feel like you must not be producing enough each feeding. Not to fear, as babies tend to feed 8-12 times per day (24 hours) once the full milk supply comes in. Things that many moms might worry about, but should not have anything to do with your actual milk supply:

• Having a fussy baby (this is common aside from getting enough milk)
• Your baby wants to nurse often (every 1.5 to 2 hours is pretty common for breastfed babies)
• Your breasts don’t leak any milk or they suddenly stop leaking (doesn’t have to do with milk supply)
• Your breasts feel softer than they used to (this is pretty natural once full supply comes in)
• You get very little when pumping after a feeding (babies are more efficient at extracting milk than a pump, and your leftover milk amount isn’t a good indication of milk supply)
• Your baby suddenly increases his/her frequency of nursing (likely will line up with a growth spurt!)

Table 1. Typical number of wet diapers and bowel movements in a baby’s first week (it is fine if your baby has more): 1 day = 24 hours

Baby’s age	Number of wet diapers	Number of bowel movements	Texture and color of bowel movements
Day 1 (first 24 hours after birth)	1-2	The first bowel movement usually occurs within 8 hours after birth	Thick, tarry, and black
Day 2	2	3	Thick, tarry, and black
Day 3	5-6 disposable, 6-8 cloth	3	Looser and greenish to yellow (color may vary)
Day 4	6	3	Soft, watery, and yellow
Day 5	6	3	Loose, seedy, and yellow
Day 6	6	3	Loose, seedy, and yellow
Day 7	6	3	Larger amounts of loose, seedy, and yellow

Footnote: If you are using disposable diapers, the absorbency may make it harder to tell if the diaper is wet. Use this chart as a guide, but talk to your child’s doctor if you are concerned about your child not getting enough milk.

[Source ¹ ]

What you can do

• Make sure your baby is latched on and positioned well.
• Breastfeed often and let your baby decide when to end the feeding.
• Offer both breasts at each feeding. Have your baby stay at the first breast as long as he or she is still sucking and swallowing. Offer the second breast when the baby slows down or stops.
• Avoid giving your baby formula or cereal in addition to your breastmilk, especially in the first 6 months of life. Your baby may lose interest in your breastmilk, and your milk supply will decrease. If you need to supplement your baby’s feedings with more milk, try using a spoon, cup, or a dropper filled with pumped breastmilk.

To boost milk production:

• Breast-feed as soon as possible. Waiting too long to start breast-feeding can contribute to a low milk supply. Hold your baby skin to skin right after birth and your baby will likely breast-feed within the first hour after delivery.
• Breast-feed often. For the first few weeks, breast-feed eight to 12 times a day — about every two to three hours.
• Check your latch. Make sure your baby is latched on and positioned well. Look for signs that your baby is swallowing.
• Be alert to feeding problems. Offer both breasts at each feeding. It’s OK for your baby to nurse on only one breast at a feeding occasionally — but if this happens regularly, your milk supply will decrease. You might pump the other breast to relieve pressure and protect your milk supply until your baby begins taking more at each feeding.
• Don’t skip breast-feeding sessions. Pump your breasts each time you miss a breast-feeding session to help protect your milk supply.
• Hold off on the pacifier. If you choose to give your baby a pacifier, consider waiting until three or four weeks after birth. This will give you time to establish your milk supply.
• Use medications with caution. Certain medications decrease milk supply, including medications containing pseudoephedrine (Sudafed, Zyrtec D, others). Your health care provider might also caution against certain types of hormonal contraception, at least until breast-feeding is firmly established.
• Avoid alcohol and nicotine. Drinking moderate to heavy amounts of alcohol can decrease milk production. Smoking can have the same effect.

Maintaining your milk supply during breast-feeding is important for your baby’s health and growth. If you’re concerned about your milk supply or your baby’s feedings, talk to your doctor, your baby’s doctor or a lactation consultant.

Tips for breastfeeding success

• Learn your baby’s hunger signs. Signs your baby may be hungry include:
  • Becoming more alert and active
  • Putting hands or fists to the mouth
  • Making sucking motions with the mouth
  • Turning the head to look for the breast
  • Crying can be a late sign of hunger, and it may be harder for the baby to latch if he or she is upset. Over time, you will be able to learn your baby’s cues for when to start feeding.
• Follow your baby’s lead. Some babies will feed from (or “take”) both breasts, one after the other, at each feeding. Other babies take only one breast at each feeding. Help your baby finish the first breast as long as he or she is still sucking and swallowing. Your baby will let go of your breast when he or she is finished. Offer your baby the other breast if he or she seems to want more. If your baby falls asleep while nursing and you are worried he or she did not get enough milk, try switching to the other breast or squeeze your breast to encourage more milk to flow and wake up your baby. Learn how to tell if your baby is getting enough milk.
• Keep your baby close to you. Skin-to-skin contact between you and baby will soothe his or her crying and also will help keep your baby’s heart and breathing rates stable. A soft carrier, such as a wrap, can help you “wear” your baby.
• Avoid nipple confusion. Do not use pacifiers and bottles in the first few weeks after birth unless there is a medical reason. If you need to use supplements, work with a lactation consultant. She can show you ways to give supplements that help you and your baby continue breastfeeding. These include feeding your baby with a syringe, a tiny tube taped beside your nipple, or a small, flexible cup. Try to give your baby expressed or pumped milk first.
• Make sure your baby sleeps safely and close by. Have your baby sleep in a crib or bassinet in your bedroom so that you can breastfeed more easily at night. Research has found that when a baby shares a bedroom with his or her parents, the baby has a lower risk of sudden infant death syndrome called SIDS ².

Check with your doctor for health issues, such as hormonal issues or primary breast insufficiency, if the above steps don’t help.

How is breastmilk made?

Breasts often become fuller and more tender during pregnancy. This is a sign that the alveoli, cells that make breastmilk, are getting ready to work. Some women do not feel these changes in their breasts. Other women may feel these changes after their baby is born.

The alveoli make milk in response to the hormone prolactin. Prolactin levels go up when the baby suckles. Levels of another hormone, oxytocin (oks-ee-TOH-suhn), also go up when the baby suckles. This causes small muscles in the breast to contract and move the milk through the milk ducts. This moving of the milk is called the “let-down reflex.”

The release of prolactin and oxytocin may make you feel a strong sense of needing to be with your baby.

What is the let-down reflex during breastfeeding?

The let-down reflex also called just “let-down” or the milk ejection reflex, happens when your baby begins to nurse. The nerves in your breast send signals that release the milk into your milk ducts. Let-down happens a few seconds to several minutes after you start breastfeeding your baby. It also can happen a few times during a feeding. You may feel a tingle in your breast or you may feel a little uncomfortable. You also may not feel anything.

Let-down can happen at other times, too, such as when you hear your baby cry or when you’re just thinking about your baby. If your milk lets down as more of a gush and it bothers your baby, try expressing some milk by hand before you start breastfeeding.

Many factors affect let-down, including anxiety, pain, embarrassment, stress, cold, too much caffeine, smoking, alcohol, and some medicines. Mothers who have had breast surgery may have nerve damage that interferes with let-down.

How do I know that baby is getting enough milk?

Always look at the whole picture to ensure that baby’s growth and development is with normal limits. The baby is getting enough milk if they:

• go through 6 to 8 wet nappies in a 24-hour period including at least a few dirty nappies
• wake for feeds by themselves and feed vigorously at the breast
• have 8 to 12 breastfeeds in 24 hours
• pass a soft yellow stool
• settle and sleep fairly well after most feeds
• is back to birth weight in about 2 weeks
• gain on average 150g or more every week for the first 3 months

How do I know if I will make enough breastmilk?

Many mothers worry about making enough milk to feed their babies. Some women worry that their small breast size will make it harder to feed their babies enough milk. But women of all sizes can make plenty of milk for their baby. The more often your baby breastfeeds, the more milk your breasts will make.

Your baby’s weight should double in the first few months. Because babies’ tummies are small, they need many feedings to grow and be healthy. You can tell if your baby is getting enough milk by the number of wet diapers he has in a day and if he is gaining weight.

If you think you have or will have a low milk supply, talk to a lactation consultant.

What if my breastmilk supply goes down?

If you don’t feel as “full” as you did in the first few weeks of breastfeeding, you may worry that you are not making enough milk for your baby. But know that the milk is still there and flowing to your baby. Usually, after a few months of breastfeeding, your body learns to make the right amount of milk for your baby.

Also, your baby may only nurse for short periods, such as five minutes at each feeding. These are not signs of lower milk supply. Your body adjusts to meet the needs of your baby, and your baby gets very good at getting milk from the breast. It’s also normal for your baby to continue to nurse longer on each breast at each feeding.

How often should I breastfeed?

You should breastfeed as soon as possible after giving birth. Then, breastfeed your baby every 2 to 3 hours each day so that you will make plenty of milk. This means that in the first few days after birth, your baby will probably need to breastfeed about every one to two hours during the day and a few times at night.

Healthy babies develop their own feeding patterns. Follow your baby’s cues for when he or she is ready to eat.

What can affect how much breastmilk I make?

You may make more or less milk, depending on:

• How completely milk is removed each time you breastfeed. An empty breast means better milk production.
• How often you nurse or pump to remove milk. The more often you empty your breasts, the more milk your breasts will make.
• The amount of milk your breasts store between feedings. If your breast stores too much milk between feedings (because your baby doesn’t empty the breast), your breast will make less milk. If your breast is emptied, it will make more milk. It is common for one breast to make more milk than the other, and it is normal for babies to prefer one breast over the other. This can affect how much milk you make in that breast.

How can I make more breastmilk?

The best way to make more breastmilk is to breastfeed often and to empty your breasts completely at each feeding.

After emptying your breasts at each feeding, less milk builds up in your breasts between feedings.

To better empty your breasts, follow these tips:

• Use breast massage and compression.
• Offer your baby both breasts at each nursing.
• Pump after nursing if your baby does not remove all the milk from your breasts. Your breasts will soften when the milk is removed. If the baby empties your breasts, then you can pump to remove milk and increase milk production between nursing sessions.

How long should breast feedings be?

There is no set time for breastfeedings. They may be 15 to 20 minutes per breast, or they may be shorter or longer. Your baby will let you know when he or she is finished feeding. If you worry that your baby is not getting enough milk, talk to your baby’s doctor.

Will my breastmilk change as my baby grows?

Yes. Your breastmilk changes in the days after birth and continues to change as your baby grows. Learn what will happen with your milk, your baby, and you in the first few weeks.

Birth

• Milk: Your body makes colostrum (a rich, thick, yellowish milk) in small amounts. It gives your baby early protection against diseases.
• Baby: Your baby will probably be awake in the first hour after birth. This is a good time to breastfeed your baby.
• You (Mom): Let your baby begin the process of searching for your nipple. This baby-led way of breastfeeding can help your baby get a good latch.

First 12 to 24 hours

• Milk: Your baby will drink about 1 teaspoon of colostrum at each feeding. You may not see the colostrum, but it has what your baby needs and in the right amount.
• Baby: It is normal for the baby to sleep heavily. Labor and delivery are hard work! Some babies like to nuzzle and may be too sleepy to latch at first. Feedings may be short and disorganized.
• You (Mom): Your body is still making colostrum. Take advantage of your baby’s strong instinct to suck and feed upon waking every couple of hours to help your milk come in faster.

Next 3 to 5 days

• Milk: Your mature (white) milk takes the place of colostrum. It is normal for mature milk to have a yellow or golden tint at first.
• Baby: Your baby will feed a lot, at least 8 to 12 times or more in 24 hours. Very young breastfed babies do not eat on a schedule. It is okay if your baby eats every 2 to 3 hours for several hours, then sleeps for 3 to 4 hours. Feedings may take about 15 to 20 minutes on each breast. The baby’s sucking rhythm will be slow and long. The baby might make gulping sounds.
• You (Mom): Your breasts may feel full and leak. (You can use disposable or cloth pads in your bra to help with leaking.)

First 4 to 6 weeks

• Milk: White breastmilk continues.
• Baby: Your baby will now likely be better at breastfeeding and have a larger stomach to hold more milk. Feedings may take less time and may be farther apart.
• You (Mom): Your body gets used to breastfeeding. Your breasts may become softer and the leaking may slow down.

How long should I breastfeed my baby?

The American Academy of Pediatrics ³ recommends breastfeeding as the only source of food for the first 6 months of your baby’s life. The American Academy of Pediatrics also recommends continuing breastfeeding (after starting solid food) beyond your baby’s first birthday and for as long as both you and your baby would like ³. The easiest and most natural time to wean is when your child leads the process. But how you feel is also very important in deciding when to wean.

Your decision may depend on several factors, such as returning to work, your or your baby’s health, or a feeling that the time is right.

When should I not breastfeed?

While rare, your doctor may advise you not to breastfeed if you:

• Take certain medicines, like anxiety medicine or certain migraine medicines, that are dangerous for babies and can be passed to your baby in your breastmilk
• Have a specific illness (like HIV or active tuberculosis)
• Get radiation therapy, though some therapies may mean only a brief pause in breastfeeding

If you take medicine or are sick, talk to your doctor before you begin breastfeeding. Medicines that are safe for you to take during pregnancy may also be safe while you are breastfeeding. But you should always check with your doctor before you start breastfeeding. Talk to your baby’s doctor if your baby shows any signs of a reaction to your breastmilk, such as diarrhea, excessive crying, or sleepiness.

Should I stop breastfeeding when I am sick?

You can usually continue to breastfeed your baby when you are sick, and if your baby is sick. If you need to rest you can pump or hand express breastmilk for someone else to feed the baby. But if you are sick with the flu, including the H1N1 flu (also called the swine flu), do not touch or be near your baby, so that you do not infect him or her. Have someone who is not sick feed your baby your pumped or expressed breastmilk.

Causes of low milk supply

Possible causes of low milk supply:

• Your baby is not attaching well at the breast (bad positioning during feeding). This may also cause nipple pain and damage.
• Incomplete latch
• Cutting feedings short (instead of letting the baby decide when he/she’s done)
• Your baby does not feed often enough. Nearly all babies need to feed at least 8 to 12 times in 24 hours.
• Tongue or lip tie in baby
• Your baby does not feed effectively at the breast.
• You have started using formula milk as well as breastfeeding.
• You have had breast surgery that is effecting your milk supply. Having fewer than normal milk ducts (ex. from surgeries or cancer)
• You have recently had mastitis.
• You are taking oral contraceptive pills containing estrogen.
• You smoke cigarettes.
• You drink alcohol.
• Using pacifiers or nipple shields
• Scheduling feedings rather than feeding on demand
• Baby sleeps too much/through the night (lessens the frequency of feeding – wake baby up more often to feed)
• Mom’s health issues (postpartum reproductive issues such as retained placenta; others such as anemia)
• Some medications, including over-the-counter and herbal preparations such as cold/flu tablets, may reduce your milk supply.
• Rarely, there may be reduced or no milk production because of a medical condition. This occurs in less than five per cent of mothers.

Other factors that can affect milk production include:

• Premature birth
• Maternal obesity
• Pregnancy-induced high blood pressure
• Poorly controlled insulin-dependent diabetes

Signs of low milk supply

Most mothers make plenty of milk for their babies. But many mothers worry about having enough milk. This video suggests that checking your baby’s weight and growth is the best way to make sure he or she gets enough milk. Let your baby’s doctor know if you are concerned.

Typical baby behavior

Some health professionals and mothers have an unrealistic expectation of how the baby will behave and might be concerned that what is normal baby behavior could indicate low supply.

If your baby is having a good number of wet nappies each day, low supply is not a likely cause.

Some issues with breastfeeding include:

• wanting to be fed often — breast milk is digested in about 1.5 to 2 hours, whereas formula takes longer to digest
• being more fussy in the evening; you might produce less milk at this time and your baby will request fewer feeds or will ‘cluster feed‘ (feed frequently at certain times of the day)
• having a fussy or unsettled time in the day that may last for a few hours
• liking to suck even if they have had a good breastfeed — sucking comforts them
• wanting lots of cuddles and skin to skin contact — this makes them feel secure and ensures that baby’s needs are being met
• wanting to feed more frequently, which will happen when a baby is having a growth spurt — increased feeding will increase your supply
• reduces the amount of sucking time at the breast — this often happens after 2 or 3 months as your baby becomes more efficient at the breast

Although breastfeeding is different for every woman, the following do not mean that you have a low supply:

• your breasts suddenly seem softer — this is normal as your milk supply adjusts to your baby’s needs
• your breasts do not leak milk, stop leaking or only leak a little
• you don’t feel a ‘let-down‘ when milk pushes out of the breast
• you are unable to pump very much with an electric pump — remember the baby is much more efficient and will always get more than a pump
• how much you pump decreases over time

How to increase your milk supply

The key to increasing your milk supply is frequent stimulation and emptying of the breasts. This may take some time and it is important that you seek advice and support from a lactation consultant, your maternal and child health nurse or other health care professional skilled in breastfeeding management.

• Hold your baby skin-to-skin at the breast (baby dressed in a nappy only, so that there is direct skin contact between you and your baby). This will help to keep your baby awake and also to increase the release of hormones involved in breast milk production.
• Breastfeed on demand (or more if the baby is not very demanding)
• Breastfeed frequently, two to three hourly (at least every 3 hours at night) – a total of at least 8-12 times in 24 hours. Your baby may need to be woken for some feeds, or may wake to feed even more often.
• Make sure that attachment is good and that your baby is both sucking and swallowing (you may need to seek help with this).
• Switch feed; offer each breast twice. When you notice your baby is becoming tired or not swallowing very frequently anymore, take your baby off that breast and ‘switch’ to the next side. Repeat on both breasts. This will ensure your baby is draining the breast more efficiently.
• Express after breastfeeds to provide further stimulation to your breasts and to ensure that your breasts are well drained. Practice hand expressing/breast massage. This will help increase your milk supply.
• Increased frequency of pumping and milk draining will let your body know that more milk is needed on a regular basis. Practice power pumping (pumping in between feeding sessions or continuing to pump after the last drops of milk have been expressed)
• If your baby is sleepy at the breast and not feeding well you may need to cut short the feed and use the time to express each breast twice, for example, five minutes left side, five minutes right side and then repeat. The expressed breast milk should then be fed to your baby.
• When breastfeeding or expressing, compress or massage your breasts to assist with milk flow and drainage.
• If you need to give your baby extra milk, give expressed breast milk separately and before any infant formula. Seek advice from a lactation consultant or other health professional before commencing infant formula.
• As the mom, get plenty of rest, try to eat a balanced diet, and drink plenty of water
• Sometimes prescription medicines are used to assist with increasing milk supply; these are available from your doctor (e.g., domperidone).

Talk to your doctor about strategies to manage feeding and expressing while you are increasing your milk supply. Often it takes about one hour to feed and express. Then you and your baby can rest between feeds. If nothing seems to work in finding a good balance for you and your baby, contact a breastfeeding professional, such as a lactation consultant, for help.

Before trying any herbal supplements, talk to your doctor regarding safety and dosing.

Foods and herbs that are supposed to help increase milk supply:

• Fenugreek: Fenugreek is likely the most commonly used galactagogue. A seed extract that can quickly increase milk supply, the recommended daily dose is 3.5-6 grams depending on your doctor’s or lactation consultant’s advice. Some women notice they have a maple syrup smell when taking fenugreek. It may also cause contractions or an allergic reaction, do not take fenugreek if you are pregnant or allergic to peanuts or soybeans.
• Blessed Thistle: Blessed Thistle has been used as a medicine for hundreds of years and has been shown to increase milk supply. It works best when taken in combination with fenugreek. It comes in capsule or tea form and should be taken three times per day.
• Alfalfa: A type of pea, alfalfa has a mild effect on increasing milk supply and is often used in combination with fenugreek. You can take alfalfa in pill, tea, or food form. Alfalfa sprouts have a pleasant, nutty flavor and have a number of health benefits. You can also make tea from alfalfa leaves or take as a tablet.
• Goat’s Rue: Goat’s Rue can be a powerful galactagogue and is often taken along with a blend of fenugreek and other herbs. Do not use it in its fresh format as it is considered toxic; use only commercially prepared dry leaves for tea or capsules. These herbal supplements are readily available online or at your local health food store. Talk to your doctor or lactation consultant before taking any supplements, particularly if you have allergies or are taking any prescription medications.
• Oatmeal
• Vegetables/Leafy greens
• Garlic (too much can change the taste of your breast milk, so be careful)
• Sesame seeds.

Breast pump

When breastfeeding directly from the breast isn’t possible, expressing your breasts is the next best option. This can be done by hand or using a breast pump. In addition to providing for your baby’s immediate needs, expressing helps establish an adequate milk supply for when your baby can feed from your breast. Many pharmacies hire and sell breast pumps.

Hand expressing combined with using an electric pump has been shown to increase the amount of breast milk you produce. Expressing quite frequently (at least 8-12 times in 24 hours) is the
most effective way to establish a milk supply that is adequate for your baby to continue breastfeeding.

Sometimes it can be difficult to express breast milk. Try sitting in a quiet, comfortable place with some water or a hot drink. If separated from your baby having a photograph to look at may be helpful.

When your baby is born earlier than expected or is unwell, providing your breast milk for feeds is very important.

If you experience any pain or discomfort when using a breast pump, seek advice from a breastfeeding specialist.

Purchasing a breast pump

There are various things you should consider before purchasing a breast pump.

• If feeding is going well you may not need to purchase a pump.
• There is no need to purchase a pump while you are pregnant – it is best to wait and see if you need one and if you do which type will best suit your needs.
• Hand or manual pumps are intended for occasional use – no more than 2–3 times a day.
• Some hand pumps can be used with electric breast pumps.
• Electric pumps are for more frequent use, for example, more than 3 times a day or for a long period of time.
• If you have a premature baby it is best to use an electric breast pump.
• How often you use a pump will determine which is the correct type for you.

Before hiring or purchasing any pump equipment get advice from a breastfeeding specialist.

Expressing by hand

Before using a breast pump start by expressing your milk by hand.

1. Place warm packs or flannels on your breast to help the milk ‘let-down’ (starting to flow).
2. Gently massage your breast downward toward the nipple then gently press around the areola inward with the thumb and forefingers.
3. Compress gently to roll the nipple between your fingers.
4. Repeat these movements for several minutes and a drop of milk may appear.
5. After a few minutes of hand expressing start to use the breast pump.

Using a hand pump

1. Start by expressing by hand as described.
2. Place the pump shield centrally over your nipple and hold it firmly against your breast, without digging in.
3. Use the pump gently but quickly at first – this helps with the let-down reflex and mimics what your baby does when they first start a breastfeed.
4. Once the milk is flowing use a slower speed but stronger suction.

Using an electric pump

1. Start by expressing by hand as described.
2. Place the appropriately sized pump shields centrally over your nipple/s and hold them firmly against your breasts, without digging in.
3. Adjust the pump suction levels so that your breasts are quite comfortable.
4. Use at high speed but low suction at first (or if using a pump with an automatic speed setting see manufacturer’s instructions).
5. Once the milk is flowing, slow the speed back to medium.
6. Increase the suction to a level that is comfortable for you, this helps the milk flow well and avoids damage to your nipples and areola.
7. Your nipple should move freely in the pump shield without your areola being pulled into it.
8. Express for the duration of the pump program or for 10–20 mins total or until your milk flow is reduced to drops.

If you are unsure about the breast shield fit, or if it is not comfortable, or you are experiencing any pain and discomfort when using the pump, seek advice from a breastfeeding specialist.

Double pumping

Double pumping (expressing both breasts at once) will decrease the time needed to express. It is recommended for longer term expressing and for mothers of twins or other multiples.

Expressing with a double electric pump kit

1. Follow steps 1–6 of using an electric pump.
2. When you are ready, place the second pump shield over your other nipple.
3. Express for 10–15 minutes total or until your milk flow is reduced to drops.

Some mothers find that expressing both breasts by hand for a minute or so after using the pump helps to get a few extra mls and help maintain their milk supply. At any time, you can use the  pump as a single pump if you prefer.

Cleaning the breast pump equipment

• Wash your hands thoroughly.
• Dismantle all pieces of the breast pump kit after each use.
• Rinse with cold water all parts that come in contact with breast milk
• Wash in warm water and dishwashing detergent
• Rinse thoroughly under warm running water
• Allow to air dry while draining on clean paper towel before storing in a clean closed container or plastic bag.
• It is recommended that the equipment is sterilized daily if your baby is in a Special Care Nursery.
• The equipment can be sterilized daily by using
  • a process such as boiling (see below)
  • chemical solution (follow manufacturer’s directions)
  • a home steam sterilizer (follow manufacturer’s directions).

Boiling method of disinfection

• Wash hands thoroughly
• Thoroughly clean all parts as above
• Completely immerse all parts of the breast pump kit in water, bring to the boil and continue to boil rapidly (completely submerged) for five minutes uninterrupted
• Remove the items without touching the inside of the containers. Long handled tongs, which have been sterilized along with the breast pump kit, may be useful

Allow to air dry while draining on clean paper towel before storing in a clean closed container or plastic bag.

Guidelines for storage of breastmilk at home

Table 2. Guidelines for storage of breastmilk at home

Breast milk status	Room temperature (78.8 °F [26°C] or lower)	Refrigerator (39.2 °F [4°C] or lower)	Freezer
Freshly expressed into container	6–8 hours If refrigerator is available store milk there	3–5 days Store at back where it is coldest	2 weeks in freezer compartment inside refrigerator 3 months in freezer section of refrigerator with separate door 6–12 months in deep freeze (-0.4 °F [-18°C] or lower)
Previously frozen thawed in refrigerator but not warmed	4 hours or less – that is, the next feeding	24 hours	NEVER refreeze human milk after it has been thawed
Thawed outside refrigerator in warm water	For completion of feeding	4 hours or until next feeding	NEVER refreeze human milk after it has been thawed
Infant has begun feeding	Only for completion of feeding	Discard	Discard

Supplemental nursing system or ‘supply line’

A full breastfeeding assessment should always be performed by a lactation consultant to see if a supply line might be likely to help with breastfeeding.

Using a supply line can help increase your milk supply. When a baby breastfeeds with a supply line it usually helps them to drink more milk at the breast and stay sucking at the breast for longer. A supply line can be used short or long term depending on your circumstances and your baby’s feeding needs.

What is a supply line?

Expressed breast milk or infant formula can be given through a fine tube, known as a supply line, taped to your breast so that the end of the tube is close to your nipple during breastfeeding. As your baby sucks, extra milk comes down the tube from a small container worn on a cord around your neck.

Types of supply line feeding devices

There are a few different types of supply line feeding devices. In your hospital the lactation consultants may use a very thin baby feeding tube attached to your breast so that the tip is close to the nipple and with the other end placed in a bottle. A range of equipment options work in the same way.

Why use a supply line?

When a baby feeds with a supply line they get more milk and are likely to breastfeed for longer. This can be helpful because extra sucking helps make more breast milk. Babies who feed only from the breast are more likely to continue to breastfeed well.

Some babies become used to feeding from a bottle and have difficulty returning to feeding directly from the breast. Using a supply line while breastfeeding may help your baby avoid this problem.

A supply line may also help babies who:

• get tired easily sucking at the breast because they are small, premature or unwell
• have lost a lot of weight and need a top-up feed
• are not breastfeeding well after a period of bottle feeding
• are taking longer than usual to improve their sucking and feeding
• need extra feeds using a nasogastric tube, cup or a bottle after breastfeeds.

A supply line can be useful for mothers who:

• aren’t able to provide all the milk their baby needs from the breast alone – this is rare and may be related to previous breast surgery or to other less common circumstances
• have been very unwell and need to re-establish breastfeeding
• have not given birth to the baby and wish to breastfeed, this could be the case with adoption, surrogacy or a same sex partner who did not give birth but wish to breastfeed.

Using your supply line

• Wash your hands thoroughly before preparing the supply line.
• Fill your bottle with the right amount of milk for your baby at this feed. Your lactation consultant will discuss this with you.
• You may be advised to breastfeed on both breasts first or until your baby is feeding a little less vigorously before introducing a supply line. Offering the breast before using the supply line in these circumstances can stimulate a better milk supply.
• When you are ready to use the supply line, place the tubing into the container of milk.
• Allow your baby to attach to your breast inserting one end of the tubing into the corner of your baby’s mouth, pointing it slightly towards the roof of their mouth. The tube may also be effective when inserted under your nipple, so that it is directly over your baby’s tongue.
• The tubing only needs to go just past your baby’s gums. Your baby will suck on your breast and the tube at the same time, drawing extra milk through the tube into their mouth (like sucking on a straw).
• Initially hold the bottle of milk at the same level as your nipple. If you need to slow or increase the flow you can do so by changing the level of the bottle. If the bottle is too high the flow will  be too fast, and your baby may swallow too quickly. If the container is held too low the flow may be too slow and your baby may become frustrated and tired. Your lactation consultant will  work with you to see what works best.
• If your baby is breathing regularly and sucking in a relaxed and rhythmic way (1 to 3 sucks per swallow) the milk flow will be working well. If your baby seems distressed, for example, pushes away from your breast, gets upset, coughs or splutters, the flow from the supply line should be slowed by lowering the bottle and waiting until your baby is calm again.

If using a supply line that you have purchased, please refer to the manufacturer’s guidelines for use and cleaning instructions.

Decreasing the use of the supply line

Your midwife, maternal and child health nurse or lactation consultant can plan this with you. Gradually reducing use, while looking out for signs that your baby is still getting enough milk, is  important. When your baby is alert and responsive and has 5-8 heavy wet nappies in 24 hours (and the nappies are pale in color and do not smell strongly), you may be reassured about your milk supply. Continue seeing your local maternal and child health nurse to talk about any concerns and for ongoing advice.

Cleaning a disposable supply line tube and bottle in the home setting

All feeding equipment needs careful cleaning.

Cleaning the tubing

• The feeding tube must be cleaned thoroughly as soon as the feed is finished. Rinse the tube using a syringe to remove any milk from the tubing and to avoid the growth of bacteria – this is particularly important when infant formula is used.
• The tube and cleaning syringe can be re-used for a total of 24 hours. Each 24 hours the tube and syringe must be discarded and replaced with new equipment.
• Use a 10ml syringe to flush 10mls of cooled boiled water through the tube.
• Flush the tube at least 3 times, more if there is any milk still visible in the tube.
• Always store the cleaned tube in a clean sealed container or plastic bag in the fridge.
• Boiled water can be made up for the whole day – boil fresh water in the kettle and pour into a clean container to cool. Cooled boiled water can be kept for 24 hours in the fridge and used as required for cleaning.

Cleaning the bottle

• Cleaning and sterilizing the bottle should occur after each feed if you are using infant formula and at least once every 24 hours if using breast milk.
• Clean the milk bottle as soon as possible after every feed is completed.
• Rinse the bottle in cold water then wash in warm soapy water and rinse clean in hot water.
• Dry the bottle with paper towel and store safely until next feed if using breast milk. Sterilize the bottle as you usually would if using infant formula.

Domperidone for increasing breast milk

Domperidone is a prescription medicine generally used for nausea and vomiting. However, in your case it is used to increase breast milk supply.

Domperidone increases the level of the hormone prolactin which is involved in breast milk production. Expressing or breastfeeding frequently, while taking domperidone, will help increase your breast milk supply.

When is it appropriate to use domperidone?

Taking domperidone to increase breast milk supply should only be done under medical supervision.

Domperidone may be used when breast milk supply is low and when extra breastfeeding or expressing are not enough to increase milk supply. It is rarely used before seven days after birth.

Domperidone may be useful for mothers of premature babies, very sick newborns or adopting mothers as keeping up a milk supply can be difficult for some of these mothers.

When should domperidone NOT be used?

Domperidone should not be used if women are taking certain (but not all) medicines such as:

• antibiotics
• antifungals
• heart medicines
• some mood medicines such as antidepressants/antipsychotic medicines.

Also, domperidone may not be appropriate if women have a history of some particular medical problems, or have been sensitive to domperidone in the past. Your doctor will discuss if this medicine is right for you.

If you start any new medication, it is important you tell your doctor and pharmacist that you are taking domperidone.

What is the usual domperidone dosage?

To increase breast milk production, you will use 10mg of domperidone (one tablet) three times a day until breast milk supply is well established. This may take several weeks.

Occasionally, your lactation consultant or doctor may increase the dose to 20mg (two tablets) three times a day. The dose may vary depending on your milk supply, but you should not have more than 60mg (six tablets) in one day.

Once milk supply is well established, you can decrease the dose, e.g. 10 mg (one tablet) two times a day for one week, before stopping the medicine altogether.

How long does domperidone take to work?

It may take a week before you notice an increase in breast milk supply and two to four weeks to achieve the maximum effect. It is important to keep breastfeeding or expressing during this time. Keep in touch with your breastfeeding specialist, such as your lactation consultant, doctor, or maternal and child health nurse, for ongoing advice.

How long is the treatment for?

The length of treatment depends on your response to the medicine. You and your doctor will decide how long you use domperidone.

Domperidone side effects

Some reported side effects include headache (most common), abdominal pain, dry mouth, rash and trouble sleeping. Other side effects such as restlessness and muscle spasm may occur, but they are very rare. Tell your doctor or pharmacist if you experience anything unusual or if you feel unwell.

Very small amounts of domperidone pass into breast milk so it is very unlikely that your baby will have side effects from the medicine. No side effects have been reported in infants of breastfeeding
mothers using domperidone.

References

1. Kent, J.C., Mitoulas, L.R., Cregan, M.D., Ramsay, D.T., Doherty, D.A., Hartmann, P.E. (2006). Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics; 117(3): e387-e395. https://pediatrics.aappublications.org/content/pediatrics/117/3/e387.full.pdf
2. Buckley, K.M., Charles, G.E. (2006). Benefits and challenges of transitioning preterm infants to at-breast feedings. International Breastfeeding Journal; 1(13): 1-13.
3. American Academy of Pediatrics (AAP) (2012). Breastfeeding and the use of human milk (link is external). Pediatrics; 129(3): e827e841.