Nursing Mothers Counsel

Maintaining an Adequate Milk Supply

"Maintaining an Adequate Milk Supply when the Infant is not Suckling"; a talk given by Debra Busta Moore, PHN, MSN, IBCLC at the ILCA Regional Conference in Berkeley on March 1 & 2, 2002, reviewed by Peggy Burgi.

Timing and Amount
Maternal Factors
Infant Factors
Pumping
Engorgement
Advice and Methods
Dietary Supplements and Pharmaceuticals

Timing and Amount
We know that breast milk 'comes in' from 2 to 5 days after the birth of the baby and causes heavy, firm and tender breasts. Lack of engorgement can signal a problem, while pathological engorgement can cause problems.

Based on two different studies, estimates of the amount of milk produced in the first days are: Day 1: about 1 oz; Day 2: 3-4 ozs; Day 3: 10-13 ozs; Day 4: about 19 ozs; and Day 5: 19-23 ozs.

Maternal Factors
Several maternal factors influence breastfeeding success: one we may not have thought about before is obesity. Obese women may have physical problems nursing (large breasts are cumbersome) or physiological problems (progesterone is stored in fat, and so the natural drop in progesterone after childbirth which triggers the prolactin levels to rise, may not happen.)

Infant Factors
Infant factors that increase risk include prematurity. Borderline prematurity (36-37 weeks) can be even more troublesome, because the babies seem fine and may be sent home early, where they may be sleepy, or may not demand to eat enough. If baby gets jaundiced, it usually peaks at day 3-5, just as mom's milk comes in. If the baby is hospitalized for the jaundice, and given formula, mom may get severely engorged, which along with separation from baby, causes breastfeeding problems from the start.

Pumping
We know that early and frequent nipple stimulation and milk removal are necessary for a good milk supply. A study noted that mothers who had a higher frequency(more than 6 per day) of pumping made more milk than those who had a lower(less than 6 per day) frequency. There was no significant difference between the amount of milk produced by women who initiated pumping earlier (less than 48 hrs after birth) and those who started pumping later (after 48 hrs) but there was significantly less milk produced by those mothers who started pumping late AND pumped less than 6 times a day. Another study found optimal milk production was associated with 5 or more milk expressions per day, totaling more than 100 minutes per day.

Engorgement
It is very important to prevent or alleviate severe engorgement, because prolonged, unrelieved engorgement results in pressure in the breasts that restricts milk flow. This increased alveolar pressure may lead to lactation suppression (remember when they used to tell mom's to press on their breasts when they wanted to stop a let-down?) The severe pain of engorgement may make pumping too painful.

To relieve engorgement: cold compresses (also cabbage leaves) after pumping will reduce the swelling. Before pumping, warm compresses will ease pain and encourage the milk to flow. Massaging the breast before and during nursing or pumping will stimulate the let-down. Pumping may not produce much milk at first; frequent pumpings, with alternating warm and cold compresses every two hours, over the course of a few pumping sessions may help to signal the body to release milk and continue milk production.

Advice and Methods
In general, when giving a mom advice, telling her why it is important may help her to remember to do it. Mom should begin pumping as soon as possible. Pump 8 to 10 times a day for first 7 to 10 days, every 2 -3 hours during the day. At night do not set an alarm, but pump when your breasts awaken you. Pump fisrt thing in the morning and last thing at night. Skin-to-skin contact increases the amount of milk mom makes.

A study showed that significantly more milk was produced when the mom massaged her breasts before and during pumping.

To help a baby who won't latch on: keep mom and baby together; Increase skin-to-skin contact; teach mom early hunger cues (rooting, sucking on fists--crying is LATE hunger cue!); let baby suck on mom's finger briefly, or introduce colostrum into baby's mouth with dental syringe or tube while sucking on mom's finger, before putting baby on breast; begin pumping within 24 hours. If bottle is necessary, give few cc's by bottle, then try breast again. Maintain the rooting reflex by eliciting rooting behavior with the bottle. Use a slow-flow nipple (should take baby 10-20 minutes to finish.) Hold the baby upright. Make sure the baby's lips are flanged out and around the base of the nipple. Pause during feeding to match what happens when breastfeeding.

Dietary Supplement and Pharmaceuticals
Fenugreek has been used to increase milk supply. It is a common dietary supplement that stimulates the sweat glands (breast tissue is a modified sweat gland.) Tea or tincture may be the most effective. In capsule form, the mom needs to take 2-3 capsules up to 3 times a day (12-15 capsules a day.) It may make her sweat smell strongly of maple syrup, and can cause asthma symptoms, diarrhea and gas in the baby.

Metoclopramide (Reglan) stimulates prolactin secretion. A study of women who experienced a gradual reduction in milk supply that did not respond to increased pumping were given Reglan and increased their milk production. The recommended dosage was 10 to 15 mg per day. To reduce side effects (nervousness, fatigue, somnolence, lassitude) taper up and down: day 1-one tab; day 2-two tabs; day 3-10-three tabs; day 11-two tabs; day 12-one tab.

Domperidone stimulates prolactin secretion. It is not available in the US, but can be purchased over the internet (it is available in Canada) with a prescription. Like Fenugreek and Reglan, it is most effective for the mother whose once-adequate milk supply has diminished. Dosage is 20 mg, 4 times per day or 30mg, 3 times per day. Milk supply should increase in 3-4 days, but may take 2-3 weeks for full effect. It has fewer side effects than Reglan, and side effects may be headache, abdominal cramps and dry mouth.