- "I tried to breastfeed, but I couldn't make enough milk."
- “My milk never came in."
- "My milk suddenly dried up!"
- "Your mother had to supplement, so you will, too."
Most mothers have heard at least one of these reports before their own babies arrive. The good news is that the majority of women can produce all the milk their babies need for healthy growth and development. More often than not, concerns about milk production are simple misunderstandings of normal newborn behavior or breastfeeding management issues that can be fixed. Rarely, a woman may have a physical or hormonal condition that makes it difficult to build or maintain milk production. One study suggests these conditions occur in about 5% of the population of women (Neifert, 2001). The following sections outline some of the medical causes of low milk production:
Maternal Conditions Related to Low Milk ProductionInsufficient Glandular Tissue: During puberty, progesterone and estrogen signal the growth and development of the mammary (breast) glands. Active growth of ductal tissue takes place during each menstrual cycle. In rare instances, the glands do not grow or develop fully during puberty, and insufficient glandular tissue, known as breast hypoplasia, may result (Neifert, Seacat, & Jobe, 1985). Some women with insufficient glandular tissue may have breasts that are unusually shaped or appear not to be developed at all. Some women may have breasts that seem to be fully developed but have a limited capacity to produce milk because fatty tissue is present, but glandular tissue is not sufficient. During a normal pregnancy, glandular tissue continues to develop, and there is usually (but not always) a noticeable change in breast size, increased sensitivity or tenderness, visible veining on the breast, and darkening of the areolas. Some signs of breast hypoplasia are:
- “oblong”, tubular shaped breasts
- “flat,” underdeveloped breasts
- widely spaced breasts (more than 1.5” apart)
- breast asymmetry (one breast noticeably larger than the other)
- very large or “puffy” areolas
- absence of noticeable breast changes during pregnancy or after birth
Breast Surgery: Milk ducts may be cut, and nerves can be damaged as a result of surgery. The milk ducts may "re-grow" (recanalize) during pregnancy as the breast changes rapidly in preparation for lactation. Mothers who are unable to produce enough milk to meet the needs of a first baby may have better milk production with the next child as a result of breast development that occurs with each pregnancy. Sometimes, chest surgery or injury may result in nerve damage that affects the milk ejection reflex, or rarely, it may cause damage to the glandular tissue of the breast and result in a decreased capacity to produce milk. Mothers who have had breast, nipple, or chest surgery or injury may find the evidence-based website, Breastfeeding After Breast and Nipple Surgeries, to be helpful and encouraging.
Hormones: Many mothers with a hormonal imbalance such as Polycystic Ovary Syndrome (PCOS) have reported trouble producing enough milk for their babies. To date, PCOS, other hormonal disorders, and related conditions such as insulin resistance and infertility are not well-understood in terms of how they may affect milk-production. Some women may produce excess milk, while others struggle to meet their babies' needs. There are medical treatments which may help maintain balance and an adequate milk supply. A woman who thinks she may suffer from a hormonal imbalance should discuss her concerns with a health-care provider and develop a breastfeeding management plan with an IBCLC before she gives birth.
Impaired Thyroid Function: Hypothyroidism is common in women and may affect “4-10% of women” in the postpartum period (Ogunyemi, 2011). Both Hyperthyroidism and hypothyroidism result in irregular production of the hormones T3 and T4 which act on the metabolism of the body. Women who are experiencing low milk production may benefit from having their thyroid hormone levels tested so that problems may be treated. Many mothers with these conditions will have improved milk production when their symptoms begin to resolve.
Hormonal Birth Control: The use of combined estrogen/progesterone hormonal birth control is associated with low milk production. Many breastfeeding mothers are prescribed progestin-only hormonal birth control because it does not typically decrease milk production. However, it can be associated with a decrease in milk production in some women especially if started before 6 weeks postpartum. Women who are planning to breastfeed should discuss alternative forms of birth control with their health-care providers.
Retained Placenta: The detachment of the placenta signals a cascade of hormones that cause the milk to "come in" after the baby is born. Even a tiny piece of placenta left attached to the wall of the uterus may cause the mother’s body to “think” it is still pregnant. When the placenta does not completely detach as it should, progesterone levels stay too high to allow copious milk production. When the placenta is shed or removed, the mother's milk production is likely to increase (Neville & Morton, 2001). Retained placenta can be very serious. Health-care providers will explain warning signs to watch for, such as very heavy postpartum bleeding.
Excessive Blood Loss: When an abnormal amount of blood is lost during childbirth or through postpartum hemorrhaging, the system that triggers the release of prolactin (the “milk making” hormone) in the pituitary gland may be interrupted, and inhibit milk production.
Infant Conditions Related to Low Milk Production
Latch: A baby who is not attached well and positioned comfortably at the breast may be unable to transfer milk efficiently. An ineffective latch may result in:
- damaged nipples
- disorganized sucking
- fussiness at the breast(Genna, 2008)
A common solution for pain during breastfeeding is to ensure baby is positioned comfortably, stabilized, and given assistance to latch deeply. Sometimes, however, a change in position and a deeper latch do not resolve pain, and there may be a structural problem such as tongue tie, lip tie, or high palate. When breastfeeding discomfort continues despite position and attachment changes, an IBCLC can help with assessment, recommendations for feeding, or referral, if necessary, to other professionals that can assist with treatment.
Suck Dysfunction: If baby is not able to suck effectively and remove milk from the breast, the result may be low milk production. Suck dysfunction is associated with some medical conditions, early birth, low muscle tone, and other problems which should be addressed by a IBCLC or other health-care provider. Some of these babies may tire at the breast while feeding, while others may use their tongues ineffectively or have trouble coordinating the behaviors associated with feeding (Genna, 2008). Sometimes, position changes that increase “positional stability” for the infant (Colson et al, 2008) may be helpful. Some babies improve dramatically with age, but in many cases, close attention from a IBCLC or other health-care provider is also necessary.
Non-Medical CausesInfrequent Nursing: In many cases of low milk production or slow weight-gain, the baby simply needs to nurse more often. Healthy newborns breastfeed an average of at least 10-14 times in 24 hours, and most babies must feed frequently in order to take in enough milk. Many babies who are not gaining weight well simply need more time at the breast, and some babies need encouragement in order to feed more often. A mother may help this process by offering the breast every 1-2 hours and paying close attention to signs that the baby is hungry or satisfied. When the breast is drained, the body responds by making more milk. Placing the baby directly onto the bare skin of the mother's chest facilitates intimate contact between the two of them and is associated with more frequent breastfeeding and greater milk production. All babies need unrestricted access to the breast in the first three weeks, when the body is “primed” to learn to make enough milk (De Carvalho, 1983).
Many factors can lead to babies spending too little time at the breast:
- Early formula supplements can lead to less breastfeeding and lower milk production.
- Frequent visitors, traveling, or entertaining can reduce the time a mother spends alone with her baby, skin-to-skin, and breastfeeding. Early feeding cues can be missed if mother and baby are not together or the baby is sleepy or overwhelmed from being passed from person to person.
- Scheduling, delaying, or limiting breastfeeding restricts the amount of milk a baby is able to remove and how much a mother can produce.
By responding to the needs of her baby when he indicates a desire to nurse, a mother eliminates the hazards of restricting access to the breast. A new family may benefit by limiting distractions and visits from well-meaning family and friends for a few weeks after birth. If people are eager to help with the new baby, the mother can suggest they provide some meals, run errands, or help with some housework. Nursing at the first sign of a hunger cue in the early weeks, can help protect milk production in the long term.
Lack of support: Many mothers experience a lack of support for breastfeeding from their communities. Well-meaning friends, family members, and even health-care providers may undermine breastfeeding by inadvertently giving inappropriate advice. Some health-care providers have little or no training in human lactation and may not be providing the most accurate information about breastfeeding. Family members may want a turn to bottle-feed the new baby. Friends might not be familiar with breastfeeding and question how frequently the baby is at the breast. These situations may result in less breastfeeding and lower milk production.
Misunderstanding normal infant behavior: A fussy or unhappy baby is not always a hungry baby. Mothers and those around them may be concerned that a baby who is fussy or needs to nurse frequently is not getting enough milk. It is not uncommon for a newborn to nurse for 20 minutes and then be ready to nurse again 10 minutes later. The mother is often told, “He can’t be hungry; he just ate,” or “You’ll spoil him.” This kind of advice can lead to giving supplements when they are not needed. Instead, a mother may need to be reassured that her baby is getting enough milk at the breast.
When Supplementation is Necessary: Sometimes babies do not gain weight at the minimal expected rate for health and development and need temporary additional nutrition. Ideally, a supplement should be the mother's own milk or donor human milk. In the early days, if a supplement is necessary, mothers should be encouraged to hand express and supplement with their own colostrum as demonstrated in this video from Stanford School of Medicine: Hand Expression of Milk. Sometimes, a mother is not yet producing enough milk to feed as a supplement and uses formula. Whether a mother supplements with donor human milk or formula, she should be encouraged to express her milk in order to maintain (or increase) her milk production. Because formula takes longer to digest, many babies who are taking supplemental feedings exhibit less-frequent hunger cues. Over time, a baby receiving this kind of supplement may feed less frequently, and if the mother is not also removing milk as frequently as her baby would normally demand, decreased milk production may result.
If a mother does not breastfeed and/or express her milk frequently or fully enough, an unproductive cycle can develop quickly; baby fills up on formula and spends less time at the breast. Baby spends less time at the breast, so the mother produces less milk. Mother produces less milk, so she gives more non-human milk, and so it continues until she is no longer making enough milk for her baby. This cycle can often be reversed if the mother instead makes sure to increase time at the breast, remove milk frequently, and use breast compressions while nursing.
If a baby needs supplemental feedings it is important to explore all of the possible maternal or infant causes of low milk production in order to help restore full breastfeeding. Supplemental feedings, while sometimes necessary, do not address the underlying cause of low milk production. Identifying the cause of the problem, if possible, may help determine the best solution. While supplemental feedings may be part of the plan of action, steps should be taken to ensure that the goal is that exclusive breastfeeding resume.
If you need help making more milk, or if you are worried if your baby is not getting enough milk, an International Board Certified Lactation Consultant or community breastfeeding support worker may be able to help. Finding the support you need can help you reach your breastfeeding goals.
ResourcesBreastfeeding After Breast and Nipple Surgeries
Hidden Hinderances to a Healthy Milk Supply
Making More Milk
MOBI Motherhood International
ReferencesAkre J. E., Gribble, K. D., & Minchin, M. (2011). Milk sharing: from private practice to public pursuit. International Breastfeeding Journal, 6(8). Retrieve December 12th, 2012 from International Breastfeeding Journal Website: http://www.internationalbreastfeedingjournal.com/content/6/1/8
Colson, S. D., Meek, J. H., & Hawdon, J. M. (2008). Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Human Development, 84(7), 441-449.
De Carvalho M, Robertson S, Friedman A, & Klaus M. (1983) Effect of frequent breast-feeding on early milk production and infant weight gain. Pediatrics, 72(3)
Genna, C. W (2008). Supporting Sucking Skills in Breastfeeding Infants. Sudbury: Jones and Bartlett Publishers.
Kent, J., Mitoulas, L., Cregan, M., Ramsay, D., Doherty, D., & Hartman, P. (2006). Volume and frequency of breastfeedings and fat content of breastmilk throughout the day. Pediatrics, e117(3).
Lieberman ,T. (2011). Booby Traps Series: Postpartum hemorrhage and retained placenta – Two birth-related causes of low milk production. Best For Babes. Retrieved December 12th, 2012 from Best for Babes Web Site: http://www.bestforbabes.org/booby-traps-series-postpartum-hemorrhage-and-retained-placenta-two-birth-related-causes-of-low-milk-pr
Marasco, L., PCOS and Breastfeeding. Retrieved Decemeber 12th, 2012 from Hcp.obgyn.net website: http://www.obgyn.net/displayarticle.asp?page=/pcos/articles/childers-chats Neifert, M.R., (2001). Prevention of Breastfeeding Tragedies, Pediatr Clin North Am., 48, 273-297.
Neifert, M.R., Seacat ,J.M., Jobe, W.E., (1985). Lactation failure due to insufficient glandular development of the breast, Pediatrics, 76(5), 823-8.
Neville, M.C., Morton, J. (2001). Physiology and endocrine changes underlying human lactogenesis II. J Nutr., 131(11), 3005S-8S.
Ogunyemi, D. A. (2011). Overview. In Autoimmune Thyroid Disease and Pregnancy.
Retrieved April 8, 2012, from Webmed LLC Web Site: http://emedicine.medscape.com/article/261913-overview
Pennington, S. S., Abrams, A. C., & Lammon, C. B. (2009). Physiology of the Endocrine System. In Clinical Drug Therapy (9th ed., p. 341). Philadelphia: Lippincott, Williams and Wilkins. (Original work published 2001)
The Academy of Breastfeeding Medicine Protocol Committee (2005). ABM Clinical Protocol #13: Contraception During Breastfeeding
West, D., & Marasco, L. (2009). The Breastfeeding Mother’s Guide to Making More Milk. McGraw-Hill.
© Jolie Black Bear, IBCLC, Serena Meyer, IBCLC, Teglene Ryan, and Adrienne Uphoff, IBCLC--All Rights Reserved
© Jolie Black Bear, IBCLC, Serena Meyer, IBCLC, Teglene Ryan, and Adrienne Uphoff, IBCLC--All Rights Reserved