LOW SUPPLY - INITIAL or TRUE LONG TERM
Breastmilk supply in the vast majority of women is abundant and in perfect amounts for your growing baby. However, in some cases, low milk supply can be an issue and close investigation is needed to determine the cause and implement remedies. Low Supply can be picked up at any stage on the postpartum journey.
It can be categorized into two categories, there could be an initial low milk supply due to the birth or events surrounding the birth or there can be true long term low milk supply and it is important to distinguish between the two. Initial low milk supply can usually be managed and corrected with some hard work and close monitoring but true low supply due to physiological reasons may need ongoing supplementation. The sooner initial low supply is caught and corrected the better the long-term supply outcomes.
Initial Low Supply as a result of birth can be due to the following:
Breastfeeding Mismanagement in the early days after birth is the number one cause of initial low supply in my experience. This can include the early introduction of formula, lack of adequate information and assistance given to the parent to teach them to latch effectively causing nipple damage or a baby not effectively drawing milk from the breast, not knowing how often to feed, delayed hand expression or pumping in the event of separation of the mother and baby, babies in nursery’s instead of next to the mother, early scheduling of feeding, disruption and a lack of understanding of normal and essential day two cluster feeding.
Extended labour – Long labours can impact the onset of copious milk production post colostrum phase.
Opioid pain medications in labour can cross the placenta leading to a sleepy or disorientated baby who does not effectively feed in the initial hours after birth.
Epidurals and IV Fluids for long periods of time can increase the fluid load in the mother’s breasts and therefore slow the onset of milk as well as make it harder for the baby to latch onto the breast due to the increased swelling and temporary flattening of the nipple. Babies also receive some of the increased fluid load from IV Fluids and birth leading to a bigger weight drop in the first day or two of life, leading to an increased likelihood of early supplementation interrupting normal breastfeeding.
Instrumental delivery can impact on both sides, one for the mother’s level of pain and discomfort, two for the baby’s level of pain and temporary impact on cranial nerves in the baby that are responsible for feeding behaviours as well as being sleepier and therefore not feeding effectively.
Emergency Caesareans also can slow down onset of milk supply due to stress, pain, additional medications, lack of immediate skin to skin, slowed baby and parent responses.
Separation of the mother and the baby, delayed skin to skin, additional handling of the child by people other than the mother.
Retained Placenta - Placentas produce progesterone and progesterone is the enemy of breastmilk production so the longer that this goes undiagnosed, the slower the kicking off of milk production and the higher the chance of initial formula feeding.
Haemorrhage of the mother after birth, depending on the severity, this can be anything from a slow initial supply, to shock and ICU care, to the rare but occasionally seen Sheehan’s Syndrome where the anterior pituitary gland responsible for milk production has been severely damaged and the mother is unable to produce breastmilk.
Birth Trauma – A mother’s feelings both physical and emotional about her birth can impact her level of oxytocin, a crucial milk making hormone.
Mastitis / Breast Abscess or Maternal illness at any point on the journey can cause a temporary drop in supply.
On the baby’s side, oral anatomy issues such as ankyloglossia better known as tongue tie, can cause pain and/or inadequate milk removal leading to shields, pumping, early bottle feeding while tongue issues are resolved.
Jaundice can lead to separation of the mother and baby, introduction of formula and a baby who is too sleepy to feed.
NICU time for any reason can increase cortisol and stress in the mother as well as separation of mother and baby.
True Long Term Low Milk Supply can be due to the following:
Insufficient Glandular Tissue - Usually this is seen when the mother reports that her breasts did not develop as expected during puberty. This is where the breasts can be very widely spaced apart, the breasts can appear tubular in nature, there can be bulbous areolas and/or soft and spongy breasts where the glandular tissue is unable to be palpated by the IBCLC. This may be on one or both breasts. There also may have been no breast changes during pregnancy.
Breast Reductions - The glandular tissue responsible for the production of breastmilk is removed. Often this is seen in conjunction with the surgical removal and replacement of the nipples and areola, severing the vital ductwork and nerves behind the nipple connecting to the breast tissue. This is not always the case, so close monitoring from an IBCLC for supply is crucial as sometimes this network of nerves can reconnect, particularly if it has been a very long time since the surgery, but a full supply may or may not be reached, requiring mixed feeding.
Breast Implants whilst less likely to impact on supply due to the nature of the surgical placement nowadays where implants are placed under the muscle and the nipple and tissue are usually not impacted, the reason for getting implants is important. An IBCLC will ask a lot of questions about your breasts before the implants to see if insufficient glandular tissue could be a factor.
Any surgical procedures from reductions, implants and breast lifts where the nipple has been cut, removed or changed.
Breast Biopsies and Other Surgical Procedures – Depending on the location of the biopsy may have had an impact on the breast tissue, nerves and ductwork, although this may only cause smaller supply concerns.
For some women, Polycystic Ovarian Syndrome or PCOS, Thyroid Imbalances such as hyper and hypothyroidism can impact on a woman’s supply, it is important to have your thyroid checked and medications monitored.
How is this fixed?
Triple feeding can be a common “fix” to a supply concern. It can be extremely effective in the case of initial low milk supply. However, it is unlikely to fix the problems associated with true long term low supply.
It should be done with careful and constant monitoring by an IBCLC. Quite often, I have seen it given as a quick fix solution with no follow up or discussion as to how to do it and how or when to stop it and no monitoring of Mums mental health.
Triple feeding can be brutal. Simply, it is a schedule of breastfeeding including switch feeding the baby at the breast, pumping after feeds, top-ups given to the baby and then repeated at usually 3 hour intervals, around the clock. Babies requiring triple feeding often are taking longer to breastfeed making the process even longer. But in positive news, when babies receive more calories, they do tend to show improvement quickly and that boost of seeing a baby improve and the supply improve has an amazingly positive impact on the mother. I find Mums love a solid and clear plan, a manageable timeframe to achieve their goals and regular reviews. Once they can see the improvement it becomes energising to be able to meet your goals. I ask for regular updates via text message so that I can be your biggest cheerleader in the process and monitor and tweak the plan from there.
Plans should be revised every 48hrs with check-ins on the baby’s weight and status. Are they becoming more alert, are they more active at the breast, are we hearing more swallowing, how many pees and poos are they producing, are pees feeling heavier, what colour is the poo, are the amounts pumped becoming higher, are the breasts feeling fuller and does the baby appear more satisfied? As the baby improves and the mothers supply improves, we slowly reduce the pumping and supplementation for an additional 48hrs and then again after that, ideally to exclusive breastfeeding as the situation stabilises. Some additional weight monitoring to ensure everything is now well established for another couple of weeks is usually wise.
Additionally, the mother’s mental health needs to be carefully monitored and the plan revised if it is too much. An IBCLC will also check in with the Mothers partner or key support person to make sure they do everything they can to support the mother including doing all of the other tasks, dressing and changing the baby, rocking and settling the baby, feeding the mother and ensuring she has adequate rest between sessions. Medications and supplements may also be a part of your plan depending on your individual history.
Combination feeding or mixed feeding is anything other than exclusively feeding the Mothers own breastmilk. It can be done using Donor Milk or Infant Formula and is the introduction of these feeds can be one or more bottles per day, top-ups after every feed or any combination of these to feed the baby.
It can be done in a variety of ways including bottle feeding, cup feeding, syringe feeding, supply line at the breast or finger feeding with a supply line. If it is for short term feeding, I usually recommend supply line feeding either at the breast or by finger feeds. For long term mixed feeding most families will opt for a bottle. Paced bottled feeding should be implemented to help protect the breastfeeding relationship.
Many mothers feel distressed when introducing mixed feeding, however working with an IBCLC can help you to understand why it is needed, how long it is needed for and the best ways to protect your breastfeeding relationship in the process.
There are many times when mixed feeding may be recommended. Low Supply requiring supplementation to ensure the baby is receiving enough calories to grow and thrive.
In the case of initial low supply, this could be a short-term solution to help a baby for a few days while the mother works to build her supply back up or to give a baby energy for a couple of days to go back to the breast. This is usually done with a triple feeding plan and is done with careful planning and consideration of the mothers breastfeeding goals and mental health in mind as well as the health and wellbeing of the baby.
In the case of long-term low supply, this is done in a way that protects the breastfeeding relationship to its fullest possible capability, while ensuring the infants calories needs are met.
Other reasons for mixed / combination feeding can include:
Maternal Request – I am proud that I am a trusted resource that mothers feel safe to ask how to combination feed. IBCLC’s assist all feeding and should do so without judgement. So, when a mother asks to introduce combination feeding, we carefully go through her current feeding plans, discuss why she feels this is the appropriate step, see if there is a way to alleviate her current concerns around feeding, and then come up with a plan to introduce mixed feeding that again protects her breastfeeding goals and relationship. This could be due to the mother’s mental health, other things happening in the home with partners or other children, returning to work, planning of medical procedures or just simply because she wants to, and any reason she has is completely fine and should be supported.
Mental Health – I prioritise a Mothers Mental Health above breastfeeding every single time. Occasionally I have seen postnatal depression symptoms that are worsened by the mother’s feelings towards breastfeeding. Additionally, some mothers with severe postnatal depression or psychosis requiring hospitalisation, whilst they should be supported to continue breastfeeding if that is their wish, often may make the decision to mixed feed or wean.
Medications and Medical Procedures – In some rare cases, some medications or medical procedures may require a temporary interruption of breastfeeding. In some unfortunate cases such as chemotherapy, breastfeeding needs to be ceased. Working with an IBCLC to work within a timeframe to cease breastfeeding without compromising your breast health is crucial.
Some medical conditions require a mother to sleep longer stretches of time. For example, in the case of Epilepsy if episodes are triggered by a lack of sleep, the mother may find someone else bottle feeding at night to be a good combination.
The above blog post is general in nature. Every single mother and baby dyad is different. The anatomy is different for everyone. Please reach out to an IBCLC to discuss your individual circumstances and build a plan that works for you and your baby. IBCLC’s are detectives, working out how and why things are happening for you individually. There is sometimes a need for ongoing monitoring and this is best done by working with one lactation consultant who has your full history and can help you as you continue through your breastfeeding journey from start to finish. If you are able to do not have access to a privateIBCLC, take advantage of the free early childhood services that are available. Write down all of your questions, ask for a clear plan, take a partner with you who can take clear notes for you in the appointment and if possible, ask for the same person to help you each time. Online forums and social groups may break your brain so take a rest from that if you find it overwhelming.
I am available for consultations on the Northern Beaches and North Shore of Sydney or via Zoom. Bookings are available here.