Questions about making milk

Today, I got three questions that deal with milk supply issues.  This is the most common fear of most new mothers and the number one reason that women stop nursing before they planned.  It is also, in my humble opinion, very rare that the breasts actually fail.  I call it “Acute onset idiopathic lactation failure” and frankly, it just doesn’t happen all that often.  I hope to make this the source of my PhD work, but I’m having a little trouble convincing the Army that it is important.  So anyway, I’ve combined all three questions into one post.  I’m sorry it is a bit long.  But that’s what you get when you ask a doctoral student about his thesis. ;)

Nicky asked: “I breastfed with my daughter who is now 18mths, I know there were times that I was worried she wasn’t getting enough milk but because her weight was increasing they told me I had nothing to worry about, She ate every 2-3 hrs. I now have a newborn who I feel is attached to me, He eats every 45 min- hr for like 20 min then sleeps. The last apt we had was the 2day apt and he had gained an oz. I have another apt this week, but I’m worried (not stressing, because he’s got poopy/ pp diapers) that he’s not getting enough.  Should I be worried and talk to someone, or should I wait to see if he’s gained any before I seek help.  Also my daughter had no problems feeding ( didn’t hurt or chap or anything) where as I feel I had to teach him a little, but when he latches it hurts at the 1st latch on then I’m fine, Is this normal?”

Nicky,  Congratulations on the birth of your new baby.  The first few weeks are a tough time, made worse by our incessant need to worry all the time about everything.  It sounds to me like you and your baby are getting along just fine.  You tell me that he is peeing and pooping and that he has gained an ounce (I assume since discharge, but if it is an ounce over birth weight he is a rock star breast feeder), all of this is reassuring. Given your first successful breastfeeding, it would put sudden unexplained “I can’t make enough milk” at the very bottom of my list of things to worry about.  You know that your breasts work.  Trust them.  I would suggest that everything is going on well enough.  That being said, you also put up a couple of little hints that things aren’t going perfect (the frequent feeds and the tender nipples), so let’s address them. 

Frequent feeds and tender nipples are both signs of a less than perfect latch.  You see, when the baby is latched on well, there is no pain.  In fact, the entire areola and nipple goes past his tongue and down his throat.  There is nothing to feel pain about.  Try this experiment.  Cup your breast in your hand and put your fingers on the boarder of your areola (that is the line where your breast changes color to form the circle of your “nipple”), now, pinch down a bit to compress the tissue.  There should be no pain. Now, slide your fingers down to your nipple and pinch there.  You should notice a significant difference.  Why?  Because the breast and areola is a protected with fat tissue, but the nipple is not.  When your baby latches well, he goes beyond the unprotected nipple to take the entire areola in his mouth.  This does two things.  First, it protects mom from sore nipples.  But even more important, it will ensure proper flow of milk to the baby.  Think of your nipples as a small bunch of straws that carry milk (which is what they are).  Now, take that bunch of straws and pinch them and try to drink from them.  What happens?  Nothing.  You can’t drink out of a pinched straw, and neither can your baby.  When your baby has a shallow latch, he pinches the tubes that brings the milk down and that makes it harder for him to get milk out.  He will go to the breast and suck, sometimes hard, fiercely even, but he won’t get much out.  Eventually, he will either get tired, or he will get a satiety signal (remember, it takes 20 minutes between first bite and full tummy signal for grown-ups and babies alike) and will come off the breast.  However, since he didn’t have a good latch, he didn’t get as much milk as he wanted/needed and will soon wake up and want to eat again. 

So your baby may be latching poorly, which leads to painful nipples and frequent feeds.  Try to make sure he has a big open mouth before he latches.  When he latches, if you feel a pinch or some tenderness, pull him close to the breast and pull down on his chin to encourage the mouth to open, the tongue will drop down and then out to cup the areola.  If it doesn’t get better in a few sucks, try it again (up to 3 times).  If that doesn’t work, take him off and try again.  Let’s see how that works, write back if there are still problems. 

Heather writes:

“My son is about to hit seven months and I've noticed lately that my milk production has decreased and I'm having a really hard time pumping, which is made worse because being in the army I only get two twenty minute breaks to pump per day. Any advice?”

Heather, I remember talking to you several months ago.  Congratulations on such a successful breastfeeding journey.  You are a rock star!!  Breastfeeding for seven months while on active duty is impressive.  If you haven’t already, I suggest you go check out “Breastfeeding in Combat Boots” a page dedicated to breastfeeding while on active duty. 

Now, to turn to your question, when the baby begins to take in solid foods, his need for breastmilk begins to decrease.  Studies have demonstrated that infant breastmilk intake drops when solids begin, and that is just logical, we can only eat so much in a day.  There is also a decrease in prolactin levels that really kicks into high gear at about six months.  While prolactin doesn’t “make milk” it allows it to be made.  But that doesn’t mean that you should stop synthesizing milk when your baby hits six months old either.

The first thing to ask is “what has changed?”  Have you started contraception (does it have estrogen?).  The questions on contraception and breastfeeding haven’t been fully answered.  There are women who are sensitive to estrogen, even 6-12 months out from breastfeeding.  Some may even struggle with progesterone only (like Depo-provera), even this far out from birth.  Have you started to have a menstrual cycle?  Menstrual cycles don’t impact breastfeeding, but it is a sign that your body is returning to its more normal state.  Ask yourself how often your baby is nursing while at home, and how much he is taking while in daycare?  Maybe you are overestimating how much you need?  Finally, and this is one that gets a lot of people, check your pump.  Believe it or not, batteries die, and so do pumps.  Pumps, even really expensive pumps are not meant to last forever, they are designed to work for about one year of daily use.  If your pump is second hand (who who buys pumps new these days?), it may be at the end of its life expectancy.  It may be time to buy a new pump (another second hand pump should tide you over). 

If everything else is the same, and your baby still needs the amount of milk you were giving him at four months, then I would fall back on the basics of pumping and milk supply.  Supply and demand is a law in breastfeeding.  The more you empty the breasts, the more milk they will make to replace it.  Spend a couple of days (perhaps over a weekend) where you pump while nursing with every feed.  After the feeding, double pump for about 10 more minutes.  This double stimulation will signal to your body that you need more than you may be making right now, and may kick production back into high gear.  The average mother’s breasts are very responsive to infant demands and will compensate for whatever the baby desires.  Give it a shot.

Finally, a little about work.  Two breaks during the day is tough, the Army certainly doesn’t make it easy on breastfeeding mothers, particularly after six months.  BFICB has some good resources for you to try, but in brief, talk about it with your boss.  Ask for one more pumping session.  You should be allowed to pump at least as often as your co-workers are allowed to smoke.  Suggest that you get a break every time one of them goes outside for a smoke.  I tend to think that even NCO’s can be reasonable when asked in the right way.  Try to ask “What do I have to do to get one more pumping break worked into my schedule?”  Come in a little early?  Stay a few minutes later?  Volunteer for a detail?  It may not be fair, but “fair” isn’t a concept found in nature.  You may have to work a little harder for what you really want.

 

And last but not least, my friend asked a follow up question about learning to pump and the law of supply and demand.

It is true that giving the baby something besides breast milk will decrease milk supply.  The lactocyte is on autocrine control after the first couple of months and synthesizes milk based on a supply and demand system.  So if you don't empty it, it will not need to replace as much, and if you repeatedly fail to empty it, the baseline function will decrease.  So there is something to be said for emptying the breast as often as possible to maintain breast function.  Where I differ from most lactation folks is that I don't believe the lactocyte is incredibly sensitive.  I think the lactocyte wants to make milk and will if you just give it the right stimulus.  There are women who could not get pregnant but are still able to nurse their adopted children.  As a woman who has delivered and breast fed there is no reason to suspect your breasts will suddenly fail you.  Of course, fear of inadequate milk supply is the number one reason for prematurely stopping.  But the actual risk of “sudden onset, idiopathic agalactia” (AKA – My breasts just stopped making milk) is less than 3% or women. 

You asked about “mother’s milk tea”, it does seem to help with putting more milk out, and we don't really know why.  It does have fenugreek, which is a galactogue, but it has not been shown to work much better than placebo in studies (I think the problem is the instruments they use to measure are measuring the wrong thing).  Mothers and doctors seem to see every complaint as a cry for food, this is re-enforced by the fact that the fussy baby calms down when you put him to the breast or give him a bottle.  I have never been convinced that a fussy baby is automatically a hungry baby.  Sucking is not only for food, it is also comfort.  If baby has a headache, sucking will make him feel better, and the milk is just a bonus.  When I have a woman who thinks she isn’t making enough, I start by asking how she knows that her breasts are failing her?  Usually (almost always) it can be attributed to a misunderstanding between mom and baby. 

As for pumping, when women develop cisterns (like cows and goats) I will put my faith in a milk machine.  The human milk ejection reflex (let down reflex) is a complicated neuropsychological process the requires several planets to line up just right, and sitting in your office plugged in to a cold impersonal pump, trying to force your breasts to "make milk" just isn't conducive to signaling the milk ejection reflex.  I hinted yesterday that the best way to pump is to put the baby on one side and pump the other.  Try that for a week and see what happens. You will probably be amazed at how much comes out while she is nursing.  That is my first recommendation for increasing supply.  The second is to remember that this is a mental game.  You have to be in the right frame of mind to pump.  If you don't have the baby around, take her blanket (it smells like her) and drape it over your breasts while pumping.  Not only will this give you the Pavlovian stimulus of a baby at the breast, it will also keep you from staring at the pump.  Relax, think about your baby, breathe in her smell and just let go of your worries and you will get better and better.  Pumping is a learned skill, not a natural ability.  Some women never figure it out, my wife can never get more than one ounce out with a pump even though she has more than 8 years of successful breastfeeding under her belt. 

My rules for making more milk are:

1) Empty the breasts often, more often than the baby needs.  Breastfeed or pump frequently for a few days in a row.  Maybe take a weekend where you and she just spend as much time as possible, skin to skin, nursing or pumping, or both.  Studies show that while decreased emptying decreases the rate and volume of emptying, it returns to baseline within 12 hours (for short term interruptions). 

2) Relax and have faith.  This is literally what your breasts are designed to do.  You have no fear that your heart will beat, or that your kidneys will filter, why would you fear that your breasts would fail you?  The only reason humans have so much trouble with nursing is that we have the capacity for worry.  Let go and trust your body to function as designed.

3) Galactogues- they certainly can't hurt, but I'm not convinced that they are necessary for the vast majority of women.  Take the tea if it works for you, but don't worry if it doesn't.