Expert: Sally Wendkos Olds - 10/4/2009

Question
QUESTION: Hello,
My son is about a month and a half old and I am having severe low milk supply issues.  He started breastfeeding about 10 minutes after he was born and was with me (co-slept) in the hospital the entire stay. Once we came home it seemed as if my milk supply would never come in or, if it did, was way too little. During pregnancy and after the birth I noticed virtually no change to my breasts. I cannot feel let down nor have any sensation of fullness. For his first two weeks home he would be up all day crying non stop. Nothing would soothe him. Only the breast. Sometimes I would be nursing for 7 hours straight. And he would still cry. We spent the first two weeks of his birth attached to the breast. He was latched on correctly and I had no pain whatsoever. He had wet diapers but none of them were soaking wet and his poops were barely there. At two weeks he went to the pediatrician and he told me that he had only gained 60 grams and I had to supplement with formula. Since then I have been breastfeeding and supplementing. I always start with the breasts (this can take about an hour usually longer, switching back and forth) then give him the formula and then try and end with the breast again. I do offer the breast all the time and feed exclusively that way at night as he sleeps with me. I have been taking fenugreek, blessed thistle, iron, prenatal vitamins, brewers yeast and no real change. Yesterday I started taking Motilium as a last resort. I have also been pumping (maximum about 1 1/2 oz from both breasts combined) throughout the day to stimulate more production. I saw a La Leche League counselor today and she thinks that it's probably my iodine intake although I am taking supplements for that since before birth. She suggested I check my thyroid (appointment in two days)although I have no history of thyroid problems nor show any symptoms. Are there any recommendations you could give me which I have not yet exhausted. I am desperate to breastfeed my child exclusively.  I do not have a retained placenta nor internal problems (my gyno gave me a clean bill of health three days ago).
Thank you.

ANSWER: Dear Gabriela,

First, congratulations for giving your son the best start in life by feeding him your good breast milk. And also, congratulations for persisting in your efforts to breastfeed despite the problems you have been having.

It does sound as if you may be in that small minority of women who cannot produce enough milk for their babies. I commend your efforts and encourage you to keep trying to increase your milk production. You have already done most of what I would suggest. I have only two thoughts that might help both you and your baby.

One is to try using a nursing supplementer; I'll attach a description below from my book. This has the advantage of feeding your baby at the breast, thereby stimulating your breasts with his sucking, and providing nourishment to him from formula at the same time.

Another thought is that at his feedings, try giving him the formula first, and then put him to the breast. This way he'll get the feeling of fullness from your breast and your nursing sessions will not be so long.

Good luck!

Sally
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Sally Wendkos Olds
Author, THE COMPLETE BOOK OF BREASTFEEDING: Eiger & Olds, 3rd edition 1999, published by Workman Publishing & Bantam Books, and available in most public libraries, bookstores & La Leche League chapters. Now in revision for a fourth edition, with pediatrician Laura M. Marks, M.D.
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Nursing Supplementers
These devices are used by women who want to increase their milk supply while supplementing their breast milk with formula, women who want to nurse an adopted child, or women who want to initiate breastfeeding after not having nursed for some time.  Supplementers deliver milk from a bottle to a baby while the baby is suckling at the mother’s breast, so that the baby simultaneously sucks the mother’s nipple and a thin tube delivering formula, and thus gets a mouthful of breast milk, along with a mouthful of formula.
The two most commonly used methods are the Supplemental Nursing System (SNS) made by Medela, Inc., and the Lact-Aid Nursing Trainer System. Whichever one you choose should be used only under the supervision of an experienced lactation specialist, and your baby must be closely monitored for healthy weight gain. These devices are helpful to a baby who is latching on well; if there is a latch problem, you need to seek a different solution.
  With the Medela SNS a thin plastic tube runs from a plastic bottle hung upside down (to take advantage of gravity) from a strap around the mother’s neck. The end of the tube is placed at the edge of the mother’s nipple and held there with surgical tape. Or you can place a small Band-Aid on your breast and run the tube under the gauze square to avoid taping and re-taping the tube. As the baby nurses at his mother’s breast, he simultaneously suckles the tip of the nursing tube and the mother’s nipple, and his efforts are rewarded by the flow of milk through the tube. Bottles come in different sizes to accommodate premature babies and those with cleft palates or other feeding problems.
  The Lact-Aid consists of a soft, presterilized plastic bag that contains milk. The bag is attached to a plug that in turn is attached to a slender nursing tube. The filled and assembled supplementer is worn on an adjustable neck strap in the mother’s nursing bra between her breasts.
  In both these systems, the baby suckles the breast and the tube simultaneously, receiving milk as soon as he starts to nurse. Because of the way the system delivers fluid, letting the baby suckle breast and tube at the same time, it provides a type of oral patterning that helps to improve or train the baby’s suckling skill and coordination. Meanwhile, the device helps to increase the mother’s milk supply, since the baby is stimulating her breasts more effectively. Throughout, the baby is getting the nourishment he needs, and both mother and baby are able to enjoy the experience of nursing at the breast, with all the warmth and intimacy that are such a rewarding part of breastfeeding.



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QUESTION: Hello again. Thanks for your fast answer. Just another quick question. In cases like mine do all the extra things I am doing have any positive effect (the fenugreek, pumping, etc...)? And specifically, does the motilium usually help in these cases? Is there a chance I could produce more milk or is it a never ending struggle? There is not much information on the internet about women who cannot produce enough milk for no apparent medical reason.
Thanks again,
Gabriela

Answer
Dear Gabriela,

Pumping often helps to increase milk supply, but from what I have seen and read, the fenugreek, other herbs, and medicines don't do too much. At a certain point you may want to tell yourself you have done all you can to build your milk production and just focus on loving your baby and caring for him and feeding him formula. I'll attach another excerpt from my book about building milk supply, but my guess is that you have probably already done everything here.

Good luck. I have to sign off this website for a while -- my husband was taken very ill today, and I'll have to focus on him.

Best wishes,

Sally
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• Nurse your baby more frequently for several days, using both breasts at each feeding. This is the single best way to enhance your milk supply.
• Wake your baby, if necessary, to feed him more often -- about every two to three hours during the day and at four-hour intervals during the night.
* Pump or express milk between feedings. But don’t get discouraged if your pumping yields as little as half an ounce of breast milk. Your baby is almost certainly getting more than this. Even the best pump is less effective than a vigorously nursing baby. (More about pumping in Chapters 16 and 17.)
• See a lactation specialist if your baby is not suckling well or nurses only a few minutes at a time.
• Cut back on your schedule. Do less. Rest more. Nap at least once a day, more often if you can manage it. Or at least put your feet up. Ask someone else to help with marketing, cooking simple meals (or getting take-out food), and doing basic laundry. Most people like to help a new mother, so take advantage of this willingness now. You can always reciprocate later on. Although people often want to help, they may not know just what you need. It may help to post a running To-Do list on your refrigerator for all to see.
* Even though everyone wants to see the new baby, ask visitors not to come for several days -- or even weeks -- unless they’re people who will wait on you, not expect you to entertain them. Let your answering machine take phone calls – which you can return later when you’re not so tired. Well-meaning family and friends can wear out the new mom.
• If you can, in the early weeks take an occasional day or two off from work or from other obligations (by, for example, having someone come in to care for your other children) so that you can focus only on nursing your baby.
• Check your diet. Are you eating enough? Are you drinking enough? Some women find that eating or drinking more seems to produce more milk. Keeping a glass of water or juice near the spot where you nurse is a good idea. You don’t need to drink any more than you need to meet your thirst, but some nursing moms find that they are thirstier than usual.
• Make a special effort to relax, as suggested in the box on page tk. Of course, this is hard when you’re concerned that your baby isn’t getting enough milk—but the more you can relax, the more milk your baby is likely to receive.
• Develop a few affirmations that you can repeat to yourself, such as: “I am a bounteous supplier of milk for my baby”; “I am doing the best thing I can as a mother”; “My baby is growing fit and healthy from my milk”; “My milk is my baby’s perfect food.”
* Visualize your baby at a little older age, looking well fed and  happy.
* Galactogogues: Virtually every culture in the world has recommended certain foods or substances to nursing mothers, in the belief that they help to make milk. In China, nursing mothers have been urged to eat “a mixture of pork fat and red gram (a type of bean), cuttlefish soup, shrimps’ heads in wine, and a special sweet wine made from glutinous rice, given together with the larvae of the blow-fly.” In India, it’s garlic, tamarind, and cottonseed; in France, powdered fennel; and in Nepal, chicken soup, buffalo milk, butter, and rice. In the U.S. vitamin B complex, brewer’s yeast, and the herbs fenugreek (also called fenugeek) and blessed thistle are sometimes recommended, as is the controversial prescription drug domperidone, which has not been approved for any use by the U.S. Food and Drug Administration. (See Chapter 10 and the Websites Appendix for more about drugs and lactation.)
  Cheston M. Berlin, Jr., M.D., a professor of pediatrics and pharmacology who has an interest in drugs and lactation, has concluded that the effects of such potions may be largely psychological. The mother thinks that a certain substance will increase her milk supply, so she relaxes and has a good let-down reflex, thus “proving” its value.

As we have stated, though, the best way to build up your milk supply isn’t what you eat. It’s what—and how much—and how often—your baby eats. The cutting edge research of Dr. Peter E. Hartmann’s Australian team (discussed in Chapter 3) has  confirmed what many breastfeeding experts have known for years: that emptying the breast is the best stimulus to milk production. The more often you nurse your baby and the more vigorously she nurses, the more milk you’re likely to have.
• Believe in yourself and trust your body.
Note: Do not offer your baby formula while you’re building up your milk supply. A few ounces soon turn into a full bottle, which soon turns into several bottles, until you find that you’re producing even less milk. If your baby is drinking from a bottle, he is not stimulating your breasts and thus not doing the most effective thing that will increase your supply of milk. In most cases, a breastfed baby should not be offered a bottle until nursing is well established—usually at about four to six weeks of age.
  The only exception to this is if your baby’s doctor (not your friends or relatives!) feels that he absolutely needs a supplement. Your doctor may be worried if your baby is sick, dehydrated, so small that his health is endangered, or if he is not gaining enough weight. Any one of these conditions may leave him without enough energy to nurse vigorously and thereby stimulate your milk production.
If a decision is made to supplement with formula, you might try offering a couple of ounces of formula in the bottle first before nursing him. This practice, which reverses previous guidelines for supplementation in the order of breast-followed-by-supplement, has become more widely recommended in recent years. This reversal of the usual feeding order satisfies the baby’s immediate hunger and gives him the nourishment he needs, but provides that he will get his final sense of fullness from breast milk, and associate this good feeling with his mother.
Some babies do better getting their supplement like this, while others thrive more on the traditional practice, of nursing first and supplementing afterwards. It’s not always clear which way will work best, so this is something you should discuss with your lactation consultant.
Another way of supplementing is to use a nursing supplementer, a device that lets your baby suckle at your breast (thus stimulating your milk production) while at the same time receiving formula (see page 000 for a description).