Low milk supply

by Cordelia Uys, NCT Breastfeeding Counsellor

August 2021

In this article we examine the impact certain factors or certain health conditions might have on a mother’s ability to produce all the milk her baby needs, either initially or long-term, and what she can do to ensure she is able to produce as much milk as possible.

1) Maternal conditions which can affect supply

Diabetes or gestational diabetes (GB)

Babies born to women with diabetes or gestational diabetes are more likely to be born with hypoglycaemia and jaundice. In order to bring up their sugar levels, these babies will need to breastfeed soon after birth and frequently, but they are likely to be sleepy and therefore may struggle to breastfeed straight away. Harvesting colostrum antenatally is therefore recommended. Often giving a baby just one or two 1ml syringes of colostrum will whet their appetite and give them the energy to breastfeed. (See my article Antenatal Harvesting of Colostrum). Supplementation with formula should be avoided if at all possible, as this could predispose the baby to developing diabetes.

If you have diabetes or GB, in order to establish your milk supply, please see the steps recommended below.

It may take a little longer for your mature breastmilk to come in; you can help it come in sooner by keeping good control of your blood glucose levels, by doing lots of skin to skin and by breastfeeding very frequently.

Once your mature milk comes in, you should be able to produce a full milk supply. Breastfeeding for more than 3 months is thought to help protect women with gestational diabetes from developing type 2 diabetes.

Hypothyroidism

If you have hypothyroidism, your thyroid hormone levels need to be checked after you give birth, to ensure you are taking the correct dosage of levothyroxine. Normally the dose is brought down after delivery but needs to be higher than pre-pregnancy. If supplementation is too low, prolactin levels will be affected, resulting in low milk supply. Unfortunately, doctors aren’t always aware of this. For more detailed information, please see the Breastfeeding Network’s (BfN) leaflet Thyroid medication and Breastfeeding.

As long as you are taking the correct dose of levothyroxine, you should have a good milk supply.

Polycystic Ovarian Syndrome

About 20% of women with PCOS are estimated to struggle with their milk supply, while 20% may have oversupply. The other 60% will have a completely normal milk supply. Please see the links below for more detailed information on galactagogues that can be helpful for PCOS. The risk of having low milk supply with PCOS can be minimised by taking the steps recommended below.

Breast surgery

Breast implants

Most women with breast implants will be able to breastfeed without any issues. However, breast reduction surgery, or any surgery around the nipple that severs milk ducts, is likely to have an impact on a mother’s chances of producing a full milk supply.

Breast reduction surgery

If you have had breast reduction surgery, it’s very much worth giving breastfeeding your best shot because there is a lot of variability in the impact of breast surgery on lactation. Even if a mother isn’t able to exclusively breastfeed her first baby, she may be able to fully breastfeed her second and subsequent babies, as the act of breastfeeding increases the growth of milk-producing tissue, and milk ducts can grow back.

Insufficient glandular tissue (IGT or hypoplastic breasts)

A very small percentage of women have hypoplastic breasts, meaning that they have very little glandular tissue. This is completely different from having small breasts.

The following characteristics might indicate IGT:
Widely spaced breasts (more than 4cm flat space between breasts).
Breast asymmetry (one breast much larger than the other).
No breast growth or changes, either during puberty or pregnancy or after the baby’s birth.
Tubular breast shape.
Very large and bulbous areola.

Women with IGT are usually able to produce some breastmilk but will often struggle to produce all the milk their baby needs.

Recommended steps

If you fall into any of the categories mentioned above, and you would like to breastfeed your baby, it is still very much worth making every effort to do so. It’s impossible to predict what a mother’s milk supply will be like. Any breastmilk will be beneficial to your baby, and the act of breastfeeding is about much more than just milk. It’s advisable to:

Arrange for support from an IBCLC Lactation Consultant or Breastfeeding Counsellor.
Harvest your colostrum antenatally.
Do lots of skin to skin from birth onwards.
Breastfeed within an hour of giving birth and then at least 10 to 12 times in 24 hours.
Hand express after all feeds for the first 3 or 4 days.
If your baby isn’t breastfeeding, within an hour of giving birth, start hand expressing on each breast at least 10 to 12 times in 24 hours.
Once your milk comes in, if there are signs of lower milk production (see my article How To Tell Your Baby Is Getting Enough Milk), double pump with a hospital grade double pump after breastfeeding, especially if supplementation is necessary.
If giving supplemental feeds, always practise paced bottle feeding or use a Supplemental Nursing System.

The pituitary gland

An additional factor that can affect supply is dysfunction of the pituitary gland. Because prolactin, the hormone responsible for milk production, is produced in the pituitary gland, milk supply can be affected by:

Previous surgery on the pituitary gland
A pituitary adenoma
Sheehan’s Syndrome – caused by severe blood loss or extremely low blood pressure during or after children. This is very rare.

2) External factors which can affect milk supply

Retained placenta

When a baby is born and the placenta is delivered, there is a drop in maternal oestrogen and progesterone levels, which triggers a rise in prolactin. If, following birth, even a small amount of placental tissue remains in the uterus, there will be an impact on milk production. As soon as this has been removed, milk production will usually normalise.

Under stimulation of breasts

Under stimulation is by far the most common cause of low milk production.

When discussing low milk supply it’s essential to point out that the vast majority of mothers are physiologically capable of producing enough milk for a single baby, twins or triplets; it’s effective, timely and regular removal of milk from both her breasts that tells a mother’s body to make milk.

Under stimulation happens if:

Milk is not being removed from breasts regularly.
The baby is not able to breastfeed effectively, either due to incorrect positioning and attachment, or a physical issue, such as tongue-tie.
Both of the above.

1) Milk not being removed regularly enough

Babies need to feed frequently

In order for a mother’s milk production to be established and maintained in the early months, milk needs to be removed from both breasts at least 8 times in 24 hours. UNICEF talk about an average of 10 to 12 feeds a day, and many babies will need to feed more often than this.

Responsive breastfeeding is essential for establishing a good milk supply

When a baby is born, their mother’s breasts are primed to make just the right amount of milk, depending on the stimulation they receive. If a mother has a naturally generous supply, her infant will need to spend less time on the breast, and feed less frequently, than the infant of a mother with a less generous supply.

The Feedback Inhibitor of Lactation (FIL)

Whenever breasts get hard and full, the Feedback Inhibitor of Lactation, a negative feedback mechanism, kicks in, telling them to stop making milk. This means milk production slows down when breasts are full and speeds up when breasts are emptier.

Breast storage capacity

Women vary in how much milk they can store in each breast before the FIL kicks in. If a mother has a smaller milk storage capacity, she will still be able to produce all the milk her baby needs, it just means her baby may need to breastfeed more frequently to get all the milk they need, and for her milk supply to be sustained. Long gaps between feeds will decrease her supply.

The impact of scheduled feeding

When babies are fed to a schedule, unless a mother has an extremely generous milk supply and large breast storage capacity, it’s unlikely her breasts will get sufficient stimulation to maintain milk production.

The impact of only offering one breast per feed

It is essential to offer both breasts at each feed. If a mother only offers one breast per feed, her baby will be getting half as much milk as they could potentially get, and her breasts will be getting half as much stimulation.

Once a baby has come off the first breast, the recommendation is to wake them and offer the 2nd breast. At the next feed, they should go back to the 2nd breast.

Importance of night feeds

Prolactin levels are highest in a mother’s body between 2am and 4am. Breastfeeding at night is therefore important for maintaining milk supply in the early months.

Dummies

Dummies can mask feeding cues, leading to reduced milk supply and slow weight gain.

Misunderstanding of cluster feeding:

In the first couple of months, it’s typical for babies to cluster feed firstly at night and then in the evenings. Wanting to be on and off the breast almost incessantly for several hours is probably an evolutionary development to ensure breasts regularly get very frequent stimulation.

The vicious circle of supplementation

Unfortunately, it’s common for mothers to misinterpret cluster feeding as a sign that they don’t have enough milk, so they start supplementing with formula. This leads to less stimulation of breasts, creating a vicious circle in which mothers need to give more and more formula.

2) The baby is not be able to breastfeed effectively

In order for a mother’s breasts to get the message to create a full milk supply, as well as breastfeeding very frequently, her baby needs to be able to remove milk from both breasts effectively. This means the baby needs to be able to take a deep mouthful of breast and draw milk out in a rhythmic suck-swallow pattern for somewhere between 5 and 45 minutes. The effective removal of milk (nutritive suckling) sends a message to the mother’s body to make more milk. If a baby is sucking gently, without actually drawing milk from the breast (non-nutritive suckling), he or she could spend an hour or more on the breast without stimulating any milk production.

Reasons why a baby might not be able to breastfeed effectively:

Baby born premature or early
When babies are born prematurely, or even just a couple of weeks early, they might initially struggle to breastfeed efficaciously.
Sleepy baby
Babies born early are often very sleepy, and it can be hard to keep them awake and actively suckling at the breast.
Neonatal jaundice
Over 50% of newborns develop neonatal jaundice in the first 2 to 3 days of their life; in most cases, this is not a cause for concern. Babies are born with more red blood cells than needed outside of the womb, and as these are broken down, a yellow pigment called bilirubin is produced. Bilirubin circulates in the baby’s blood and can cause their skin and the whites of their eyes to turn yellow. The main issue for most jaundiced babies is that it can make them very sleepy and therefore difficult to rouse and feed. The best way to flush the bilirubin out is for the baby to drink lots of breastmilk. Breastmilk is more effective in this regard than formula milk.
Tongue-Tie
A tongue-tie can make it harder for a baby to get a deep latch, to create a seal, and to transfer good volumes of milk. Sometimes a tongue-tie has an immediate impact on milk production, but if a mother has a naturally generous supply, the effect might not become apparent for a few weeks. Please see my article https://www.cordeliauys.co.uk/what-is-tonguetie
Attachment and positioning
If a mother isn’t holding her baby close enough to her body, and in a position that enables the baby to take a deep mouthful of breast, there can be a similar impact on milk supply as with a tongue tie. Babies need to breastfeed, not nipple feed.
Tightness in the baby’s head, jaw or neck muscles
A long second stage of labour, a difficult foetal presentation before birth, the cord round the baby’s neck, or an instrumental (forceps or ventouse) delivery, can all create stiffness in the baby’s body that might hinder their ability to latch deeply and achieve proper suck-swallow coordination. Cranial osteopathy can help to gently release any tensions in the baby’s body. Please see the article on cranial osteopathy and breastfeeding on my website.

3) Milk is not being removed from breasts regularly and the baby is not able to breastfeed effectively

This combination is a double whammy for a mother’s milk supply, and can quickly turn into a vicious circle in which the mother supplements with formula/ the baby is full of formula and not interested in breastfeeding/the mother’s breasts don’t get sufficient stimulation/her milk supply decreases/the baby gets less milk at the breast/ the baby can’t draw much milk/the breasts get less and less stimulation.

Factors that are often misinterpreted as low milk supply

Please note that the vast majority of mothers are physiologically capable of producing as much milk as their baby needs.

Many mothers misinterpret normal baby behaviours, or other factors, as signs of low supply.

It is NOT a sign of low supply if:

After the first 6 weeks, your breasts no longer feel constantly full and/or are no longer leaking.
- This just means the prolactin receptors in your breasts have settled down and worked out exactly the right amount of milk to produce for your baby.
You don’t produce much milk when pumping.
- Milk yield from pumping isn’t an accurate reflection of milk supply because oxytocin, the hormone that delivers the milk, is triggered by loving feelings, and most mothers don’t love their pump.
Your baby cluster feeds for several hours a day.
- In the first couple of months, it’s typical for babies to cluster feed for several hours, firstly at night and then in the evenings.
Your baby guzzles a bottle of milk.
- A combination of gravity and a baby’s sucking reflexes means they can easily drink large volumes of milk from a bottle, even when not particularly hungry.
Your baby won’t settle after a feed unless they’re in your arms.
- Babies have evolved to make a fuss when not being held, to ensure they are kept safe from predators and other dangers.
Your baby wakes frequently at night.
- Frequent night waking throughout the first year is normal and protects from SIDS.
You aren’t eating the perfect diet.
- Your milk is made from your blood. The amount and type of food you eat has no effect on milk supply.

The only reliable indicators of low supply are:

If your baby isn’t gaining an appropriate amount of weight.
And/or your baby isn’t producing sufficient wet and dirty nappies.

Please see my article How To Tell Your Breastfed Baby Is Getting Enough Milk.

Recommended steps to increase milk supply

See suggestions under Maternal conditions that might affect supply above.
Ask your GP to check your thyroid function.

If your baby isn’t taking the breast:

Arrange support from an IBCLC Lactation Consultant or Breastfeeding Counsellor who can create a feeding and pumping plan for you.
Do lots and lots of skin to skin with your baby – this will stimulate your breastfeeding hormones and will promote feelings of wellbeing in you and your baby.
Hire or buy a hospital grade double pump – double pumping is like telling your breasts you have twins.
Double pump at least 8 times in 24 hours, including once between 2am and 4am when your prolactin levels are highest. It’s normally recommended to pump for 20 to 30 minutes, but please discuss this with your IBCLC or BFC. (Hand expressing, rather than pumping, is recommended in the first 3 or 4 days).
Check your breast shields fit properly.
Don’t worry if at first you can barely produce any milk while pumping. It might take several days of regular pumping before you see an increase in output.
By cutting holes in an exercise bra, that fits comfortably, you can create a pumping bra to hold the pumpsets in place, allowing you to massage your breasts while double pumping, which stimulates production.

If your baby is breastfeeding:

Offer the breast as soon as your baby is showing early feeding cues.
Breastfeed your baby as frequently as they want, and at least 10 times in 24 hours. Wake them if necessary. UNICEF talk of an average of 10-12 breastfeeds in 24 hours and many babies need to feed more often.
If possible, increase the number of times you are offering the breast.
Always offer both breasts at each feed.
Compressing/massaging your breasts regularly during feeds will send more milk down to your baby.
Switching back and forth between breasts several times during each feed can help ensure a baby does lots of nutritive suckling. Once your baby is no longer actively swallowing on the first breast, switch them over to the other side.
Double pumping immediately after breastfeeds provides very effective stimulation. Don’t worry if this means temporarily producing less milk. Think of it as an investment: you are sending in the order for the next feeding/pumping session.
If giving supplemental feeds, always practise paced bottle feeding or use a Nursing Supplementer. The traditional way of bottle feeding can lead to breast refusal because babies get used to a faster flow.
Discuss with your IBCLC or BFC the possibility of taking galactagogues, such as fenugreek, goat’s rue or domperidone. (Fenugreek & blessed thistle: 3 tablets x 3 times a day). Please note galactagogues won’t work unless you are also doing lots of breastfeeding and/or pumping.

Regular pumping can be stopped once supply has increased. These steps are hard work but often very successful.

Links:

Antenatal harvesting of colostrum: https://www.cordeliauys.co.uk/antenatal-harvesting-of-colostrum

Reasons for low milk supply: https://breastfeeding.support/reasons-low-milk-supply/

Hypoglycaemia of the newborn: https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2010/10/hypo_policy.pdf

Gestational diabetes: https://www.gestationaldiabetes.co.uk/breastfeeding/

https://www.laleche.org.uk/diabetes-and-breastfeeding/

Hypothyroidism: http://www.breastfeedingnetwork.org.uk/wp-content/dibm/2019-09/Thyroid%20medication%20and%20Breastfeeding.pdf

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