Low Breast Milk Supply: Signs, Causes and Ways to Increase Supply

A breastfeeding mother worries whether her milk is enough or not especially when the baby is wanting to eat constantly or acting fussy after breast feeding. These are not the definite signs of low milk supply. Before you doubt yourself whether your milk is enough of not, learn about what are the signs of baby getting enough at breast. If you are exclusively breastfeeding and your baby is gaining weight adequately, most likely your breast milk is enough. Hence, regular baby well check exams are extremely important and necessary. A breastfeeding mother should be aware of the signs to look for in her baby especially if she feels her baby is not getting enough breast milk.

Signs of baby isn’t getting enough milk:

• Track diapers: Diapers are a great indicator of the hydration and nutrition status of the baby. See below the diaper expectation for 1 week of age. Usually after the baby is 1 week old and your milk is in, the expectation of diapers for a each day is to have at least 4-6 pale yellow urine diapers and 1-2 stools. See your health care provider if you notice your baby is having less than 4 pee diapers a day and no stools for over 2-3 days. Also having dark-concentrated urine diapers sometimes with pink crystal can be indicative of signs of dehydration.

• Regular weight checks: Most babies lose weight after birth. As long as the weight loss is below 7% of weight loss in the first few days of life, usually no supplementation is required. Even a weight loss of 7-10% may be considered normal for breastfeeding babies but does warrant a breastfeeding evaluation.

1. A breastfed baby starts to gain weight again once your milk is in. The expectation of weight gain is approximately 20-30 grams per day  and be back to birth weight by 2 weeks of age.  If your baby hasn’t began gaining weight by day 5-6 or has not reached her birth weight by 2 weeks of age, an evaluation for lactation is recommended.
2. Then from birth to 6 months of age, a baby gains about 5-7 ounces a week, with doubling the birth weight by 5 months of age. Whereas, for 6 to 12 month old baby gains 3-5 ounces a week, with tripling the birth weight at 1 year of age.  Hence, it is extremely vital to routinely visit your pediatrician for well-baby exams. The pediatricians usually would plot the baby’s weight on a growth chart and continue to monitor your baby’s weight.

• Watch for signs of dehydration: babies can get dehydrated very quickly. Babies have low fluid reserves with high metabolic rate, making dehydration more severe in newborns. Common early signs of dehydration to watch for are as follow:

1. Concentrated dark-colored urine
2. Fewer number of wet diapers
3. Dry mouth
4. Lethargic
5. Irritable
6. Decreased or no tears with crying
7. Pale less elastic skin

Causes of Low milk Supply in Mother:

• Early Supplementation: With production of colostrum in the first few days of life and lack of education on the significance of colostrum results in many mothers perceiving they don’t have enough milk supply for their newborn resulting in early and unnecessary supplementation. Even later during growth spurts, cluster feeding phases are often mistaken for low milk supply resulting in supplementation. Early and unnecessary supplementation especially with formula leads baby spending less time at breast resulting in low stimulation of hormones which in turn leads to low milk supply. Decrease in stimulation at breast result in less milk being emptied from the breast which in turn sends a negative feedback to the body stating to make “less milk”. This on-going cycle between supplementation and decrease in breastfeeding sessions is one of the major causes for low milk supply in postpartum mothers. If supplementation is needed for any medical reason, it is vital for a mother to begin pumping, in order to promote increase in milk supply.

• Maternal Stress: increase level of stress can also lead to sudden decrease in milk supply. Even separation away from baby can result in emotional and physiological stress to a mother. For instance, a mother of a baby admitted to neonatal intensive care unit (NICU). It is essential for a mother visit her baby frequently and if possible to also do skin to skin, if medically appropriate. Mother’s of NICU baby’s should be set up with pumping as soon as possible to prevent any delay in milk coming in or decreasing supply.

• Maternal Medical Illness: endocrine problems such as PCOS, diabetes, thyroid imbalance, other hormonal disorders, and high blood pressure may impact the hormones necessary to stimulate the production of breast milk, resulting in low milk supply. Management of these medical illness is vital. Proper treatment to these health problems can prevent any issues with low milk supply.

• Breast Hypoplasia: also known as Insufficient glandular breast tissue (IGT).  Breast hypoplasia is a condition in which a mother has not fully developed glandular tissue.  Glandular tissue in the breast plays a key role in the milk production. Usually during pregnancy, there is an increase in milk ducts and glandular tissues resulting in increase in breast size as one progressing in their pregnancy. However, a mother with insufficient glandular breast tissue will notice that her breasts were unchanged or there was only little change in her breast size during pregnancy. Signs of hypoplasia may include:

1. Widely spaced breast (usually more than 1.5 increases apart),
2. Tubular shaped breast (elongated in shape)
3. Asymmetry: One breast is larger than the other
4. Swollen or enlarged areola
5. Absence or little change in breast size during pregnancy

Most mothers with breast hypoplasia do suffer with low milk supply but are still able to enjoy the breastfeeding experience using a supplemental nursing system (SNS). Few mothers with the help of pumping and taking supplements to boost supply are able to increase their production. It is vital to seek an assistance of a lactation consultant in exploring your options in order to enjoy the breastfeeding experience.

• Retained placenta or excessive blood loss:  postpartum hemorrhage and/or retained placenta can impact milk coming in process usually during the first few days after delivery. Left over placenta into the uterus after delivery may impact the prolactin levels to not rise preventing your body to begin the milk making process. Excessive blood loss can also inhibit milk making process due to the maternal physiological stress.

• Breast surgery: Breast surgeries done for medical or cosmetic purposes can impact milk production. The impact to milk production may vary based on the technique used to do the surgery, nerves impacted during surgery, time lapse between surgery and current pregnancy, and the presence of scarring or damage to the breast tissue. Some mothers are able to breastfeed with a full productions without any challenges, while others may need more stimulation and supplementation to augment the milk supply. Breast augmentation/lift with breast implants under the muscle have more favorable milk production results than breast implants above the muscle. Peri-areolar (around the areola) incisions with complete detachment of areola during surgery are usually seen to cause low milk supply. The time lapse is important, with time there is new production of ducts and regaining of nerves functionality enabling normal milk production in mothers. For mothers with history of breast surgery need to be monitoring for adequate weight gain in their breast feed babies.

• Medications: If you notice a sudden decrease in your milk supply. Self-asses to see if you have started taking any of the following medication:

1. decongestants containing Pseudoephedrine like Sudafed, Zyrtec-D, Claritin-D, Allegra-D
2. antihistamines (Diphenhydramine/Benadryl, Cetrizine/Zyrtec),
3. birth control pills (containing estrogens): the progestin only birth control are preferable options during postpartum while you are breastfeeding.
4. fertility medication (clomiphene/clomid)

These medications are known to decrease your milk production. Inform your health care provider you are breastfeeding, they may be able to recommend a better substitute for these medication.

1. Excessive alcohol consumption: will also lead to low milk supply. Limiting the alcohol intake to one drink is recommended.
2. Herbs: Surprisingly there are also herbs that can lower your milk supply. Herbs and spices such as sage, peppermint, oregano, lemon balm, parsley and thyme are know to decrease milk production if taken in large quantity. Small amount or a little sprinkle of these herbs is not going to impact your supply.
3. Inadequate milk transfer due to sucking issues: you may be having a normal milk-making process but due to inadequate milk transfer overtime you notice a decrease in milk supply. One of the major causing of inadequate milk transfer that is seen commonly is tongue-tie and lip tie issues with newborns. Tongue-ties and lip-ties are usually easy to fix. Your pediatrician or Lactation Consultant can help assess your baby for sucking issues related to tongue tie and lip ties.
4. Latching issues: Latching issues can also cause inadequate milk transfers as the baby is not latched deep enough to use his/her tongue adequately to draw milk out. Inadequate milk transfer results in low stimulation and less emptying of breast which in turn eventually leads to low milk supply. Hence, it is vital to consult with a lactation consultant early on especially if you are having painful latching or sore nipples.
5. Skipping night feeds: not emptying the breast throughout the night can result in dropping in prolactin levels (which are high at night) resulting in negatively impacting the supply and demand ratio which in turn result in low supply.

Ways to Increase Breast Milk Supply:

• Increase stimulation: frequent stimulation is especially essential during the first few days after delivery. This stimulation helps the transition from colostrum to mature milk easier. There are several ways to increase stimulation of oxytocin/prolactin hormones which can augment milk supply. The key with increasing supply is the more your empty your breast (more demand), the more milk you make (more supply).

o   Skin to skin contact with your baby can cause surge of prolactin levels. Skin to skin is a great way to promote bonding and relaxation for both mother and baby.

o   Breastfeeding on demand is the best form of stimulation to increase milk to match your baby’s growing demands (supply = demand). Feeding from one breast completely before offering the other side also promotes increase stimulation. Always offer the other breast to the baby, your baby may and may not take from the other side. Avoiding unnecessary supplementation, can also aid from not losing out on stimulation at breast. Night time feedings also important as the prolactin levels are very high at night and skipping night feedings can result negatively impacting the supply and demand ratio which in turn result in low supply.

o   Pumping is also a great way to increase stimulation, especially if your baby is in the NICU or you are having difficulty with breastfeeding. After delivery, if you are required to supplement your baby for any medical reason, always began pumping to help increase your stimulation. Always ensure you have the right flange size when pumping to get optimal results. Your nipples should move freely in and out during pump suctioning.

1. If you are breastfeeding and still having low milk supply, pumping after and between feedings can be helpful. Consult with your lactation consultant on how often to pump based on your situation. Some mothers also try “Power Pumping”, which is pump for 10 min followed by  10 mins rest for 3 subsequent pumping sessions.
2. Double pumping is always more stimulation then single pumping.
3. Hands on pumping or breastfeeding: Massing while pumping and breastfeeding has shown to improve milk flow, breast emptying and increase in fatty content (hind milk) of milk. Wearing a hands free bra is helpful in holding the flanges in place and having your hands free for massaging. Start with massaging when you first begin pumping at a maximum comfortable suction level. This will help stimulate a letdown. Massage in a circular motion over hard lumpy area, to assist in better emptying of all ducts. If you notice the spray of milk has slowed down or stopped, begin massaging again.

• Maternal relaxation and care: Like stress is known to reduce milk supply, similarly, relaxation can promote milk flow and production. Eating nutritious meal, taking prenatal vitamins, drinking to thirst are the basic known maternal postpartum care requirement which are often neglected due to added stress of having low milk supply or something even returning back to work. Having your spouse or family member give you a nice back rub, promotes breast nerve stimulation.  Meditating, relaxed breathing, listening to soft music and getting enough sleep are also great way to relax the mind and body which in turn will stimulation prolactin release to improve supply.

• Herbal Galactagogue: Galactagogues are products that assist with initiating, maintaining and increasing milk supply in a lactating mother. There are several herbal galactagogue commonly used all over the world for the purpose to augment milk supply. One of the most widely used is fenugreek. Other herbal products that has been gaining popularity in the developed countries are Shatavari (indian asparagus), Fennel, Goat Rue, Blessed Thistle, Cumin, AlfaAlfa, Brewer’s Yeast, and so on. Foods items that are known to increase milk supply are called the lactogenic foods, which can be incorporated into the mother’s diet, for instance, eating one bowl of hot oatmeal a day. Galactagogues, herbal products or prescription medication should be incorporated along with frequent stimulation and/or breast emptying via breastfeeding and/or pumping. Always remember you make more milk by emptying more milk.  Also, seek advise from your health care provider before starting any supplements or medications to promote milk supply especially if you are taking other medication for any health issues or illness.

1. Fenugreek: in India is referred as “Methi”. Fenugreek is popularly used for many years in India, Middle East and America. There are several studies being conducted on use of fenugreek and its effectiveness in increasing milk supply. Most studies conclude its effect being subjective, not justifying its effectiveness in increasing milk supply (Reader, Legrand, O’Connor-Von, 2013). However, a study published in the “The Journal of Alternative and Complementary Medicine” concluded having an increase in milk supply with fenugreek herbal tea. Mothers in the study group who consumed the herbal tea with fenugreek daily had infants with better regain of weight in the first week of life as compared to the control group who didn’t have fenugreek herbal tea (Turkyılmaz, Onal, Hirfanoglu, Turan, Koç, Ergenekon & Atalay, 2011). Thus, there are varying data available on use of fenugreek to increase milk supply. The recommended dose of fenugreek usually is about 1200 to1500 mg three times a day (i.e. 2 tablets of 600mg three times a day). There are also fenugreek seeds readily available in any international focused or indian grocery stores. One can have ½ to 1 teaspoon of fenugreen seeds 3 times a day (can be soaked in water over night). Most mothers who take fenugreek often know they having adequate dose, when their body fluid (like sweat and urine) smells like maple syrup. Fenugreek is not recommended in mother’s with history of diabetes as it can cause a adverse effects of hypoglycemia. It is also not recommended in mother with asthma or peanut/chickpeas allergy. Hence, always consult a Lactation Consultant or your health care provider.
2. Fennel: fennel mimics estrogen like properties which is used widely in combination with fenugreek to make galactagogues capsules. It mostly used in Mediterranean food. Fennel is also known for improving digestion.
3. Blessed Thistle: is a medicinal herbs used for centuries to increase milk supply. Most supplemental galactagogues are prepared along with fenugreek for more optimal outcomes. Usually sold as tea or capsules form and recommended to take three times a day. Blessed thistle may cause gastric irritation. Blessed thistle is not recommended for pregnant women as it may cause uterine stimulation causing contractions.
4. Gout’s Rue: widely used along with blessed thistle and fenugreek to augment supply. Never take in its fresh/raw content as it may be toxic. Goat’s rue may cause low calcium, low blood pressure and coughing.
5. Alfalfa: is a form of pea. Its sprouts have a great nutty flavor which have numerous health benefits. Alfalfa is also given to dairy animals to help stimulate milk production. It is known to be rich in fiber, protein, antioxidant and vitamins. It aids in improving digestion and lowering cholesterol. Potential side effects is dose related bleeding.
6. Shatavari: is a great herb to help fight respiratory and reproductive problems in both men and women. In women, it is used for relieving menstrual related symptoms and promoting fertility. Should be avoided in pregnancy due to its potential teratogenic effects (can effect the development of embryo/fetus). It comes in capsule, power and liquid forms.
7. Moringa: the tree of moringa is also called the “Miracle Tree” due to its numerous medicinal properties. It is rich in vitamins, iron and essential amino acids. It comes in power, tea, oil and capsule forms (5000mg).
8. Brewer’s yeast: is commonly known for making beer. It is also known for increasing milk supply in nursing mothers. It is rich in protein, iron, selenium and vitamins to promote general energy and mood in postpartum mothers. It is available in powers, flakes, liquid and tablet forms.

• Medications: Medications are generally used as a last resource in attempting to increase supply. Prescription medications like Domperidone (motilium) and Metoclopramide (Reglan) are widely used to augment breast milk supply. These medications increase the level of prolactin hormone which in turns assist in increasing supply. Your doctor may recommend you to have blood work to have your prolactin levels checked. If your prolactin levels are low, these prescription medication may help. The main mechanism of action of Domperidone and Metoclopramide is by blocking dopamine, which in turns increases prolactin levels. These medications will not help in mothers who have already high or normal levels of prolactin level.

1. Metoclopramide (Reglan): is an approved medication mostly used for GI issues like nausea and vomiting. It is an off-label use for postpartum mother with low prolactin levels. One of the major side-effects to watch with Reglan is depression. Hence, it is not very widely recommended in USA for increasing supply as it can cause serious anxiety and depression in mother with or without previous history of depression. Other side effects to watch for are diarrhea, nausea, seizures, twitching, sedation and so forth. Reglan is used as a daily dose of 30-45mg and seen to show positive outcomes with supply in mothers with low prolactin level in about 3-5 days of its use.
2. Domperidone (Motilium): is not FDA approved for increasing milk supply and FDA warns against its use due to safety health concerns with reported cases of cardiac arrhythmias, cardiac arrest and sudden death.  For that reason also, Domperidone is not available in US.

Hence, two known medication that can help increasing milk supply in mother with low prolactin levels are still not widely used due to its serious side effects.

In conclusion, first try to identify the possible causes of low milk supply. If you feel you are suffering from low supply, monitor your baby closes for any early signs of dehydration. Knowing the cause for your low milk supply is important in knowing an appropriate management to increase supply. Always remember, the most important step in increasing your supply is stimulation or frequent breast emptying via breastfeeding/pumping. Consult with a lactation consultant to obtain continued support and guidance required in reaching your goals.

References:

Turkyılmaz, C., Onal, E., Hirfanoglu, I. M., Turan, O., Koç, E., Ergenekon, E.

Atalay, Y. (2011). The Effect of Galactagogue Herbal Tea on Breast Milk Production and Short-Term Catch-Up of Birth Weight in the First Week of Life. The Journal of Alternative and Complementary Medicine, 17(2): 139-142.

Reader, C., Legrand,A. & O’Connor-Von, S. K. (2013). The Effect of
Fenugreek on Milk Production and Prolactin Levels in Mothers of Preterm Infants. Clinical Lactation, 4 (4): 159-165