October 13, 2008

Breast Milk Supply: Protocol to Increase Breastmilk Intake

Breastfeeding an infant

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Also Good For Overactive Letdown Reflex (“too much milk”) and Colic

by Dr. Jack Newman

Most mothers have lots of milk or could have had lots, but the problem is that the baby is not getting the milk that is available. Sometimes, mothers are told they have too much milk, and it may come out very quickly in the beginning and then the baby will fuss when the flow slow down. Thus, this is our Protocol for managing the milk intake better.

Although the following symptoms are not necessarily due to the baby’s not getting enough milk, this Protocol can be used to help resolve concerns about:

• The sleepy or “lazy” baby (babies are not lazy, they respond to milk flow and if flow is slow they tend to sleep at the breast) or baby who seems to want to “pacify” (sure, sucking feels good, but getting food while sucking feels better!)
• Frequent feedings or long feedings or babies who don’t seem to ever wake for feedings
• Jaundice (see also handout Jaundice)
• The baby who pulls or fusses at the breast
• The baby who is fussy or “colicky” (see also handout Colic in the breastfed baby)
• Mothers who feel they have an overactive let down, or their babies choke at the breast; or whose breasts don‘t seem to “drain”

[ad#ad-2] To Ensure Baby Drinks as Well as Possible…

1. Get the best latch possible. This needs to be shown by someone who knows what they are doing. Anyone can look at the baby at the breast and say the latch is good. A good latch is asymmetric, does not hurt, and allows baby to get the milk that is in the breast. Baby’s chin should be in the breast, nose far away from the breast, covering more areola with the lower jaw, head in a tipping-back position so baby has to reach forward to latch on. See When Latching diagram and video clips at www.drjacknewman.com. Get good “hands on” help.

2. Know how to know the baby is getting milk. When a baby is getting milk, he will have an open mouth wide–>pause–>close-mouth-type of suck. He is not getting milk just because he has the breast in his mouth and is making sucking movements. When he is sucking and not getting milk his chin will move rapidly with no pausing in the rhythm—this means: I am trying to get the milk out but it is not coming. If you wish to demonstrate this to yourself, put your index or other finger in your mouth and suck as if you were sucking on a straw. As you draw in, your chin drops and stays down as long as you are drawing in. When you stop drawing in, your chin comes back up. This pause that is visible at the baby’s chin represents a mouthful of milk when the baby does it at the breast. The longer the pause, the more the baby got, so it is obvious that telling mothers to feed the baby 10 or 15 or 20 minutes on each side makes no sense. A baby who drinks very well (as opposed to just sucking) for, let’s say, 20 minutes straight, might not even take the second side. A baby who nibbles (doesn’t drink) for 20 hours will come off the breast hungry. You can see this “pause”on the videos at www.drjacknewman.com.

3. Compressions: Once the baby is only sucking and no longer drinking on his own, use compression to increase flow to the baby. Babies tend to pull at the breast when the flow of milk is slow, so it is useful to know how to know the baby is actually getting milk and not just sucking without getting milk. When the baby no longer seems to be getting milk, and is sucking without getting milk, this is the time to start compressions, while the baby sucks, but does not drink. Keep the baby on the first breast until he doesn’t drink even with compressions. See handout Breast Compression. You can see how to use compression on the videos at www.drjacknewman.com.

4. Switch Sides: When the baby no longer drinks even with compressions, switch sides and repeat the process. Keep going back and forth as long as the baby gets reasonable amounts of milk at the breast.

When The Above Is Not Working Or Not Working Well Enough…

5. Herbs: Take fenugreek and blessed thistle. These two herbs seem to increase milk supply and increase rate of milk flow. Because herbs are not standardized, we recommend mother take enough Fenugreek so that she notices its scent on her skin. Often, 3 capsules of each Fenugreek and Blessed Thistle (or 20 drops of tincture) taken 3x/day will help and should work within 12-24 hours. If they have not worked by 72 hours, and mother smells of Fenugreek, then they are unlikely to work. For other herbs that may help to increase supply, see handout Herbal Remedies.

6. Lying Down: In the evening when babies often want to be at the breast for long periods (as mothers tend to have less milk in the evenings), get help to position the baby so that you can feed lying down. Let the baby breastfeed and maybe you will fall asleep. Or rent videos and let the baby breastfeed while you watch! See handout Safe Co-Sleeping.

Still Not Working…

7. Domperidone is a medication which increases the rate of milk flow to the baby by increasing the milk supply. It is not a panacea (a magic bullet). Sometimes it can be useful even if your supply is already substantial (as when the baby does not know how to latch on). (See handout Domperidone I, II)

8. Supplementation: It is not always easy to decide if a baby needs supplementation. Sometimes applying this Protocol for a few days gets the baby gaining more rapidly. Sometimes more rapid growth is necessary, and it may not be possible without supplementation. If practical, get banked breastmilk to use as a supplement if you can (for more info: www.hmbana.org). If not available, infant formula may be necessary. However, sometimes slow but steady growth is acceptable. The main reason to worry about growth is that standard growth is one sign of good health. A baby who grows well is usually in good health, but this is not necessarily so. Neither is a baby who grows slowly necessarily in poor health, but physicians worry about a baby who is growing more slowly than average.

Growth charts are frequently interpreted poorly. A baby who follows the 10th percentile line is growing as he should be. Too many people, including physicians, believe that only babies on the 50th percentile or higher are growing normally. Not true. Growth charts were developed on information based on information gathered about normal babies. Somebody has got to be smaller than 90% of all other babies—somebody normal.

9. Lactation Aid: If it is decided to supplement, the best way is at the breast with a lactation aid. Introduce the supplement with a breastfeeding supplementer (lactation aid, #5 French 36” feeding tube), not by bottle, syringe, cup, or finger feeding. (See handout Lactation Aid). Supplement only after steps 3 and 4 above and the baby has breastfed on at least both sides. Why is it better to use the lactation aid?

• Babies learn to breastfeed by breastfeeding
• Mothers learn to breastfeed by breastfeeding
• The baby continues to get your milk and therefore helps you to make more milk
• The baby won’t reject the breast
• There is more to breastfeeding than the breastmilk

10. Solids: If the baby is older than three or four months, and supplementation appears to be necessary, formula is not necessary and extra calories can be given to the baby as solid foods. First solids may include: mashed banana, mashed avocado, mashed potato or sweet potato, homemade oatmeal, etc, as much as the baby will take, and after the baby has breastfeed, if he is still hungry. Even at this age giving bottles when the baby is not getting much from the breast will often result in breast rejection. If you must give formula, mix it with the baby’s solids.

Giving solids at three or four months if everything is going well is not recommended. Solids should normally be started when the baby is showing interest in eating solids (usually around six months of age, See handout Starting Solids).

11. Slow Weight Gain: If your baby was gaining well for a few months and now is not gaining well, see the handout

Slow Weight Gain After the First Few Months. Reasons for a decreased milk supply are listed there. Fix what you can, and then follow this Protocol.

Questions? Email Jack Newman at drjacknewman@sympatico.ca, or Edith Kernerman at breastfeeding@sympatico.ca or consult: Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA) or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding; or The Latch Book and Other Keys to Breastfeeding Success; or L-eat Latch & Transfer Tool, or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond. See our website at www.drjacknewman.com.

To make an appointment email breastfeeding@ccnm.edu and respond to the auto reply or call 416-498-0002.

Handout, Protocol to Increase Breastmilk Intake May 2008
Written and Revised by Jack Newman, MD, FRCPC 1995-2005

Revised by Edith Kernerman, IBCLC and Jack Newman, MD, FRCPC © 2008

This handout may be copied and distributed without further permission, on the condition that it is not used in any context that violates The International WHO Code on the Marketing of Breastmilk Substitutes

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Alexis Rodrigo