Coping with low milk production is difficult even in the best of circumstances. At times, mothers are faced with additional challenges such as exclusive pumping, premies, multiples, relactation, or induced lactation for a surrogate- born or adopted baby who requires specialized strategies to increase milk production.

Exclusive Pumping

Long-term pumping and bottle-feeding happen for a variety of reasons. You may have had problems that made feeding at the breast difficult or impossible. Or you may want the best for your baby but don’t want to breastfeed. Exclusive pumping challenges milk production because the infant has been taken out of the equation. Even when given human milk, babies fed by bottle tend to develop feeding patterns that are different from how they would have breastfed, so baby’s eating pattern is not always the best guide for developing an appropriate pumping routine for your body. Nor does the same schedule work equally well for every exclusively pumping mother. Some mothers are able to sustain pumping large amounts of milk in just a few sessions a day, while others need to pump more often to maintain adequate production It’s wiser to pump more frequently in the early weeks and store any extra milk in the freezer than cut back too quickly to the fewest number of sessions necessary to obtain a certain amount of milk. Eventually, you may be able to get by with fewer pumping sessions, but for the first several weeks, shoot for pumping at least eight times per twenty-four hours. Rather than pumping at certain intervals, you’re likely to get more milk by keeping the amount of time in between pumpings as short as possible so the breasts don’t get overly full and slow down production.

 After the first three or four weeks, you can experiment to determine how often and how long it is necessary to pump to have enough milk for your baby. All breasts respond differently so pay attention to how your breasts feel and not just the clock. When most of the available milk has been removed, they’ll feel soft and light. After pumping a few times, you’ll learn what this feels like. Sometimes it will take longer, sometimes shorter, And sometimes you’ll pump past that point to provide extra stimulation. Pumping intuitively will keep your pumping routine efficient.

If you’re having difficulty meeting baby’s daily needs, first make sure he isn’t being overfed. If not, power pumping or increasing the number of pumping sessions per day may help increase your supply. The suggestions for effective pumping in blog 11 as well as many of the strategies suggested for working mothers in Blog_13 may help.

Galactogogues are most effective when there is frequent milk removal to go with them.

Exclusive pumping for an extended time period requires dedication, and sometimes it can be hard to stay motivated.

Premature Babies

When a baby is born prematurely, lactation rarely begins normally because of the events surrounding the early birth. A small but otherwise healthy baby may be able to breastfeed soon, but chances are good that he may not be strong enough to get all his nourishment from the breast right away. Quite often, premature babies are not ready to breastfeed at all after birth; the earlier they come, the more likely this is true. So you will need to start pumping as soon and as frequently as possible to establish good milk production.

One question is whether the breast is “fully operational” for mothers who deliver prematurely. Because the basic glandular structures are complete by the first half of pregnancy, it has been assumed that full milk production is possible. However, this may not be true for all mothers, especially when delivering between twenty-two and thirty-four weeks of gestation. Milk-making cells enlarge during the second half of pregnancy, and the impact of shortening this growth time was unknown before now. But new research is showing that milk volume in the beginning is directly related to gestational age at birth and rises as gestational age increases.

Another new insight is a previously unnoticed relationship between the use of corticosteroids such as betamethasone and a delay in milk production after birth. These drugs are often given when premature delivery threatens because they can improve the baby’s ability to cope and survive. The amount of time between the treatment and the birth seems to make a difference; from zero to two days the effect was small, but from three to nine days it was much greater.

 Finally, there is the question of why baby was born early, because preexisting medical or in- fertility conditions that can result in premature births might also subtly affect the developing breast. If your baby was small for gestational age (SGA), intrauterine growth restricted (IUGR), or a problem with the placenta was suspected, be sure to read about placental problems in Blog_9 and remember that breast tissue can still be built up after birth.

calibrate high enough. If one or both babies are at home from the hospital, use the strategies in Blog_4 for supplementing in a way that is supportive of breastfeeding as you work to in crease your milk production.

Begin pumping as soon after birth as possible, preferably within the first hour, with a goal of eight or more fifteen-minute double-pumping sessions per day. Trying to fit in that many pumping sessions when you are also visiting your babies in the hospital each day can be difficult, so don’t worry about spacing pumping sessions evenly; it’s fine to cluster some of them closer together, just as your babies are likely to cluster some of the feedings together when they begin nursing.

Keep in mind that when you first start pumping more frequently, you are likely to see less milk in each pumping session, but the total amount will be the same, and higher later on. See_Blog_11 for tips to enhance your milk output.

Once both babies are able to breastfeed, you may be able to discontinue pumping, depending on how effectively each breastfeeds. If you aren’t sure, a little extra “insurance pumping” will guarantee that the breasts are drained well and adequately stimulated. But, if the babies aren’t removing milk effectively overall, it’s better for both your sanity and milk production to spend more time on pumping and less on breastfeeding until they can nurse better.

Simultaneous nursing can be a real time- saver, with the added advantage that the babies can help each other in stimulating milk ejections. It doesn’t work well for everyone, but it’s worth giving a try. There’s no rush; wait until at least one baby is able to latch and nurse effectively before you attempt both babies together. It may be easier to first latch the baby that has more difficulty.

If milk production is a struggle even though you’ve been doing “everything right,” one additional thing to consider is whether the babies were conceived with or without fertility assistance. If there was a hormonal problem that affected your ability to conceive, it may now be affecting your milk production. (Addressing the specific hormonal problem, when possible, may improve lactation See_Blog_9).

Relactation

 Relactation is the process of rebuilding a milk supply weeks or months after baby stopped breastfeeding, which can happen for many reasons. Sometimes milk production appeared to be so low that it originally didn’t seem worth the bother to continue breastfeeding. In other cases, doctors have told mothers they have to wean in order to take certain medications or undergo diagnostic tests, or just because breastfeeding has been a struggle and they don’t know how to help Long separations from baby or breast rejection can also lead to unintended weaning. Though it seemed like the right decision at the time, some women later regret their decision to wean and decide to reclaim their breastfeeding relationship. Or it simply may be that baby isn’t tolerating formula and needs mother’s milk.

In general, it may take about the same amount of time to resume exclusive breastfeeding as has elapsed since baby weaned, provided you once had a full supply. This means that if your baby was weaned a month ago, it may take up to a month to reestablish full milk production.

 It can be reassuring to keep in mind that babies are born to breastfeed, and there are many ways to gently entice a baby back to the breast. Younger babies are usually more willing to return to nursing, but older babies have been known to take to it easily as well. For some, it may be necessary to get milk production back up before they’ll agree to nurse. At-breast supplementers can help because they provide immediate satisfaction for baby’s sucking effort. Or you also may find it helpful to give baby some milk by an alternate method before offering the breast (See_Blog_4). If he still won’t latch don’t hesitate to enlist the help of an experienced lactation consultant, who may provide some helpful tips customized for your situation. Once baby is latching easily, avoid giving him a pacifier and encourage him to nurse at every opportunity.

The rate of milk production will increase more quickly if you’re still in the early postpartum period than it will if you have an older baby. The less involution that has occurred, the better your chances for full relactation; however, t speed at which this happens varies and cannot be easily predicted. If you had a full milk supply before baby stopped breastfeeding, you’re more likely to recover it than if you had reached only a half supply before stopping. When weaning happens prior to six weeks postpartum the breasts may not have had a chance to fully develop the milk-making tissue and hormone receptors.

Relactation boot camp” is promoted on some Internet websites, but it involves nothing more than very frequent nursing, similar to a “baby moon” or “nursing vacation,” and isn’t likely to provide baby with enough milk in the short term when your milk production is low or nonexistent. The technique advises eating a very healthy diet and consuming large quantities of fluid even though increased nutrition, calories, and hydration have not been shown to have a significant effect on the amount of milk produced unless the mother is extremely malnourished or dehydrated, as discussed in Blog_6. Frequent nursing and a positive “can do” attitude can certainly help, but supplementation combined with effective methods to increase milk production beyond baby’s sucking, such as pumping with a hospital-grade pump and using galactagogues, are usually necessary.

 Induced Lactation

 Induced lactation is the process of creating a milk supply for a child you have not birthed. With a long historical tradition in native societies, it is becoming more common as women learn that it is possible.For both adoptive mothers and mothers of surrogate babies, breastfeeding is about more than the milk- it’s a way to connect at a deeper level with your new baby and contribute to his growth beyond the pregnancy. Although it will require time, motivation, perseverance, tenacity, and patience, breastfeeding your baby can be tremendously rewarding.

As with relactation, the younger the baby, the more likely he is to latch onto the breast easily. A baby older than three months is liable to have more difficulty learning what to do than a new- born. All babies nurse more willingly when there is more milk, so it helps to do all you can to maximize your production. Achieving a full supply may be possible provided there aren’t underlying problems such as hormonal dysfunctions or underdeveloped breast tissue. If you struggled with infertility in particular, there may be a hormonal problem that could limit your milk- making capability. However, most mothers can make at least some milk, and the total amount of milk need not interfere with a satisfying breast- feeding relationship. While you won’t produce true colostrum, the milk you make will be the same quality as a birth mother’s mature milk.

 If you’re currently nursing but want to breastfeed a new baby you did not birth, you may not be able to increase milk production enough to meet the new baby’s needs fully because you are in the autumn season of lactation now. But it’s always worth trying because your new baby will benefit from whatever extra you can make.

 Methods of Inducing Milk Production

In traditional cultures, women have successfully stimulated milk production just by putting the baby to the breast very frequently. Our Western approach relies more often on breast pump technology, but pumping is an imperfect way to induce milk production because it is cold mechanical, and vacuum-centered only. Plus, it takes time to become comfortable and proficient at pumping. Even birth mothers with excellent milk production aren’t always able to pump effectively, especially in the beginning. A nursing baby adds a positive emotional element; not only does suckling stimulate milk ejection, but the psychological effect of baby’s smell, sight, and sounds triggers additional oxytocin releases that a pump cannot. If possible, combining pumping with nursing baby using an at-breast supplementer can provide the best of both worlds. Adding galactogogue medications and/ or herbs can result in significantly higher milk production.

Basic Pumping Protocol for Induced Lactation

  1. Two to four weeks (or more) prior to the baby’s arrival, begin manual massage of nipples and breasts for ten minutes eight to ten times per day for two weeks.
  2. After two weeks, begin double pumping with a hospital-grade pump for ten to fifteen minutes eight to ten times per day If you find pumping without a flow of milk to be uncomfortable, try putting a bit of breastfeeding- grade lanolin on your nipples or lubricate the funnel with a bit of vegetable or olive oil be- fore pumping
  3. When baby arrives, use an at-breast supplementer to provide feedings at the breast (See_Blog_4). Pump after feedings or several times per day, as time permits (see “Power Pumping” in Blog_11). Keep a close watch on baby’s weight gain to ensure that he is get- ting enough nutrition.
  4. As your breasts begin to feel full, heavy, and slightly tender, see if baby will nurse at the breast without supplementation for the first few minutes of the feeding if he is willing. Continue to watch diapers or track weight gain.
  5. As long as hunger cues aren’t frantic and weight gain is sufficient, gradually decrease either the amount of milk in the supplementer or the length of time the milk is allowed to flow from the supplementer during the feeding. Eventually, you may reach a point where you can no longer decrease the amount of supplement you offer without leaving baby hungry. That is the amount that will be needed for now, and maybe for the long term.
  6. In the beginning, you have only your standby skeletal crew of lactocytes to start up milk production. Be patient. Induced lactation really is more like building a milk factory by hand from bricks and mortar instead of having the construction company, pregnancy, do it with all their specialized parts and equipment. Not as fancy and takes longer, but sooner or later new workers and assembly lines will slowly start to kick in, and your production will pick up.

Hormonal Simulation

 Hormonal protocols for inducing lactation at tempt to artificially simulate a pregnancy in order to build a milk factory. The amount of hormones used is less than what is normally produced during pregnancy. A birth control pill containing estrogen and progesterone is taken for a specific amount of time in order to stimulate the growth of more milk-making breast tissue. Then a prolactin-stimulating medication is introduced. Finally, pumping is begun to remove milk and further stimulate milk production.

In most cases, hormonal protocols result in more milk production than simple pumping The more time you spend in the pregnancy- mimicking phase, the more milk-making tissue will be created. Starting at least four months before baby is expected to arrive produces the best results. You can initiate a protocol even after your baby arrives, but the shorter the lead time, the less you should expect to produce.

Milk does not come in until the pumping phase and first appears as clear drops that eventually become more opaque and white in color. As the milk volume increases, you may begin to see small sprays that eventually become streams of milk. The amount of time it takes to reach the streaming phase varies from mother to mother and depends on the type of protocol that she follows. It may take days, weeks, or months for milk production to begin. You’ll know your bod;y is gearing up to make milk when your breasts increase at least one bra cup size and feel full, heavy, and slightly tender. If you don’t experience at least some tenderness within fifteen days, it may be necessary to increase your progesterone intake.

Because hormonal protocols entail the use of prescription drugs, it is essential to consult a physician. Present the entire protocol and explain that the birth control pill is not being used as a contraceptive but rather to develon lactation tissue. The medication can be started at any point in the menstrual cycle because the purpose is to simulate a pregnancy rather than prevent one.

Mothers who have blood clotting problems (a history of thrombosis), heart conditions, or severe blood pressure problems (hypertension) should not use hormonal protocols. Nor should mothers who wish to tandem nurse, because the existing milk supply will be reduced initially.

The Newman-Goldfarb protocols were developed by Lenore Goldfarb, B.Comm., B.Sc., IBCLC, in consultation with Dr. Jack Newman, as a result of her personal experience and subsequent work with other mothers, and are still evolving. They represent a new strategy that has not been formally tested in clinical trials but has been described theoretically by Dr. Peter Hartmann and his research group in Australia. Many mothers have found the protocols to be effective. Similar but more limited protocols using medications to stimulate lactation hormones have been tested and found to be effective as well. There are several versions of the Newman Goldfarb protocol to accommodate the varying amounts of time available before baby arrives and the mother’s hormonal situation.

Mothers who prepare for six months or more by following the “regular protocol” are more likely to induce a full milk supply, while mothers who do so for fewer than six months and follow the “accelerated protocol” are often able to induce a 50 percent supply. Mothers who follow the “menopause protocol” may produce a 25 percent or less milk supply.

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