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In the next five blogs, we will explore various reasons for low milk production. This is an exciting part of the journey because finding answers provides an explanation for what is happening and allows the possibility of targeting specific changes to the true cause so you can make the most milk possible.

Finding Causes of Low Milk Production

An important question to ask yourself as you begin this process is, “Was there ever a time that I felt like I had a lot of milk?” If your milk came in well but then something happened to sabotage your supply, there’s a good chance that your problem will be found among the secondary causes in this blog or the next. If your milk production seemed low from the beginning, however, or dropped off despite you and baby doing everything right, BLOG_8 through 10 about problems originating with your body may hold your answers. There may also be more than one cause. If there is both a secondary and primary cause, the impact upon your milk production may be even greater than if there is only one factor. For this reason, it is important to keep an open mind as you read through these possibilities because there may be unexpected answers.

The Milk Supply Equation Sufficient glandular tissue

+ Intact nerve pathways and intact ducts

+ Adequate hormones and hormone receptors Adequately frequent, effective milk removal and stimulation (mother’s side: management)

=GOOD MILK PRODUCTION

Secondary problems can be divided into “management” and “infant” issues. Fortunately, low milk supply caused by these problems is usually reversible. The management problems described in this blog are aspects of lactation that are under your control, such as how often and long you feed your baby, how you bring baby to your breast, and the possible effects of foods, herbs, and medications on your milk supply. So they may be relatively easy to fix. Infant problems as described in the next blog, on the other hand, occur despite good breastfeeding management because something isn’t working on baby’s side of the equation.

Latch Problems

One of the most common causes of low milk production in the early weeks is poor attachment to the breast. When baby is latched too shallowly, he doesn’t have enough breast in his mouth to effectively draw out milk. Less milk is removed, and the breast responds by cutting back on production.

Clues for poor attachment are usually obvious. The breasts will not soften much during nursing because milk is not being drained. Friction to the nipple causes pain and damage (never normal!). As the situation worsens, the baby becomes fussy at the breast, pulling off or falling asleep too quickly. Diaper output is scant, weight gain is inadequate, and if the baby is jaundiced, the condition does not improve after the milk comes in. While initially, the breasts were fuller at feeding time, they begin to feel soft and empty all the time.

Some well-intentioned but misinformed health care providers recommend limiting how long baby breastfeeds on each side to prevent or treat sore nipples. However, it’s not how much time a baby spends at the breast that causes pain but the quality of the latch and suck. Limiting the amount of time baby nurses without correcting the underlying problem can reduce milk production by limiting milk removal. A much better strategy is to determine why breastfeeding is painful in the first place and fix the problem.

The good news for latch-related supply problems is that correcting the problem is often relatively easy. you aren’t able to fix it on your own, the problem could be related to baby’s ability to suck effectively(SEE__BLOG__7) and may require the help of a lactation consultant.

When Milk Seems to Dry Up Overnight

Between two and four months postpartum some mothers experience what seems like a sudden drop in milk production. Their babies act hungry all the time, while the mothers’ breasts feel empty. One possible explanation is that baby’s appetite has temporarily increased due to a growth spurt. This isn’t a problem unless you start giving supplemental bottles, which reduce milk removal and slow production. The result can be a downward spiral of more fussiness, more bottles, and less milk, until one day you feel like you’ve “just dried up.

” A similar “drying up” phenomenon is related to feeding schedules that call for baby to feed every so many hours (often three or longer) by the clock. Everything seems to be working until one day the milk seems to start disappearing The most likely explanation is inadequate development of prolactin receptors due to chronic infrequent feeding; once prolactin levels have dropped, the existing receptors cannot sustain the earlier production level. Milk supply may rebound with renewed stimulation, but other times it is difficult to resurrect. Feeding more often, possibly coupled with the addition of a galactagogue (see BLOG 12), is usually the best strategy for turning things around.

In very rare cases, this occurs despite frequent and effective feedings, due to either hormonal changes or underlying difficulties with prolactin receptors. Have a lactation consultant review your history and the clues you’ve collected after reading this book. The next step is to make an appointment with your physician, provide a summary of what you do right and what you’ve ruled out, and request hormone testing SEE__BLOG__9.

Stealthy Saboteurs Common Substances That Inhibit Milk Production

In the same way that a galactogogue stimulates milk production, an anti-galactogogue is a substance that decreases milk production. Once you’ve identified and removed the offending item, milk production will often improve on its Own.

Medications

Several medications are known to inhibit milk production. Bromocriptine (Parlodel), once used to dry up the milk of mothers who didn’t want to breastfeed, is still used to treat excessive prolactin levels. Cabergoline (Dostinex), another prolactin inhibitor, is used more commonly because it’s much safer, but its effects are longer lasting than bromocriptine. Buproprion, marketed as Wellbutrin and Zyban, has negatively affected some women’s supplies. Pseudoephedrine, found in Sudafed (not Sudafed PE) and many allergy and cold medications, can also be a problem, especially in later lactation. Ergot alkaloids such as methylergonovine maleate Methergine, discussed in BLOG__9) and dopamine receptor agonists can also lower milk production.

Alcohol

The effects of alcohol (ethanol) on breastfeeding have been widely debated. Mothers have long been advised to drink a glass of beer or wine to relax and get their milk flowing. Beer especially has been recommended, and a positive effect on milk supply has indeed been documented. However, it’s actually the polysaccharide from barley that stimulates milk synthesis; a good nonalcoholic beer has the same effect. Alcohol itself inhibits both the milk ejection reflex and milk production, especially when taken in large amounts. Even a moderate amount, such as a single beer or glass of wine, can disrupt the balance of lactation hormones in breastfeeding women, While the immediate effects of alcohol on milk production and delivery last only as long as the alcohol is in your system, chronic alcohol use has the potential to lower your milk supply overall.

Cigarettes  

Cigarettes contain nicotine, which is believed to inhibit prolactin secretion and milk production. In a classic study of both smoking and non- smoking mothers pumping ilk for their premature babies, the nonsmoking mothers were producing 25 percent more milk two weeks after birth than the mothers who smoked. At four weeks, the smoking mothers’ milk supplies still were unchanged, while nonsmoking mothers increased another 20 percent. Of further concern, the fat content of the milk from smoking mothers was almost 20 percent less than that of non- smoking mothers.

Herbs

Just as there are herbs that may help in crease milk production, others seem to de- crease it. A lactation consultant once visited a mother whose milk came in with each baby but disappeared soon after. She watched as the mother was served a steaming bowl of home-made chicken soup heavily spiced with sage, an herb known to reduce milk supply. The mother proudly shared that her helpful husband made it for her after the birth of each baby! Once she stopped eating the soup, she was able to breast- feed exclusively for the first time. Parsley is another seasoning herb considered to have lactation-suppressing properties in large amounts such as in a dish like a tabbouleh.

Peppermint is also reputed to decrease production when consumed in larger or concentrated amounts and has been used to help control some cases of oversupply. Frequent brushing with toothpaste containing real mint oil or even eating potent mint candies has caused trouble for some mothers. Jan Barger, RN, IBCLc, tells the story of a mother who called around Christmas complaining that her milk production had abruptly plummeted. It turned out that she had been eating peppermint candy canes “right and left,” and once she stopped, her supply rebounded. Most of these herbs don’t usually cause problems unless they are consumed regularly or in large amounts. The occasional breath mint, candy cane, or modest serving of Thanksgiving turkey stuffing seasoned with sage should not be a problem.

Hormonal Medications

Certain hormones such as estrogen, progesterone, and testosterone can inhibit milk production if their levels are too high or if synthetic versions are introduced at the wrong time during lactation. It has long been recognized that “combination” birth control pills containing forms of both estrogen and progesterone can significantly decrease milk production. Newer “minipills” are estrogen-free and better for nursing mothers, but a small number of women still experience a drop in supply untıl the medication is stopped. Similar problems have happened with patch and subdermal implant birth control, and a case of low supply related to a hormonal intrauterine device (IUD) has been reported. Depo-Provera, a long-acting injectable type of hormonal birth control, poses more serious problems because it lasts for three months and cannot be reversed; the best option is to try a galactagogue to counter the effect. SEE BLOG 12

Hormonal birth control has a greater chance of causing problems in the early days after birth, when progesterone and estrogen receptors are plentiful than it does later after they naturally decline post-pregnancy, reducing the effect of the hormone. Many physicians feel that a safe time to introduce these methods is around the time of your six-week postpartum checkup. However, waiting three months or longer further reduces the risk of problems.

Pregnancy

If your production has mysteriously dropped off especially if your nipples are also newly tender, a new pregnancy might possibly be the culprit. As your body prepares for the new baby, hormones switch gears and lactation is no longer the first priority. Most women begin to notice a decrease in milk production within the first several weeks; many babies also notice a difference, as both vol- ume and taste change.

Fortunately, continuing to nurse during pregnancy will not endanger the new baby. In fact, many mothers have successfully breastfed through pregnancy without incident. One factor that does need to be considered is the age of the current nursing when a new baby is conceived, because 70 percent of women experience a decrease in milk production by mid-pregnancy.4 If the nursing is still quite young supplementation may be necessary.

What are your options for increasing pro- duction during pregnancy? It really is a case of swimming upstream against nature, because your body shifts priority to preparing for the new baby. Nursing more often may help, but many mothers can’t tolerate it because of nipple tenderness. Herbal galactogogues are another option but must be chosen carefully as some can induce contractions or have other properties of concern during pregnancy.

The dairy industry has learned that a dry period toward the end of pregnancy helps maximize milk production after the calf is born. Cows with high production in late pregnancy tend to have less milk for the new calf. So might stimulating a higher milk supply during pregnancy cause problems for the next baby’s milk supply? While this question hasn’t been extensively explored, human lactation expert Dr. Peter Hartmann suggests that concerned mothers consider feeding their current nursing from only one breast starting in the third trimester so that the other returns to pure colostrum production. This is a compromise between continuing to nurse the older baby and maximizing milk production after delivery.5 While many mothers successfully use both breasts throughout pregnancy, those who barely meet baby’s needs may benefit from this suggestion.

Outside Interference

Some nursing mothers sail smoothly along until poor advice rocks their boat. This happens when a mother facing a medical procedure, drugs, or hospitalization is told that she can’t nurse for a period of time, usually by staff unfamiliar with current information. To make matters worse, little or no guidance is provided on how to maintain production, and by the time breastfeeding is “allowed” again, milk supply is damaged. Educating yourself on the facts is your best defense, and regular pumping your backup. Consider if the person telling you that you can’t breastfeed is up to date on lactation information. Always get a second opinion from someone with expertise and resources in lactation before the following advice to stop breastfeeding. Dr. Thomas Hale’s book, Medications and Mothers’ Milk (updated biannually) is an excellent safety reference. You or the person questioning breastfeeding can then discuss this information with the baby’s health care provider.

Feeding Frequency and Duration

Newborns must feed frequently to fuel their growth and get your milk production up and running. Your job is to make sure that baby has all the opportunities he needs. The following can interfere with this process and sabotage your milk factory if they aren’t caught early.

The Sleepy or Nondemanding Baby

There is an old saying, “Let sleeping dogs and babies lie. Sounds like a good idea, especially if you’ve been told to feed the baby “on cue” and he isn’t “asking” at the moment, right? While this advice is fine for an older baby who is gaining well, it isn’t appropriate for a newborn who is jaundiced, lethargic, or not gaining weight well.

Excessive sleepiness has several possible causes. A newborn may be drowsy after delivery because of medications given to you during labor. The effects may be brief, or they can linger for several days. During this time, lots of skin-to-skin contact can help stimulate your baby and trigger his nursing instincts.

Simply not getting enough milk can also cause a baby to sleep too much. He may eventually rouse and show clear signs of hunger but fall asleep again within minutes at the breast if the milk isn’t flowing quickly or he doesn’t have much energy to feed. This, in turn, leads to needing longer periods of sleep to conserve precious energy. Until milk production can be increased this baby needs supplementation for energy to feed well at the breast. Becoming fatigued during a feeding and falling asleep too soon can also happen as a result of suck or medical problems or baby’s side (discussed in BLOG_7).

Another cause of infant drowsiness is jaundice, a temporary yellowing of the skin that often looks like a suntan. Normal physiologic jaundice is caused by elevated levels of a blood by-product called bilirubin and is a healthy response to moving to live outside the womb. Early and frequent feedings minimized jaundice by stimulating bowel movements, through which bilirubin is eliminated. Water isn’t helpful because it produces only urine. If bilirubin levels rise significantly in the early days, enticing baby to eat more challenging because bilirubın makes babies sleepy and lethargic. While babies need to eat to get rid of the bilirubin, sleepy babies can be difficult to feed. A jaundiced baby should be awakened to feed at least every two to three hours until he begins to wake more on his own. Gentle methods such as holding him upright, massaging his body, talking to him, undressing him, or changing his diaper are most likely to result in willingness to feed.

Babies usually need more of mother’s milk, not less, to resolve jaundice. But a baby whose bilirubin levels are very high and unresponsive to regular management may require temporary suspension of breastfeeding (usually twenty- four to forty-eight hours) and feedings of an elemental formula until levels begin to drop.S It is critical to maintain frequent, thorough milk removal by other methods until baby can do the job himself again.

Pacifiers

Pacifiers can mask the hunger cues of babies who are easily soothed by them. They are often given in the belief that the baby is supposed to be full after so many minutes at the breast and stay content for a certain amount of time. An assertive baby will spit it out and insist on more milk, but an easy- going baby may not be as persistent. This can disrupt the baby-driven milk-making pro forcing inappropriately long feeding intervals that ultimately reduce milk supply. Pacifiers may also affect the baby’s suck, further decreasing the amount of milk made. Although the American Academy of Pediatrics workgroup on sudden infant death syndrome (SIDS) recommended pacifiers in 2006, forgoing them in order to protect your milk supply does not increase the risk of SIDS when your baby is allowed to nurse whenever and wherever he desires.

Busyness

Juggling a baby and the conflicting demands of a busy household is challenging. Feedings can be unconsciously postponed when you’re preoccupied by other tasks, trying to get “just one more thing” done. It’s especially difficult if you have older children and are always on the run driving them around, and the temptation to put off feedings instead of taking time to nurse right now may be strong.

In the midst of all that you have to do, it may be hard to remember how long you used to spend sitting and feeding your first children, but think back carefully. Are there differences that might be contributing to the problem you’re experiencing now? Though this may sound difficult, it is crucial to slow down and remember that this baby will only be young once, and his needs are immediate and important. Keeping him close in a soft baby carrier can help you respond to early feeding cues while on the go.

Clock-Driven Feeding Durations and Feeding Schedules

When do you eat supper? How long does it take? Is it always the same time of day, and do you always take the same amount of time? Probably not. Yet, it’s common for mothers to be told that they should nurse only every so many hours or for a certain number of minutes on each side.

Traditional cultures understand that babies should be put to the breast when they ask and nursed as long as they wish, and that how often and how long varies according to each baby’s emotional and physical needs at any given time In our society, however, we tend to believe that babies should breastfeed only for nutrition Mothers are urged to get baby on a schedule as quickly as possible to instill early discipline, to fit him conveniently into family life, to make life more predictable, or for “sleep training.” Whatever a parent’s fear or motivation, schedules are often regarded as an important parenting goal.

Some authors claim that babies who are fed when they want will never learn delayed gratification. Schedules are touted as essential for parental survival and are sometimes promoted under the premise that “teaching” babies to self-soothe and be independent is necessary for healthy development. But the opposite is true: studies show that babies whose parents respond to their cues for feeding and comfort cry less and are more confident and secure as they grow up.

Schedules may seem helpful to parents, but they don’t always meet the needs of breastfeeding mothers and babies. Rather than allowing milk production to be driven by the baby as nature designed, schedules artificially determine when feedings will take place. Mothers with abundant production and vigorously nursing babies may do well, but mothers with marginal supplies or babies with difficulties often do not. Even if all looks well in the beginning production can happen after a few months if an insufficient number of hormone receptors were established in the early weeks.

Some books now tout “flexible routines” as a more reasonable approach to feeding baby, While they are an improvement, the “flexibility” in these new methods translates to bending only on special occasions such as growth spurts, with the goal of getting back to the designated schedule as soon as possible. Bottom line: advice that supersedes your instincts on when to feed your baby can undermine yo ur milk supply.

Your Need for Sleep

New mothers can become obsessed with sleep simply because it’s hard to get enough. Sleep deprivation can drive us to desperation, and the around-the-clock needs of young babies can seem like an impossible demand to meet. Mothers in traditional cultures tend to take babies nighttime needs in stride, but Western living involves clocks, deadlines, schedules, and appointments that don’t always suit a baby’s way of life. s it any wonder that we feel stressed over lack of sleep and fear that this stage of life will never end?

The desire for more sleep is the most common reason given for nighttime bottles. But each skipped feeding decreases milk production by that same amount unless you compensate by pumping, preferably at about the same time, which defeats the purpose of a relief bottle. Realistic expectations are important. If your newborn feeds eight to twelve times a day and you want him to sleep eight hours at night so that you can have a long stretch of uninterrupted sleep, when is he going to get those feedings in? He has just sixteen hours, which means he needs to nurse every two hours, assuming adequate breast storage capacity and that baby isn’t taking milk faster than it is being made after a long night of inactivity. Can you really accommodate this? It is more realistic and normal for a baby to space his feedings throughout the day and night.

It’s easier to breastfeed at night if the baby is in bed with you or sleeping nearby. You may not even wake up completely while baby nurses. Co-sleeping is a time-honored tradition that has unfortunately come under fire as newspaper headlines inflame parents fears of overlying. However, Dr. James McKenna and other infant sleep researchers have shown conclusively that babies and mothers are biologically hardwired to sleep together, affording them not only more rest but safer sleep for babies. If you choose to co-sleep, be sure to do so in a safe manner, just as it’s important that a crib be used in a safe manner.

Unnecessary Supplementation

There are certainly times when baby isn’t get ting enough milk and must be supplemented. But there are also times when unnecessary supplements sabotage milk production by reducing milk removal and stretching out feeding intervals. The Santa Barbara County Breastfeed ing Coalition studied reasons mothers stopped breastfeeding before the baby was a year old and found that mothers often introduced bottles before problems with milk production developed, rarely noticing a connection to their eventual loss of milk supply. Problems usually start with just one bottle a day” or “just a few bottles a week,” but the more supplements are given, the more is needed because milk isn’t made when it isn’t removed. It becomes a slippery slope where bottle-feeding eventually seems more convenient or baby appears to like it better. Gratuitous supplementation is the sneakiest cause of management-induced low milk production because it “just sort of happens.”

 Are Bottles Really Necessary?

Even when regular separations aren’t planned, bottles are often introduced out of concern that baby won’t accept them later on. This is realistic in that there does seem to be a window of opportunity in the first three months when babies are more willing to take a bottle. But if you won’t be away from baby on a regular basis, there’s really no need to introduce one. In an emergency, he could be fed by cup, spoon, or other devices and will survive. Introducing a bottle just so baby will take one for an unplanned future event isn’t necessary and may underline your milk supply. It makes more sense for bottle-feeding mothers to make sure their babies can breastfeed just in case no formula is available!

Another reason frequently given to use bottles is for others to bond with baby. This is one of society’s great myths. The truth is that baby bonds to those who hold, touch, and love him not just the person who feeds him. Do you feed your partner in order to bond, or is touch the magic ingredient? Helping family members to find other ways-such as burping, baths, and massages to connect with the baby is a much better alternative than having them compete with you for feeding opportunities. Even if you’re pumping milk for the bottle, this can interrupt the early mother-baby dance and lead to baby preferring the bottle, especially if there have been any difficulties with breastfeeding.

Nutrition Mothers

often worry that they aren’t eating enough of the “right” foods to maintain adequate milk production. Yet produce enough milk even when their eating habits aren’t the best. And if caloric intake is low, a nursing mother’s prolactin levels rise, apparently to compensate. It’s only when you’re severely malnourished that the quantity or quality;y of your milk can diminish significantly. Most of the time, your own body will suffer before baby does.11 However, there are certain foods reputed to promote good milk production that may be helpful to some mothers (see__BLOG__12).

Gradual weight loss through moderate dieting will not reduce your milk production. However, a sudden, dramatic decrease in calories over several days or longer (such as crash dieting) can lower it by forcing the body to cut back on noncritical uses of energy to ensure its own threatened survival. Consuming at least 1,500 to 1,800 calories per day is the minimum amount most women need to maintain their supply.

Eating Disorders

Mothers with a history of eating disorders such as anorexia or bulimia can usually breastfeed fully, especially if body weight is back to normal. Milk production during active eating disorders has not been studied, but it seems reasonable to assume that loss of fat reserves and “starving” the body can force it into survival mode, resulting in decreased milk output. Milk composition may also be affected, although this has not yet been studied. It is known that some bulimic women do not experience the full nighttime surge of prolactin and that the effect is tied to the frequency of bingeing. If you’re struggling with an eating disorder while breastfeeding, consider consulting a nutritionist, who can help you maximize your nutritional intake.

Mothers who follow a vegetarian or vegan diet may be at risk for insufficient amounts of B2, which may cause a loss of appetite and drowsiness in a breastfeeding baby, with a corresponding decrease in milk production.14 For this reason, vitamin B12 is recommended for breastfeeding mothers who follow a strict vegetarian or vegan diet.

Gastric Bvpass Surgery

With the rise in surgical treatments for obesity, breastfeeding after gastric bypass surgery is a hot new topic. Cases of low milk production have been reported by lactation consultants even though the medical literature currently reflects only problems with B12 deficiency in some patients’ milk. Women who have the Roux-en- Y procedure especially are at risk for calcium folate, vitamin B12, iron, and protein deficiencies.15 One mother experienced significant problems with milk production until she discovered that her zinc was low and her B12 was “very low- normal.” When she began taking supplements of both nutrients, her milk production increased to normal levels. Blood tests will show if you are absorbing enough nutrients.

Women who have gastric bypass surgery are often encouraged by their doctors to avoid pregnancy in the first two years after surgery while they are healing and completing their most rapid period of weight loss. During that time they are mostly metabolizing fat, and their low caloric intake makes it difficult to consume enough essential nutrients to adequately support pregnancy and lactation.16 Once they pass this period, gastric bypass mothers who consume at least seventy grams of protein per day along with vitamin supplements generally don’t have trouble making milk.12But it is also important to consider that low milk production after bypass surgery may be related to preexisting hormonal conditions associated with obesity (discussed in BLOG__9)

Hydration

A pervasive myth in many cultures is that not drinking enough water causes low milk supply. While it’s true that life-threatening, severe dehydration may cause your body to cut back on milk production, the mild dehydration that most of us operate under does not. An old but still valid study from 1939 reported that nursing mothers who were given one liter less of water a day than was recommended continued to produce plenty of milk.

The flip side of this belief is that drinking more water makes more milk, which is just as wrong; in fact, drinking too much water can actually decrease milk production rather than increase it. The body’s reaction to excessive water intake (well beyond thirst) is to dump the excess fluid through the urine in order to maintain the proper electrolyte balance. Water is diverted away from the breast, and lower milk volume can result. Dr. Christina Smilie explains the misconception this way: Milk production doesn’t increase because of drinking more fluid; it is actually the other way around. Women who make lots of milk will be thirsty in order to replace the fluid they use to produce milk. When a mother is making less milk, she does not need to drink as much. Until an increased demand stimulates higher supply, the excess forced fluids will be wasted, and you’ll just urinate more. The best advice is to drink to thirst. Keep your urine a pale yellow, and you’ll be drinking just the right amount to make milk.

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