How to determine if a breastfeeding woman has a supply problem Published online in Clinical Pearls by HealthEd, 21 October 2015 As GPs, breastfeeding women often express concern to us about their milk supply. Given that supply is directly dependent on the amount of milk transferred out of the breasts (except in those cases where an underlying medical conditions affects milk production), supply is really a secondary phenomenon, and our primary concern is actually the efficiency of milk transfer and frequency of opportunity to feed. Here are my tips on how to respond to a mother’s concern about her supply. 1. Check that the baby has good output. Half a dozen heavy wet disposable nappies daily is a reasonable rule of thumb; stool is variable but in exclusively breastfed babies with good milk transfer and unrestricted access, we do expect to see liquid stool in the nappy at least daily, usually more. We particularly want to see a palm-sized stool in the nappy a few times a day in the first six weeks, as supply is being established.1 Breastfeeding problems in the first week or two week post-birth, when prolactin receptors are laid down in the breast in response to frequent efficient milk removal, can result in low supply down the track - that is, poor weight gain, excessively frequent feeds, or satiety problems with crying and fussing. For this reason, making the right support available from the first days after the birth (rather than ‘waiting to see’) is vital. Efficient milk transfer and unrestricted access are the best way to ensure good supply, and also result in good output.2, 3 2. Check that the baby is gaining weight appropriately. I tend to plot on both the Centre for Disease Control (CDC) USA percentile charts (found in the Red Book in Queensland) and the WHO percentile charts, particularly if I’ve got any concerns. In fact, even the CDC recommends that WHO percentile charts are used under two years of age, because the latter were created out of a very large multi-national cohort of breastfeeding children. Breastfed babies tend to gain more weight in the first few months and then less in the subsequent few months compared to the small cohort of formula-fed US babies from whom the CDC charts were created. In the first few months of life, breastfed babies gain on average 200-250 gm/week. But if the baby is well and settled, with good output, gaining the traditional 120 gm/week or so on average, and tracking nicely along his or her percentile line, there is no reason for concern.4 3. Check that the baby is not ‘marathon feeding.’ It is not possible to overfeed a breastfed baby, but it is important to identify underlying breastfeeding problems which disrupt normal manageable - if irregular - feeding patterns. The most important problem to detect is impaired milk transfer (a vital separate topic for health professionals supporting lactating women), which results in both excessively frequent feeding and excessive night-waking. Another problem that sometimes causes unmanageably frequent feeding is functional lactose overload (but we also can’t deal with that here). 4. Check if the baby has cry-fuss problems. The first four months are the crying period, it’s true - but there is usually a lot that can be done to help downregulate an unsettled baby. Poor satiety is often a factor, and breastfeeding needs to be assessed for problems of milk transfer and of feeding frequency. These babies may do much better with weight gain closer to the 200-250 gm/week. Impaired milk transfer is caused by multiple factors (as mentioned, a big topic), most often of fit and hold. Deliberate spacing of the feeds due to misplaced concerns about ‘overfeeding’ is common - and commonly exacerbates poor satiety and cry-fuss problems.5 Both impaired milk transfer and deliberate feed-spacing due to ‘overfeeding’ concerns will decrease supply.6 5. Check if the family have begun formula supplementation. Low supply often emerges in the context of formula rescues. Supplementing with formula certainly makes life more manageable in the short-term for families coping with the distress and extreme sleep deprivation of excessive breastfeeding, excessive night-waking, and associated cry-fuss problems, if no-one has been able to identify and help with the underlying breastfeeding problems.7 But formula use masks these underlying problems and may quickly further diminish a mother’s breastmilk supply. She was already at risk of poor supply because of the undetected problems. With the right help, and non-intrusive reminders that breastfeeding is actually easier than formula feeding once everything is properly sorted out, the breastmilk supply itself can often be rescued in this situation. (How to do that is yet another important separate topic!) 6. Responding to women’s queries about expressing, breast fullness, and let-downs Many mothers worry that their supply is down because they can’t pump or express much breastmilk, because their breasts don’t feel full, or because they can’t feel many let-downs. However, it is quite common to be unable to express much breastmilk at all – by pump or by hand – and yet have a perfectly good supply. The amount pumped or expressed is not a reliable measure of milk production. Similarly - and particularly after the early weeks - some women’s breasts may not feel engorged or particularly tense at any time and yet they have perfectly good supplies. And let-downs and leaking also do not tell us about supply – some women don’t feel let-downs; some women with high supplies don’t leak; some women with low supply do.6 It’s important to respond to women’s queries about the role of expression volumes, breast fullness and let-downs in determining supply with accurate information, so that we can allay unnecessary anxiety. 1. Nommsen-Rivers LA, Heinig MJ, Cohen RJ, Dewey KG. Newborn wet and soiled diaper counts and timing of onset of lactation as indicators of breastfeeding inadequacy. J Hum Lact. 2008;24(1):27-33. 2. Hill PD, Aldag JC, Chatterton RT, Zinaman M. Primary and secondary mediators' influence on milk output in lactating mothers of preterm and term infants. J Hum Lact. 2005;21(2):138-150. 3. Kent JC, Mitoulas LR, Cregan MD, Ramsay DT, Doherty DA, Hartmann PE. Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics. 2006;117(3):e387-e395. 4. De Onis M, Garza C, Onyango AW, F R-CM. WHO growth standards for infants and young children. Archives of Pediatrics. 2009;16:47-53. 5. Douglas P, Hill P. Managing infants who cry excessively in the first few months of life. BMJ. 2011;343:d7772. 6. Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession. 7th ed. Philadelphia: Elsevier Mosby; 2011. 7. Odom E, Scanlon K, Perrine C, Grummer-Strawn L. Reasons for earlier than desired cessation of breastfeeding. Pediatics. 2013;131:e726-732.