Milk Supply

Milk Supply: The volume of milk the lactating breasts produce

Directly nursing parents do not actually “know” their milk supply and that’s normal. A healthy milk supply is not measured by the exact number of ounces, but rather by its ability to meet the growth needs of the unique baby it is responding to.

Pumps have become more accessible (every insurance company is required to cover it by 2015 under the Affordable Care Act) and effective (they are quiet, comfortable, and they work).  

Over the years of use, it is becoming clear that a milk supply doesn’t require a baby’s sucking input to be protected and promoted.

It feels important to contextualize milk supply here before I simply categorize supply into three overly simplified ranges.

Sustaining the life of the baby you birthed with your lactating mammaries is an ancient human physiological act. 

Much like birth, the body knows what to do and we opt to intervene often because the body isn’t always safe doing what it is trying its best to do.

When speaking about milk supply, there is only one question that guides us toward “normal milk supply.”

Is there enough milk for the baby to grow? Once, that was the only measurement of milk supply. There is so much risk and uncertainty in that, it makes sense that modern parents opt towards having more data to guide their decision making.

So, it is with that context, that I present my proposal of how to best understand a lactating parent’s unique, ever changing milk supply. 

Type of Milk Supply

Your milk supply is responsive to the stimulations is has received over the past 3-5 days.

Here we use the unit of measure of ounces per twenty four hours which also helps us estimate the ounces produced per hour.

A milk supply will adjust to its “average” by about 4-6 postpartum.

In the past 3 days, with ___ # stimulations, my milk supply was  ____oz in the past 24 hours.

• Under Average Supply- less than 24 ounces per 24 ounces (>1 oz/hr)
• Average Milk Supply- 24-32 ounces/ 24 hours (1-1.5 oz/hr)
• Oversupply of Milk- more than 32 ounces/24 hours (1.5 oz+/hr)

If you’re exclusively pumping and not nursing at all, and do not intend to, there is a shift in mindset and management of supply. Refer to “Special Circumstances: Exclusive Pumping” 

If you’re nursing at all, here’s how to gauge your milk supply since you can’t directly measure it for 24 hours.

Average Milk Supply

• If you have an average milk supply and you are exclusively feeding breastmilk (i.e., not supplementing with formula or feeding solids), your baby probably gains about five to seven ounces a week. 
• Most often, your baby accepts both breasts at each feeding, though at times, they may want just one. That is most often the first thing in the morning when your breasts feel fuller. 
• If you pump within 15-20 minutes of completing a breastfeeding session, you will probably get one to two ounces combined. If you pump in place of breastfeeding, about two or three hours from your last breastfeeding or pumping session, you will collect about three to five ounces from both breasts combined. Occasionally, if the baby gives you a blessed chunk of sleep or you accidentally go four to six hours without pumping, you may get six ounces combined. 
• If you have an average supply, once your baby is about five to six weeks old, you most likely don’t “feel” like you have to pump or feed the baby at the two- to three-hour mark. Rather, your boobs start to get a little engorged around the four- to six-hour mark. If you have met with a quality IBCLC at two weeks postpartum or later and she has done a transfer weigh, your baby probably will have eaten about 45-60 milliliters from the first breast and an additional 15-30 milliliters from the second breast. 
• Lactating Parents with an average milk supply usually don’t complain about their baby “chugging,” “choking,” or “coughing” at the breast. Their babies may show small signs of spit up, but not at every feeding and not copious amounts. It is notable, though, that babies can spit up for a lot of reasons. 
• Babies who nurse from an average milk supply enjoy a pretty textbook nursing pattern. They cue to be fed every two to three hours around the clock. The baby often nurses for fifteen to twenty minutes on the first breast and another ten to fifteen minutes on the second breast. 

Oversupply of Milk

• If you have an oversupply of milk, your baby probably gains about eight to 16 ounces a week. Most often, your baby accepts one breast at each feeding. It is rare that your baby accepts both breasts, though if they do, it is almost always in the evening when your breasts feel softer. 
• If you pump within 15-20 minutes of completing a breastfeeding session, you will probably get three to five ounces from the breast the baby did not drink from and one to three ounces from the breast the baby did drink from. If you pump in place of breastfeeding, about two or three hours from your last breastfeeding or pumping session—well, here is where your true oversupply will show us what it can do. If average is three to five ounces combined and you are getting that from each breast, you have an oversupply. If you are getting more than five ounces from each breast (and, ahem, you don’t have twins) then you have, let’s call it, an aggressive oversupply. You body thinks it is feeding three or four babies, not one. Occasionally, if the baby gives you a blessed chunk of sleep or you accidentally go four to six hours without pumping you wake up very uncomfortable.
• If you have an oversupply, you are probably constantly aware of the fullness of your breasts and your need to nurse. You can barely make it to the three-hour mark without coaxing the baby to nurse (perhaps even before they are ready) because you need the relief. If you have an oversupply, you may be reliant on your pump at least once if not multiple times per day if the baby doesn’t do a good enough job softening you. 
• If you have met with a quality IBCLC at two weeks postpartum or later and she has done a transfer weigh, your baby probably ate about 90-120 milliliters (three to four ounces) from the first breast. If that baby dared attempt the second breast, he may have taken in (accidentally or on purpose) an additional 30-60 milliliters (one to two ounces).

Under Supply of Milk

• If you have a low supply of milk and you are exclusively breastfeeding (i.e., not supplementing with formula or feeding solids), your baby probably gains less than the recommended five ounces a week.  Often, this baby needs to be supplemented with additional milk to grow appropriately. 
• If you have a low supply, your baby accepts both breasts at every feeding and sometimes still seems hungry after taking both breasts. You may even find yourself needing to offer “four boobs” or switch nurse back and forth from breast to breast in order to get your baby satisfied. 
• If you pump within 15-20 minutes of completing a breastfeeding session, you will probably get less than an ounce from each breast. If you pump in place of breastfeeding, about two or three hours from your last breastfeeding or pumping session, you will collect less than the equivalent of an ounce per hour. So, if you pump after three hours, you will collect less than three ounces from both breasts combined. Occasionally, if the baby gives you a blessed chunk of sleep or you accidentally go four to six hours without pumping, you may not get much more than that three ounces. 
• If you have met with a quality IBCLC at two weeks postpartum or later and she has done a transfer weigh, your baby probably will have eaten less than one ounce from the first breast and even less from the second breast. Hopefully she set you up with a safe, realistic, and kind plan to boost your supply and supplement the baby and you are following up with her weekly.
• Those with a low supply report a baby that pops on and off the breast and “is almost always hungry after a long breastfeeding session.” Their babies ask to eat sometimes hourly around the clock and often go no longer than two to three hours without eating. Ever. This baby often nurses for a long time and mom often has to take the baby off and move him to the second breast because, despite breast compressions and 30+ minutes of nursing, the baby isn’t swallowing.

Managing Supply

Managing Oversupply

• Some babies who are nursing on a breast that is very full of milk will cough, sputter, or “chokes” while nursing. Anytime you hear your baby struggling to “keep up” with the milk, take notice and consider the following strategies to help the baby cope.
• Look for early signs of overwhelm. They may start to widen their eyes and slowly pull away from the breast, shallowing their latch. If this isn’t hurting you and the baby is still keeping up, allow this behavior. Notice if baby is better able to swallow more quickly in this posture. 
• If baby can’t keep up with the flow and begins to make sounds like he is struggling, unlatch him, but keep him in the nursing position (he may get really mad if he thinks you are taking the boob away). Let him catch his breath while your milk sprays or drips. Once your baby and your boob settle, try again. 
• Take frequent breaks whenever baby seems to need one. 
• Burp often. 
• Consider intermittently using the pacifier for non-nutritive sucking time. If your baby latches, sucks a few times, then pulls away to only latch again and pull away, he may want to suck and not eat. Use the pacifier to help gauge if your baby really is still hungry or just wants to suck, which may also help with the spit up problem you may be having.
• Get baby in an easier drinking position. Get baby a little more upright, then lean back so that baby has an extra second to cope with the flow before it hits the back of his throat.
• Be careful not to squeeze. You may be supporting your breast with a little too much pressure. Make sure you aren’t squeezing your boob, which can increase the force of your flow. 

Bossy Boobs: When your baby doesn’t want to eat and your boobs do want the baby to eat, you have a problem: to pump or not to pump.

• Know the consequences of pumping. Every time you pump in addition to breastfeeding, you will maintain your oversupply and possibly increase it. Having extra milk is great, but feeling like you have to pump isn’t always great.
• Allow milk to sit a little. It is okay to be full, but try to avoid uncomfortably full. If your breasts feel uncomfortably full and baby is not hungry or is asleep, pump enough to “take the edge off.” This is a great time to use a hand pump, hand expression, or the HaaKaa Pump rather than an electric pump so you don’t take out more than you need to. When you leave your breasts full, but not uncomfortably full, it asks your body to slow down milk production just enough so you don’t feel the need to pump after breastfeeding. Applying cool compresses and a well fitting bra between feeds can help you to cope with the uncomfortable feeling of fullness. This is also the case if your baby only nurses on one breast at a feeding, but your opposite breast can’t handle waiting three hours for the next feeding. Don’t pump the unused breast fully; just take the edge off.
• Please note that when you start asking your body to down regulate like this, you are at a higher risk for plugged ducts and mastitis because your milk is sitting stagnant in your breasts. Be ready to do a complete pump to drain your affected breast if this happens. It will set you back a little, but you can get back on track soon enough.

Managing Under Supply

Reasons To Suspect Low Supply

• Poor infant weight gain: Baby is not back to birth weight by two weeks, once back to birth weight baby is gaining less than 5 ounces per week. 
• Decreased wet diapers (less than 5 per day in a baby older than 4 days old). 
• Significant change (one- to two-ounce drop) in pumping output when pumping in place of breastfeeding. 
• Infant becoming very fussy at the breast, refusing to breastfeed, or needing to be given a bottle after or in place of breastfeeding. 

First

• Increasing a low supply of milk isn’t as easy as the internet makes it sound. There is no magic drink or pill to “fix” low supply.
• The medical community gives little to no attention to this issue and wildly under-reports the incidence of insufficient milk supply.
• Managing a low milk supply can be incredibly physically and emotionally exhausting. 
• You can continue to breastfeed and complement with formula. Here at Balanced Breastfeeding we call that “hybrid feeding.” 

When troubleshooting low supply, we take a four-pronged approach that follows the Breastfeeding Rules:

• Feed the baby at the breast and strategically supplement after. 
• Promote the milk supply with stimulation and herbal supplements
• Support the mama with extra rest and encouragement
• Seek helpful help to set realistic goals and track improvement

Approach to Increasing Under Supply 

Feed The Baby

• Strategic supplementation of baby with your own expressed breastmilk and/or formula is key. A well-fed baby is a better breastfeeder, so we can’t allow baby to get too behind on weight gain.
  • Nurse, then supplement.
    • Aim for eight to 12 feedings in a 24-hour period, going no longer than four hours between feedings. 
    • Coax your baby to drink from both breasts at every nursing session. 
    • When breastfeeding, be sure to have a deep latch. Look and listen for drinking, not just sucking without swallowing. 
    • Use breast compressions while the baby is sucking to encourage swallowing. 
    • Limit breastfeeding sessions to about 10-15 minutes on each side because you have two more steps to complete.
  • Supplement your baby with infant formula or expressed breastmilk after breastfeeding.Volumes are total volumes per feeding and include what your baby may be getting from your breast; therefore, these supplementation guidelines may best serve as the upper limit of how much to supplement your baby after breastfeeding.
    • Feed this to your baby slowly using the paced bottle-feeding method. Milk comes out of a bottle much faster than it comes out of the breast, so be sure you give your baby frequent breaks and burps to give him time to realize his belly is full. There is no one bottle that is best; just focus feeding the baby slowly and watch for signs that he needs a break.

Promote the Supply.

3 Ways

• Increase frequency of stimulation and milk removal (nursing and pumping)
• Hormonal manipulation (prescription or herbal supplements)
• Nutrition and hydration

Any change in supply and demand takes about three to five days to make any change, with the full effect seen in two weeks.

Pumping after breastfeeding is a helpful way to fully drain your breasts and send your body a message to make more milk. This is the extra demand that will hopefully yield a higher supply.

Pumping Tips:

• Pump within 15-30 minutes of finishing breastfeeding so you don’t cut into baby’s next feeding.
• Pump at the highest comfortable vacuum. 
• Pump both breasts simultaneously if you can for 10-30 minutes. Use or make a hands-free pumping bra to help out.
• Pumping to promote supply is about stimulation, not collection, so don’t be discouraged if you see little to no milk when you are pumping.

Choose a supply boosting pumping strategy:

• Pump after breastfeeding. This should be done within 15-20 minutes of finishing a feeding. You do not need to pump after every breastfeeding. This is way too exhausting and too much pressure for a new mom. Instead, pump after most daytime feedings when you feel like you can. The more you can get in the better, but at least four is a great start. You have permission to skip nighttime pumping. It is too disruptive to sleep.
• Power pump: For three days, try power pumping. Pump after baby nurses, then pump an hour later, then again after baby nurses. The idea is that you want to stimulate your breasts frequently in quick succession. 
• Pump in place: Don’t feel like you need to do this feed, supplement, pump-at-every-feeding cycle. Feel free to skip direct nursing at some feeds and just pump and bottle feed. This may be particularly useful at middle of the night feedings and at times when you have a second set of hands to bottle feed while you pump so everyone can hurry up and go back to sleep! Just remember if you bottle feed without breastfeeding first you will lean on the higher side of the feeding volumes in the chart.

Hormone manipulation comes in two ways: prescriptions and herbal supplements. There is no safe or effective prescription medication in the United States as of the writing of this document. 

• Reglan is available in the U.S. and is occasionally prescribed for low supply but can only be used for a short period of time due to physical side effects for mom. Reglan has a high incidence of a side effect of severe depression, especially in postpartum women. If Reglan increases supply at all, it often drops again when the medication must be stopped. 
• Domperidone is a highly effective medication for increasing milk supply, but is not available in the United States at this time. It is in FDA clinical safety trials but has not yet been released for safe use at all, let alone in breastfeeding mothers. To be clear, there have been incidences of maternal death from use of this medication. Some breastfeeding women order Domperidone online from foreign marketplaces without a prescription from their medical professional. It is the position of Balanced Breastfeeding that this practice is not worth the risk to mother or baby.
• There are a number of herbal medications that are available on the market right now that claim to increase milk production. It is overwhelming how many there are. We acknowledge that these are not approved by the FDA either; however, an herbal supplement is vastly different than a prescription medication when it comes to risk and safety. 

At Balanced Breastfeeding, we feel strategic use of herbs that increase milk supply is a safe and appropriate practice. 

• We most often recommend Upspring Milkflow or Upspring Milkflow Max. This product has the full potency of the recommended dose of herbs in the fewest number of pills per day.
• If you have a sensitivity to Fenugreek, have any thyroid issues or blood sugar instability, we like the fenugreek free: Liquid Gold by Legendairy. 

Nutrition/Hydration: Work up to three healthy meals and two to three healthy snacks per day for calorie intake. Drink a minimum of 64 ounces of fluids per day, but ideally at least half your weight in ounces (so if you weigh 150 pounds, aim for 75 ounces to drink each day). It can be helpful to drink an extra hydrating electrolyte drink like Gatorade or Body Armour.

A note about “magic foods:” You may see claims that one particular food or drink increases milk supply. Currently, blue Gatorade, the pink drink from Starbucks, and Double Stuffed Oreos are Internet favorites. Hydration and extra calories can sometimes help milk supply, so these tricks may work, or they might not. Unfortunately, there is no magic bullet to increase a low supply of milk. And why the blue Gatorade? That’s creepy….

Support the Lactating Parent

Are you:

• Eating three meals and ideally two to three snacks per day?
• Drinking at least 64 oz, but ideally about half your weight in ounces of water?
• Continuing to take your prenatal vitamin with DHA?
• Asking for and accepting help?
• Minimizing any extra outings or commitments?
• Connecting with other low supply mamas?
• Being kind to yourself and reminding yourself that although you may not make enough milk for your baby you are enough of a mother for your baby?
• Reminding yourself that formula is not failure, but that it is a tool we use to grow a healthy, nourished baby?

Seek Help

I hope you have a safe, realistic, kind IBCLC working with you. I hope she is seeing you weekly, talking about how you are coping with this stressful process, and offering solutions to manage the lack of sleep and the overwhelm you are likely experiencing. I hope she is helping you come to terms with needing to let formula help out, not placing judgment or shame on it.