Low Milk Supply - Cause or Symptom?

New mothers understandably find it really hard to trust easily in a process they cannot measure. Concerns about low milk supply is the number one reason mothers give for not being able to begin early breastfeeding after birth and also the number one reason to not continue breastfeeding for as long as  the stated standard recommendation — breastfeeding for minimum of first two years of baby’s life.
In my many years of experience of supporting mothers, interesting, I began to notice that milk supply issues are much easier to address than most other breastfeeding related issues. That seems to open up a whole different discussion and perspective. Many mothers may find that quite surprising and often get interested to know why and how. Most if not all new mothers, family and friends around often think low supply is the cause for breastfeeding not going well. This has a potential to make mothers feel inadequate and in secured. On the other hand, the mother-to-mother support forums and group tend to think milk supply issues are a myth and perceived by mothers. The reality truly lies in between. A clear understanding of four most important components of breastfeeding can help us understand to know how to differentiate true milk supply issue and symptomatic low milk supply:

How the lactating breasts work?

Mothers feel empowered when they understand how breast work to nourish their babies. They begin to trust in the process more and begin to appreciate the amazing process of exclusively supporting their newborn’s life even more. The third and the most significant development of breast happens during pregnancy apart from during embryonic stage or during puberty. The many hormones of pregnancy which include progesterone, prolactin, estrogen among others work synergistically causing significant changes to occur in the breast such as development of lobes and lobules, nipple tissue, the areola, and the Montgomery glands during pregnancy preparing the body for breastfeeding a baby. It is interesting to know that a mother’s breasts begin to make milk as early as second trimester of the pregnancy as against what is often believed to be 2 or 3 days after birth. This is often called as “Milk Coming in” in almost all cultures of the world. What this “milk coming in” really is-is only an expected increase in milk making rather than just the beginning of milk production after the placenta is expelled after birth causing a plunge in the hormone progesterone and increase in prolactin levels. Therefore the low milk supply during the early days after birth is often a perceived one or delayed milk production is often an aftermath of a poor management of labour, birth and mother’s bonding with the baby soon after birth.
Post birth, knowing that more milk is constantly being produced in the alveoli (milk making sac) will give a mother the confidence she needs to put her baby to the breast, even when it feels empty to her. Infact the empty breasts is what is needed to stimulate more milk production.  
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Birth practices affect on milk supply: 
It is extremely important to understand that even though labor and birth may most often take only few hours, how the birth experience is has a direct and profound effect on how the breastfeeding gets established. Research has now established that birth drugs and procedures not only affect the baby’s ability to suck, swallow, and breathe which hinders in early stimulation of breast immediately after birth but these drugs and procedures also interferes with the natural augmentation of mothers’ hormones essential for normal lactation along with rendering the mother incapable of caring for her baby due to pain, sedation and separation.  The lack of early and frequent breastfeeding results in low milk production rather than low milk supply causing a breastfeeding failure. It then helps to know that protecting the mother’s birth experience and being instinctive can go a long way to set the stage for a smooth beginning of breastfeeding. For more understanding refer to the Dec 2012 issue of Mother’s World.
 

• Poor management of breastfeeding

 Some of the most common iatrogenic cause of diminished milk supply are often a result of poor management of breastfeeding besides poor birth management as discussed above:

• Over use of supplementation – Unnecessary use of formula supplementation due to mother-baby separation in the early postpartum period or due to baby’s unsettled behavior interferes with natural milk making process.
• Over use of pacifiers – limits the time baby spends at the breast reducing the required frequent stimulation to the breasts reducing the milk supply significantly and gradually in many mothers.
• Over use of breastfeeding aids – The repercussions of a poor management of labour & birth and lack of expertise in effective breastfeeding assessment of the mother-baby leading to an over use of breastfeeding aids such as nipple shields, bottles, spoons ect
• Use of medications such as hormonal birth control pills, certain antihistamine medications, diuretics among others can diminish milk supply production and mothers in need of such medications should be referred for evaluation of the stage of lactation the mother is in to an International Board Certified Lactation Consultant (IBCLC).
•  Scheduled and short infrequent breastfeeding – the wisdom of cue-based feeding with a understanding that baby is expected to be fed every 1.5 to 2 hours at least 10 – 12 times a day is supportive of protection of milk supply.

• Use of block feeding or offering one breast during a feed – In appropriate use of feeding on one breast for continued time frame or offering only breast per feed during the early stages of lactation with no clear indication for the need of such practices may hinder the optimization of lactation in young mothers. 
• Insufficient evaluation and assessment of sleepy and fussy baby – Lack of understanding of demand feed sometimes leads to very infrequent feeding especially in sleepy and fussy babies. A thorough oral motor evaluation by a IBCLC is essential to determination of adequate nutrition for baby.
• Lack of good psychological and emotional family and societal support - may lead to loss of self esteem and encouragement for the mother to overcome breastfeeding challenges or even continue breastfeeding.

 
Mother-related low milk supply issues 
Mothers often take on personal responsibility thinking that low milk supply is somehow a sign of their inadequacy. Most reasons are due to lack of early and frequent stimulation of breast. Being proactive and better management of birth and postpartum can address most.
 

• Retained Placenta – Expulsion of placenta during the third stage of birthing process signals the brain to lower the levels of progesterone hormone and increase the levels of prolactin hormone. Sometimes small fragments of placenta remain in the uterus that has a profound effect on milk supply. Retention of placental fragments can occur both in a surgical birth as well as natural birth.
• Insufficient Glandular Tissue – In rare cases, mothers  are sometimes found to have had insufficient growth of the breast tissue during the growing years due to lifestyle changes, environmental toxicity, poor diet and over use of medications classified as epigenetic reasons resulting in low milk supply.

• Medical conditions or Illnesses such as Iron-deficiency Anemia, Thyroid, Polycystic Ovarian Syndrome (PCOS), Postpartum bleeding, hormonal imbalance, pregnancy induced diabetes (PID) or hypertension (PIH) among others may be a cause of low milk supply in case of failure of increase in milk supply with increased frequent of breastfeeding or breast stimulation.
• Breast trauma or surgery - Mothers who have had accident during their life time causing damage to breast tissue such as burns or invasive medical treatment may experience low milk supply. Extensive breast reduction or breast augmentation surgeries may pose a high risk of inability to establish adequate milk supply especially if milk ducts have been severed during surgery or nipple has been repositioned.
• Breast conditions - Poor or delayed management of breastfeeding could lead to breast infections or inflammation such as breast engorgement, plugged ducts and breast abscess and pain which stop or diminished the milk production by sending a signal to the brain to slow down the process.

 
Baby-related low milk supply issues   
The most significant piece of the puzzle of low milk supply syndrome is the infant ability to suck effectively and efficiently. The various concerns related to a baby are often undiagnosed, unacknowledged or remain unaddressed. 
 

• Inability to latch – Sometimes a baby finds it difficult or impossible to latch at the breast due to traumatic birth experiences such as vacuum birth, forceps birth, prolonged intense labour, quick inducted and augmented birth and separation from mother for prolonged periods of time.
• Weak sucking – Many premature and preterm (babies born before 40 – 42 weeks of gestation) babies often have weak sucking ability who are unable to sustain an effective latch and suckling. 
• Inability to manage flow of the milk – Babies who have subtle oral motor dysfunctions such as undiagnosed swallowing difficulties, subtle submucosal cleft palate which is often difficult to identify.
• Sleepy Baby - These infants may sleep at the breast but not effectively drain the milk from the mother’s breast due to various reasons such as weight loss, inadequate weight gain, newborn jaundice, birth trauma, oral motor dysfunctions among other reasons.
• Birth anomalies such as Tongue Tie, Lip tie, Cleft lip and Palate,  low tone baby,
• Fussy and colicky babies – This is often caused by oral thrush, reflux, food sensitivity in mother’s diet and cow milk protein allergy.  
• Infant Illness – make the baby lethargic and a passive breastfeeder and may need frequent small feeds and additional breastmilk supplementation using other methods of feeding.

Increasing your milk supply
The basic simple mechanism of milk making process is breast stimulation. Ensuring to address primary infant sucking issues for better latch and better effective suckling of milk will protect and improve dramatically the more fragile milk supply issue during the post partum during the establishment of lactation by expert assessment and clinical lactation management from an International Board certified Lactation Consultant (IBCLC). Most other secondary low milk supply issues can be addressed either by timely counseling and basic lactation support by certified lactation Educators (CLE) or La Leche League Leaders (LLLL).