Low Milk Supply

The thinking used to be that all women are capable of producing ample milk to feed their babies. Now we know that's not always the case—and the problem may even be on the rise.

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When I had my first child 11 years ago, I was confident I wouldn't have a problem breastfeeding. Not only had my three older sisters proved that the Anderson girls were lactation mavens, but the books and experts told me so: All women are made to breastfeed, they assured me, and all breasts are up to the task. And, sure enough, Dylan latched on like a champ and never let go.

So imagine my shock when, nine years later, my breasts let me down. Claire and Aidan, twins born at 34 weeks, were just too sleepy and weak to nurse efficiently, causing my milk supply to drop. Despite frequent feedings and pumping, various herbs, incessant fretting and several teary consults with lactation consultants, my milk never rebounded. I resigned myself to a regimen of nursing, pumping and supplementing with formula.

My story isn't unique. Not only is low milk supply now recognized as a valid concern, it may even be on the rise. And women who, like me, have been convinced that it doesn't occur are blindsided when it does, leading to feelings of failure and inadequacy. "There's nothing worse than the devastation of not being able to breastfeed, or breastfeed exclusively, when you really want to," says pediatrician Marianne Neifert, M.D., a co-founder and medical consultant to The Lactation Program in Denver, and author of 2009's Great Expectations: The Essential Guide to Breastfeeding. "Women end up feeling it's their fault."

The chances are good that you won't have a similar experience—a study that evaluated breastfeeding success at three weeks postpartum found that approximately 15 percent of women experience inadequate milk supply. But it pays to be on the lookout. "It's a lot better to prevent low milk, when possible, than to try to remedy it," Neifert says.

Rare but Stubborn Causes

Occurring among approximately 4 percent of women, primary causes of low milk supply are the more difficult to treat and include such medical issues as breast and hormonal problems. "Previous breast surgeries, insufficient mammary tissue and thyroid or other hormonal disorders are some of the more common causes," Neifert says. "A woman who has difficulties during delivery, such as very heavy bleeding, can also have problems." So may a woman who is severely exhausted.

Other Causes of Primary Problems

Environmental toxins: A woman's surroundings—or even her mother's— may play a role in her milk supply. A small study conducted in 2006 found that daughters of women who grew up in a pesticide-contaminated agricultural valley of Mexico had a much higher incidence of insufficient mammary tissue—or, in some cases, no mammary tissue—than those living on a hilltop in the same area.

"We're seeing a dramatic increase in the number of women who have primary problems, possibly because of environmental contaminants," says Diana West, IBCLC, a coauthor of 2008's The Breastfeeding Mother's Guide to Making More Milk. "Lactation consultants around the world are reporting increases in the numbers of women who can't produce enough milk."

Underlying fertility problems: "Interventions are allowing people to get pregnant when they wouldn't otherwise, causing babies to be born to women who might not have fully functional reproductive systems," West says. "For example, many women with PCOS [polycystic ovary syndrome, a condition that can cause ovulation problems] also have much less functional breast tissue."

More Treatable Causes

Management problems, which Neifert says are the most common and treatable cause of low milk supply, often involve having an abundant supply at the outset that then dwindles. Neifert puts the number of women who experience such problems at about 11 percent.

"The most common scenario is that the milk comes in but doesn't get well drained," she says. "If a woman's breasts don't start draining adequately, she's already behind the eight ball by the end of the first week." Even with a well-established supply, milk production can decrease later if a mother goes long intervals without draining her breasts (such as not pumping regularly during the work day). Reasons for incomplete drainage include:

An ineffective latch: If a baby doesn't have a good "docking" with the breast, he may not be able to stimulate and drain the breast effectively. (For instructions on how to latch your baby on properly, visit fitpregnancy.com/breastfeeding/latch.)

A premature baby: Preemies can be particularly ineffective at stimulating the breasts because they tire easily and are so sleepy.

The woman's lifestyle: "Many women want to schedule feedings and stretch out the nighttime interval, which throws a wrench in the supply-and-demand of breastfeeding," says Nancy Hurst, Ph.D., R.N., IBCLC, assistant director of the lactation program and Mother's Own Milk Bank at Texas Children's Hospital in Houston. "If the breasts aren't completely emptied early on—and often—a woman can really take a hit in terms of her potential ability to produce milk."

Her storage capacity: Some women have greater milk-storage capacity, and their babies may be able to go longer between feedings without affecting the volume of milk; women with smaller "containers" may suffer in terms of supply if their breasts aren't emptied more often. "A woman's storage capacity isn't related to her breast size, but to the amount of functional glandular tissue she has," Hurst says.

When You Have a Problem

If you suspect you have low milk supply, see a lactation consultant as soon as possible. (To find one, visit the International Lactation Consultant Association at ilca.org.) She can identify risk factors, evaluate how much your infant drinks during a breastfeeding session, and start you on a pumping regimen to improve milk drainage. There's no blanket fix; treatment must be individualized.

That said, many lactation consultants follow a typical course of action, especially when it comes to management problems. The first step is to increase milk removal, which often involves a combination of nursing and pumping. Next, "a lactation consultant might recommend herbs to help boost your supply, such as fenugreek, goat's rue or shatavari," West says. Some also recommend prescription medications such as metoclopramide or domperidone.

Experts say that with the right approach, you should be able to boost your milk supply—especially if you catch the problem early. "Almost everyone can make more milk," West says. "It may not be enough to sustain your baby, so you may still need to supplement, but that's OK. You need to celebrate what you can do and see your breasts as being half full."

How to Tell if You Have Enough Milk

With bottle-feeding, it's easy to tell if your baby's getting enough food; not so with the breast. "Breasts aren't clear and calibrated," says lactation consultant Nancy Hurst. Since you can't tell what's going in, the alternative is to watch what comes out. "I recommend the 'Rule of 4,' " says pediatrician Marianne Neifert, M.D. "By 4 days of age, a breastfed baby's stools should turn yellow and seedy; he should have at least four stools a day; and that pattern should continue for at least four weeks."

Also, he should urinate at least six times a day and the urine should be clear, not dark yellow. Your newborn should breastfeed at least eight times in 24 hours, and you should hear frequent swallowing while he nurses. Schedule an extra weight check if you have any concerns.