Management of insufficient milk supply

Assessment of effective breastfeeding, which includes observing and assessing feeding patterns, positioning and attachment, sucking behaviour and breast fullness should be carried out by a skilled person who has received training (1)

The following can be carried out in women who are concerned about their milk supply:

• provide support on effective positioning and attachment (2)
• explain to the mother that exclusive breastfeeding is sufficient and extra food or drinks are unnecessary till the age of about 6 months (3). Also inform her that:
  • baby may lose weight for few days soon after birth but if they are healthy and feeding well they will recover their birth weight by 2 weeks of age (2)
  • during the first few weeks the infant will have 8 to 12 feedings every 24 hours which will decrease to around 8 times per 24 hours after breast feeding is well established (but may increase the frequency again with growth spurts or when an increase in milk volume is desired) (3)
    
    
• make sure that the mother is aware that in babies who are getting sufficient milk will:
  • have plenty of wet nappies - 2 or 3 in the first 48 hours which becomes frequent as at least six every 24 hours from day 5
  • be growing and generally gaining weight
  • be awake and alert for some of the time (4)
  • starting from 4th day to the first few weeks the baby will pass at least two yellow stools a day (each stool at least £2 coin size)
  • infant will be content after most feeds and will come off the breast on their own (5)
    
    
• advice her not to use a dummy until breastfeeding is established (5)

In women with low milk supply:

• refer infants with weight loss
  • traditional consensus rule is that if the weight loss is >10% the infant should be assessed in a hospital where biochemical tests are available (although this has been questioned recently)
  • hypernatraemic dehydration may occur when there is poor milk intake in an otherwise healthy full term and in extreme cases may lead to brain injury and death (1)
• ensure correct positioning and attachment
• encourage frequent feeds, breast drainage and how to express milk after feeds
• advice the mother to offer both breasts at each feeding and to alternate between breasts 2 or 3 times throughout each feed (6)
• consider galactagogues
  • no drugs are licensed in the UK for this purpose
  • Domperidone is the drug of choice
    • should only be used if advised by an expert
    • should only be used after other treatable conditions have been excluded (such as poor attachment), and after increased frequency of breastfeeding, pumping or hand expression of milk has not been successful.
      • other indication are:
        • presence of a maternal or infant illness and prematurity which results in faltering milk supply
        • separation of mother and infant
        • when a decline in milk production occurs after several weeks of milk expression by hand or with a pump
        • adoptive nursing
        • relactation (re-establishing milk supply after weaning) (7)
• supplementary feeds may be necessary if the intervention is unsuccessful (6)
• in women who have had breast reduction surgery, milk supply will be reduced due to interruption of nerves or blood vessels, advice that partial breastfeeding is usually possible (1)

Reference:

• 1. Hoddinott P, Tappin D, Wright C. Breast feeding. BMJ. 2008;336(7649):881-7
• 2. World Health Organization (WHO) 2009. Infant and young child feeding. Model chapter for textbooks for medical students and allied health professionals
• 3. Gartner LM et al.Breastfeeding and the use of human milk. Pediatrics. 2005;115(2):496-506
• 4. National Collaborating Centre for Primary Care (NCCPC) 2006. Postnatal care. Routine postnatal care of women and their babies
• 5. Department of Health (DH) 2009. Birth to five.
• 6. British Columbia Reproductive Care Program 1997. Nutrition part 1. Breastfeeding the healthy term infant
• 7. UK Medicines Information (UKMi) 2010. Drug treatment of inadequate lactation