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Everything you will ever need to know about breastmilk supply, cream etc

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Everything you will ever need to know about breastmilk supply, cream etc

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Well almost! But really detailed article by Maureen Minchin

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Maureen Minchin BA(Hons), MA (Melb), TSTC is a medical historian and health educator, and author of Milk Matters. She is all that, AND she is an active contributor in our Breastfeeders in Australia community on Facebook. Maureen recently sent me this post and asked me to share it far and wide, so I'm uploading it onto our website to facilitate that. Maureen is a very educated person, and some of the language used in her post may feel overwhelming. I can not stress this enough - if you have questions, please ask, as we are all learning, and we are all here to help each other. You can comment with questions, you can email us at breastfeedersinaustralia@hotmail.com or you can join our Facebook group and post there.
"The basics: hormonal stimulation + emptying of milk from breast
Obviously you need to allow baby to feed as needed.
And feeding must be effective and no obstacles put in the way of milk drainage.

Stimulation creates and maintains a basal level of prolactin, essential to getting increases in supply from birth, and later if supply has dropped . (But by three months a happily breastfeeding mum's basal prolactin levels are comparable to a non -lactating mum - it is the repeated bouts of sucking-stimulated prolactin level rises that does the job of enabling lactose and so milk production, with prolactin returning to baseline in between if intervals allow).

Initially breasts overproduce, and then supply drops down to the level of milk taken on a daily basis. Lactation is energetically expensive, and thoughout human history women have never been able to afford to waste energy. So volume is regulated by need, and responds rapidly to change in demand. How?

Regulatory controls are within the breast itself. If a feedback chemical (FIL) reaches a certain level in the breast, it signals that milk is not needed and secretion is inhibited, and eventually stops.

The second internal down-regulator is high pressure. If enough pressure flattens the rectangular-ish secreting cells, then they stop work; over time they regress and disappear. That can be a local or a whole breast pressure. So habitual finger pressure that prevents drainage from one area, or an underwire bra that sticks into a particular spot, or surgical scarring, or a tight crop top, can have an effect. As can over-distension because of too long a gap between feeds from a breast. Or from sleeping/lying on one's stomach, OK for some mums, hopeless for others (check out massage, might be best not to be too long facedown, and much massage can be done seated). If pressure gets high enough, it not only squashes the secretory cells, it can cause milk from the ducts and cells to leak into surrounding tissues and trigger inflammation. (mastitis) (SO feed before massage, time appt for the afternoon preferably; be prepared for some leakage. Towels and large absorbent pads in bed can be useful, save bed changes..)

Milk is made continuously, and is mostly water based, with about 7% cream. (The most variable component of milk, and babies drink less by volume of a high fat milk.) The watery part of the milk flows out of cells rapidly, the fat has to be extruded, sort of squeezed out by the cell into that aqueous fluid. The oxytocin contracts tiny muscles around those cells and pushes milk out into the ducts (the let down). A vacuum in the baby's mouth is created when the baby's jaw drops, and baby sucks. The seal needed for vacuum is created by tongue, cheek pads, and upper gum ridge etc. The vacuum - lower pressure area - allows milk to flow out from the breast - higher pressure area with letdown pushing milk out.

The relative amount of cream in milk varies over a feed, between feeds, between breasts, over the day, over time, following the general rule that the emptier the breast and the more letdowns it has been exposed to, the higher the fat levels. So after an interfeed interval, milk from the start of the first breast is 'waterier' than the milk at the start of the second breast will be, because the second breast has had oxytocin squeezes while the first is being fed from. And swapping back to the first breast after the second can mean an even richer milk again. Babies can be trusted to know when they are satisfied, and it sometimes takes the extra cream of a 'third' breast to do so.

Once lactation is established, the interfeed intervals are heavily influenced by the interaction between breast storage volume, and infant stomach volume. Over a day a baby takes about 750mL. A breast with storage capacity of 800mL could theoretically mean one feed a day, except that a baby's stomach capacity won't allow that! SO: a breast with very small storage volume will mean more frequent feeds at shorter intervals. So too does a small tummy. A baby with a big tummy capacity means fewer feeds per day if the mum's storage capacity allows that tummy to be filled up (it can even get down to 3-4 feeds in 24 hours in some thriving babies under 6 months old.) They say the size of the baby's stomach is roughly the size of its fist, but it can be distended comfortably. (If over-distended the baby will blurt back the extra - sometimes too much comes up, so yet another feed is indicated to settle things.) Being creamy, sometimes only a few extra mouthfuls are needed to get bub to drop off drunk.

Rates of milk synthesis vary over the day, and are governed by the degree of breast fullness. When the breast is close to its residual baseline (it's never truly empty), synthesis rates are faster. When breasts are fuller, synthesis rates are slower. The small breast that empties quickly also refills quickly.

During the night sleep, longer intervals and higher-at-night prolactin levels combine to produce a full breast by morning. Take out a single feed then, and refilling will be slow: the 600mL capacity breast might have dropped to 500mL, but there's still plenty there, so no rush to refill. By the next feed volume might be back to 540mL, and drop down to 450 after that feed. Over the day, by evening you can come close to running on empty, with baby staying at breast and drinking pretty much as you produce it. That milk may move from the stomach on into the small intestine at much the same rate, so baby doesn't get that satisfactory FULL STOMACH feedback signal and fall off looking drunk, or else will sleep for a short time but wake up and want more. [There's stuff that could be said here about gastric hormones and signalling, but no need.]

But take out a lot of milk in the am, by feeding on one side and pumping the other breast, then letting baby have the second side for as long as wanted, and milk synthesis rates speed up to replace milk in both breasts. SO this is the ideal time to express milk for storage or as a reserve. (Don't be persuaded to think about expressing after every feed unless it's for a medical reason: it creates too much work, keeps breasts cold, and is a pain.) And while you would freeze that extra expressed morning milk, it can be stored in the fridge during the day till it's clear there's enough been made to keep baby full that day; if not, you can pour off some and feed it to baby bu spoon, cup, syringe, whatever.

I developed this strategy to deal with what I called six o'colck starvation, when I just could not satisfy baby wioth a full feed. Before I tried this, I had to keep baby at breast for hours, contentedly getting small dribs of milk but refusing to leave or drop off to sleep. Topping baby up in the evening with some of the morning milk meant she went off to sleep, my empty breasts refilled before she woke again a few hours later, and in between I got my other two kids to bed and cleaned up. This was where the Kaneson pump came in handy, as it's a simple silent no-strain one-handed pump: draw back the outer cylinder a tiny bit to create the slight suction needed to relax the ring of muscle around the nipple and milk pours out of the second breast when oxytocin hits both breasts and triggers letdown). But not until mums are comfortably feeding and can multi-task should they think about trying this. Getting position and attachement right and baby feeding well and breasts producing well is the first priority. When mums can feed and drink a cuppa they can do this no trouble. If they want to get milk to store. Or to give an older child a glass, or make breastmilk ice blocks. Or whatever it's needed for.

Breasts being peripheries, they are colder than other parts of the body. They need to be warm for blood circulation to bring in nutrients for milk making. Simple things like hotpacks or having a small patch of wool, silk or fleece to tuck into the bra around the breast not in use can make a difference to refilling rates. So can an afternoon nap. I never ran dry on days when I snuggled down with a baby and had a full-body after-lunch rest. I always did if I worked through the day and only sat down for feeds. Some mums can cope with strenuous exercise and still lactate successfully; others can't. (Babies don't like the taste in milk of lactic acid created by exercise, but it disappears after about 30 minutes.)

So increasing milk production means increasing sucking stimulus, and frequency, increasing synthesis rates by breast emptying, and decreasing any competing activities. In short, go to bed with baby and sleep and feed feed feed, and (optional) express first thing in the am. After 2 days of more frequent feeding, basal prolactin levels rise - they may have fallen too far - and milk-making increases. A babymoon it's sometimes called. Not possible for many mums with children and dogs and household tasks. Using drugs to increase prolactin has its risks and in any case will not work if the problem is insufficent breast emptying and natural feedback down-regulation of supply.

Decreasing milk production is equally simple. Increase intervals between feeds, for example by one-breast feeding with only short times on the second breast, back to the emptier first breast for a couple of hours, monitoring the unsuckled breast and expressing only to comfort and to avoid mastitis. Within 24-48 hours of one-breast feeding supply will drop, sometimes catastrophically. It's disaster to suggest this to new mums with oversupply, as many hospital-based midwives have done. The mums go on for more than 24-48 hours and then wonder why their milk has gone. Lying face down compressing boobs, wearing a tight crop top or bra, creating pressure feedback, and you may achieve the same outcome via mastitis. (In a breast with no skin damage, most mastitis starts with milk leaking into breast tissue where it shouldn't be, under pressure.)

Mums need to know what an efficient working breast feels like: soft and flexible even when heavy with milk, filling up, softening again after a feed; maybe tight and tense to touch if the interval is too long but immediately relieved by milk removal. Warm but not heated, not reddened skin. Not lumpy, even up in the armpits where there is some glandular tissue in many women. There's always a reason for any change and thinking though exactly what's happened can find it, and prevent recurrences.

There is a lot more in Breastfeeding Matters 1998 edition that would be of interest and relevance, in chapters on milk supply, nipple problems and mastitis. Breastfeeding is a skill that has to be learned, and without early practical support and understanding of how supply is regulated, women struggle."

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Milk Production - What All Breastfeeders Need To Know by Maureen Minchin

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Maureen Minchin BA(Hons), MA (Melb), TSTC is a medical historian and health educator, and author of Milk Matters. She is all that, AND she is an active contributor in our Breastfeeders in Australia community on Facebook. Maureen recently sent me this post and asked me to share it far and wide, so I'm uploading it onto our website to facilitate that.

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Revised
Newborn babies are weighed and measured regularly to check they are growing well and thriving. Weight is the variable most often used to measure growth or faltering growth in the UK. When breastfeeding is going well, a baby's weight will roughly follow the shape of one of the pre-drawn curves (or centiles) on the weight-for-age charts in a baby's personal development record (called 'the red book' in the UK). But what if a breastfed baby's growth curve is much flatter or steeper than the lines on the chart?

This article

This article looks at what to expect in terms of normal growth for healthy, term babies; how to interpret your baby's weight chart; when to be concerned about your baby's weight, and when to take action. This is a companion article to Baby Not Gaining Weight and Is My Baby Getting Enough Milk?

Normal growth in the breastfed baby

In 2006 the World Health Organisation (WHO) published new growth standards that reflected the normal range of growth in healthy term breastfed babies across the world from non-smoking mothers. These are the charts that have been used in England since 2009 and replace charts that were previously based on growth in formula-fed babies. There are separate coloured charts for boys and girls because they grow at slightly different rates. Follow the links to see the WHO weight-for-age charts for 0-6 months (percentiles) for boys (blue) and girls (pink).

Normal loss and gain

The article Is My Baby Getting Enough Milk? reviews the losses and gains expected according to the WHO weight-for-age charts in the first few days of life:

The first two to four days
It is normal for a breastfed baby to lose a little weight before his mother's milk comes in during the first two to four days of life and babies are well equipped for this. A loss of 5-7% weight is usually accepted as normal although more research is needed. If your baby has lost more than 5-7% of their bodyweight or is still not gaining weight after 2-4 days contact your breastfeeding specialist to review how breastfeeding is going.

After the first few days
Once your milk has come in, a weight gain of 30g-40g per day (or 7-10 ounces per week) in the first three months shows your baby is growing well . This slows down between 3-6 months to an average gain of 20g per day.

Regaining birth weight

It is commonly accepted that babies will be back to birthweight by two weeks of age . Macdonald et al found that breastfed babies regained their birthweight by an average of 8.3 days of life.

Unexpected weight loss

A baby may have a higher than expected weight loss in the first few days if a mother had IV (intravenous) fluids during labour or if breastfeeding is not going well. Monitoring your baby's poop during this time can help with identifying milk intake; if milk is going in to your baby, lots of poop will be coming out (and be yellow by day five).

Later

Babies generally double their weight in the first four months and will have tripled their birth weight by the end of the first year ( WHO growth standards, 2006).

What are centiles?

The lines marked as 3rd, 15th, 50th, 85th and 97th on the WHO charts are known as percentiles or centiles. Centiles divide the range of normal weights into 100 parts and are a useful measure of percentage in statistics. All healthy children will grow somewhere between the 1st and 100th centiles. For example:

If your baby is growing along the 3rd centile they are one of the smallest babies for their age. For every 100 babies only three weigh less than him or her (3%) and 97 weigh more (or 97%).

The 50th centile represents an average weight of all babies. Half of all healthy babies will be below this line, the other half will be above and one is not better than the other.

If your baby is growing along the 97th centile they are one of the largest babies for their age. For every 100 babies, 97 babies weigh less than him or her and only three (or 3%) weigh more.

Following centiles, normal growth

Growth patterns vary between babies and growth rarely follows a textbook curve. However, weight gain usually tracks within the space between two centiles , with periods of slower and faster growth. Despite fluctuations, the general direction of growth will follow the pre-drawn curves.

Above charts adapted from the WHO child growth standards chart, source: who.int/childgrowth/standards/weight_for_age/en/ accessed 20/09/2016
Crossing centiles

If a baby was born above the 50th centile, but later moves down to below the 15th centile, their growth curve would be described as having crossed two centiles (see baby B below). Crossing two or more centiles can be of concern because if a baby is not growing normally, his health could be at risk. Reasons for crossing centiles might include:

Baby not getting enough milk (the most common reason).

A medical problem or genetic syndrome.

Normal adjustment. Some babies who cross centiles may simply be adjusting from the nutritional conditions in the uterus to their genetic potential for growth . Perhaps their parents are both small and petite.

Faltering growth

If your baby's growth continues to falter, their weight could eventually drop below the chart altogether and your baby's health could be compromised. Stay in close contact with your health professionals and breastfeeding expert if your baby's weight is crossing centiles and see the examples and ideas for action below.

So how is a doctor supposed to know which of the children who fall under the three percent curve are sick and which are healthy? Well that's why the doctor went to medical school.

What are Z scores?

Z scores are another way to classify and compare data which you may see on some graphs. Z scores are explained in The Z-score or Standard Deviation Classification System (WHO).

Monitoring growth

Weight is generally used to measure growth but a baby's length, and head or upper arm circumference may be measured too. Other signs that your baby is getting plenty of breast milk include your baby having plenty of wet and dirty nappies (diapers), your baby's urine being pale coloured, and being contented between feeds-see Is My Baby Getting Enough Milk? for a summary.

How often to weigh your baby

Historically babies were weighed weekly in the UK. More recently, official advice in the UK has swayed towards weighing once a month between the ages of two weeks and six months, and less often after this time . While this frequency of weighing might be reasonable when breastfeeding is going well and a mother has good breastfeeding support, breastfeeding is not always established yet by two weeks after birth. If breastfeeding is not going well, leaving a newborn baby with poor or borderline weight gain for four weeks is too long both for baby's health and for his mother's potentially dwindling breastmilk supply.

Weigh weekly until breastfeeding is established

Until breastfeeding is well established, and you are reassured that your baby is easily gaining between 30g and 40g per day, weighing regularly will pick up any problems with weight gain early-so that help can be given to increase baby's intake of breast milk. The sooner problems are addressed the better for your baby and your milk supply.

Plotting your baby's weight

Your midwives and health visitors will record your baby's weight in his personal development record (red book). The WHO chart in the red book shows the 0.4 centile and 99.6th centile. If you're not sure whether the chart in your baby's record is for breastfed babies you can plot your baby's weight yourself by downloading the appropriate WHO chart ( boys 0‑6 months and girls 0‑6 months).

Examples of growth faltering

The following scenarios are hypothetical and simplified, although they mirror real cases of poor growth associated with breastfeeding issues. Always consult with your health professionals if you have any concerns about your baby's weight. Charts adapted from the WHO child growth standards: accessed 20/09/2016.

Growth faltering due to poor breastfeeding management

In this example baby A's weight faltered for nearly seven weeks. Her mother had been told to feed from one breast per feed every three to four hours (" to get to the hindmilk") and her milk supply gradually dropped as a result. Simple changes such as increasing the frequency of feeds to every two hours or more, using both breasts per feed, using breast compressions and pumping will all help to increase milk supply. If mother's milk supply responds quickly, formula supplements (or donor milk) will not be needed and in this example, baby A's weight gain steadily improves once she gets more breast milk.

Growth faltering due to difficulty latching or poor tongue function

In our second scenario baby B's weight dropped two centiles during his first six weeks of life despite frequent feeding. Baby B might be very fussy and restless when feeding-often coming off the breast-or might fall asleep after a very short feed. Help from a breastfeeding specialist might identify poor positioning, latch, a tight frenulum (membrane under the tongue), high muscle tone, or find a combination of issues for adjustment. Once breastfeeding issues are addressed at six weeks, baby B gains more weight.

Growth faltering and supplements needed

Baby C's weight had been faltering for four months. Although still bright and alert, baby C would be very small and health care workers would be concerned. Baby C might breastfeed constantly but without 'driving' his mother's milk supply-which would be very low after four months of poor feeding. Donor milk or supplemental formula would be needed here to provide immediate calories while work began on building mother's milk supply. A very underweight baby might initially bring back some of the top ups as his stomach would be used to small volumes. Within a day or so these babies often respond with a voracious appetite and might gain as much as 100g - 120g per day for the first few days, and continue with good catch-up gain-until baby reaches the weight they should have been.

Weight loss, hospital admission

Baby D continued to lose weight for nearly three weeks before being admitted to hospital for tests and supplemental feeds. In those first weeks, health care workers may have believed breastfeeding could pick up on its own. However, intervening with good breastfeeding management at the first sign of continued weight loss at three or four days of age could have avoided this high weight loss and potentially irreversible damage to this mother's milk supply. There can be many reasons for low milk supply or seemingly no breast milk after delivery, while these are being addressed, a baby needs to be fed with donor milk or formula.

When to take action

Take action early

As soon as weight gain falters consistently, a health check from your baby's doctor to rule out medical issues and a breastfeeding assessment from a specialist to get breastfeeding back on track, can prevent a cycle of further weight loss, sleepy baby, and low milk supply ending in formula supplements. There are lots of ways to increase a milk supply so that baby can gain 30-40g per day, but sometimes supplements will still be needed. If your health professional or breastfeeding helper doesn't seem sure how to review breastfeeding, contact an IBCLC lactation consultant for a full assessment and see Baby Not Gaining Weight.

Don't "wait and see"

Advice from health professionals, friends or family to wait and see what baby's weight is like in a week/fortnight/month, under the assumption that it can take a while to get breastfeeding established, is time wasted when you could be identifying fixable reasons for low milk intake-and making sure your baby gets the calories he needs. Equally, advice to start topping your baby up with formula after each feed without looking at breastfeeding management, misses the opportunity to problem solve to get back to exclusive breastfeeding where possible.

Breastfed baby gaining too much weight?

Babies above the 99.6th centile for height are almost always healthy . If a child's weight is above 99.6th centile or if their weight and height centiles are very different, the advice from Department of Health (UK) is to calculate their body mass index (BMI). Over the age of two years, the BMI is the simplest way to measure whether a child is overweight or underweight. The Centers for Disease Control and Prevention (CDC) in the United States do not recommend BMI-for-age growth charts for children younger than two years of age . To plot weight against length for children under two years refer to the WHO Child Growth Standards for length/height.

Breastfeeding is thought protective against obesity in later life , however, certain health issues can be a cause of unusually high weight gain, so always stay in close contact with your health professional if you have any concerns about your baby's weight.

Summary

Although breastfeeding is the normal and natural way to feed a baby, situations can arise where babies may not thrive. A growth curve that crosses two or more of the pre-drawn centiles on the WHO charts indicates growth faltering, but there's no need to wait until this happens before taking action. Taking action as soon as there are growth concerns-by seeing your health professional and a breastfeeding specialist- can prevent compromising both your baby's health and your milk supply later. The sooner a low milk supply is addressed the easier it is to fix it. If donor breast milk or formula supplements are needed, this doesn't have to mean the end of breastfeeding-it is very important that your baby is getting the food they need. Contact your IBCLC lactation consultant for a tailor made care plan to get breastfeeding back on track and see Baby Not Gaining Weight for more information.
If you have any worries about your baby's weight gain or growth contact your health care professional for help. This article is not intended to replace medical advice.

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Understanding Your Baby's Weight Chart - Breastfeeding Support

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Revised Newborn babies are weighed and measured regularly to check they are growing well and thriving. Weight is the variable most often used to measure growth or faltering growth in the UK.

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Useful for reference as this may be what HPs are using. Very measurement based and sets weight not back to birth wt at 3 weeks as time for concern - too late!

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1.2.1 Consider using the following as thresholds for concern about faltering growth in infants and children (a centile space being the space between adjacent centile lines on the UK WHO growth charts):

a fall across 1 or more weight centile spaces, if birthweight was below the 9th centile

a fall across 2 or more weight centile spaces, if birthweight was between the 9th and 91st centiles

a fall across 3 or more weight centile spaces, if birthweight was above the 91st centile

when current weight is below the 2nd centile for age, whatever the birthweight.

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Faltering growth: recognition and management of faltering growth in children

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1.2.1 Consider using the following as thresholds for concern about faltering growth in infants and children (a centile space being the space between adjacent centile lines on the UK WHO growth charts): a fall across 1 or more weight centile spaces, if birthweight was below the 9th centile a fall across 2 or more weight centile spaces, if birthweight was between the 9th and 91st centiles a fall across 3 or more weight centile spaces, if birthweight was above the 91st centile when current weight is below the 2nd centile for age, whatever the birthweight.

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People are delighted when they observe baby undergoing catch-up growth. But most become needlessly worried when a baby's growth slows as a result of catch-down growth, mistaking this as poor growth. Catch-down growth is as normal as catch-up growth. Both forms of healthy growth demonstrate baby's growth is getting back on track.

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We need to know this! I have included this article mainly for the photographs which show what an underweight baby looks like. It is a long, complicated article, addressing a particular concern about health professionals (and others) who discourage top ups when babies are not growing. So don't feel you have to read and digest all of it!

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We've been running our weekly infant feeding clinic in Yorkshire for years now, and during that time it's been fascinating to note the changing trends when it comes to feeding babies.

When we first started, a common problem was parents were advised their baby needed additional milk when they didn't. This happened because their growth was plotted on charts based on the growth patterns of formula fed babies, resulting in the breastfed babies older than a few months, appearing not to grow adequately. We spent so much time reassuring parents that their babies were growing perfectly well for a breastfed baby and didn't need coaxing to take additional milk.

Many believe formula fed babies gain weight more rapidly than their breastfed peers; however initially the reverse is actually true. The non-breastfed baby typically gains weight more slowly in the first four months, it's after this the shift occurs and they start to gain weight more rapidly compared to those who are breastfed.

Thus historically on the old charts, many breastfed babies appeared to have suboptimal gain and as a result the UK growth charts were updated to reflect the typical growth patterns of those exclusively breastfeeding.

In our clinic in the last couple of years, things have definitely shifted. Now it's rare we see an over-supplemented baby, instead we've observed a steep increase in actual cases of "faltering growth" - that is babies who aren't a little underweight, but chronically so.

What's perhaps most surprising is both these babies above were under the care of and regularly seen by healthcare professionals.

In the case of the first baby, they were eventually referred to a paediatrician. I completed a new growth chart for them to take, so weight trend was clearly visible. Baby had a tongue tie and we can see when the supplement plan was initiated at 7 weeks. Mum however was reluctant to give extra milk as her group online had warned her it would impact her supply (untrue, a baby not transferring milk will do that) and that anyone suggesting formula wasn't truly supportive of breastfeeding. This meant additional milk was given (provoking gain), withdrawn (resulting in the same amount gained lost again) and re-introduced again - creating the static pattern at the end.

Note the growth trend - how far away from that bottom curve are the dots (the minimum typically expected weight) and we can see there's a consistent pattern of faltering growth resulting in a 38% deficit based on expected weight.

It was a cold winter's day when they attended their paediatric review and baby was dressed in a fleece snowsuit. The paediatrician didn't feel it necessary to undress the baby, instead they unzipped the suit enough to listen to baby's chest with a stethoscope. They asked if he was peeing and pooping and said they weren't concerned about weight as we had plotted the chart wrong....

They said that although baby was 38 weeks when born and a typical weight of over 7lb, they felt a premature chart should be used (designed for babies born before 37 weeks and of a lower weight), and so adjusted the baby's chart in his red book notes to reflect this:

The bold dot and arrow indicates where the consultant felt the dot should be with this adjustment. Baby was a couple of days shy of 8 weeks at the last weigh in, (as you can see from the original dot now marked with the arrow), yet the new mark is plotted at 5 weeks. This results in an almost 3 week adjustment...

I can still recall the exact words the mother said to me when I expressed surprise at the consultant's nonchalance and checked additional milk was going to be continued : "You're the only one who is concerned about my baby's weight, everyone else thinks he's fine". A relative expressed she felt I was causing the mum unnecessary concern and worry, when clearly "those in the know" were happy with his gain.

If parents find their baby is struggling to gain weight, they can soon find themselves on the receiving end of contradictory recommendations and conflicting advice. They may be told by some just to "feed, feed, feed" or take baby to bed and "baby-moon" (both of which of course assume effective milk transfer when baby is feeding, rather than just burning yet more calories), whilst others are expressing concern and suggesting additional milk is needed alongside identifying the original issue that has led to growth faltering.

A further problem is many don't really understand the charts, sometimes the graph isn't even completed by healthcare providers. This means at a glance nobody can even see the growth pattern, let alone know if the baby is tracking an appropriate curve.

First we need to understand they're based on averages. If we take a huge group of healthy, term, breastfeeding infants - we can identify the typical maximum and minimum rate of growth they undertake. That's not to say every baby outside this range absolutely has an issue, only that its atypical enough (when compared to the masses) to warrant further investigation.

If we use this data of healthy babies to create a chart - the heaviest infants will of course sit around the top and the lightest infants will sit near the bottom. We can also calculate the "average" - which would be the 50th percentile line (so half the babies will sit above this line and half below). This range allows for genetics, stature, build and so on.

It isn't desirable to sit on a particular place on the charts - in fact that's really quite illogical. We wouldn't take a group of adult females and identify their average weight is 7-13 stone, then tell everyone their optimal weight was 10 stone. We'd expect the weight of someone who was 5ft and of petite stature, to be less than someone who was 6ft and of broader stature?

The same is true for babies.

Once on the chart, we can similarly expect different levels of gain from those at the top and bottom too - and we know that typical healthy young babies gain roughly 5-8 ounces per week (140-225g), after the first few days and doing so will result in them returning to birthweight by around day 10 and tracking a curve on the chart.

Babies may sometimes plot slightly above or below a line, it doesn't have to be an exact track of a centile but should be thereabouts.

Below we can see the growth chart of a twin baby girl born at 38 weeks, weighing 5lb (2.27kg) and with a tongue tie. Baby was readmitted at a week old with significant weight loss and you can see on the chart where the hospital implemented a "top up" plan. The next jump up the charts is when the tie was released:

If babies don't gain the expected amount as outlined above, instead if following a curve we see a flatter line appearing as they slide down the charts. Crossing two centiles triggers referral to a paediatrician to rule out underlying and potentially significant causes. Thus the saying "a gain is a gain" is ridiculous; I've heard this said when babies have gained 30g per week, the amount expected per day - that somehow as they haven't lost all is well. Considering nobody seems to check intake before this referral - it also seems a costly exercise too.

When babies are underweight not only can they lack the energy to take a full feed, but they become disorganised and less effective - creating a catch 22 situation. If this continues week after week, the energy and weight deficit often simply continues to get bigger, rather like you trying to run a marathon when you've just spent a month with Bear Grylls on a desert island.

What evidence are people working from that they feel a very underweight baby is better than one who is supplemented?

The first choice of course would always be mum's own breastmilk, however if baby feeds very frequently due to not transferring enough per feed, finding time to express may be difficult. If baby has been taking less than they needed for weeks, mum's body similarly may have reduced production and supply may need additional stimulation.

Donated milk may be an option depending on accessibility and more mums are using and sharing donor milk, both informally and via their local milk bank; but for many it will mean considering infant formula. The concern is that formula disturbs the microbiome, which is of course true - but we surely have to ask whether we believe there are no risks to inadequate food at a time of rapid growth when energy demands are high.

Not enough calories also means potentially not enough vitamins and minerals either. This could be a whole new discussion in itself, but let's pick one we know is important for the immune system, zinc:

"Infants and toddlers are vulnerable to zinc deficiency due to their rapid growth rate and high demand for tissue synthesis, neurological development; immune function and tissue growth (Aggett 2000; Friel 1994; Krebs 2014). Cells with rapid turnover demand the highest concentrations of zinc, notably skin, gastrointestinal, immunological, neurological, and, in the developing infant, skeletal cells.

"Mild to moderate zinc deficiency is characterised by stunted growth, deficits in immune function, and altered integrity and function of the gastrointestinal tract (Krebs 2014). Zinc deficiency may be associated with deficits in attention, and motor and cognitive development in children ( Black 1998" here

We International Board Certified Lactation Consultants, often the only ones trained in infant feeding - can frequently find ourselves undermined by a whole range of people.

The twin baby above as an example was on a feeding plan - as she had a tie, combined with the fact mum hadn't received adequate advice on protecting her milk supply prior to our visit, this meant at the point we saw them baby couldn't physically transfer enough and the increased demand now exceeded supply.

Despite this a "sling consultant" who works with multiples, saw fit to advise the parents to drop all the supplements and just feed her babies. Thankfully the mother contacted us confirming this wasn't correct, but I do wish people would consider the implications of their lack of specialist knowledge and how parents feel when they receive this conflicting advice, from someone absolutely not in a position to be giving it.

We hear sometimes of underweight babies who seem happy and settled - they sleep long periods, yet surely if they were hungry they'd wake and cry? The reality is that hungry babies cry, very hungry babies who've experienced consistently reduced intake don't have the energy to expend crying. On the contrary, they often sleep longer spells to conserve calories and don't signal too much (which again burns energy) if the feed intake is less than they'd like. Some will feed very frequently yet never really seem "milk drunk" or full and that's without considering that persistent weight gain concerns can be a huge cause of maternal anxiety.

It's really difficult for parents who are with babies to accurately gauge gain in their newborns based on visual appearance. Babies change a lot in the early weeks and when with someone a lot it's harder to notice subtle or gradual changes - which is precisely why we weigh newborns. It's what we do with this information that counts, the earlier a problem is spotted - the more rapidly it can be resolved. Reassuring people things are ok when they're not, in the longterm doesn't help anyone.

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A Gain is Not a Gain. Faltering Growth in Breast & Formula Fed Babies.

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We've been running our weekly infant feeding clinic in Yorkshire for years now, and during that time it's been fascinating to note the changing trends when it comes to feeding babies. When we first started, a common problem was parents were advised their baby needed additional milk when they didn't.

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How do I convey this knowledge to parents?

Postnatally, when supporting a mother, how can I distinguish between a milk production issue and a milk removal issue?

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The basics that we need to know to be able to explain supply and demand issues to women

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By Kelly Bonyata, BS, IBCLC

To understand how to effectively increase (or decrease) milk supply, we need to look at how milk production works...
For the most part, milk production is a "use it or lose it" process. The more often and effectively your baby nurses, the more milk you will make.
In the Beginning...

Endocrine (Hormonal) Control of Milk Synthesis - Lactogenesis I & II

Milk production doesn't start out as a supply and demand process. During pregnancy and the first few days postpartum, milk supply is hormonally driven - this is called the endocrine control system. Essentially, as long as the proper hormones are in place, mom will start making colostrum about halfway through pregnancy (Lactogenesis I) and her milk will increase in volume (Lactogenesis II) around 30-40 hours after birth.

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During the latter part of pregnancy, the breasts are making colostrum, but high levels of progesterone inhibit milk secretion and keep the volume "turned down". At birth, the delivery of the placenta results in a sudden drop in progesterone/estrogen/HPL levels. This abrupt withdrawal of progesterone in the presence of high prolactin levels cues Lactogenesis II (copious milk production). Other hormones (insulin, thyroxine, cortisol) are also involved, but their roles are not yet well understood. Although biochemical markers indicate that Lactogenesis II commences approximately 30-40 hours after birth, mothers do not typically begin feeling increased breast fullness (the sensation of milk "coming in") until 50-73 hours (2-3 days) after birth.

These first two stages of lactation are hormonally driven - they occur whether or not a mother is breastfeeding her baby.

Established Lactation...

Autocrine (Local) Control of Milk Synthesis - Lactogenesis III

After Lactogenesis II, there is a switch to the autocrine (or local) control system. This maintenance stage of milk production is also called Lactogenesis III. In the maintenance stage, milk synthesis is controlled at the breast - milk removal is the primary control mechanism for supply. Milk removal is driven by baby's appetite. Although hormonal problems can still interfere with milk supply, hormonal levels play a much lesser role in established lactation. Under normal circumstances, the breasts will continue to make milk indefinitely as long as milk removal continues.

By understanding how local/autocrine control of milk synthesis works, we can gain an understanding of how to effectively increase (or decrease) milk supply.

What does current research tell us about milk production?

Current research suggests that there are two factors that control milk synthesis:

Milk contains a small whey protein called Feedback Inhibitor of Lactation (FIL) - the role of FIL appears to be to slow milk synthesis when the breast is full. Thus milk production slows when milk accumulates in the breast (and more FIL is present), and speeds up when the breast is emptier (and less FIL is present).

The hormone prolactin must be present for milk synthesis to occur. On the walls of the lactocytes (milk-producing cells of the alveoli) are prolactin receptor sites that allow the prolactin in the blood stream to move into the lactocytes and stimulate the synthesis of breastmilk components. When the alveolus is full of milk, the walls expand/stretch and alter the shape of prolactin receptors so that prolactin cannot enter via those receptor sites - thus rate of milk synthesis decreases. As milk empties from the alveolus, increasing numbers of prolactin receptors return to their normal shape and allow prolactin to pass through - thus rate of milk synthesis increases. The prolactin receptor theory suggests that frequent milk removal in the early weeks will increase the number of receptor sites. More receptor sites means that more prolactin can pass into the lactocytes and thus milk production capability would be increased.

Both of the above factors support research findings that tell us:

FULL
Breast
=
SLOWER
Milk
Production

EMPTY
Breast
=
FASTER
Milk
Production

Research indicates that fat content of the milk is also determined by how empty the breast is (emptier breast = higher fat milk), rather than by the time of day or stage of the feed.

How does milk supply vary throughout the day?

Earlier researchers observed that milk volume is typically greater in the morning hours (a good time to pump if you need to store milk), and falls gradually as the day progresses. Fat content tends to increase as the day progresses (Hurgoiu V, 1985). These observations are consistent with current research if we assume the researchers were observing babies with a fairly typical nursing pattern, where baby has a longer sleep period at night and gradually decreases the amount of time between nursing as the day progresses.

Storage capacity: Another factor that affects milk production and breastfeeding management is mom's milk storage capacity. Storage capacity is the amount of milk that the breast can store between feedings. This can vary widely from mom to mom and also between breasts for the same mom. Storage capacity is not determined by breast size, although breast size can certainly limit the amount of milk that can be stored. Moms with large or small storage capacities can produce plenty of milk for baby. A mother with a larger milk storage capacity may be able to go longer between feedings without impacting milk supply and baby's growth. A mother with a smaller storage capacity, however, will need to nurse baby more often to satisfy baby's appetite and maintain milk supply since her breasts will become full (slowing production) more quickly.

Think of storage capacity as a cup - you can easily drink a large amount of water throughout the day using any size of cup - small, medium or large - but if you use a smaller cup it will be refilled more often.

What does the research tell us about increasing milk supply?

Milk is being produced at all times, with speed of production depending upon how empty the breast is. Milk collects in mom's breasts between feedings, so the amount of milk stored in the breast between feedings is greater when more time has passed since the last feed. The more milk in the breast, the slower the speed of milk production.

To speed milk synthesis and increase daily milk production, the key is to remove more milk from the breast and to do this quickly and frequently, so that less milk accumulates in the breast between feedings:

EMPTY
Breast
=
FASTER
Milk
Production

In practice, this means that a mother who wishes to increase milk supply should aim to keep the breasts as empty as possible throughout the day.

To accomplish this goal and increase milk production:

1. Empty the breasts more frequently (by nursing more often and/or adding pumping sessions between nursing sessions)

2. Empty the breasts as thoroughly as possible at each nursing/pumping session.

To better empty the breasts:

Make sure baby is nursing efficiently.

Use breast massage and compression.

Offer both sides at each nursing; wait until baby is finished with the first side before offering the second. Switch nursing may be helpful if baby is not draining the breast well.

Pump after nursing if baby does not adequately soften both breasts. If baby empties the breasts well, then pumping is more useful if done between nursing sessions (in light of our goal to keep the breasts as empty as possible).

Are you having problems with oversupply?

Mothers who are working to remedy oversupply usually need to decrease supply without decreasing overall nursing frequency or weaning baby. One way to accomplish this is by "block nursing" - mom nurses baby as frequently as usual but restricts baby to one breast for a set period of time (often 3-4 hours but sometimes longer) before switching sides. In this way, more milk accumulates in the breast before mom switches sides (thus slowing milk production) but baby's nursing frequency is not limited.

See also:
Frequently Asked Questions about Milk Production I'm confused about foremilk and hindmilk - how does this work?
Anatomy of the human breast. Diagram by DT Ramsay, RL Hartmann, PE Hartmann

Note: the graphics above are copyrighted. Do not use without express written permission.

Many thanks to Denise Fisher of Health e-Learning for the valuable feedback!

Additional information

How the breasts make and deliver milk from AskDrSears.com

Examining the Evidence for Cue Feeding Breastfed Infants by Lisa Marasco, BA, IBCLC and Jan Barger, MA, RN, IBCLC

Human Milk and Lactation by Carol L Wagner, MD

References

Cox DB, Kent JC, Casey TM, Owens RA, Hartmann PE. Breast growth and the urinary excretion of lactose during human pregnancy and early lactation: endocrine relationships. Exp Physiol. 1999;84(2):421-34.

Cox DB, Owens RA, Hartmann PE. Studies on Human Lactation: The Development of the Computerized Breast Measurement System. June 1998. Accessed May 28, 2004.

Cox DB, Owens RA, Hartmann PE. Blood and milk prolactin and the rate of milk synthesis in women. Exp Physiol. 1996 Nov;81(6):1007-20.

Cregan MD, Mitoulas LR, Hartmann PE. Milk prolactin, feed volume and duration between feeds in women breastfeeding their full-term infants over a 24 h period. Exp Physiol. 2002 Mar;87(2):207-14.

Hartmann PE, Prosser CG. Physiological basis of longitudinal changes in human milk yield and composition. Fed Proc. 1984 Jun; 43(9): 2448-53.

Hurgoiu V, Marcu A, Sopon E, Olariu M. Dynamics of the composition of lipids in human milk during lactation. [French]. Pediatrie. 1985 Apr-May;40(3):201-5.

Ingram J, Woolridge M, Greenwood R. Breastfeeding: it is worth trying with the second baby. Lancet. 2001 Sep 22;358(9286):986-7.

Marasco L, Barger J. Cue Feeding: Wisdom and Science. Breastfeeding Abstracts. 1999 May;18(4):28-29

Mohrbacher N. Breastfeeding Answers Made Simple. First Edition. Amarillo, Texas: Hale Publishing; 2010. 390-401.

Neville MC, Morton J. Physiology and endocrine changes underlying human lactogenesis II. J Nutr. 2001 Nov; 131(11): 3005S-8S.

Neville MC. Anatomy and physiology of lactation. Pediatr Clin North Am. 2001 Feb; 48(1): 13-34.

Neville MC, Morton J, Umemura S. Lactogenesis. The transition from pregnancy to lactation. Pediatr Clin North Am. 2001 Feb; 48(1): 35-52.

Peaker M, Wilde CJ. Feedback control of milk secretion from milk. J Mammary Gland Biol Neoplasia. 1996 Jul;1(3):307-15.

Perez-Escamilla R, Chapman DJ. Validity and public health implications of maternal perception of the onset of lactation: an international analytical overview. J Nutr. 2001 Nov;131(11):3021S-4S.

Ramsay DT, Kent JC, Owens RA, Hartmann PE. Ultrasound imaging of milk ejection in the breast of lactating women. Pediatrics. 2004 Feb;113(2):361-7.

Walker M. Physiology of the Breast During Pregnancy and Lactation. In: Walker M, editor. Core Curriculum for Lactation Consultant Practice, Sudbury, Massachusetts: Jones and Bartlett; 2002. 27-34.

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How does milk production work? * KellyMom.com

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To understand how to effectively increase (or decrease) milk supply, we need to look at how milk production works... For the most part, milk production is a "use it or lose it" process. The more often and effectively your baby nurses, the more milk you will make.

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nearly comprehensive, yey manages not to mention retained placenta! Also v american so medication focussed

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"Your baby isn't gaining enough weight" - words every breastfeeding mother dreads to hear. It immediately makes you doubt yourself, your milk and your instincts. Of course, before you panic, you should make sure that your baby really has a problem; often the problem is actually with the health care worker's interpretation of the growth chart (see on how to correctly interpret a growth chart). But sometimes the truth is inescapable: your exclusively breastfed baby is not growing as he should. Does this mean the end of breastfeeding? Not at all! In this post I'll walk you through a number of steps to take when you get this distressing news, so that you can preserve your breastfeeding relationship while making sure that your baby is getting enough nutrition.

Start by identifying the problem

There are a number of reasons why a baby can have problems with weight gain. Before I start listing them, let me make one thing very clear: it's never because your milk is not nutritious enough! Nature only has one recipe for making breast milk, and it has worked for billions of years. Instead, you probably have one or more of the following problems:

A milk production problem

A small minority of women will have some anatomical or medical condition that prevents their breasts from making enough milk. This can include problems with the breasts or with the hormone systems that regulate milk production.

Breast problems

Let's look at breast problems first. There are two main problems to be aware of:

Insufficient glandular tissue in the breast is a rare condition where the breast tissue never adequately developed. You may have this condition if your breasts didn't grow or change at all during pregnancy, your breasts are shaped like a Coke-bottle (instead of like a ball or bowl), your one breast has always been a lot bigger than the other or you have a very wide space between your breasts. IMPORTANT: the size of the breast doesn't matter - small breasts don't necessarily have less glandular tissue!

If you've had breast reduction surgery in the past. If not done carefully, breast reduction surgery can easily cut through the nerves and milk ducts that are needed for lactation. Modern surgical techniques tend to do as little damage as possible, but it is important that you be aware that this could damage your ability to make enough milk.

In cases where there is a problem with the breast, you should definitely work with a lactation consultant to help you make as much milk as possible, but also to ensure that your baby is getting adequate nutrition. Sadly, it is often not possible to bring in a full milk supply if you simply don't have the breast tissue to do it, and formula top-ups may be necessary. The most important thing is that baby must get enough milk to allow him to grow and develop. Your motto in this situation should be: "any amount of breast milk is better than none."

Hormonal imbalances

Next, let's look at the hormonal problems. As if PMS and baby blues were not bad enough, our hormones can also mess with our ability to make milk. Milk production is influenced by a number of hormones, not just by those directly related to lactation. Fortunately, hormonal problems are a bit easier to address. The following hormones are the important ones to look out for:

Prolactin is the main hormone that drives milk production, especially in the early days. Prolactin is produced whenever the breast is emptied of milk: removing milk from the breast leads to increased prolactin secretion, and the prolactin then stimulates the breast to make more milk. It follows, then, that if you do not have enough prolactin, you won't have enough milk. This is especially true in the early days of breastfeeding, when your breasts are still figuring out how much milk to make. The most common cause of low prolactin levels is simply that the breast is not being emptied effectively - see the discussion on milk removal problems in the next section. However, you can also have lower prolactin levels if your baby was premature, if you lost a lot of blood during the birth or for an unfathomable number of other reasons. Luckily, there are a number of pills that increase prolactin levels - this is how all the pills that are prescribed for milk production work (and it's also why they don't always work - higher prolactin levels will only help you if you had low prolactin levels to begin with!)

Thyroid hormones are often overlooked as a cause of low milk supply. Both an underactive and an overactive thyroid can cause problems. An underactive thyroid will lead to low levels of thyroxine, which will cause you not to produce enough milk. Luckily this is easily treatable with synthetic thyroid hormone in tablet form. An overactive thyroid, on the other hand, will not reduce your milk production, but it can inhibit your let-down reflex. This makes it very difficult to pump milk.

Sex hormones are the last culprit. If you have PCOS, or you struggled to get pregnant in the first place, there is a good chance that your sex hormone levels are out of balance. It's not a given that you will have low milk supply - I know of a number of women with PCOS or IVF babies who have successfully breastfed - but it is important that you need to monitor your milk supply very closely (want to know how to do that? Look at ). Contraceptive pills, implants and injections also contain sex hormones, which is why some of them can also reduce your milk supply - be sure to mention to your doctor that you're breastfeeding when you go to choose your contraception!

Fortunately, as I mentioned earlier, hormonal problems are mostly treatable, so you should be able to get your milk production back up to speed fairly easily once you receive the right treatment.

A milk removal problem

The next group of problems are by far and away the most common reason why breastfed babies don't gain enough weight: they simply don't get enough milk out of the breast! The milk is there, the breast is producing beautifully, but the baby just can't get at it. There are a number of reasons why a baby might struggle to get enough milk out of the breast:

Not spending enough time at the breast is the most basic reason why a baby wouldn't get enough milk. Some so-called experts still recommend only feeding for a certain number of minutes per breast, or only after so many hours. Nonsense! A baby needs to feed for as often and as long as they want to. So if you have in any way been limiting baby's time at the breast, stretching out feeds or trying to get baby to drop feeds, stop. Just feed baby on demand. (Of course, it is equally possible that baby is not "demanding" enough - this is often the case in babies who are very sleepy due to e.g. jaundice or a rough birth. In this case it's probably best to wake baby up every 2-3 hours to ensure he gets enough feeds)

A poor latch will also make it difficult for baby to get enough milk out of the breast. Check out to make sure you know what a good latch looks like and how to achieve one!

Prematurity will have a major effect on your baby's ability to breastfeed effectively. Premature babies simply don't have a mature suckling reflex. Any baby born before the end of 37 weeks of pregnancy is at risk of having an ineffective suck - indeed, some babies are still struggling even at 38 weeks. In this case you should absolutely call in the help of a lactation consultant or speech therapist who will teach you some exercises to help your baby learn to suck more effectively. In the meantime, you may need to do breast compressions or top up with expressed breast milk to ensure that your baby gets enough nutrition.

Problems with the mouth or tongue can make it difficult for baby to breastfeed effectively, since the muscles of the mouth and tongue are doing all the work to get the milk out. There are a number of anatomical problems in the mouth that can cause sucking problems: lip and tongue ties, submucosal soft palate clefts, arched palates and buccal ties are just a few. You should suspect an anatomical problem if baby simply can't stay latched on to the breast, or if it is downright impossible to get a good latch. In this case, you should again have it checked out by a or speech therapist - they will know exactly what to look out for and how to treat it.

So you see that in all these cases the problem is not that there isn't enough milk, but that baby isn't able to access the milk that is there. Of course, if the breast is not being emptied regularly, your milk supply will begin to decrease - but as soon as you address the problem and start emptying the breast more thoroughly, your milk supply will quickly recover (Want to know how that works? Check out ).

A medical problem

Sometimes the reason why baby is not growing has absolutely nothing to do with the milk: there is enough milk and baby is drinking enough, but the growth just isn't what it should be. In this case, you need to start looking for a medical reason, and that is a job best done by your baby's doctor. Here are a few things to look out for, though:

Infections increase the body's demand for calories. Sometimes baby has an underlying infection that you don't even notice - urinary tract infections are a common culprit. Lung infections, especially TB, also cause poor weigh gain. Your doctor can do a simple blood test to check for infections, and treat them if necessary.

Iron deficiency or other types of anaemia can cause poor weigh gain. This is most common in premature babies. Insist on a blood test for iron levels before you give any supplements - giving unnecessary iron will do more harm than good!

Heart problems that were present from birth also cause poor weight gain. These can sometimes be overlooked at the time of birth, especially if your baby was not seen by a paediatrician (such as in most of the smaller government hospitals)

Ways to increase your baby's weight gain

As with most things, once you have an idea of what caused the problem, you will have a pretty good idea of how to fix it (just look at the suggestions included in the discussion above). However, while you are addressing the problems, your baby still needs to eat! Here are some suggestions for ensuring that your baby takes in more milk:

Feed more often. Simple, really - wake baby up for a feed every two hours or so. Baby doesn't even need to be fully awake - even a half asleep (or mostly asleep!) baby can suckle quite well. Check if you can see baby swallowing - that's the best way to know that baby is getting some milk out of the breast.

Take a babymoon: get into bed with baby for a day (or two or three, depending on what you can get away with!) Go topless, undress baby down to his diaper, keep him on your chest and just feed, feed, feed. The skin-to-skin contact will entice baby to drink more often and also stimulate your body to make more milk.

Do breast compressions while baby is feeding. This is a bit like hand expressing and feeding at the same time: baby is sucking and you're "pushing" the milk to help him. It works like this: When baby is latched, grab a hold of your breast, but put your hands far to the back so that your fingers won't get in baby's way. As soon as baby suckles, squeeze the breast - it will cause the milk to flow a bit faster, and baby will get more milk with each suck. This works really well for babies who are struggling to suck, such as premature babies, sleepy babies or babies who have a latching problem.

Express milk from the breasts after feeds. You can either do this or with a pump. This will do two things:

1. It stimulates the breast to make more milk. Remember, removing more milk means more prolactin is secreted, which increases the amount of milk the breast makes

2. It gives you extra milk to use as a top-up

Give a top-up of expressed breast milk after feeds. If your baby is having any latching or suckling problem whatsoever it is very, very important that you do not use a bottle for this! Giving a bottle at this point will only make thing worse. Feed the milk to baby with a syringe or a .

If baby is over 6 months, you can also focus on giving more nutrient-dense foods. Adding healthy fats like peanut butter, olive oil, coconut oil or avocado can give baby's weight gain a boost (my personal favourite: mashed banana mixed with peanut butter. Yum!).

If you were giving any water, juice or tea, stop. Babies under 6 months need only milk; babies over 6 months still need mainly milk, and water only if they are constipated. Tea contains no nutritional value and it takes the place of more nutritious foods; leave it out.

If all else fails, formula may need to enter the picture. But please note: formula is the last resort, not the first one! If it is the first thing your doctor suggests, the I highly recommend you find someone else to help you solve this problem - a would be best, but even most dietitians (especially at government hospitals) can do a decent job.

While doing this, you will of course have to keep a close eye on baby's weight gain to make sure it's working. Have baby weighed once a week - and remember, always weigh naked, and always on the same set of scales!

Recap

Wow, that was a mouthful! A suitably complicated answer for a pretty difficult question! Let's just simplify it all and recap what the important things are:

First, make sure you really do have a weight gain problem - check out on how to read a growth chart.

Secondly, try to figure out why baby is not gaining weight:

Is it a problem with your breasts or hormone levels?

Is it a problem with how often or how effectively baby is suckling?

Is it a medical problem unrelated to feeding?

If you can't figure out the problem by yourself, enlist the help of a !

Thirdly, make a plan to address the problem you identified - look at some of the suggestions I've offered in this post.

And finally, make sure that baby is getting more milk by feeding more often, keeping baby skin-to-skin, doing breast compressions and/or expressing your milk and using your expressed breast milk for top-ups.

I hope that this post has given you the tools that you need to get your baby's weight gain back on track, or that it at least pointed you in the right direction. As always, I love to read your comments on what you found helpful. If you have any more tips for helping a baby gain weight, please share them in the comments below!

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How to increase weight gain in a breast-fed baby - Love and Breast Milk

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"Your baby isn't gaining enough weight" - words every breastfeeding mother dreads to hear. It immediately makes you doubt yourself, your milk and your instincts. Of course, before you panic, you should make sure that your baby really has a problem; often the problem is actually with the health care worker's interpretation of the growth chart (see on how to correctly interpret a growth chart).

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Inspiring article about development of breast tissue during lactation

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Inspiring article about development of breast tissue during lactation

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A useful one to share with mothers and a reminder to us that we don’t know what is possible

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At age 21, my parents offered to pay for cosmetic surgery, and I decided to do it. By this time, my sternum was deeply indented and my heart was pushed to one side. (Let's hope I never need CPR!) The plastic surgeon inserted a silicone breast implant through an incision below where my right breast should have been, and he positioned the implant sideways, so that I now had a right breast and my chest indentation was filled in. I didn't look 100% normal-my chest was still a little sunken below my collarbone-but it was better, and I didn't feel nearly as self-conscious.

From age 29 to 35, I gave birth to my 3 boys, and I spent a total of 12 years breastfeeding them, nursing on both sides. When I was 5 months pregnant with my first, I learned at my first La Leche League meeting that women could exclusively breastfeed twins and triplets, so I deduced correctly that one working breast was all I needed.

I loved breastfeeding and became a La Leche League leader so that I could help others meet their goals. I also served as a resource for La Leche League International for those with questions about nursing with breast implants. When controversy erupted, I even appeared on CNN to weigh in on whether breastfeeding with implants could cause later health problems in children. (Time and science found that it didn't.)
A Stunning Discovery
In my 50s, during a routine mammogram, I received shocking news. As the technician took picture after picture, I finally said, "You do know that I have a breast implant, don't you?" She said yes and added, "But I can't find it."

Eventually she found my implant on images taken in my cleavage area. She told me my implant's location had shifted. By this time, my sternum had become so deeply indented that it nearly reached my spine. (Yes, that grosses me out, too.) Over the years, as the indentation deepened, my breast implant fully migrated into the middle of my chest. Yet even without any implant remaining in my right breast, it now appeared to be fully developed.

I was stunned to realize that my formerly "bionic" right breast was now a real breast.

How did this happen? Science tells us that a woman's milk-making glands grow and develop during pregnancy, and after birth this milk-making tissue continues to grow (study HERE). We also know that with breast stimulation, women who have never been pregnant can grow functioning breast tissue and produce milk for adopted babies (article HERE). I was aware of all of this when my mammogram tech gave me the news, and I knew immediately that my 12 years of nursing had gradually grown a real right breast where none had grown before.
Using My Story to Help Others
How can my strange story help others? Some women plan to breastfeed only to learn that their breasts didn't develop normally. Called "breast hypoplasia" or" insufficient glandular tissue," in this situation, there are not enough milk-making glands to produce 100% of the milk a baby needs. (See a wonderful book about this HERE.) This might also happen in a woman with a history of breast reduction surgery (see a another wonderful book HERE) or a transgender man who has had top surgery to remove breast tissue and later delivers a baby.

It can be devastating when someone highly motivated to exclusively breastfeed cannot. Breastfeeding is a part of our sexuality, and when a woman discovers she can't do what others seem to do so naturally, it is a genuine loss-like infertility-that deserves to be acknowledged and mourned. In my private lactation practice, I sometimes sat and grieved with a mother who had to face this heartbreak.

Part of my job in that situation was also to discuss her remaining options. Most assume that giving up on breastfeeding is the only choice, but that is not actually true. Today, when I meet women who are struggling with low milk production, I always share my story. My long-term perspective gives them a glimpse not only of their options today, but how their choices now may affect their breastfeeding future.
Breastfeeding Options

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My Magical Breast: Where No Breast Had Gone Before

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My body is not like most. The internet tells me my odd deformity will not shorten my lifespan, but it makes me different. It affected my breastfeeding experience, but what was truly unexpected was the way breastfeeding affected my most peculiar body. Why should you care?

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That bête noir! This may help you think about what is and isn't problem solving

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Many times over the years have I had my knickers in a knot over advice versus information and support. It was the great late Pam Lacey, chair of the Association of Breastfeeding Mothers that first really opened my eyes to this concept - and it's one I really wish more breastfeeding supporters would recognise..

So if you're a breastfeeding counsellor, peer supporter or anyone who works with mothers as a lactation worker - please read on!

"Advice is a form of relating personal opinions, belief systems, personal values and recommendations about certain situations relayed in some context to another person, group or party often offered as a guide to action and/or conduct. ".

"Recommendations concerning future action, typically given by someone regarded as knowledgeable or authoritative.

We see advice in many forms: "What I would do if I were you", "you need to", "you must", "you should", right through to a blunt "do X".

The role of a breastfeeding counsellor is not to convey personal opinion or beliefs or to tell mothers what they should do; it is to support the mother and help her explore her options, to help her unpick any confusion she has surrounding a problem and empower her to reach a resolution she is happy with (regardless of whether this sits with your individual beliefs - this isn't your journey).

Good reasons not to give advice:

To give advice assumes superiority, it presumes you know better than the person asking the question, it also makes you responsible for the outcome. If you give someone advice and they follow it - what if it doesn't work or worse still has a negative impact?

Here's an example of one I see regularly.
"My baby's poop is green, do I need to worry? What should I do?".

Example of a typical "advice" giving reply: "This is caused by too much foremilk, you should start single side feeding - one breast per feed".

We know there are actually various reasons for green stools, one of which can be insufficient milk intake. Limiting the baby to one breast could potentially create a more serious problem, particularly if the baby is very young.

And another

"My baby is colicky and refluxy, won't settle, what should I do?"

Example of a typical "advice" giving reply: "You need to cut out all dairy ASAP".

We know there are actually numerous reasons for colic, one of which is dairy sensitivity - but what if that isn't the problem in this case and so doesn't improve or resolve things? What if just being told to cut dairy without discussion, exploration or explanation sounds so drastic to the mum asking that she decides to formula feed instead, worried her milk is causing the problem?

It doesn't empower anyone. Often mums have already had numerous people give advice - how do they pick who to listen to? If a counsellor gives advice and then a paediatrician gives conflicting advice, who would you listen to as a vulnerable new mum? How do they tell good advice from bad?

Giving advice can leave you open to mistakes. A mum starts telling you about a situation, you think you have all the information, so you tell her she should do "X". After hearing your suggestion the mum adds no she doesn't think that would work because of "Y" - a new bit of information the mum hadn't shared before. Oh you say, then in that case I would do "Z". The mums confidence is now faltering in you.....

Longer term advice doesn't help. What does the mum do next time she has a problem? She again needs to contact someone for advice! If the mum had been encouraged to help resolve her own problems with information and support, this empowers her with skills to apply to future issues.

Advice involves making a "judgement" - offering a non judgemental ear can be very satisfying to the "talker", and help people to feel a weight has been lifted. People can be reluctant to share what they feel the "listener" won't agree with if judgements are involved.

Sometimes what people state initially as the problem, actually may not be the real issue - if you give advice rather than encouraging them to unpick their thoughts, this may not come to light.
Alternatives to advice:
Active Listening:
Don't consider problem solving, but listen (really listen) to the big picture. Ask open and closed questions to get all the relevant information so the mum can unload everything in a safe space.

Reflection:
Always clarify clarify and clarify again - "so it sounds like you're saying X, is that right?", sometimes reflection can literally just be echoing back what the person said - when the mum hears it back or summarised, it gives her chance to add things or realise X point isn't as significant as Y and so on. It can help clarify things for mum too!

Give information:
There is often more than one way of resolving a situation; discussing various options with a mum so she can select what she feels works best for her situation. Examples include "some mums find X works for them, whilst others prefer " - recommending that a mum with four other children to take her baby to bed and baby moon for a few days may simply not be feasible (particularly if baby is a few weeks old and partner is back at work)

You can still give firm "facts" without giving advice - eg "we know that to maintain a supply if baby isn't at the breast, mums need to express 8-12 times per day".

Outlining WHY often empowers mum to begin to recognise poor advice eg "your breasts know how much milk to make based upon how frequently and how effectively they're drained - therefore if baby isn't feeding directly at the breast, we know mums need to express 8-12 times per day in order to mimic this and protect supply".

Support mum to think things through:

"So you feel X is the biggest issue, what would be the absolute ideal outcome for you?" or "If X was resolved, do you feel that would resolve everything?". "Do you feel X would be practical for you or is Z something you feel more comfortable with", "could X be impacting on Y do you think?"

Mums who receive advice, often leave an encounter feeling more confused than before they arrived - especially if they have previously received conflicting information. Mums who have received information and support often feel "lighter", as though they have offloaded. Listening can in itself make a person feel valued.

Believe it or not the most valuable tool you have as a breastfeeding supporter is not your mouth, but your ears.

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Many times over the years have I had my knickers in a knot over advice versus information and support. It was the great late Pam Lacey, chair of the Association of Breastfeeding Mothers that first really opened my eyes to this concept - and it's one I really wish more breastfeeding supporters would recognise..

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And it's relevance to our practice

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Relevance to practice

There are three main considerations in relation to lactation practice:

1. A rapid first milk ejection is important for efficient milk removal

2. Breast shields need to be the correct size for each individual mother

3. Hand positioning is important when supporting the breast during expression

1. A rapid, efficient first milk ejection is important for optimal milk removal
Large volumes of milk are not stored in the ducts as no lactiferous sinuses were observed, therefore very little milk can be removed prior to milk ejection. It is known that a baby will initially utilise a rapid sucking action, which stimulates milk ejection ('let down'). Research shows that a rapid first milk ejection will then lead to more subsequent milk ejections. In fact, 80 per cent of the breast milk is removed in the first seven minutes when using a 2-Phase breast pump at maximum comfort vacuum (Kent et al 2008).

It is therefore important to ensure a good latch to help initiate milk ejection during breastfeeding, as well as using a breast pump that can stimulate the milk ejection efficiently.
2. Breast shields need to be the correct size for an individual mother
A correctly fitting breastshield will avoid compression of the superficial milk ducts, supporting effective breast drainage.
3. Hand positioning: when supporting the breast or expressing
As 65 per cent of the glandular tissue is situated within the first 30mm of the nipple and the ducts are quite superficial, it is important to consider position of hands and fingers when feeding or pumping. Pressure on the ducts and tissue can prevent milk from flowing freely and this can lead to blockages and in turn to engorgement and then a reduction in milk supply. When milk is not removed from the breast, a protein called feedback inhibitor of lactation (FIL) is produced. When the amount of FIL increases, a signal is sent to the hypothalamus to reduce prolactin and hence milk production is reduced. To avoid this happening, mothers should be advised on how to position the baby so that they do not have to put too much pressure on the breast during a feed or whilst pumping.

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When performing ultrasound scans on the lactating breast, Dr Donna Geddes from The University of Western Australia began to question the anatomical diagrams that appeared in textbooks. The standard model of the breast was based on anatomical dissections carried out on cadavers by Sir Astley Cooper in 1840.

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A good explanation of why these are unhelpful terms to use

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A good explanation of why these are unhelpful terms to use

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Revised
There is a lot of confusion and poor breastfeeding advice arising from the idea that there are two sorts of breast milk-namely foremilk (watery, low calorie) and hindmilk (high fat, high calorie). And, depending where you live, the confusion may go one step further, you may hear about three kinds of milk; watery soup, dinner and pudding.

All breast milk is good

As a result of not understanding that all breast milk is good, and not really understanding how breastfeeding works, mothers are being told to stay on one breast per feed or feed from one breast for random blocks of time to "get to the hindmilk". After all, the watery soup is no more than water and without that fatty pudding a baby can't gain weight, right? Wrong. Even if that was right, why stop short of offering the "three course meal" from the second breast? Especially if a baby is having trouble gaining weight.

This article

This article looks at how babies grow, how breastfeeding works, the facts about foremilk and hindmilk, and how staying on one breast to get to the hindmilk can sabotage a breast milk supply.

How babies grow

Babies grow and gain weight from drinking lots of breast milk. All breast milk is good, it is a nutritious and complete diet and babies need plenty of it. As a rough guide babies need about 800ml or 27 fluid ounces per day in the first six months. Whether it is foremilk or hindmilk or in-the-middle-upside-down-milk, babies need lots of milk to grow.

Quantity not quality

It is the volume of breast milk that is the important factor determining a baby's weight gain not the fat content in a particular feed. Kelly Bonyata explains:

The research tells us that baby's milk intake (the volume of milk - not the amount of fat in that milk) is the only thing that has been correlated with infant growth in exclusively breastfed babies. [...] average fat content of human milk is highly variable, but has not proven to be significant when calculating baby's total energy intake or weight gain. (Aksit 2002, Butte 1984, Cregan 1999, Mitoulas 2003, Mitoulas 2002.)

Whether it is foremilk or hindmilk or in-the-middle-upside-down-milk, babies need lots of milk to grow. Click To Tweet

How breastfeeding works

Your breasts make milk on demand; so that the faster your baby drinks the available milk, the faster your breasts will make more milk to replace it, indefinitely. Breasts gauge demand by their degree of fullness:

Whenever a breast is full, milk production slows down

Whenever a breast is emptied regularly, milk production increases

Storage capacity

The ideal way to make plenty of breast milk in the volumes your baby needs, is to feed your baby as often as he wants-letting him finish the first breast before offering the second side. Only your baby knows when one side is empty and whether he needs one breast or two, because breasts vary in how much milk they can hold (storage capacity). Storage capacity is explained more fully in One Breast or Two per Feed:

Breasts vary in their breast milk storage capacities. Where one mother's baby might only want one breast per feed and not be hungry for two hours, another may need both breasts per feed and be hungry again in an hour. Let your baby decide how many breasts he wants at a particular feed by looking for his feeding cues and offering him plenty of opportunities to breastfeed.

Ignoring your baby's cues and keeping to one breast to reach the hindmilk i.e. keeping your baby on one breast after he has emptied it, means the opposite breast gets little drainage, and slows down milk production. It's like trying to build a milk supply by only pumping from one breast instead of pumping from both breasts.

If you have a low storage capacity then keeping to one breast is potentially denying your baby half his milk or more. Your baby may need the "hindmilk" from both breasts.

Increasing milk supply

If your baby falls asleep after less than ten or twenty minutes into a feed, breast compressions can get him to start sucking again by simulating another let down of milk. By offering the other breast when the first is finished, and repeating breast compressions if needed, your baby will get the correct balance of foremilk and hindmilk automatically. Using both breasts when needed will drive up and maintain your supply.

But what about foremilk and hindmilk?

Foremilk and hindmilk are the names given to subtle differences between breast milk at the start and at the end of a breastfeed.

Foremilk describes the breast milk at the start of a breastfeed, it has a lower fat content, but has plenty of lactose the principal sugar in breast milk, not to mention all the other great ingredients in breast milk. Lactose is important for developing the brain and central nervous system, and provides 40% of a baby's energy needs. Lactose helps with calcium and iron absorption and, along with other oligosaccharides (short chain carbohydrates) promotes the growth of friendly bacteria such as Lactobacillus bifidus to fight pathogens. As the breastfeed progresses, the fat content of "foremilk" steadily increases .

Hindmilk is the name coined for the breast milk towards the end of a feed as the breast empties. There is less of it but it has a higher fat content and all the other nutritious ingredients found in milk.

There aren't two distinct types of breast milk with one being inferior to the other, it is a continuum of subtle changes. The more frequently you breastfeed, and the emptier the breasts become; the higher the fat concentration in all the breast milk. And remember, weight gain depends on the quantity of milk not just the fat content in the last few drops. Kelly Bonyata's analogy with a hot water tap is useful. When you turn on the tap (start feeding) the water starts cold (low fat milk) but as it continues to run (as the feed progresses) the water gets warmer and warmer (higher fat). If you turn the tap off and on again quite soon, the water will still be warm (high fat milk will still be present at the start of the next feed). And you don't need to run your tap for 30 minutes or an hour to get to the warmer water (if you do, call an engineer!)

What is foremilk hindmilk imbalance?

If a mother has lots of milk, more than her baby can comfortably handle, her supply will usually adjust downwards over time to meet her baby's actual needs. In the mean time some babies may get an excess of lactose rich foremilk. This is sometimes referred to as foremilk hindmilk imbalance. Babies may also get foremilk hindmilk imbalance if a mother has a robust supply and continually takes her baby off the breast before he has finished feeding i.e. switches sides too soon.

Temporary lactose intolerance

In these situations the baby can find it difficult to digest all the abundant lactose in the plentiful foremilk causing temporary lactose intolerance or lactose overload. They may be fussy and uncomfortable with copious green, frothy and foamy nappies. The sheer volume of milk and high sugar content often means babies gain weight very well with foremilk hindmilk imbalance-even though they aren't getting their "pudding". However occasionally some babies may not gain enough weight in this situation. Advice to stay on one breast per feed or for a block of time can be very helpful with true foremilk hindmilk imbalance to ensure babies get a good proportion of higher fat milk. See Lactose Intolerance in Babies for further information and consult your breastfeeding specialist.

Confusion about green nappies

Health visitors who are already hooked on the idea of staying on one breast to get to the hindmilk may think this is an absolute certainty if you mention your baby has lots of green nappies. However the frequent scant green nappy of a baby not gaining weight is NOT the same as the copious frothy green nappy of a baby with lactose overload. Staying on one breast is not the answer for a baby with green "starvation stools". See your IBCLC lactation consultant for further information if you are not sure what your baby's nappies mean or whether block feeding is a good idea for your baby.

I kept to one breast per feed and my baby gained weight just fine!

Keeping to one breast may work perfectly if your storage capacity suits this regime. But be guided by your baby and his weight chart, not by any pre-set rules or clock-watching instructions to reach that elusive hindmilk at the bottom of the barrel.

My baby isn't gaining weight

When a baby isn't gaining weight they most likely need more milk, not more time on an already empty breast which will further reduce a mother's supply. An extra 7-8 ml of high fat milk from the same breast is no substitute for the extra 70-80 ml of fore-hind-and-in-the-middle-milk they might need from the other breast. Check with your IBCLC lactation consultant for the reasons for low weight gain for your baby and see Baby Not Gaining Weight. For increasing milk supply see How to Make More Breast Milk.

Supplements are sometimes needed

If you have been following the advice to "stay on one breast to get to the hindmilk" for quite some time, you milk supply may be quite low. If your baby has not been gaining weight properly, or has been losing weight, he won't be able to wait while you build your supply. He may need supplements ( donor milk or formula) to build back his body weight so that he is strong enough to drive your milk supply all by himself.

Summary

Confusion about how breastfeeding works is causing some health professionals to unwittingly sabotage breastfeeding by recommending staying on one breast to get to the hindmilk: either as a general rule or as specific advice when a baby is not gaining weight. It is not helpful to think of breast milk as two or three different kinds of milk. All breast milk is good and babies need lots of it to grow. Breasts have different storage capacities and what works for one mother and baby may not work for another. Contact your breastfeeding specialist for tailor made recommendations for your unique situation. And forget about foremilk and hindmilk.

1. Did you ever wonder what's in... ? Student Project by Cecily Heslett, Sherri Hedberg and Haley Rumble, 2007

2. Core Curriculum for Lactation Consultant Practice, ILCA, 2013

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Forget About Foremilk and Hindmilk - Breastfeeding Support

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Revised There is a lot of confusion and poor breastfeeding advice arising from the idea that there are two sorts of breast milk-namely foremilk (watery, low calorie) and hindmilk (high fat, high calorie). And, depending where you live, the confusion may go one step further, you may hear about three kinds of milk; watery soup, dinner and pudding.

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I'm not entirely happy with this article, but it does at least stress the importance of good attachment