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Many women worry that their body is not capable of making enough milk. Actually nearly all women’s bodies can make enough milk - provided that milk keeps being taken out of the breast. This link gives detailed information on how it works.

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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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Why you don’t need to worry about foremilk and hindmilk!

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Why you don’t need to worry about foremilk and hindmilk!

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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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What you eat and drink will not affect your milk

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What you eat and drink will not affect your milk

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Here’s the very sensible MilkMeg on worries sbout whether breastmilk will be nutritious enough.

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I just read an article and let me tell you, I had to actually take some time to stop myself from screaming at the computer. This article claimed that they had all of the steps you need to take to make the "best recipe" for breastmilk. This is not only completely misleading, it's in my opinion dangerous and just annoying. We are BOMBARDED with information 24/7. We hear all sorts of things about how to make the healthiest milk and most of them are just plain wrong and all it does is confuse people.

→Research shows that almost every component in breastmilk is actually not changed by the mother's diet, with one of the only exceptions being fatty acids [1].←

This is because our bodies are actually brilliant at survival! We have been around (as what we know as the modern human species) for around 200,00 years. Our ancestors were here 6 million years ago. And we have evolved in a way that allows us to nourish our babies, toddlers and small children with our milk without having to rely on a perfect diet to have the perfect composition. Why is this?...

Historically we have not had food security (we went through feast or famine for most of our history as humans) and of course millions and millions of people around the world still live like this. Our bodies are designed to be able to nourish and grow our offspring without needing to spend thousands of dollars on supplements, relaxation CD's for milk supply, lactation cookies, teas and having a perfect diet.

→So what do we need to do instead? These two simple steps...←

1. Eat real, whole foods as much as possible, including those filled with good bacteria (fermented and cultured foods).

2 Drink some water.

Oh, AND just so you know:

Yup you can drink coffee... After spending a collective total of a decade (plus) of breastfeeding my three boys...coffee was my happy place. Will is affect some babies? Yes. If you drink a cup and your baby acts unsettled then don't drink coffee. However, luckily for us caffeine loving mamas, research shows that for the vast majority of women, having a cup or two of coffee per day will not affect their babies...or the nutrient status of the milk. Caffeine is categorised as Lactation Risk Category L2 (safer) [2]. If I couldn't have had a cup of coffee or two while breastfeeding I think I would have actually died. Here is a photo of me surviving, drinking coffee.

Yup you can eat broccoli, onion, garlic and whatever other spice or vegetable they are telling you to avoid...This one really gets my knickers in a twist. Do you think that in a place like India (where they use heaps of spices, onion and garlic in cooking) suddenly stop eating these foods once they are lactating? Definitely not! WHEN EATEN IN MODERATION and/or as they were eaten by us during pregnancy, they are highly unlikely to affect our babies. Did you eat a huge pile of broccoli and cabbage and noticed your baby had increased gas? Don't do that tomorrow then. Just eat 2 pieces of broccoli and a small pile of cabbage instead. Of course if you overdose on one of these foods it has the ability to upset your baby. But that's with any type of food, medication or drink. Have a colicky baby? Don't cut out onion, read this article here for guidance.

NOPE, exercise has nothing to do with it... Another thing this article said was that exercising encouraged good breastmilk quality and production. Um...I don't know about you but between breastfeeding, not sleeping, barely having time to pee or eat or poop without an audience...exercise was not my priority for a long time. And there is absolutely NO RESEARCH WHATSOEVER that shows exercise is vital to having high quality breastmilk. Because again let's be logical here...we're busy. We've always been busy since the beginning of time. If exercise was a key component to making perfect milk then we'd have died out as a species looooooooong ago.

NOPE, a bowl of oatmeal and spices will not support milk supply... How great would it be if this was actually true? I could just show up to people with a bowl of oatmeal and cinnamon to increase the "quality" of their milk! You could eat 3 bowls of oatmeal per day and fill every meal with spices...the composition of your milk will still be the same.

NOPE, lack of sleep will not affect your supply or your milk quality. If that was the case then all of us sleep deprived mothers who have not slept in ten years would have been dried up and started formula feeding. We all want more sleep, we all dream (day dream of course because w're not sleeping so we're not for real dreaming) about more sleep, and talk about wanting more sleep...but it is not going to affect the quality of our milk. (Head here if you want some more info on all things sleep)

NOPE, you don't need to spend 1,000 worth of supplements to make nutritious milk. Just eat real foods. Drink some water throughout the day. Use some common sense. Keep it simple. We don't need to complicated this. Eat real, whole foods as much as possible including healthy fats (avocados, olive oil, coconut oil, nuts, fermented soy products, fish, meat and eggs). As recommended to every single human being on earth, regardless if they are lactating or not...don't eat junk. We're not that special just because we happen to be breastfeeding. Sorry, but it's true! And I don't know about you, but it actually brings me some comfort knowing this.

Keep On Boobin'! ♥

Meg Nagle, IBCLC

1. https://academic.oup.com/ajcn/article/99/3/734S/4577501

2. Hale T. Rowe H (2017) Medication and mother's milk, New York: Springer Publishing Company.

{I hope you feel better now about the quality of your milk! If you are concerned about the VOLUME of your milk and that you have low supply, please contact me.}

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How can I make my breastmilk rich and nutritious? | The Milk Meg

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I just read an article and let me tell you, I had to actually take some time to stop myself from screaming at the computer. This article claimed that they had all of the steps you need to take to make the "best recipe" for breastmilk.

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It seems that having too much milk is a champagne problem, but it is a problem nonetheless. Don't believe me? Be sure to read Wendy's story about oversupply before reading on.

Before I explain how to manage too much milk, I first want to define what it means to have too much milk. But before I can define "too much milk," I want to define what is average or normal. Defining normal is important for two reasons: One, you should not follow the advice in this series of blogs if you do not, in fact, have an oversupply of milk. Two, if you are a mom who makes too much milk, you need to offer that up as a disclaimer every time you talk to another breastfeeding mom. For instance, during the dreaded "how much do you pump" conversation, the oversupply mom may say, "I pump six ounces (or more) from both breasts combined. But, I am an overproducer." It is simply not fair to average breastfeeding moms for them to believe that their three ounces combined from both breasts is too little, because it isn't at all.

Also, note that determining whether or not you have an oversupply can't be done until two weeks at the earliest, ideally closer to four weeks. In the early weeks, your body is still trying to figure out how much milk you want it to make, so it can easily and quickly increase or decrease.

Okay, so what is normal?

If you have an average milk supply and you are exclusively breastfeeding (i.e., not supplementing with formula or feeding solids), your baby probably gains about five to seven ounces a week. Most often, your baby accepts both breasts at each feeding, though at times, she may want just one. That is most often first thing in the morning when your breasts feel fuller.

If you pump within 15-20 minutes of completing a breastfeeding session, you will probably get one to two ounces combined. If you pump in place of breastfeeding, about two or three hours from your last breastfeeding or pumping session, you will collect about three to five ounces from both breasts combined. Occasionally, if the baby gives you a blessed chunk of sleep or you accidentally go four to six hours without pumping, you may get six ounces combined.

If you have an average supply, once your baby is about five to six weeks old, you most likely don't "feel" like you have to pump or feed the baby at the two to three hour mark. Rather, your boobs start to get a little angry around the four to six hour mark.

If you have met with a quality IBCLC at two weeks postpartum or later and she has done a transfer weigh, your baby probably will have eaten about 45-60 milliliters from the first breast and an addition 15-30 milliliters from the second breast.

Moms with an average milk supply usually don't complain about their baby "chugging," "choking," or "coughing" at the breast. Their babies may show small signs of spit up, but not at every feeding and not copious amounts. It is notable though that babies can spit up for a lot of reasons. It is not a good idea to follow the advice on this blog just based upon your baby spitting up.

Finally, moms with an average milk supply enjoy a pretty textbook nursing pattern. Their babies ask to eat every two to three hours around the clock. The baby often nurses for the classic fifteen to twenty minutes on the first breast and another ten to fifteen minutes on the second breast. Moms with an average supply usually report having a baby that "hangs out on the breast and uses it as a pacifier." This is because once that baby is done eating, there is nothing but a delicious tasting nipple left to just suck and nap on.

So, then, what is oversupply?

If you have an oversupply of milk your baby probably gains about eight to 16 ounces a week. Most often, your baby accepts one breast at each feeding. It is rare that your baby accepts both breasts, though if she does, it is almost always in the evening when your breasts feel softer.

If you pump within 15-20 minutes of completing a breastfeeding session, you will probably get three to five ounces from the breast the baby did not drink from and one to three ounces from the breast the baby did drink from. If you pump in place of breastfeeding, about two or three hours from your last breastfeeding or pumping session... well, here is where your true oversupply will show us what it can do. If average is three to five ounces combined and you are getting that from each breast, you have an oversupply. If you are getting more than five ounces from each breast (and, ahem, you don't have twins) then you have, let's call it, an aggressive oversupply. You body thinks it is feeding three or four babies, not one. Occasionally, if the baby gives you a blessed chunk of sleep or you accidentally go four to six hours without pumping... oh wait, this probably rarely ever happens to you because your boobs will wake you up before the baby wakes you up.

If you have an oversupply, you are probably constantly aware of the fullness of your breasts and your need to nurse. You can barely make it to the three hour mark without coaxing the baby to nurse (perhaps even before she is ready) because you need the relief.

If you have an oversupply, you may be reliant on your pump at least once if not multiple times per day if the baby doesn't do a good enough job softening you. You may be a little too familiar with plugged ducts and mastitis.

If you have met with a quality IBCLC at two weeks postpartum or later and she has done a transfer weigh, your baby probably ate about 90-120 milliliters (three to four ounces) from the first breast. If that baby dared attempt the second breast, he may have taken in (accidentally or on purpose) an additional 30-60 milliliters (one to two ounces) before tapping out.

Moms with an oversupply report that their babies are "quick nursers," sometimes finishing in as short of a period as five to ten minutes! They report that their babies seem like they are drinking really fast the whole time. Their babies cough and sputter if they let down their guard for even a moment and disorganize their suck, swallow, breathe pattern. (I like to joke that there are bones in mom's milk when this happens). Moms with an oversupply worry they are "drowning" their baby. There is often milk everywhere. All the time.

Their babies may or may not spit up. Some babies can handle big feedings like champs, others regularly overeat themselves and promptly "vurp" up the extra. And yes, I 100% believe that breastfed babies can overeat themselves if they are drinking copious amount of milk being poured into their mouths faster than they can think.

So, do you think you might have an oversupply? Read on.

The next question we must ask is, "So what?" Is oversupply causing a problem in your life and/or your baby's life and does it require attention?

If you have a happy, fat baby who may or may not happily puke on himself, your baby doesn't have a problem with your milk supply.

If you have boobs that feel full most of the time, but have adjusted to taking turns at every other feeding without needing to be pumped, your boobs don't have a problem with your oversupply.

If you have a fussy, spitty, pukey baby...

If you have a baby with lime green poops...

If you have a baby that seems gassy because she swallows so much air while nursing...

If you are a slave to your pump and your baby...

If you have chronic and repeated boughts of mastitis...

If you have hundreds of ounces in your freezer and there is no room left for ice cream...

You may have an oversupply problem. Check out the next blog on how to manage your oversupply.

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Do You Make Too Much Milk? - Balanced Breastfeeding

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It seems that having too much milk is a champagne problem, but it is a problem nonetheless. Don't believe me? Be sure to read Wendy's story about oversupply before reading on. Before I explain how to manage too much milk, I first want to define what it means to have too much milk.

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Sometimes it's not so much that there is too much milk, but that it comes out too fast

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KellyMom.com - Breastfeeding and Parenting

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Forceful Let-down (Milk Ejection Reflex) & Oversupply - KellyMom.com

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Is forceful let-down the problem? Does your baby do any of these things? Gag, choke, strangle, gulp, gasp, cough while nursing as though the milk is coming too fast

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Hints and tips for coping with a range of issues

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While it's good to have plenty of milk, some mothers produce more milk than their babies need. This is usually called oversupply.

Some babies cope very well with a generous milk supply; however, others will be unhappy and uncomfortable even though they are gaining weight and appearing to thrive. Oversupply can also make feeding uncomfortable and increase the risk of mastitis.

Symptoms of oversupply
How does oversupply happen?
How is your milk supply established?
A note about foremilk and hindmilk
What can I do about the symptoms of oversupply?
Reducing your milk supply
If you still have problems
Breast compression
Adjusting to the new normal

Symptoms of oversupply

The main symptoms of oversupply for a baby are:

Very fast weight gain, moving upwards through centile lines

Explosive green frothy poos

Struggling to control milk flow

Pain and excessive wind or 'gas'

You may also notice the following:

Choking, coughing, and pulling on and off the breast

Clamping down and biting to slow the flow of milk

Frequent spitting up

Always appearing hungry and unsatisfied despite large weight gain

Unwillingness to nurse to sleep

Breast refusal

Faltering weight gain due to breast refusal

Lots of wet and dirty nappies

General 'colicky' behaviour

A mother with oversupply may have the following symptoms:

Some of these symptoms may have other causes; allergies and reflux, for example, can have similar symptoms to oversupply. They may also fall within the normal range. Therefore, it is important to rule out other possibilities before taking steps to reduce your milk supply, as this can have longer term consequences.

How does oversupply happen?

Some mothers naturally produce large quantities of milk, and we tend to produce more milk with each baby. Occasionally, there are medical reasons for having much more milk than your baby needs. Oversupply can also occur as a result of breastfeeding management, for example, when a baby's feeds are scheduled, or if a mother is told to feed from each breast for a certain amount of time. It can happen if a pump is used too often, or used in a way that overstimulates the breast.

Milk production is best regulated by your baby's appetite. When you breastfeed responsively, rather than by following a schedule, your milk production adapts to their needs. Occasionally, a poor latch can contribute to oversupply as a baby might feed very frequently to get the volume they need. However, this tends to reduce milk supply over time.

How is your milk supply established?

After your baby is born, milk production is regulated on a supply and demand basis. Put simply, the more milk you remove, the more milk you are likely to make. How quickly or slowly milk is made depends on the fullness of the breast - an 'empty' breast makes milk more quickly, a full breast makes milk more slowly.

It takes a few weeks for your supply to settle down to what your baby actually needs. It is not unusual in the early weeks to feel as if you have too much milk, and to have times when the breasts feel full or even engorged. This is not the same as oversupply.

Feeding frequently and removing milk from the breasts is essential to resolving engorgement - it won't make the engorgement worse or result in too much milk.

Babies usually nurse more during developmental leaps and growth spurts, and many mothers find there are changes to their baby's nursing pattern during holidays and family get-togethers, or during periods of stress. Milk supply is very adaptable - if you follow your baby and your body, your supply will most likely regulate itself.

Read more about how milk production works.

A note about foremilk and hindmilk

One of the symptoms of oversupply in a baby is green frothy poos, gas, and pain. This is sometimes called lactose overload or a foremilk-hindmilk imbalance.

You may be given confusing information about foremilk and hindmilk, and how long a feed 'should' last. Or think that there are two different kinds of milk - lower-fat and fat-rich - and that one is better than the other.

Typically, the fat content does increase during a feed, as the fat globules tend to be drawn down towards the end of a feed. However, it is not the length of a feed that is important, but the length of time between feeds. Fat content is determined mostly by the fullness of the breast. If there is a long gap between feeds and the breast is full, the baby may get a large quantity of lower-fat milk before much of the fat starts getting pulled down. The same may be true if a mother naturally produces very large quantities of milk. In the absence of fat-rich milk, the lower-fat milk moves through the gut faster than it can be digested, causing green poos, gas, and pain.

All breastmilk is good! What matters most to weight gain is overall milk volume.

What can I do about the symptoms of oversupply?

To start with, you might like to:

adjust your position and your baby's attachment to help them manage a fast letdown

feed responsively (as often as your baby wants) and/or offer more frequent feeds

use breast massage

avoid overpumping

Managing a Fast letdown
A fast letdown can be one symptom of oversupply. It is possible to have a fast letdown with an 'average' milk production. When your baby nurses, a hormonal reflex causes milk to release, (what is known as 'letdown'). When this happens, it is not unusual for milk to spray out quickly. Some babies like this fast flow, but others are upset by it and struggle to coordinate sucking, swallowing, and breathing. You may find it helpful to:

Ensure that your baby is deeply attached at the breast. This will make it easier for them to manage a fast flow.

Try different positions. Some parents use gravity to help them by feeding in a 'laid-back' (reclined) position. Others find it helps to feed in a more upright position such as a 'koala hold', or to feed while using a sling or baby carrier. Side-lying may also be helpful as excess milk can easily leak out.

Allow your baby to come off the breast when they need to catch their breath, and use a muslin to catch the spray.

Some mothers hand express a little to slow the flow before bringing the baby to the breast (however, if this is done frequently, it may make oversupply worse).

If your breast is very full and engorged, you might try 'reverse pressure softening' to move fluids away from the nipple area as this can help your baby to latch more deeply.

Feed frequently so that the milk spray doesn't have quite so much volume and force behind it.

Try breastfeeding before your baby is really hungry, or while they are slightly sleepy.

Responsive feeding
How do you know how often or how long to feed your baby for? Let your baby tell you! We all have different milk storage capacities and this may determine how frequently your baby feeds, and whether they feed from one side or two. Allow your baby to feed from the first breast for as long as they want to before offering the second breast - they may or may not take it.

Sometimes babies will only take one breast, and sometimes two (or three or four!). Most babies will take both breasts, at least some of the time. Babies are very good at letting us know how often they want to feed, and if in doubt, it is always fine to offer.
Breast massage
You could do what is sometimes called the 'breast milkshake'. This involves massaging each breast very gently for half a minute or so before feeding, then using a combination of massage and breast compression (see below) during a feed to help dislodge some of the fat. Any massage should use a light fingertip pressure such as you would use to apply body lotion.
Expressing
Overuse of pumps - or using a pump in a way that unintentionally stimulates milk production (such as a silicone pump to collect dripping milk) - can make oversupply worse. If you've been expressing regularly, reduce this gradually to avoid further problems.

Reducing your milk supply

If your baby is gaining more weight than average and you and your baby are happy, then you don't need to change anything. It is not possible to overfeed a breastfed baby.

If you or your baby are struggling with some of the above symptoms, you have ruled out other causes and changes to breastfeeding management do not help, then you may want to consider taking steps to gradually slow milk production.

Consult an LLL Leader before using these approaches. This is especially important if your baby is under one month old, or you are experiencing other problems such as sore nipples or mastitis.

Monitor your baby's weight gain to ensure it doesn't drop below expected levels, and keep a close eye on nappy output.

One side per feed
Limit your baby to one breast per feed. If your baby wants to have a short rest during a feed, then offer the same breast again. When a mother has a generous milk storage capacity, their baby may only need to feed on one side. This approach may help milk production to reduce in line with their baby's demand.

Block feeding
Block feeding involves feeding on the same side for a set period of time (block), e.g. for two or three hours. If your baby wants to feed again within that time block, offer the same side. As a starting point, you might like to:

Limit your baby to one breast for about two hours, allowing them to nurse as often and for as long as they like, but only on that one side.

Continue in this way, switching breasts every two hours. If your baby is asleep, switch breasts when they wake.

It is important not to have a rigid approach to block feeding: read your breasts and your baby, not just the clock. By doing this, you will find the time block that works best for both of you. If the unused breast feels uncomfortably full before the next feed then 'express to comfort' only.

It is possible to experience oversupply in just one breast, in which case you could nurse for longer periods on the unaffected side.

Full drainage and block feeding method
For more severe oversupply - for example, if you are suffering from recurrent blocked ducts or mastitis and your breasts never feel soft and comfortable even after a breastfeed - you will need to keep your breasts well drained while you take steps to reduce milk production.

You could try the following, in consultation with an infant feeding specialist, in addition to block feeding:

Express from both sides thoroughly to 'empty' your breasts as fully as possible.

After expressing, immediately offer both 'empty' breasts to your baby.

Next, limit your baby to one breast changing sides every two or three hours (see block feeding above).

Some mothers will need to use this approach only once. However, if your breasts feel uncomfortably full, you may need to repeat it, increasing the interval between each pump for your breasts to readjust.

Medications and herbs to reduce milk production
There are herbs and medications that can help dry up your milk production. Talk with your health care provider or a lactation consultant.

If you still have problems

After 4-7 days, your breasts may be more comfortable. If you and your baby still have trouble coping with the supply of milk, you can gradually increase the time block you keep your baby to one breast. Some women with extreme oversupply have gone as long as six or more hours before switching breasts to adjust milk production. A hormonal imbalance may cause overproduction of milk, but this is rare. A visit to your doctor may be helpful if the suggestions offered here aren't enough.

Block feeding should be a temporary measure. In practice, it is suggested that it is done for no more than one week, and only when babies are gaining double (or more) the average weight for their age. Once supply has settled, you can return to a more normal feeding pattern, following and trusting your baby and your body.

Breast compression

Babies used to a generous milk flow can become fussy at the breast when milk flow slows. They may have to work harder at the breast and deepen their latch to remove milk effectively. Breast compression will increase milk flow and encourage your baby to keep feeding actively:

1. Support your breast with one hand - thumb on one side, fingers on the other.

2. Wait while your baby breastfeeds actively (slow, rhythmic sucking, lots of swallowing). When their swallowing slows, compress your breast gently to increase milk flow and encourage swallowing. Hold it squeezed while they continue nursing actively, then release your hand.

3. Rotate your hand around your breast and repeat step 2 on different areas of the breast as needed. Be gentle - this shouldn't hurt.

Adjusting to the new normal

Always monitor your baby's weight gain, wet and dirty nappies, and overall well-being while following these strategies. Monitor their weight over a period of several weeks to see a trend. If your baby had been gaining weight very quickly, you may see 'catch-down' growth. Your baby will gain weight steadily, but may gradually drop against the percentile lines as your milk production adjusts. Their weight should then settle into following a new percentile line on the chart.

As your supply reduces, your breasts will feel softer and more comfortable, and leaking will be reduced. Soft comfortable breasts between feeds during the early weeks are normal and a sign that your milk production is in tune with your baby's needs.

Written by Charlotte Allam

Last updated May 2023

Kimberly Seals Allers' photos on this site are used under a creative commons license of Black Breastfeeding 360° http://mochamanual.com/bb/

Further Reading
Mastitis
Engorged Breasts - Avoiding & Treating
Hand Expression of Breastmilk
Is My Baby Getting Enough Milk
Comfortable Breastfeeding
Rhythms & Routines
The Unhappy Breastfed Baby
Reflux
Allergies and Intolerances
Fat Content of Breastmilk - FAQs
Positioning and Attachment

Other websites
UK-WHO Growth Charts: www.rcpch.ac.uk/growthcharts
Block Feeding Dos and Don'ts: http://www.nancymohrbacher.com/articles/2013/10/9/block-feeding-dos-donts.html?rq=oversupply

Books
The Womanly Art Of Breastfeeding. LLLI, London: Pinter & Martin, 2010

Copyright LLLGB 2023

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While it's good to have plenty of milk, some mothers produce more milk than their babies need. This is usually called oversupply. Some babies cope very well with a generous milk supply; however, others will be unhappy and uncomfortable even though they are gaining weight and appearing to thrive.

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So, you have determined you have too much milk (TMM) and you have decided you don't want to be the primary pumping station for the human milk bank. You want to make a little less milk. That's okay! Don't feel guilty for wanting less!

You should, however, feel guilty for pouring perfectly good milk down the drain because you have nowhere to store it. There are teeny tiny babies in NICUs across the country who NEED YOUR MILK! P.S. If this is the case, you just might be a milk hoarder and just might need help.

Block feeding is an effective technique for the following circumstances:

1. You have determined that you have TMM and you have at least one of the problems listed in the TMM blog: the Drowning Baby or the Bossy Boobs.

2. Your baby is having a foremilk/hindmilk imbalance. ** Please read my blog "The Good Milk" before you get married to the idea of having a foremilk/hindmilk imbalance. If you are thinking of following this block feeding advice because your baby had one spinach green poop, read "The Good Milk" and reconsider.

Warning: Block feeding will decrease your milk supply. If there is any doubt in your mind that you have TMM, don't block feed. If you do and your supply drops too low, you will need to read about boosting your supply.

Disclaimer: This blog involves decreasing and spacing baby's feedings. DO NOT follow this plan unless your baby is gaining like a big fatty (this was part of the TMM, blog if you need to reference what "gaining like a big fatty" means. But, do not follow this plan just because your baby is a big fatty. This isn't a diet plan for babies, folks.

Another warning: Block feeding puts you at higher risk for plugged ducts and mastitis. If you decide to block feed, please read these blogs first to familiarize yourself with what they are and what to do if you get them.
How block feeding works:
Block feeding has both short-term benefits and short-term discomforts. The whole process takes at least three days, if not longer, to work.

You have to understand that block feeding has two purposes. First, it creates a low level of engorgement on the unused breast. This low level of engorgement sends a feedback message to your brain, telling it, "TOO FULL! TOO FULL!" Your brain, eager to protect your boob from explosion, sends a message back down to your boob to slow down the milk making machine. This negative feedback process takes an average of three to five days. During this period, you will have alternating hard, sore, overly full boobs. A little ways down, I will remind you of what to do with that rock hard booby.

The other purpose of block feeding is to allow the baby to not get drowned at the boob at every other feeding. Or, for the baby with foremilk/hindmilk imbalance, to get thicker, fattier milk at every other feeding. The second time you feed on the same boob, it has had less time to fill and is therefore producing at closer to an average supply. You see the catch here, right? The unused boob, which has been filling for double its usual fill time, is very, very full. Sure, the baby enjoys half of his feedings at the emptier boob, but the fuller boob is even more vicious.

Your baby will be okay. I know it is hard to see him getting sprayed in the face with your milk, but he's a trooper, trust me.
How to block feed:

1. Determine how often you breastfeed now and if it is always or sometimes on both breasts. Most women with TMM have been nursing on only one breast for quite some time.

2. If you are nursing on both breasts at all or most feedings, start by trying to nurse on one breast at each feeding. That means the unused breast will stay full until the next feeding. (FYI, some people think feeding on one breast at each feeding is block feeding. It is not. It is simply feeding on one breast at each feeding).

3. If you are already feeding on one breast at each feeding, your next step is to feed on one breast for a designated amount of time, or two feedings in a row. So, if you have an every-90-minutes-nurser, hold him off until closer to the three-hour mark. You can do that by using a pacifier (you are using a pacifier since you have TMM, right?). If you are breastfeeding about every three hours, that means you will nurse on the same breast for six hours and your opposite boob will need to hold it for six hours.

What to do with your full boob:
So, the big full boob sits angrily by while the other boob gets to feed, again! The jerk line jumped and took his turn twice!!

The name of the game: Comfortably Full.

In order to send the proper message to your brain to make less milk, that breast has to stay full. I know you wanna pump it soooo bad. But you can't. You can, however:

Let it passively leak. Let that puppy out while her neighbor is nursing. Put a very absorbent cloth (or a disposable diaper) or a Milkies on the big angry boob and let it passively leak. This will let a little milk out without sending a stimulating message to your brain.

Apply ice or cool cabbage. Ice decreases swelling and cabbage decreases milk supply (honest!). It can help keep you comfy.

Take the edge off. If you just can't take it anymore, hand express or hand pump just a little bit. It usually isn't the best idea to set up the electric pump in this circumstance. It is just too much power too quickly. If you aren't careful, you will have four ounces before it switches to the expression phase at the two-minute mark. There isn't a set volume that "takes the edge off." It is different for everyone and different at various times of day. Bottom line: You want to take out the least amount possible to make you comfortable again.

When should you fully pump a boob?

As I warned you earlier, with block feeding comes the increased risk for plugged ducts and mastitis. Here is a good practice for breastfeeding in general and block feeding in specific.

Feel your boobs. After you breastfeed, feel the boob(s) you nursed on. The nursed on boob(s) should feel uniformly softer. There shouldn't be a section of your breast that is soft and a section that is firm. If there is a firm section, take a note of it because you need to focus on that section next time. If after the second feeding, the firm section is still there, focus on getting it out. That means starting the plugged duct regimen. If that section continues to get fuller, firmer and more sensitive to the touch, try harder. If the baby won't do it, get the pump out. If it isn't gone in three days, call your OB or midwife.

Yes, fully pumping will mess up your block feeding process and probably put you back to square one, but it is better than getting mastitis.
How will I know block feeding it is working?
You will know block feeding is working when those full breast feedings get a little less intense. Look for less spraying and less crying (from both of you).

Continue to stick to the block feeding system you are using for a few more days. If it continues to work well for you, change nothing.

If it seems like your baby is less satisfied the second go around on the same breast, you may need to go back to one breasted feeding for a while, rather than doing two feedings in a row per breast.

If it seems like there is still an oversupply issue, try feeding on the same breast for three feedings in a row. Same concept, just longer period that your unused breast stays full.

Oftentimes, block feeding is a rotating system. You have TMM, so you block feed for three to five days. After block feeding for three to five days, your supply seems to have dropped and baby seems frustrated with feeding on the same breast twice in a row. You return to feeding from one breast at each nursing session for a week or more. You feel like you have TMM again, so you block feed for three to five days.

Please always remember that your supply is constantly changing and evolving and you need to act accordingly. Please also remember that you have two boobs. If it seems like block feeding worked a little too well and you have too little milk, as an over supplier, chances are you have forgotten that you can nurse the baby from the second breast!

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So, you have determined you have too much milk (TMM) and you have decided you don't want to be the primary pumping station for the human milk bank. You want to make a little less milk. That's okay! Don't feel guilty for wanting less!

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Feeling like you want to avoid feeds or feeling agitated during feeds

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Feeling like you want to avoid feeds or feeling agitated during feeds

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BAA or 'aversion' is a phenomenon that some breastfeeding mothers experience, which includes having particular negative feelings, often coupled with intrusive thoughts when an infant is latched and suckling at the breast (Yate, 2017).

The two days before I get my period, I get nursing aversion at night. This usually feels like being very agitated, and the need to get my baby off me and what only be described as extreme itching all over my body but under the skin." -Nadia

These feelings are often unexpected, and almost always unwanted, as many mothers who experience aversion would like to continue breastfeeding. Mothers can experience feelings of:

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Anger

Agitation

Disgust/Self-Disgust

Irritability

Rage

Skin itching/crawling

Shame & Guilt (usually afterwards)

Intrusive thoughts are known to occur in motherhood (Kleiman, 2010), but with BAA these appear to be specific to breastfeeding and can include, but are not at all limited to:

Wanting to 'run away' so as to not be feeding

Overwhelming urge to stop breastfeeding

'Feeling trapped' or a like a prisoner

Wanting to 'pinch' the infant or child so they stop suckling

Thoughts and feelings about being 'touched out'

These feelings disappear after the infant stops breastfeeding and is not latched.

The phenomenon of BAA is known to exist in varying degrees and durations, along a spectrum that is individual for each mother - as the onset and severity is unpredictable. However, the expression or manifestation of aversion is similar, with mothers describing very similar feelings and thoughts, often using the exact same phrases (Yate, 2017).

I didn't actually know there was a term for this. I get so angry, like a rage when my son latches now, and I am not sure why. I used to LOVE breastfeeding and we had such a good relationship. All I think about now is leaving, running away when he suckles. Then I feel so guilty it hurts." -Hanna

Guilt and Shame

Mothers feel a great sense of shame and guilt due to these negative feelings and intrusive thoughts. Many don't tell anyone, and struggle with an 'internal conflict' of wanting to breastfeed, but once engaging in the activity, experiencing aversion toward it. Some mothers have to wean due to experiencing BAA, if it is long-lasting or severe, or if they do not know what it is. This also can cause feelings of guilt over having to end breastfeeding before a mother or infant was ready.

I am so glad I found this group [online support group]; I thought I was going mad... that I was the only one who felt like this when nursing. I just want to scream and pull my baby off." -Preena

Is BAA like Dysphoric-Milk Ejection Reflex (D-MER)?

In the experience of negative emotions whilst breastfeeding, yes. However, for mothers who experience BAA, there is often an overwhelming urge to de-latch the suckling infant, as once aversion hits it will not abate until the infant has stopped suckling. This is noted in distinction to the condition of D-MER, which is the experience of feelings of dysphoria when the milk releases, as these dissipate shortly thereafter - not staying throughout the whole feed as is the case with BAA. The feelings themselves are also generally different: anger and agitation are not the same emotions as dread, despair or sadness, although there can be crossovers. Mothers can experience both D-MER and BAA, and at the same time, but they are different phenomenons.

What causes BAA?

The paucity of research on BAA is very apparent, there are no research studies that investigate what causes aversion experienced in this manner whilst breastfeeding. There are a few academic studies and books that mention it. Recently, in 2016, a small group of women were interviewed in a study that concluded that breastfeeding can trigger 'negative embodied emotions', which are negative feelings that are projected onto the infant, and aversion was referred to (Watkinson, et.al 2016). Adventures in Tandem Nursing by Hilary Flower refers mainly to women who are pregnant or tandem nursing experiencing 'agitation' at the breast (Flower, 2003). However, in a study asking 694 women to describe the phenomenon of aversion, there was no distinction found between mothers breastfeeding a single infant and those who were pregnant or tandem feeding (Yate, 2017). Possible causes from other published works in parenting and lactation that could lend some understanding towards the reasons for BAA are discussed. These are grouped loosely under the following categories in the discussion section of the study:

Hormones

Some mothers are able to tie experiences of BAA to their menstruation (even ovulation), and manage it for a few days each month, once they have identified this pattern, and they realise it will pass. This indicates that the cause could be hormonal for some women, something perhaps similar to pre or postmenstrual stress. It is also likely to be hormonal for the women that get a bout of BAA in pregnancy as the body changes, breast and nipple sensitivity is heightened, and overall energy 'costs' on a woman's body to fulfill both gestation and lactation all plausibly playing a role. It is possible for some women that aversion is their bodies' way of suggesting weaning (Neville, 2010. Hinde, K, 2009, Grey, 2013).

Breastfeeding dynamic

Many women write they experience aversion once their infant starts to get a bit older (i.e., is not a baby), and they still maintain 'feeding on demand'. There could be a number of reasons for this, including the difficulty to say no or 'set boundaries' with their child, or the fact the child is less reliant on milk for survival but is still breastfeeding very frequently, even at night. The breastfeeding relationship is an important consideration in the experience of BAA, because if mothers have unrealistic expectations on infant sleep due to societal or cultural pressures, are the only source of milk, coupled with the decline of a 'tribe' or milk-sharing duties/wet nursing over the past few decades, this can put the pressure and stress on the mother alone for milk. It is plausible this stress can manifest whilst breastfeeding and in the interactions of the mother-infant dyad at this time, especially considering the hormone cortisol (Hinde, K, 2014).

Sleep deprivation and 'self-care'

Lack of sleep can affect us in many ways, including causing chronic diseases, and even depression. This is well documented. The mothers who responded in the study would often note being sleep deprived in their responses, and how difficult it was for them to maintain breastfeeding on demand, especially at night, in this state. This is the one key area many mothers noted BAA would strike, often alongside not eating properly with a well-balanced diet, and not hydrating sufficiently.

Triggers

Sleep deprivation or not having any time for self-care are commonly reported as 'triggers' for BAA, including the sensations of an infant's latch, 'wandering hands' and 'nipple twiddling/tweaking'. Many mothers report the pre-cursor to experiencing aversion is that they are 'touched out'. This term refers to women feeling overwhelmed by the amount of physical contact with their infants, and not being able to have any time apart/alone/for themselves without being touched. This was especially true for mothers who tandem fed, or were breastfeeding very demanding toddlers.

There is not enough research on BAA to know how many breastfeeding women it affects, why it affects some women and not others, and what women can do about it. There is anecdotal information that suggests cognitive distraction, taking certain supplements, and mother peer-to-peer support can help lessen the experience or manage it until it abates.

A resource website on Breastfeeding Aversion and Agitation, how to figure out what can help, and the latest research can be found here: www.breastfeedingaversion.com. If you are struggling with aversion you can join a closed online peer to peer support group on Facebook, or reach out on the public awareness page about aversion on Facebook, or Instagram @breastfeedingaversion.

About Zainab Yate:
Iranian born Zainab Yate is Vice Chair of North London Research Ethics Committee, for the Health Research Authority (HRA), and a member of King's College London (KCL) Research Governance Board in the UK. She volunteers as a breastfeeding peer supporter with the National Health Service (NHS), and is volunteering to support the work of World Breastfeeding Trends initiative (WBTi) in the UK. As an independent researcher and research consultant, with two breastfed toddlers, she spends her free time raising awareness of BAA and supporting mothers who experience it. In September 2017, she hopes to start an online structured programme for mothers who experience BAA, to help them reach their breastfeeding goals.

References

1. Yate ZM. A qualitative study on negative emotions triggered by breastfeeding; describing the phenomenon of breastfeeding/nursing aversion and agitation in breastfeeding mothers. Iran J Nurs Midwifery Res. 2017 Nov-Dec; 22(6): 449-454. doi: 10.4103/ijnmr.IJNMR_235_16.

2. Watkinson M, Murray C, Simpson J. Maternal experience of embodied emotional sensations during breast feeding: An Interpretative Phenomenological Analysis. Midwifery 2016;36:53‐60.

3. Flower H, O'Mara P. Adventures in Tandem Nursing: Breastfeeding During Pregnancy and Beyond. Schaumburg Ill: La Leche League International; 2003. p. 327.

4. Heise AM, Wiessinger D. Dysphoric milk ejection reflex: A case report. Int Breastfeed J 2011;6:6.

5. Neville MC, Anderson SM, McManaman JL, Badger TM, Bunik M, Contractor N, et al. Lactation and Neonatal Nutrition: Defining and Refining the Critical Questions. J Mammary Gland Biol Neoplasia 2012;17:167‐88.

6. Hinde K. Richer milk for sons but more milk for daughters: Sex‐biased investment during lactation varies with maternal life history in rhesus macaques. Am J Hum Biol 2009;21:512‐9.

7. Amir LH, Dennerstein L, Garland SM, Fisher J, Farish SJ. Psychological aspects of nipple pain in lactating women. J Psychosom Obstet Gynaecol 1996;17:53‐8.

8. Picciano MF. Pregnancy and Lactation: Physiological Adjustments, Nutritional Requirements and the Role of Dietary Supplements. J Nutr 2003;133:1997S‐2002S.

9. Ussher JM, Perz J. PMS as a process of negotiation: Women's experience and management of premenstrual distress. Psychol Health 2013;28:909‐27.

10. Neville MC, Morton J. Physiology and Endocrine Changes Underlying Human Lactogenesis II. J Nutr 2001;131:3005S‐8S.

11. Hinde K, Skibiel AL, Foster AB, Rosso LD, Mendoza SP, Capitanio JP. Cortisol in mother's milk across lactation reflects maternal life history and predicts infant temperament. Behav Ecol 2014;26:269‐81.

12. Hinde K, Capitanio JP. Lactational programming? Mother's milk energy predicts infant behavior and temperament in rhesus macaques (Macaca mulatta). Am J Primatol 2010;72:522‐9.

13. Grey KR, Davis EP, Sandman CA, Glynn LM. Human milk cortisol is associated with infant temperament. Psychoneuroendocrinology 2013;38:1178‐85.

14. Borra C, Iacovou M, Sevilla A. New Evidence on Breastfeeding and Postpartum Depression: The Importance of Understanding Women's Intentions. Matern Child Health J
2014;19:897‐907.

15. Kleiman K, Wenzel A. Dropping the Baby and Other Scary Thoughts: Breaking the Cycle of Unwanted Thoughts in Motherhood. New York, NY: Routledge; 2010. p. 272.

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Breastfeeding / Nursing Aversion and Agitation (BAA) * KellyMom.com

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By Zainab Yate (MSc) What is the phenomenon of Breastfeeding Aversion and Agitation (BAA)? BAA or 'aversion' is a phenomenon that some breastfeeding mothers experience, which includes having particular negative feelings, often coupled with intrusive thoughts when an infant is latched and suckling at the breast (Yate, 2017).

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A new kind of device for pumping milk from New Zealand - this review gives some information and warnings about cheap copies.

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An earlier version of this piece was first published on the blog for Growing Families ahead of their conference in Manchester in October 2016. This current piece has been amended and updated as new information has been made available, and to the best of our abilities we will continue to amend and update where new evidence is produced which materially changes the content.
This year's big thing in the infant feeding related products world seems to be the Haakaa silicone breast pump. Coming from New Zealand, the company information on Facebook says they are a "baby brand that provides parents with Safe, Natural, Non-toxic, Eco-friendly baby products" http://www.haakaa.co.nz/ The 'buzz' around this product is so strong that people all over the UK have been importing from the other side of the world so they can get their hands on this item, and leaving rave reviews! I have been hearing a lot about them and wanted to provide a good discussion of what the fuss is all about.

This new-ish product is essentially a clever combination of two items which have been around for a long long time - breast shells and breast relievers.

Breast shells are designed to be tucked into the bra of a lactating woman, and the hole goes around the nipple so that any leaked milk is caught in the 'shell'. The shape of the part which touches the breast, and the size and placing of the hole, creates gentle pressure on the lactiferous ducts behind the areola and actually encourages milk flow and so stimulates leakage.

Two examples here

Breast relievers are designed to pump milk from the engorged breasts of lactating women when the baby they have been feeding baby cannot or does not wish to be fed. They rely upon a combination of suction (creating a vacuum which draws the milk out), rhythm (which might stimulate the 'let-down' reflex) and pressure on the lactiferous ducts, which stimulates milk flow. These devices have been around for well over 100 years and are still used today. See this one in the British Science Museum which was apparently in production between 1870 and 1901, although many like this were used much more recently - but also this one which is one of many similar ones available online now.

Where these have been promoted as breast 'pumps' in the past I have been a little concerned as this suggests the milk is being saved for use in feeding baby, and I'm never sure how one would effectively clean the 'bulb' - which both gets squeezed to create the vacuum / pumping, and also serves to store the collected milk. Nor whether the plastics or rubberised materials used, might leech substances into the milk - which is a worry if this is to be used for feeding baby, but of less concern of course if it is purely used to relieve engorgement and the resulting milk is discarded. However I don't know many lactating women who are happy about the idea of discarding breastmilk!!

So when I first saw the Haakaa in a breastfeeding group online I was impressed by the simplicity of the design and the ethos behind it - namely that it's simple to care for, and non-toxic!
How does it work?
For this we can turn to the company's own website: "Simply suction to your breast and let the pump do the work for you as it draws your milk using suction". It's true - the reports I have had tell me that the flange is placed on the breast, nipple lined up with the 'neck' of the device, and then the bulb is squeezed to compress which expels air from the bulb and creates a vacuum around the flange on the breast, securing it to the breast. Mums tell me that they then feed their baby on the other breast and while they are feeding the device fills up with their milk! The device has a scale on the side up to 90ml but I suspect it would accommodate 100ml - whether it could do this without falling off the breast as the vacuum reduces and the device itself becomes heavier with milk, is another matter - but you could hold it on.
How is it different from other pumps?
Most breast pumps work in a similar way - there's a flange or funnel which sits on the breast, a hole and tube which accommodates the nipple, and then something on the other side to provide the vacuum in a rhythm so that it does actually pump the breast. Usually there's some sort of valve so that the milk once removed from the breast is released into a bottle via some sort of 'one way' affair and cannot come back out again into the body of the pump. Whether hand pump or electric, whether double or single, costing £10 or £200 - all the same basic design. So there are at least 4 parts, of which at least 2 are moving. Usually many more than 4, and first time assembly for the exhausted new parent is akin to completing a passport application using only your mouth to hold the pen! But the Haakaa is just one piece of silicone and not really a 'pump' at all - no valve, no pumping required - though the manufacturers do say that you COULD squeeze and release the 'bulb' at the bottom, which contains any milk, if you choose to - it isn't necessary. Because it involves no 'pumping', in spite of the dictionary definition of pump only meaning to move liquid through suction or pressure, for some reason I'm a little uncomfortable calling it a 'pump' and am finding myself using the word 'device' to describe it!
How can it be cleaned?
Unlike any of the more complicated 'moving part' pumps there's only one piece to this device which makes it far simpler to wash inside and out (in hot soapy water) and of course no assembly required. Unlike its predecessors the breast reliever, Haakaa's device is also dishwasher safe (not sure how to position it so that it would definitely get washed and rinsed thoroughly, however - dishwashers tend to send small light things like this spinning around inside the machine during the cycle, in my experience), and because we don't want any nasty things leeching into baby's milk they are made from 100% food grade silicone and certified BPA, PVC and Phthalate free. So it's as simple as it looks.

Which brings us to a troubling issue with these devices:
Copycat pumps.
Since these devices have become popular, almost inevitably some copycat devices have spring up on the internet - some in China, some in Malaysia. Examples here

Some look identical to the Haakaa, some do not, and are not. The authentic Haakaa pumps were originally available only from New Zealand, costing $27NZ (about £15) and it was not possible to buy them from the UK without relatively high transport costs. The main (New Zealand-based) websites selling them would charge around £27 to sell and deliver one to an address in the UK, within about 2 weeks. UPDATE: at the bottom of this piece we have included a link for purchasing in the UK, updated 28th August.

However, the copycat pumps are available through amazon and other mainstream retailers, claiming prices from as little as £3 delivered! From the families I have spoken with who have ordered these copycat pumps, I know that the very cheap ones often do not turn up at all, and sometimes the refunds have been impossible to secure, also that even the £12-20 ones have been arriving without proper packaging - this is one example given to me by a local mum

As you can see - the packaging isn't quite as sophisticated!

These copycat pumps are often more 'solid' than the authentic Haakaa, made from a material that feels more rigid to the touch, and weighs more - 100g compared to 74g. This suggests they are not made to the same standards as the authentic Haakaa. Reviews on some of the copycat pumps on eg Amazon.com suggest that this thicker silicone actually causes pain when it is suctioned onto the breast, and there have been reports of burns to the skin, like chemical burns, from users - the reviews on some of the third party selling sites containing these damning claims have now been removed as far as I can see.

Interestingly the copycat pump shown above donated by a local mum has a different pattern on the silicone to the Haakaa, but the design is identical and it's just as squishy - even came shrink- wrapped squished in the post as you can see above! BUT it weighs LESS than the authentic Haakaa - so the copies are getting more sophisticated but still are not the real thing. The copycat pumps sometimes have Chinese lettering on them, whereas the authentic Haakaa one, a representative from the company tells me, have the word HAAKAA written down the side.

The authentic Haakaa pumps are certified BPA free. BPA is Bisphenol A - an industrial chemical used in the production of polycarbonate which is a hard, clear plastic, used in many consumer products. BPA is also found in epoxy resins, used as a protective lining on the inside of some metal-based food and beverage cans. It also leeches into liquids and is now thought to be carcinogenic, to which end it has been banned from the production of baby bottles since 2011 in the EU.
Buyer Beware!
Copycat pumps make some claims on the advertising and packaging but we cannot of course be sure if these are true. One mother I spoke to was concerned about these copycat pumps and, fearful she had bought one, she emailed the seller to ask if they were safe and what testing they had had. The response she received was that they had no idea, they were just selling and sending them out. In the UK/EU the importer actually has the responsibility for the safety and conformity of imported products, the 'CE markings', so if a UK resident is importing things from abroad then as the importer, THEY are responsible for checking that the products are appropriately CE marked for conformity to required standards.
Are they any good?
Assuming we're now talking only about the authentic Haakaa silicone pump, what most families will want to know, I imagine, is are they any good?

If you go online and search for Haakaa reviews, a few clicks will bring you many many positive stories, lots of five star feedback, youtube videos and so on. The point is it's a simple idea, and it works. Gentle pressure on the lactiferous ducts, plus gentle vacuum as the bottle expands, plus feeding baby or active pump on the other breast to create a 'let-down', will elicit a flow of milk into the device. Some women find they could completely fill it, others just an ounce - but as many mothers have told me - they have always failed at expressing, they are no good at it, and this device gives them an ounce they would never otherwise have had! Mothers who have trouble with leakage while feeding on the other breast and so use lots of breast pads, are finding this saves them lots of breast pads and leakage AND gets them some milk to store.

A word of caution though - a quick search of reviews online shows that some babies think it's a great game to knock them off the other breast as they are feeding, and because of the design, a knocked Haakaa pump can spill ALL the milk collected - up to 4 ounces - all over the place. So now you have been warned about that, there's no use crying...!

Lots of rave reviews however, and little images sent in of milk collected in them!

From the Haakaa Facebook page
Are there any drawbacks?
However because they apply the gentle pressure on the lactiferous ducts AND a gentle suction too, they will encourage continued leaking and can exacerbate the issue for anyone for whom leaking is already an issue; so as breasts are really supposed to work individually - assuming you are feeding only one baby! - if you have a problem with leaking from one side when the other is 'working', or perhaps a slightly different but related issue such as an over-supply, perhaps it's better to manage that rather than encourage more of the same by collecting the milk in a device like this. See someone qualified and experienced in supporting mothers with breastfeeding issues - perhaps from the voluntary sector (ABM, BfN, LLL or NCT) or an IBCLC www.LCGB.org/Find-An-IBCLC has a list of local practitioners.
Nutritional content of milk collected
One final potential drawback of these devices which should be noted before going ahead and using or encouraging their use, is that used as described above, ie simply attached to the breast and left to gather milk which is spontaneously ejected from the 'other' breast while feeding or expressing on the first breast, they may basically collect 'drip milk' which is not suitable for use exclusively as a full feed for baby, as it's the watery carbohydrate-rich milk, not the fattier richer milk. Fat soluble nutrients will be contained in the fattier richer milk in greater quantities. Babies feeding directly at the breast of course access the full spectrum of milk which the breast is capable of making, via a combination of variations in pressure, suction and mum's letdown.

If milk collected by the Haakaa or any other collection device is used as an occasional drink to be left when mum isn't able to feed, then probably the only negative issue would be baby being slightly less satisfied or needing slightly more volume to become satisfied - not a big deal. However if you fed nothing but 'drip milk' to a baby it would not do so well. In milk banking 'drip milk' is not suitable for donation because it is not whole milk, essentially it's skimmed milk.

A very quick search for evidence to corroborate my assertion about 'drip milk' when chatting online about the potential drawbacks of this device, brought me this from 1978 http://www.ncbi.nlm.nih.gov/pubmed/571325 - the author of that piece Alan Lucas does take money from the infant formula industry (though this was long ago so not sure whether this pre-dates the industry money) and so some may pooh-pooh the impartiality of his work, but we cannot dismiss everything he does on that basis alone - he has come up with some interesting stuff! And industry-funded work is often extremely informative too - no sense throwing the baby out with the bath water so to speak!

I know too from my experience working withthe UK Association for Milk Banking UKAMB for these past many years, and as a member of the 2009/2010 Development Group for NICE Guidance on Milk Banking, that the donation or collection of 'drip milk' is not recommended within milk banking as it is not suitable for fully-feeding growing vulnerable babies in the NNU, because of the nutritional shortfalls it may have. However, as an antidote, of course one could hand express a little of the much fattier richer milk from the breast after a feed, to even up the nutritional composition, and make it more suitable for using as a full milk feed. The best 'how to' guide I have seen online for massage before pumping and for expressing by hand is to be found here.

Because of the vacuum, it's likely to be slightly less 'drip milk' than milk which is REALLY dripping out, but not much more than the milk elicited by the breast shells which apply pressure to the areola. In some of the photos posted online, the colour of the milk is suggestive of higher water / carbohydrate content and lower fat content - but of course composition of breast milk will be slightly different from mum to mum and from one session to another, and it's impossible to judge nutritional content from a photo posted online! Haakaa confirm that there are no studies to determine the nutritional quality of the milk elicited as yet, and as a non-clinical researcher I'm certainly not in a position to provide this evidence myself.

It's worth pointing out too, that though Haakaa's website says "simply suction to your breast and let the pump do the work for you as it draws your milk using suction", apparently the instructions inside the box that comes with the genuine Haakaa also state that milk can be elicited by 'pumping' the bulb of the device.
Other online blogs about this product
Most of the blogs I found - a quick google search brings up loads! - seem to be rave reviews about the product, or akin to an instruction manuals, rather than a look at how they work and why it's so important to get an authentic one and not a copycat: however in this FB post from May, Ellen from New Zealand, who is a midwife, compares the 'China Cheapie' to the authentic Haakaa pump, and shows that they cheaper one is less flexible and much heavier.

Taken from Breastfeeding Illawarra's post about the Haakaa and the 'China Cheapie'!

As reported above however, newer copycat pumps are now on the market which look much more like the authentic pump, and behave in a similar manner - the pattern on the pump is different on the one I have (authentic Haakaas have a bamboo pattern - this one is flowers!), but the shape, feel and function are almost identical. The main factors pointing to a copycat pump rather than an authentic Haakaa device are the packaging - this one arrived in the shrink-wrap shown earlier, and stuffed into a plastic mailing envelope, not the cardboard tube of the Haakaa pump - and the weight is just 5g less. So we have no idea what it is made from or where it was made.

As with everything, Buyer Beware - and in this case, you definitely get what you pay for - so if the Haakaa is the pump for you then be sure you order a genuine Haakaa!
One final note - I have, at time of writing, not seen a genuine Haakaa pump - and I have not trialed it as I am an IBCLC and researcher, not a lactating mother anymore, so this is all theoretical and historically based and gathered from currently available evidence. I would welcome new evidence or experience on anything related with which to update this piece.
Haakaa have updated me that the pump is now available direct in the UK, via Amazon at £16.10 including delivery via Amazon Prime - and since I have heard that people importing from overseas have been billed for import duty in some cases, this seems like the best way to buy now!

AUGUST 2016

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By Shel Banks, Chair of LIFIB, Infant Feeding Information Specialist and IBCLC An earlier version of this piece was first published on the blog for Growing Families ahead of their conference in Manchester in October 2016. This current piece has been amended and updated as new information has been made available, and to the best of our abilities we will ...

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Feeling awful each time you start breastfeeding?

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Feeling awful each time you start breastfeeding?

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Dysphoric Milk Ejection Reflex is a condition affecting lactating women that is characterized by an abrupt dysphoria, or negative emotions, that occur just before milk release and continuing not more than a few minutes.

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What is Dysphoric Milk Ejection Reflex?

Definition

Dysphoric Milk Ejection Reflex is a condition affecting lactating women that is characterized by an abrupt dysphoria, or negative emotions, that occur just before milk release and continuing not more than a few minutes.

D-MER is often found through Google searches such as "breastfeeding problems" or "sadness when breastfeeding". Information about D-MER is expanding through awareness and increased online content.

Preliminary anecdotal evidence shows that D-MER is treatable if severe and preliminary investigation shows that inappropriate dopamine activity at the time of the milk ejection reflex is the cause of D-MER.

Dysphoria is defined as an unpleasant or uncomfortable mood, such as sadness, depressed mood, anxiety, irritability, or restlessness. Etymologically, it is the opposite of euphoria.

D-MER is like a reflex. It is controlled by hormones and can not be controlled by the mother. She can not talk herself out of the dysphoria.

What D-MER is Not

D-MER is not a psychological response to breastfeeding. It is a physiological response to milk release.

D-MER is not nausea with letdown or any other isolated physical symptom or manifestation. D-MER has a negative emotional component above all else.

D-MER is not postpartum depression nor is it classified as a postpartum mood disorder.

D-MER is not a general dislike of breastfeeding. Impatience with baby at the breast, irritability from nipple pain, sadness during pumping because of separation from the baby; these things are not D-MER.

D-MER is not the "breastfeeding aversion" that can happen to some mothers when nursing while pregnant or when nursing older toddlers.

Characteristics of D-MER

The dysphoria a mother feels comes on suddenly before letdown and leaves within 30 seconds to 2 minutes.

She feels the dysphoria before she feels the letdown sensation in her breasts (though not all mothers feel a physical letdown sensation).

Often by the end of the first letdown she feels fine again, the dysphoria is gone.

It can happen for the first letdown of a feeding or for all letdowns in a feeding, depending on the intensity of her D-MER.

She may or may not have dysphoria with letdowns when pumping and before spontaneous letdowns, this also is dependent of the intensity of her D-MER.

D-MER has nothing to do with nipple contact or with irritation with the sensation of nipple tugging. The mother does not even have to be thinking about breastfeeding (for example with spontaneous letdowns) for the dysphoria to happen when a milk release is triggered.

Dopamine's Role in D-MER

D-MER has been linked to an inappropriate drop in dopamine that occurs whenever milk is released. In a mother with D-MER at the time of letdown dopamine falls inappropriately, causing negative feelings.

Milk release itself isn't caused by dopamine dropping; it's caused by oxytocin rising. In D-MER, the MER (milk ejection reflex) is a result of rising oxytocin (needed to move the milk out of the breast) but the D (dysphoria) is a result of inappropriately falling dopamine. Dopamine gets involved because it inhibits prolactin (which is what makes the milk) so dopamine levels need to drop for prolactin levels to rise in order to make more milk. Normally, dopamine drops properly and breastfeeding mothers never knew it even happened, in D-MER mothers however, it doesn't drop properly and causes an instant and brief wave of a negative emotional reaction that lasts until the dopamine levels restabilize after prolactin has begun it's rise.

D-MER follows the same pattern as any other reflex. You can tell yourself your knee isn't going to jerk when you hit it... but it does, just as much the hundredth time as it does the first, and it stops as soon as the stimulus stops. The D-MER reflex involves e-motion rather than motion because a hormone shift is triggered instead of having a muscle nerve triggered.

Spectrum and Intensity

The experience of D-MER is variable and a mother will have either despondency D-MER, anxiety D-MER or agitation D-MER. Her dysphoria will fall on it's own place on the emotional spectrum, ranging from homesickness (mild despondency D-MER) to anger (severe agitation D-MER.)

The D-MER experience is variable. Because of this D-MER is defined on a spectrum.

Think of a color spectrum; red is not the same as blue, even though they are both colors. Like this, D-MER can present with different "colors" of emotion for different mothers; despondency, anxiety or anger.

There are three intensities of D-MER that included mild, moderate and severe. These intensities are determined by the mother's interpretation of intensity, how long the D-MER takes to self correct, how many letdowns per feeding she feels the dysphoria and other criteria.

Mild often self correct in the first 3 month, moderate by month 9 and severe sometimes does not correct until after the first year or later.

Correction of D-MER

For mothers with mild D-MER, education goes a long way in treatment. Many find their symptoms more easily managed once they are aware it is a medical problem not an emotional problem.

Moderate D-MER can also be reduced using education as treatment. If this is not enough than these mothers should be encouraged to track their D-MER in a log to help them become aware of things that may aggravate their symptoms (stress, dehydration, caffeine) and things that may help relieve the symptoms (extra rest, better hydration, exercise.) They should look into lifestyle changes and natural remedies to help them further.

Mothers with more severe D-MER may need a prescription in order to manage her D-MER if she feels she may wean because of it. Thus far, treatments that increase dopamine levels in a mother treat D-MER effectively. If her D-MER is severe, and yet she is not at risk for weaning then using education as treatment, natural remedies and lifestyle changes is the more appropriate course of action.

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Definition Dysphoric Milk Ejection Reflex is a condition affecting lactating women that is characterized by an abrupt dysphoria, or negative emotions, that occur just before milk release and continuing not more than a few minutes. D-MER is often found through Google searches such as "breastfeeding problems" or "sadness when breastfeeding".

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If you are wondering about this, or are worrying about getting the hindmilk, please read this.

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Over the course of her breastfeeding journey, it is almost inevitable that a mother will encounter the terms "foremilk" and "hindmilk". There is certainly no shortage of confusing and conflicting advice on the concept, which has led to a lot of misunderstanding.

In The Breastfeeding Answer Book, "foremilk" and "hindmilk" were defined as follows:

"Foremilk" is the milk the baby receives when he begins breastfeeding, which is high in volume but low in fat (1).

"Hindmilk" is the milk near the end of the feeding, which is low in volume but high in fat (1).

Actually, the terms "foremilk" and "hindmilk" only really refer to samples of breastmilk taken right at the beginning of a feed ("foremilk") and samples of breastmilk taken right at the end of a feed ("hindmilk"). Even then, the advantage of using these terms is debatable. A photo on

Why?

Wikipedia "helpfully" shows two 25ml samples of human breastmilk: "foremilk" on the left and "hindmilk" on the right:

The problem with showing a sample of breastmilk from the start of a feed together with a sample of breastmilk from the end of a feed is that it tells us nothing about what happens to the breastmilk in between the two samples. Mothers end up mistakenly believing that their breasts make two different types of milk, and wonder how long they must feed for before the "foremilk" magically switches over into "hindmilk" (2).

So if the terms "foremilk" and "hindmilk" are misleading and there's no "magic switch" from one to the other, what really happens?

Since The Breastfeeding Answer Book was published in 2003, research in human lactation has advanced (2), so we now understand more about how breastmilk is produced:

Your breasts make just ONE type of milk

There is no magic switch between two different types of milk over the course of a feed. In fact, The answer lies in what happens to the
there is no sharp distinction between breastmilk at the start of a feed and breastmilk at the end of a feed (3). "Milk does indeed change consistency during a feed - but this happens gradually rather than suddenly" (4).

Why does the consistency of breastmilk change over the course of a feed?

fat in breastmilk when breastmilk is

Your breasts are continuously making just one type of milk, containing 'sticky' fat globules that tend to stick to each other and to the milk ducts in the breast as breastmilk is produced (2,3,5).

Breastmilk produced between feeds moves down towards the nipple and collects in the breast, leaving increasing amounts of fat globules 'stuck' together further up the milk ducts (3).

When let-down occurs, the milk ducts dilate (5) and the milk is ejected from the breast. The milk removed at the beginning of a feed may be lower in fat because the fat globules are still 'stuck' further up in the milk ducts (6). As the feed progresses, multiple milk ejections occur (5) and the breast is emptied, more and more fat globules become dislodged and the breastmilk increases in fat (3,6). This has the overall effect of a gradual increase in fat content of breastmilk in each breast independently as milk is removed.

How do we know that the increase in fat is gradual?

Studies involving several mothers have been conducted in which samples of breastmilk were taken at intervals over the course of a feed. The evidence from these studies suggests that the fat content of breastmilk increases gradually as the breast becomes progressively emptier over the course of a feed (7,8).

It's much easier to explain this gradual increase in fat content using pictures...

...so, revealing the crazy lengths I'm prepared to go to so I can prove a point, I visited The Countess of Chester Hospital, where several wonderful people enabled me to take consecutive small samples of breastmilk from one breast only over the course of one pumping session, and professionally photograph the results. The samples were then taken to the Cheshire and North Wales Human Milk Bank, where the fat content of each sample was analysed.

This is the snapshot we got of the gradual increase in fat content of my milk over the course of one pumping session:

Note the gradual colour change of each breastmilk sample. This is the gradual increase in fat content from the beginning of a feed (test tube 1) to the end of a feed (test tube 12).

Remove test tubes 2-11, and the result is a picture similar to the one on Wikipedia:

This shows a sharp contrast between the breastmilk at the When breastmilk is left to stand for a while, it separates into two layers. This very beginning and the breastmilk at the very end of a feed only - it tells us nothing about what happens to the breastmilk in between the two samples. Only the photo containing all 12 test tubes shows the complete picture: a gradual increase in fat content.

isn't the separation of "foremilk" from "hindmilk"; it is simply the fat in the milk rising to the top, not the separation of two different kinds of milk (4).
So what's that stuff that rises to the top of expressed breastmilk?

The reason this separation doesn't occur in a bottle of cow's or goat's milk you buy in a shop is that this milk has been homogenised. "

Whole homogenised milk is identical in fat and nutrient content to whole standardised milk however it has undergone a process known as "homogenisation" which breaks up the fat globules in the milk. This spreads the fat evenly throughout the milk and prevents a creamy layer forming at the top." (9)

After a while, the breastmilk in our test tubes separated into two layers (click on the image to open a larger version in a new window):

Again, removing test tubes 2-11 shows
Note that the breastmilk in test tube 1 does, in fact, contain a layer of fat.

Note also the increasing thickness of the fatty layer that collects at the top of the breastmilk from test tubes 1-12. This further demonstrates a gradual increase in fat content from the beginning of a feed (test tube 1) to the end of a feed (test tube 12).

only a sharp contrast between the thin fatty layer that rises to the top of the breastmilk at the very beginning, and the much thicker fatty layer that rises to the top of the breastmilk at the very end of a feed.

This photo tells us Before I continue, I must stress that this is just a snapshot of
nothing about what happens to the breastmilk in between the two samples. Remember: only the photo containing all 12 test tubes shows the complete picture: a gradual increase in fat content.

Showing us pretty pictures is nice, but how much fat did the breastmilk samples actually contain?

my breastmilk. It is unlikely that the results shown here will be an exact reflection of what happens to every mother's breastmilk. However, it does provide a rough idea of what happens, so here are the results of the analysis of each sample of my breastmilk:

If looking at raw data isn't your thing, here's a line
TS = Total Solids, ie. the bulk of the rest of the milk
Protein, carbohydrate, fat and TS values are in grammes per 100ml

graph showing the amount of protein, fat, carbohydrates and total solids present in each of my 12 breastmilk samples (fat content is shown in red).

The graph clearly shows there was a gradual (if slightly wobbly) increase in fat content as the breast is emptied. Quite plainly, there is no arbitrary "magic switch" between two different types of breastmilk during a feed.

Remember, though, that all of this is just a tiny piece in a vast breastfeeding jigsaw...

Although it is true that the fat content does gradually increase as the breast is emptied, it is important to understand that the difference in fat content between milk at the beginning of a feed and milk at the end of a feed can vary greatly from mother to mother. Not only this, but it can vary greatly over a 24 hour period, even among individual mothers (2). The difference in fat content can also depend to some degree on the amount of time elapsed between each feed (this is truer the younger the baby is) - another reason why it might not be a good idea to wait for your breasts to "fill up" before a feed.

the higher the fat content of the milk

the lower the difference in fat content between the breastmilk at the beginning and end of a feed (2,3)

This is not simply a case of the longer the feed, the higher the fat content: if there is a shorter gap between feeds (such as during periods of cluster feeding), the milk at the beginning of a feed may not necessarily be low in fat (2,10).

"Babies can show a wide variety of feeding patterns, suckling for varying lengths of time and at varying intervals over the course of a day, and maintain a healthy weight" (4,10)

Whilst fat is important, we can and do get far to preoccupied with the issue of fat content - take another look at the graph showing the amount of protein, fat, carbohydrates and total solids present in each of my 12 breastmilk samples:
The most important thing to remember is this:
In the vast majority of cases, as long as you are:

breastfeeding on cue

and allowing your baby to come away from the breast spontaneously at the end of a feed,

there is no need to worry about what's in the breastmilk your baby is getting. ALL of the components of breastmilk are essential for the growth and the physical and mental development of your baby, not just its fat content.

_________________________________________________________

If you liked this article, please consider making a small donation to Cheshire and North Wales Human Milk Bank (a charity which does a fantastic job of getting breastmilk to our most vulnerable babies), without whom this article could not have existed.

Lynda Coulter (Cheshire and North Wales Human Milk Bank) for very kindly agreeing to analyse the samples of my breastmilk.

Janet Beech and Linda Gendler (Cestrian Ward, The Countess of Chester Hospital) for entertaining my mad idea and helping to co-ordinate the experiment.
Becca Williamson (Bosom Buddy breastfeeding peer supporter) for being my extra pair of hands.

Jenni Ross (Medical Photography, The Countess of Chester Hospital) for taking such excellent photos of my breastmilk samples. This article has been republished as a guest blog on
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Acorn Pack
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Foremilk and Hindmilk: In Quest of an Elusive Arbitrary Switch.

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Over the course of her breastfeeding journey, it is almost inevitable that a mother will encounter the terms "foremilk" and "hindmilk". There is certainly no shortage of confusing and conflicting advice on the concept, which has led to a lot of misunderstanding.

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If you are worried you may not have enough milk, please read this. It will help you work out if you do have a problem and also has tips to help.

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Forgive me for asking but...Do you REALLY have low milk supply?
This is a very important place to start. Please bear with me. I don't mean to doubt your situation but it's crucial to note that the MAJORITY of new mothers who fear they have low milk supply DO NOT.

The majority of women who start to use formula because they worry they aren't making enough or baby isn't getting enough DO NOT HAVE A PROBLEM.

I cannot emphasise this enough. Apologies for the capital letters.

Every day mothers panic and end breastfeeding or start using formula and there is not an underlying problem with their milk supply. But of course - once they start using formula without correct support, they often will start to send signals to their breasts to really reduce supply.

You do not have low milk supply just because your baby won't go the X number of hours between feeds that the book on your coffee table tells you they should. Or your mother-in-law. Or the X number of hours your friend's baby is going between feeds.A normal happy healthy baby who has a gorgeous mummy with a normal healthy milk supply might get hungry an hour after the last feed, or 90 minutes, or 45 minutes or two hours. They might be cluster feeding and hardly want to come off the breast at all. They might be having a growth spurt and feed every hour for a day.

You do not have low milk supply because your breasts have stopped leaking. Some mothers leak less than others. MOST mothers notice that leaking reduces at the weeks go by and the teeny tiny sphincter muscles responsible tighten.

You do not have low milk supply because your breasts feel softer than they used to. The excessive fullness we experience in the early days of breastfeeding is about vascular engorgement (blood and lymph) and it's about the body inefficiently storing unnecessary amounts of milk between feeds. As time goes by, the breasts get cleverer at storage (don't forget milk is also made while a baby is actually feeding). There is also less blood and lymph needed in the breasts as breast tissue growth slows down. At the beginning, it's often very obvious which breast is going to be fed from next. That feeling goes. And many mothers mistakenly connect it with a reduction in milk supply. We are not all supposed to continue feeling heavy and full throughout our breastfeeding experience. Don't ever think 'I'll wait to let my breasts fill up!' Noooooo. This shows a misunderstanding of how lactation works to a spectacular degree. When breasts are fuller, milk production slows down. When breasts are emptier, milk production increases. Emptier softer breasts may well be making a heap more milk in a 24 hour period than the engorged full versions.

You do not have low milk supply because your baby feeds for a short time. Plenty of babies get everything they need in under ten minutes. Probably not five - but sometimes a feed might even be five minutes long. Lots of babies use their tongue and jaw muscles super efficiently and gulp and glug and slow down as the milk gets fattier and thicker and then come off happy. It might take them nine minutes or nineteen. A baby might start off life needing 30 minutes to drain a breast (when we say 'drain', breasts are never completely empty, it just means the baby has taken out all the milk they usefully want to). As a baby gets older, this can dramatically reduce. It doesn't mean less milk is going in. If a small sleepy jaundiced baby falls asleep very quickly at the breast without some solid minutes of good swallowing, that's a different story. Overall however, a longer feed does not always mean a better one.

You do not have low milk supply because you have small breasts. Large breasts are a combination of fatty tissue and glandular tissue. You cannot tell much about someone's milk production by the size of the breasts. If you are really worried your breasts don't 'look right', we'll come back to this later.

You do not have low milk supply just because your baby wakes up a lot. Plenty of young babies feed with similar intervals day and night. Plenty continue waking every 2-3 hours for a while.

You do not have low milk supply because your baby won't 'go down' after a feed. So you feed your baby and they drop off to sleep on the breast. You move them to the Moses basket and they wake up as if you just placed them on a sheet of molten lead. And they seem to be rooting again. This happens because being next to you skin-to-skin was nice and cosy and relaxing and warm and it smelt good. The Moses basket is cold and NOT YOU. You probably triggered the Moro startle reflex when you moved them. You probably moved them about 15-30 minutes after a feed when the hormone cholecystokinin had dropped in their blood stream causing them to be more wakeful. Your teeny primate mammal baby finds the breast a lovely place to be. They like to suck to relax themselves. Babies like second helpings. This does not mean you are not making enough milk.

You do not have low milk supply because your baby will take milk out of a bottle after a feed. Put a teat against a young baby's palate and you trigger that baby's sucking reflex. Babies will usually continue to take milk beyond the point that they need it. This is one of the reasons we see links between bottlefeeding and obesity.

You do not have low milk supply because you don't pump very much milk. Pumping and breastfeeding are surprisingly unrelated. Your baby removes milk in a completely different way. Plenty of women with healthy milk supplies fail to pump much at all. Their bodies can't be tricked into eliciting the milk ejection reflex (or 'letdown'). Plus pumps don't always work. Suction goes as valves get old.

These are the things that REALLY tell you a mother might have low milk supply:

Weight gain problems. A newborn is born and then loses weight. They regain birth weight at around two weeks. They then put on about 150-200g a week after that. That slows down after around four months. If your newborn loses more than 10% of their body weight, we might pay attention but we'll also want to look at things like your birth. Did you have a drip in labour that filled you and your baby with fluid? Did your gorgeous newborn look a wee bit like the Stay Puft marshmallow man in their first photos? That fluid elevated the birth weight and as it comes out again in the first few days, we might see more of a weight drop. That doesn't necessarily mean feeding or supply is a problem. However wouldn't want your baby to lose weight after about day five or lose weight a second time. It might take some babies three weeks to get back up to birth weight.Have a look at the chart in your red book. Notice how we have birth weight line and then a space where the curvy lines don't go and they start again at week two. Just because your baby was born on the 75th percentile, that doesn't mean we would expect them to definitely re-start on the 75th after that two week gap. That's why the lines don't continue. That's why we have that space. We start again at two weeks. Your baby might be on the 50th then. They then ideally will roughly stick in the same vicinity. But babies wobble around a bit. They might dip below. They might get close to the 25th. And then they might bob back up again. We don't expect all babies to hug a line exactly. This chart is a guide. It's about averages. It's not about mathematical certainties.

Nappies. In the early days (first four weeks), we look at poo and pee. After your milk has come in (around day two to five), we'd expect to see six wet nappies in 24 hours and three poos the size of a £2 coin or bigger. After week four, some babies poo rate can slow right down. This doesn't mean anything is wrong. Some babies can skip several days between poos and this isn't anything to do with milk transfer or supply. However if someone tells you it's OK for a ten day old baby not to poo for a few days, don't believe them. We'd need to investigate that situation. Only later on do we relax.

Weight gain and nappies. That's it. Those are the only things that tell us about milk supply. You may hear people say that 'babies should be settled after a feed' but some babies get wind or need to poo or have reflux or wake up and want second helpings. Let's be careful about even saying that. Let's look at weight gain and nappies.

So let's now assume you do have low milk supply. How many of you are still with me? I'm sorry if you are. I'm sorry if your baby only put on 60g last week and 90g or less or nothing the week before that and they are slipping down the percentiles. I'm sorry because I know how scary that can feel. Nothing feels like it matters more. There are things we can do.
Find people.
Find people who know about breastfeeding. Someone who tells you just to use formula in this situation is not who you need. If that's all they can offer you, they don't know about breastfeeding and you need someone else. You need someone who understands how lactation works. These people may actually still tell you to use some formula in some situations (or donor breastmilk) but they will do so alongside telling you how to protect and develop your milk supply. You also need people close to you to look after you. If you are going to do all the other stuff on this list, you need to have people who love you who will cook your dinner and run you a bath sometimes. And text you just before the weigh-in clinic next week to say they are thinking of you.
Breastfeeding M.O.T.
Someone like a breastfeeding counsellor or IBCLC (lactation consultant) should check your latch. You might not be sore and your nipples might not be misshapen after a feed but something still might be going wrong. Your latch needs checking. Is baby's chin deep into the breast? Is baby's body close to yours? Is baby's ear/ shoulder/ hip in a line?

They shouldn't just check your latch but look at your breastfeeding management. Are you feeding enough? Maybe your baby doesn't show cues very strongly and someone told you to wait for them and you're sometimes going four hours between feeds? Maybe you need to feed more frequently?

When are you changing sides? Too quickly? (and baby is missing the fatty milk). OR did someone tell you to stick on one side forever to get that 'hind milk' and the baby is on 45 minutes without doing a heck of a lot? Maybe you need to change sides at 20-30 minutes instead and get baby a greater volume of milk overall and fatty milk overall. Both of these habits can cause weight gain problems. Get someone to help you recognise what swallowing looks like so you'll know when to change sides and when good feeding has finished.

Google 'breast compressions'

You'll get to a video and handout from Dr Jack Newman. You can finish a feed with breast compressions and get an extra dose of fatty milk into baby.

You have 3 sides and 4 sides. This is 'switch nursing'.

Try and go back to the first side. There will be milk there. The more breastfeeding you do, the more milk you will make. The second time you return to that breast, the milk will be fattier and richer and you'll send great signals to your body to make more.
Find time.
If you are going to build up your supply, get help. You can't devote time to switch nursing and skin-to-skin when you have to go to Tesco to buy milk and pick up another child from school. If this is 'Operation Milk supply', who can help you? You'll read people talking about a 'babymoon'. Go to bed, they say. Just you and the baby. Feed lots. If that sounds appealing, go for it. Personally my babymoon would involve the sofa and box sets and crisps. However there's no point in babymoooning until next Christmas if your latch and breastfeeding management are the issues. Get that checked first.

Using a pump.

Baby feeding effectively is first choice but pumps can be useful. You can pump on an emptier breast to send even more signals to your milk supply. But we're not going to take a baby off the breast do be able to pump.

You don't need to wash and sterilize a pump every time you use it. Pop it in a plastic bag and put it back into the fridge between pumping sessions. 10 minutes is ample. If you are pumping for 30 minutes and 'nothing is coming' out, you are not getting a letdown and you are not doing yourself any favours. Use hand expression before and after (google 'Marmet hand expression') and prepare the breasts with warm compresses and massage if you can. You can take an hour and do some 'cluster pumping' or 'power pumping'. Pretend to be a baby having a cluster feed. Pump for ten minutes. Break for five. Pump again and repeat.

Just check your pump is the best one available. If it's second hand or you have had it a while, it might need servicing or replacement parts. You also might want to consider hiring a hospital grade double electric pump from someone like www.ardobreastpumps.co.uk to give yourself the opportunity to pump both sides together as effectively as possible.

Pumping shouldn't hurt. Make sure your flanges are the right size - that means they are the right diameter for the size of your nipple. Don't think that cranking up the suction will automatically do better things. And don't think, "I don't want to pump because I will empty my breasts and baby will have less milk." Certainly they might be less appreciative if you pump just before a feed is due and you leave them with an emptier breast full of thicker fattier milk but pumping overall will increase milk supply and stimulate milk production. You are not 'taking their milk away'.

You might also be someone who always gets better results with just using hand expression so stick with that.

Of course, you might not want to pump at all and just focus on feeding baby more effectively and frequently.
Galactagogues.
Taking herbs and medication that increase milk supply. Not right for everyone but some women really feel they helped. You need to read about side effects and dosage on sites like kellymom.com. Fenugreek, blessed thistle and goat's rue are popular. Some doctors prescribe domperidone in certain situations. These are never a substitute for good breast emptying and a breastfeeding MOT.
The science part.
In a book, this bit would be under a little flap as we're only talking to a small group of people.

Did you have breast surgery?

Are your breasts very widely-spaced or asymmetrical, or very tubular with a bulging areola? Did they not really change much in pregnancy (or puberty)?

Do you have PCOS? Some women with PCOS (not all) have a reduced milk supply.

These are times when it's worth finding an IBCLC and getting technical.

Some doctors will do hormonal testing for you. There are medications that can help develop breast tissue especially in pregnancy.

What about your thyroid levels? This is something relevant for more people than you might realise. If you are trying everything and low milk supply continues to be a problem, ask your doctor to check your thyroid levels. There are sometimes medical reasons mothers have a low milk supply and doctors and lactation consultants may be able to help you. These are not the most common reasons why people have low milk supply by a long shot. Hence the need for the flap.

Most people who genuinely have low milk supply got themselves into a pickle with using artificial nipples or not breastfeeding enough or breastfeeding ineffectively. And it can almost always be reversed.
Also remember that just because you had low milk supply in your first breastfeeding experience, it doesn't mean a subsequent lactation will also be a struggle. The development of all that breast tissue first time round often helps.

Hold in your mind the fact that women can relactate after not breastfeeding at all for several weeks. We CAN send signals to increase supply again in the vast majority of cases. There are tons of us in real life and online who want to support you.

After a career as a primary school teacher and Deputy Head in London, Emma had her own children and soon realised how much need there was for breastfeeding support among new parents. She initially trained as a Mother Supporter and Breastfeeding Counsellor with the Association of Breastfeeding Mothers ( www.abm.me.uk) before going on to qualify as an International Board Certified Lactation Consultant in 2011. She volunteers in Haringey, North London at three drop-ins as well as answering calls on the National Breastfeeding Helpline and the ABM helpline. She is currently chair of the Association of Breastfeeding Mothers. Her eBook, "You've Got It In You: a positive guide to breastfeeding" will be published later this year.

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Low Milk Supply - Attachment Parenting UK

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Low Milk Supply by Emma Pickett Forgive me for asking but...Do you REALLY have low milk supply? This is a very important place to start. Please bear with me. I don't mean to doubt your situation but it's crucial to note that the MAJORITY of new mothers who fear they have low milk supply DO ...

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Video - how to see if your baby is getting enough milk

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Video - how to see if your baby is getting enough milk

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'Is Your Baby Getting Enough Milk - Breastfeeding Series' on ViewPure

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By Global Health Media Project. Download link: http://globalhealthmedia.org/videos/\n\nA common concern of a new mother is whether her baby is getting enough milk.

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Simple steps you can take to increase your milk supply. It is important to check that low milk is a problem first. Do please always get support from a skilled person if you are worried about milk supply or your baby's growth.

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Most mothers are able to provide their babies with all the milk they need. However, if a baby is not thriving as she should, this video shows a mother steps to improve her milk supply and the baby's feeding. About the Breastfeeding Series " DOWNLOAD

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A detailed article by that grandmother of breastfeeding, 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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