LOW MILK SUPPLY

One of the most common concerns of new breastfeeding parents is whether they have enough milk. One of the most asked questions is “Is my baby getting enough milk?” Luckily, even though there aren’t full/empty gauges on your breasts, there are many ways to tell if your baby is getting enough milk. Review the page above for more information.

But sometimes the answer to that question is “no,” and the next question is “Why is my baby not getting enough milk?” Here are some things to consider.*

• You don’t necessarily have a low milk supply if baby won’t go the X number of hours between feedings that your baby book, mother, friend, or health care professional says they should. Normal babies sometimes feed every 2 hours but they can also want to feed again after 20 minutes or 45 minutes or… If they are having a growth spurt they may want to feed every hour for a few days. They may cluster feed and then sleep for a longer stretch (this often happens in the evening). All of these feeding spacings are normal and a baby might do all of them in one day or over the course of a week.
• You don’t necessarily have a low milk supply if your baby is nursing more often or fussy during part of the day. Often, this could be an indication of a growth spurt. It could also be the typical “witching hour” behavior, especially in the evening when your milk supply is naturally at a lower level and baby is more likely to be overstimulated.
• You don’t necessarily have a low milk supply if your breasts aren’t leaking anymore or if they feel softer than they used to. Around six to eight weeks after giving birth your breasts will no longer have the excess of lymph and blood flow that they had in the early days and they will feel softer. Some mothers never experience leaking and for those who did have leaking most find the leaking episodes decrease as their bodies get used to breastfeeding.
• You don’t necessarily have low milk supply because you only pump X amount of ounces. It can be tempting to pump or express milk in an attempt to tell how much you are producing. A pump is generally less efficient at removing milk than your baby meaning that it gives you a false sense of how much you are producing.
• You don’t necessarily have low milk supply because you have small breasts. The size of your breasts has very little to do with the amount of milk making glandular tissue. If your breasts grew during your teen years and grew again during pregnancy then it is very unlikely that you don’t have sufficient glandular tissue to support breastfeeding.
• You don’t necessarily have low milk supply because your baby won’t stay asleep if you put them down after a feeding. Babies often drift off to sleep at the breast and then wake up the minute you put them down. This happens because babies are happiest in their favourite environment (your chest). Many babies also like to take a short break, have a little nap, and then come back for the second breast. This is normal.
• You don’t necessarily have low milk supply just because your baby will take milk out of a bottle right after you have breastfed. The sucking reflex is so strong that babies will take milk if a bottle nipple is put in their mouth even if their tummies are full.
  

*Adapted with permission from LLL Canada Blog, “Breastfeeding and Low Milk Supply”

There are two things that may indicate that you that you have a problem with low milk supply:

• Weight gain problems: Babies almost always go down from their birth weight. Most babies have regained birth weight by two weeks and then continue to put on 5-7 oz per week. Be sure that your care provider has a good understanding of breastfeeding growth rates when looking at the weight gain of your baby.
• Diaper Output: After the first week we expect to see 6-8 wet diapers per 24 hours and several poops that are at least big enough to cover a quarter. If this is not what you are seeing when you change baby’s diapers, then it is time to follow up with your healthcare provider or local LLL Leader. Check out more about baby poop here. 

POSSIBLE CAUSES OF LOW SUPPLY

The following can cause or contribute to low milk supply:

• Supplementing– Many parents begin to supplement because they are worried that they are not producing enough to breastfeed exclusively. If you wish to continue nursing, it is important to be aware of and avoid the supplementing cycle. If you are looking to exclusively nurse, be sure to pump or hand express to replace the missed nursing session.
• Strict schedules– Schedules may seem helpful to parents and are often encouraged by parenting or baby experts, but they don’t always meet the needs of nursing parents and babies. We often say in LLL, “Watch the baby, not the clock.” This means following your baby’s hunger cues rather than a schedule that predetermines when feedings occur. Parents with plenty of milk supply may do fine with schedules, but parents who struggle with milk supply or have babies with feeding difficulties often see a drop in supply when following strict schedules. Even if all looks well in the beginning, a sudden drop-off in production can happen later if an insufficient number of hormone receptors were established in the early weeks. Letting baby nurse on cue allows breastfeeding to get established from the beginning. Having loose routines rather than strict schedules can be helpful for parents looking to add more structure to their days.
• A “Good ” Baby or Sleepy Baby– Some babies are more go-with-the-flow than others. Sometimes, sleepy or more relaxed babies are less likely to signal when they are hungry and are more likely to sleep through feeds. Going extended periods without nursing, especially in the beginning, can lead to milk sitting in the breasts for a long period and thus your body scaling down milk production. This can be especially true for babies who sleep long periods from birth or the early weeks. Often, they are skipping much-needed feeds. Until baby regains birth weight, it is important to wake them up to nurse.
• Block Feeding– Offering only one breast per feeding, also called block feeding, may be fine if your milk supply is well-established and your baby is gaining weight. If you are trying to increase your supply or if you are worried about baby not gaining weight, it is important to offer both breasts at each feeding.
• Nipple confusion from bottles or pacifiers– Bottles and pacifiers are different in shape and texture than a breast and nipple. A baby may develop a preference for artificial nipples and attempt to suck on the breast in the same way, leading to a less efficient suck.
• Nipple shields– Some parents notice that a long-term reduction in supply when using a nipple shield. Nipple shields can reduces the stimulation of breast tissue, leading to less milk production and possibly a worse milk transfer.
• Health or anatomical problems with baby
  • • Tongue or lip ties (read more below)
    • Low muscle tone
    • Uncoordinated suck
• Health or anatomical complications with the nursing parent
  • • Retained placenta
    • Postpartum hemorrhage
    • Anemia
    • Hypothyroidism (read more below)
    • Breast reduction or augmentation surgery (links in Resources)
    • Breast injury
    • Hormonal conditions including PCOS
    • Medications including hormonal birth control 
    • Hypoplasia and Insufficient Glandular Tissue (IGT)

TONGUE AND LIP TIES

Are you experiencing pain while breastfeeding, possibly combined with slow weight gain for your baby? While the vast majority of such breastfeeding problems can be resolved by adjusting positioning and attachment, and with good breastfeeding management, occasionally tongue tie might be the cause of the problem.

Tongue tie (ankyloglossia) is caused by a tight or short lingual frenulum (the membrane that anchors the tongue to the floor of the mouth). The frenulum normally thins and recedes before birth. Where this doesn’t happen, the frenulum may restrict tongue mobility. Tongue tie often runs in families and is thought to be more common in boys than girls. There is an association between high or unusual palates and tongue tie, because restricted tongue movement can affect the shape of the palate.

Tongue tie affects tongue movement to varying degrees. The shorter and tighter it is, the more likely it is to affect breastfeeding. Some babies with a tongue tie breastfeed well from the start, others do so when positioning and attachment are improved. But any tongue tie that restricts normal tongue movement can lead to breastfeeding difficulties. A baby needs to be able to move his tongue freely and extend it over the lower gum with his mouth open wide to be able to breastfeed well.

Tongue and lip ties can restrict mouth movement so that a baby does not receive adequate milk from the breast. This can also lead to milk production dropping over time since milk is not being removed efficiently from the breast.

Read more about Tongue and Lip Ties.

HYPOTHYROIDISM (UNDERACTIVE THYROID)

Thyroid issues often cause difficulty with milk supply and with milk removal. You may find your thyroid levels change with pregnancy and childbirth, which is why frequent testing is recommended. Depending on the medication, your baby’s levels may also need to be checked regularly postpartum.

• Indicated when the TSH level is high and T3/T4 levels are low.
• Symptoms – dry skin, sensitivity to cold, depressed, hair loss, constipation, increased menstrual frequency and flow, mild enlargement of the thyroid.
• Most common form is Hashimoto’s disease.
• Thyroid hormone replacement is the first form of treatment.
• In pregnancy, this can result in pregnancy-induced hypertension and low birth weight.
• Those with hypothyroidism are at risk for delayed or insufficient milk production as well as postpartum depression.
• Studies also indicate there may be a negative effect on oxytocin.

HYPOPLASIA/INSUFFICIENT GLANDULAR TISSUE (IGT)

“Maybe you just need to try a little harder.” “Have you tried fenugreek?” “You’re probably not drinking enough water.”

Those who struggle with milk production and low milk supply hear advice like this from well-meaning friends and family members (and sometimes, from breastfeeding supporters who should know better). While the vast majority of milk production problems can be remedied by addressing issues of breastfeeding management, there are some for whom making enough milk to sustain their babies is difficult or impossible. Called “primary lactation failure”, this condition occurs when a mother’s body does not make an adequate amount of milk for her baby, even when everything else is in order (including but not limited to: latching and positioning, breastfeeding frequency and exclusivity, mother and baby being kept together, baby’s oral anatomy is fine with no tongue-tie or cleft palate).

Primary lactation failure can be due to a variety of factors, including previous thoracic or breast surgery that severs critical nerves or ductwork; hormonal complications, such as those that accompany polycystic ovarian syndrome or thyroid abnormalities; and a condition in which mammary tissue simply did not develop during adolescence. Called tubular (or tuberous) breast deformity in the plastic surgery literature, hypoplasia of the mammary gland (also called insufficient glandular tissue or IGT) was previously thought to be a simple issue of cosmetics. Corrections addressed the appearance of a woman’s breasts, with little regard for their function. However, as breastfeeding gains significance as an issue of public health, more mothers seek to nourish their babies in this manner, but little is known about what to do when breastfeeding doesn’t work.

Read more about Hypoplasia and Insufficient Glandular Tissue (IGT).

RESOURCES

Breastfeeding: More than Milk, LLL USA

Is My Baby Getting Enough Milk?, LLL USA

Helping to Get Breastfeeding Off to a Good Start: Milk Supply, LLL USA blog

Perceived Insufficient Milk, KellyMom

Increasing Low Milk Supply, KellyMom

Breastfeeding after Breast Augmentation and Reduction Surgeries (PDF), LLL USA’s New Beginnings

Breastfeeding after Breast or Nipple Surgery, Cleveland Clinic

Breastfeeding After Reduction Information and Support, BFAR.com

Breastfeeding After Reduction (BFAR), Facebook Group (not affiliated with LLL USA)

Feed The Baby: Building A Milk Supply, LLLI

At-Breast Supplementer Nursing, LLLI

PERSONAL STORIES

What Breastfeeding Taught Me about being a Mother (Low Milk Supply), LLL USA blog

Evolution of a Breastfeeding Mother, LLLI

Breastfeeding With A Lactation Aid, LLL USA blog

IS YOUR CONCERN OR QUESTION NOT COVERED HERE?

Please contact a local LLL Leader with your specific questions.

Medical questions and legal questions should be directed to appropriate health care and legal professionals.

Page updated March 2022

Portions partially adapted from LLLI materials.