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4.4 Increasing milk supply

Key Points - Case Study D

Sally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?

Topic 4.1: Initial assessment
To assess the adequacy of breast milk intake ask about: number and length of feeds; elimination patterns; general infant behaviour; breast and nipple concerns; and maternal confidence. Also check: infant weight gain; jaundice and general infant wellbeing.

Sally is confident with her breastfeeding and her breasts and nipples are fine. Her breasts feel a little fuller early in the morning, but she has not had problems with engorgement like some of her friends. Emily is feeding approximately six times a day and feeds for 15-20 minutes before falling asleep. She is having four wet nappies a day – two of which are damp. She is having a bowel motion every three days or so. Emily weighs 3800 grams. On examination, she is not dehydrated. You are concerned that Emily is not getting enough breast milk.

Topic 4.2: Milk production
Oxytocin and prolactin are the main hormones necessary for the initiation of lactation. Factors such as diabetes, primiparity, caesarean section, stress and pain in labour, obesity and preterm delivery can interfere with the onset of lactation. Once lactation is established, milk removal is the main determinant of milk production.

What may cause inadequate growth in breastfed infants such as Emily?

Topic 4.3: Causes of inadequate infant growth
The main reasons for inadequate growth in a breastfed infant are: reduced milk intake due to suboptimal feeding patterns or routines; low milk supply; difficulty transferring milk; and increased energy expenditure in the infant.

How could Sally increase her milk supply?

Topic 4.4: Increasing milk supply
To increase a mother's milk supply correct any underlying problems, if possible, and increase breast drainage. Encourage adequate rest and a balanced diet. Some women require galactagogues. Some infants who are malnourished at presentation, or do not respond to effective, frequent feeding, may need supplementation with donor breast milk or infant formula.

How could Sally increase her milk supply?

First, ensure there are no medical problems or other underlying factors that could be affecting Sally's milk supply or Emily's growth. Appropriate management of these factors is necessary in addition to the following suggestions to increase milk production.

Increase breast drainage

Click on the bullet points below for more detail:

Food and rest

While poor maternal diet and fatigue do not necessarily result in low milk supply, some women find improving their diet and resting when possible increases their milk production2. There is no evidence that increasing a mother's fluid intake will increase her milk supply, especially in women who are adequately hydrated (3,4).

Galactagogues

Herbal remedies such as fenugreek, goat's rue, blessed thistle and marshmallow have been used as galactagogues, although there is little evidence-based research to suggest that they have a significant effect on milk supply5. The two most commonly prescribed galactagogues are metoclopramide and domperidone, which increase prolactin levels by their antidopaminergic action. Both have been shown to increase prolactin levels and increase milk production in lactating women when prolactin levels are low, at doses of 10 mg three times a day (metoclopramide) and 10–20 mg three to four times a day (domperidone). Women appear to suffer few side-effects at these doses, although domperidone appears to cause fewer side-effects than metoclopramide. Milk transfer of the drugs to the infant is minimal. Tapering of the dose once the desired effect on milk supply has been achieved is recommended to minimise any reduction in supply (6,7).

Supplementation

Most infants will stabilise any weight loss and begin to gain weight using these suggestions without the need for additional supplementation. However, supplements of donor milk or infant formula may be required if the infant appears malnourished at presentation or does not respond to effective, frequent breastfeeding. A suggested minimum amount of supplement is 50ml/kg/day given in divided volumes after breastfeeds when the infant appears hungry1. As the mother's milk supply increases, the amount of supplement can be decreased. A supplemental nursing system can provide the supplement to the infant while he or she is feeding at the breast. This form of supplementation encourages further breast stimulation, and is often time efficient for the mother.


© B.Ingle IBCLC


Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # Powers NG (2001) How to assess slow growth in the breastfed infant. Birth to 3 months.
  2. # Lawrence RA et al. (2005) Breastfeeding: a guide for the medical profession
  3. # Dusdieker LB et al. (1990) Prolonged maternal fluid supplementation in breast-feeding.
  4. # Morse JM et al. (1992) The effect of maternal fluid intake on breast milk supply: a pilot study
  5. # Humphrey S (2007) Herbal therapeutics during lactation
  6. # Hale TW (2007) Medications that alter milk production
  7. # Montgomery A et al. (2004) Clinical Protocol #9: Use of galactogogues in initiating or augmenting maternal milk supply