Common lactation problems

By Allison Ward-Moore, MD, IBCLC

Dr. Ward-Moore is a board certified ob/gyn and internationally board certified lactation consultant.

 

Photo by Dave Clubb on Unsplash



Fourth trimester

While breast feeding is the biologic norm, that doesn’t mean it’s easy or comes naturally to all moms and babies! In days gone by, grandmothers, aunties, sisters and cousins possessed a collective wisdom that while not comprehensive was almost always adequate to assist new moms if they were struggling to feed their newborns. Mothers also had watched other family members nursing and working out the kinks since they were small children themselves and had more realistic expectations of life with a newborn.  A new focus on the postpartum period is called the Fourth Trimester and aims to help with some of these issues.  We have lost some of that knowledge but luckily we are gaining it back through hard work and the internet! Here are some common issues that a new mom might face while breast-feeding.

 

Perceived low supply


Many women worry their milk supply has diminished when they lose the sensation of being full or engorged. Often times this is due to a normal down-regulation from the abundance of milk and swelling which happens as the milk comes in. It is also common for breast-fed infants to eat frequently- commonly 10 to 12 times per day.  Many women perceive that they don’t have enough milk because the baby is eating frequently whereas this is a normal feeding schedule. Some mothers may be comparing their infant to formula-fed infants who feed less often. The reason for the difference is that human milk is digested differently than cow’s milk-based formula.
Another reason women may perceive they don’t have enough milk is that as women return to work and express milk to give to their infants, they may note that the volume taken by breast-fed infants is smaller than that taken by formula-fed infants. In general babies on breastmilk should consume 24-30 oz per 24 hours. This averages out to 1 to 1.25 ounces per hour. Breast milk babies usually get hungry every 2-3 hours during the day so bottles are usually 2-4 oz. If infants are sleeping long stretches at night they may need to eat more than 1 to 1.25 ounces per hour. In addition, the volume of breastmilk consumed does not increase as the infant grows. This seems counterintuitive as a larger infant would be expected to take more milk in order to continue to grow, however, growth rate slows after the first four months.  After six months, the addition of solids begins to add additional calories. In fact after nine months or so the volume of milk needed per 24 hours actually starts a slow slide down to about 18 ounces per 24 hours by one year. In addition since the volume taken by the baby at the breast is difficult to quantify many mothers get worried that the baby is not taking enough volume due to changes in how quickly they empty the breast, distractibility, or nursing strikes.
If you are concerned about inadequate supply, one thing to look at is the baby’s weight. Having weight gain of 20 g per day in the first four months shows adequate milk intake. This is about a half an ounce per day or 4-7 ounces per week. After four months 3 to 5 ounces per week shows adequate weight gain. Another marker of good intake is having an adequate number of wet and dirty diapers as well as seeming satisfied after nursing. Here is a link to more info about perceived insufficient milk.

Low supply due do maternal issues


Some women do have low milk supply despite adequate stimulation by the infant. Some causes are: unrecognized thyroid disease, insufficient glandular tissue of the breast, hormonal imbalances such as high testosterone due to ovarian cyst or polycystic ovarian disease, retained placenta, new pregnancy, medications such as decongestants, heavy smoking or alcohol use, and postpartum hemorrhage leading to a rare failure of the pituitary called Sheehan‘s syndrome. Your obstetrician can help evaluate if any of these issues apply to you.


Low supply due to infant issues


Breast milk synthesis is a supply and demand system . Milk supply becomes adequate when the demand by the infant stimulates the breast with frequent emptyings. Sometimes inadequate stimulation by the infant can lead to failure to properly stimulate a normal milk supply of the mother. Tongue ties and poor oral muscular development can lead to weak or uncoordinated suck which leads to poor emptying of the breast. Information about tongue ties can be found here.   Sometimes a low supply is caused by poor advice given to the mother to limit the infants time at the breast or frequency at the breast. Infants should be fed on cue which may included awake periods with lip smacking, putting their hands to the mouth, and rooting. Most infants nurse 10 to 12 times in 24 hours for up to the first few weeks as the milk supply becomes established. Also a mother’s perception of a normal feeding interval or amount of time at the breast can influence the amount of stimulation the breast receives. An infant who is not allowed to feed at the breast as needed because limits are set on total feeding time or the interval between feedings will not be able to stimulate a full milk supply. Delay in stimulation due to illness of the infant can also have long lasting effects on milk supply. Pumping or hand expression should be initiated by the mother if the infant isn’t able to latch within the first few hours after birth.  Late preterm and early term babies may also lack the ability to adequately stimulate the breast due to weaker or uncoordinated suck. This website has a more information about low milk supply and may be of benefit.

Oversupply


Some women have an overabundance of milk either naturally or due to excessive stimulation due to pumping. This is called oversupply. At first glance this may not seem like a problem but having excessive amounts of milk can lead to maternal discomfort when the breasts are not emptied regularly. Not emptying the breast can lead to mastitis and clogged ducts which will be discussed later. Most of the time mild naturally occurring oversupply will regulate if given time and treated conservatively. However some women inadvertently worsen the issue by pumping to relieve the fullness which continues the production of the excess milk. Slowly weaning the amount of milk removed in excess will usually help to resolve the problem. Occasionally medications may be needed in order to resolve the issue.
Here’s a more comprehensive discussion of oversupply

Mastitis and clogged ducts

 

Mastitis is an infection of the breast usually accompanied by fever, redness, and tenderness of the breast. It often occurs in a wedge shaped area of the breast along a milk duct. A related issue is a clogged duct. This is when a ropey area is felt in the breast along the milk duct. It is occasionally tender and can develop into mastitis. Treatment of both includes adequate emptying of the breast while massaging the area that is clogged. The clog is usually located closer to the nipple. Ibuprofen should be taken regularly for help with the inflammation as well as maternal symptoms of pain and fever. Vibration in the area of the clog may help to loosen it as well. The Kellymom website is a great resource for breast-feeding. Here’s their information on mastitis and clogged ducts. 

Breast massage may alleviate some of the discomfort.  It is described well here: 

 

In conclusion, many women have minor if any difficulties with breast-feeding their children. However, it is not unusual for problems to develop and for moms to have difficulty finding knowledgeable help. Here are some other resources that can help women navigate through difficulties in order to reach their breast feeding goals.

https://kellymom.com/

https://med.stanford.edu/newborns/professional-education/breastfeeding.html

https://www.lllusa.org/

 

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