Session 12.
Milk supply
challenges
12/1
© WHO/Yoshi Shimizu
Session 12. Objectives
Milk supply challenges
After completing this session, participants will be
able to:
• explain normal newborn feeding behaviour and intake;
• list the signs and symptoms a newborn may not be
getting enough milk;
• explain the common reasons why a newborn may not
get enough breast milk;
• explain how to prevent and manage milk insufficiency
in newborns;
• explain the difference between perceived and actual
milk insufficiency;
• help a mother whose baby is not getting enough breast
milk;
• help a mother who thinks her baby is not getting
12/2
enough milk.
First weeks of newborn’s life
• Day 1-3 • Day 6-7
▫ Baby gets colostrum ▫ Baby loses weight
▫ Breasts feel soft ▫ Fluid and glucose needs
covered by extra in
• Day 3-4
infant’s body from before
▫ Milk “comes in”, birth
changes ▫ Once breastfeeding
▫ Volume produced established, weight
increases increases
▫ Breasts feel full • Day 10-14
▫ Infant regains birth
weight
12/3
Newborn stomach:
Size and volume
Day 1 Day 2 1 Week 1 Month
5-7 mL 22-27 mL 45-60 mL 80-150
mL
Bergman NJ. Neonatal stomach volume and physiology. Acta Paediatrica. 2013;102:773–7.
Zangen S, DiLorenzo C, Zangen T, Mertz H, Schwankovsky L, Hyman PE. Rapid maturation of gastric relaxation in newborn infants. Pediatr Res. 2001;50:629–32. 12/4
Best Start Resource Centre: Ontario's Maternal Newborn and Early Child Development Resource Centre
Normal newborn feeding behaviour
• First 24 hours
▫ Breastfeed in the first hour, may be followed by a long sleep
▫ Breastfeed then 5-12 times in the first 24 hours - babies vary
and can depend on skin-to-skin and rooming-in
• Day 2-3
▫ Frequency often increases to 10–12 times, still variable
• After day 3
▫ Milk “comes in,” changes
▫ Maybe longer intervals between feeds, as feeds become
larger
▫ Feeds on average about 8 times in 24 hours
▫ Mothers should keep babies close and respond as they show
signs of readiness
▫ Alert and moving, turning head, hand to mouth, moving
mouth
▫ A baby who rooms-in with a mother who responds, gains
Wight N, Marinelli KA, and the Academy of Breastfeeding Medicine (2014). ABM clinical protocol #1: Guidelines for blood glucose monitoring and treatment of hypoglycemia in term and late-preterm neonates.
Breastfeeding Medicine, 9 (4), 173-179.
more weight over the first 7 days 12/5
Kellams A, Harrel C, Omage S, et al. (2017). ABM clinical protocol #3: supplementary feedings in the healthy term breastfed neonate. Breastfeed Medicine, 12 (3), DOI: 10.1089/[Link].
Holmes AV, McLeod AY, and Bunik M. (2013). ABM clinical protocol #5: peripartum breastfeeding management for the healthy mother and infant at term. Breastfeeding Medicine, 8(6), 469-473.
doi:10.1089/bfm.2013.9979.
Signs and symptoms:
Newborn not getting enough milk
1. Clinical evidence of significant
dehydration not improved after
assessment and management of
breastfeeding
2. Weight loss 810% by day five (120 hours)
or weight loss >75th percentile for age
3. Delayed bowel movements, fewer than
four stools on day four, or delayed
transition from meconium to transitional
stools (by 120 hours)
Adapted from: Kellams A, Harrel C, Omage S, Gregory C, Rosen-Carole C. Academy of Breastfeeding Medicine. ABM Clinical Protocol #3: Supplementary
feedings in the healthy term breastfed neonate, revised 2017. Breastfeed Med. 2017;12:188–98. doi:10.1089/[Link].
12/6
Signs mothers think they do not have
enough milk
• Baby ▫ Infrequent, small
▫ Not satisfied at stool
breast
▫ Cries often • Mother
▫ Refuses to ▫ Breasts did not
breastfeed enlarge during
▫ Breastfeeds pregnancy
frequently ▫ Milk did not “come
▫ Breastfeeds for in” after delivery
long periods ▫ No milk comes with
▫ Hard, dry or green expression 12/7
stool
Common causes:
Insufficient milk in first weeks
• Delay initiating breastfeeding
• None or little skin-to-skin contact
• Milk “coming in” delayed due to:
▫ complications of delivery
▫ maternal illness
▫ diabetes
• Poor attachment and ineffective suckling
12/8
Common breastfeeding factors
• Feeding at fixed
times
• Short feeds
• Supplementary
feeding
• No nighttime feeding
• Infrequent feeds
12/9
Psychological factors
• Lack of
confidence
• Worry and stress
• Dislike of
breastfeeding
• Tiredness
• Lack of bonding,
rejection of
newborn © WHO/Yoshi Shimizu
12/10
After 2 weeks of age:
Actual or perceived insufficiency
• Perceived insufficiency
▫ The most common reason for a mother giving up
exclusive breastfeeding is because they think they
do not have enough milk.
▫ Almost all mothers are able to produce as much milk
as their baby needs.
▫ Often there is an issue in the interaction between
mother and infant
▫ How many mothers could continue breastfeeding if
they had skilled support and help?
• Actual insufficiency
▫ In some cases, the mother does have a supply issue.
▫ Assess the possible causes: physical, psychological or
other causes. 12/11
Practices:
To prevent and manage insufficient milk
intake and transfer
• Early skin-to-skin contact at
delivery and initiation of
breastfeeding as soon as
possible
• Skilled support of
breastfeeding after delivery
to ensure good attachment
and effective suckling
• Practice rooming-in 24 hours
a day
• Exclusive breastfeeding, 12/12
unless supplements
Not enough milk:
Helping the mother
• Listen to the mother and take a detailed history
▫ If she is doubting her milk supply, try to learn why.
In this way, you can help her to build her
confidence.
▫ Explore the mother’s ideas and feelings about her
milk and pressures she may be experiencing. This
pressure can come from family and friends.
• Assess the infant’s health
▫ Determine whether the baby is getting milk or not,
using the signs and symptoms we have discussed.
▫ Determine whether the baby is being fed
exclusively at the breast or is being supplemented.
Adapted from: LEAARC. Core curriculum for interdisciplinary lactation care. Burlington (MA): 2019.
12/13
Not enough milk:
Helping the mother
• Assess the big picture
▫ Is the baby’s weight within the expected range?
▫ Has supplementation played a role?
▫ Is baby removing milk from the breast?
▫ What is the baby's output (urine and stooling
pattern)?
• Assess the mother’s health
▫ Does the mother have risk factors for lactation
problems?
• Observe one or more feeds
▫ Assess latch, milk transfer and positioning to
check positioning and attachment, as well as the
12/14
condition of the mother and baby.
Adapted from: LEAARC. Core curriculum for interdisciplinary lactation care. Burlington (MA); 2019.
Not enough milk:
Helping the mother
• If there is a problem
▫ Make sure baby is adequately fed. This may
require supplementation.
▫ Try to determine the cause. Has the problem been
present since birth? When did the problem become
apparent?
▫ Screen for breastfeeding management problems
and factors related to the mother.
▫ If milk remained in the breast after feeding,
determine the cause for the baby’s inability to
remove milk.
• Support milk production as needed and address
any problems as soon as possible 12/15
Adapted from: LEAARC. Core curriculum for interdisciplinary lactation care. Burlington, MA; 2019.
