How to increase milk supply 3 weeks postpartum

This guide was originally published on May 3, 2019 in NYT Parenting.

I will never forget being told by a lactation consultant that, after a 45-minute nursing session, my 10-day-old daughter had consumed only half an ounce of breastmilk. Early breastfeeding challenges led my husband and I to try a “weighted feed,” in which our baby was weighed before and after feeding. While it was devastating to learn how little our daughter was taking in, we were grateful for the information. It revealed the severity of the milk supply issue I was facing and helped us create an action plan.

Estimates on the prevalence of low breastmilk supply vary. While a handful of studies suggest low supply affects 10 to 15 percent of mothers, the lactation consultants I spoke to said it is one of the top reasons they receive calls for help. According to Wendy Wisner, I.B.C.L.C., a board-certified lactation consultant in private practice in New York City, low milk supply is often cited by mothers as a cause of early weaning. Aside from medical risks to a mother’s milk supply, like a breast surgery or thyroid problems, simply not breastfeeding frequently enough in the early days after giving birth can set a new mother up for inadequate supply, even if her body is capable of producing enough.

For this guide, I spoke with three lactation consultants, a pediatrician, a postpartum doula and the founders of the Fed Is Best Foundation. There is no magic formula for increasing milk supply besides frequently and completely emptying the breasts of milk, said the experts. While you are working to increase your supply, it is imperative to ensure your baby is fed, whether that means short- or long-term supplementation. A hungry newborn can go on to develop serious complications like dehydration, prolonged jaundice and failure to thrive. The experts I spoke to emphasized the importance of getting help from skilled medical professionals with both breastfeeding and supplementation, and letting go of an “all-or-nothing” mentality around breastfeeding.

What to Do

• Assess your risk factors and make a feeding plan
• Know how to recognize low milk supply
• If you have low supply, supplement with breastmilk or formula
• Treat medical issues and up demand to increase supply
• Resist an all-or-nothing mindset around feeding
• When to Worry

Assess your risk factors and make a feeding plan

There are a few “yellow flags” that might indicate future milk supply issues before you give birth, according to Julie Rosen, I.B.C.L.C., a board-certified lactation consultant in private practice in New York City and northern New Jersey. For example, an absence of breast changes — fuller, more sensitive breasts with darkened veins and areolae — during pregnancy may be a sign your body is not preparing to make milk. Especially asymmetric and widely spaced breasts could suggest a lack of milk-making breast tissue, a condition known as insufficient glandular tissue, or I.G.T. Aside from these yellow flags, breast surgeries, polycystic ovary syndrome (P.C.O.S.), thyroid issues and diabetes might also impact supply. Finally, a host of other factors are associated with insufficient milk supply, including maternal diet, weight and pollutants.

None of these risk factors assure insufficient milk supply, said Wisner; conversely, someone with no risk factors could end up with a supply issue. This is good reason to set up a feeding support system before giving birth, and to understand what successful breastfeeding entails. Wisner recommended finding a pediatrician who is supportive of breastfeeding and will recommend supplementation when necessary.

Choose a pediatrician nearby to ease frequent check-ins in the early weeks, recommended Dr. Laurie Schulwolf, M.D., a pediatrician at Tribeca Pediatrics in Manhattan. It’s also important to understand that to ensure supply, you must breastfeed very frequently in the beginning. “Eight feeds a day is the bare minimum; you really need to be feeding the baby more like 10 to 12 times a day,” said Rosen. If you suspect any impediments to frequent breastfeeding, such as returning to work early or other responsibilities, low breastmilk supply may be more likely.

Know how to recognize low milk supply

The most reliable way to determine if you have low milk supply is by weighing your baby, said Wisner. While nearly all babies lose some weight in the first three days of life, the American Academy of Pediatrics recommends no more than a 7 percent (of birthweight) loss, and the beginning of weight gain by the fifth day. Typically, by day three, milk “comes in,” replacing the thick yellow colostrum that is produced in pregnancy and feeds a baby for the first few days. Insufficient weight gain could indicate a supply issue, or just a delay in milk coming in. A 2010 study of 431 first-time mothers showed that 44 percent experienced a delay (greater than 72 hours), and identified several risk factors including older maternal age, greater maternal weight, and greater infant weight. A delay is not associated with low supply but can make managing the early days more challenging.

Assuming your milk has come in, “if you are breastfeeding frequently, every two hours, and your baby has a good latch but is not gaining weight, then you probably have low supply,” said Wisner. Parents are often told to keep a log of wet and dirty diapers as a proxy for feeding, but according to Wisner, a baby could be producing the correct amount of diapers but still not be getting quite enough milk. This is why weighing your baby naked on the same scale is key, Wisner said. Dr. Schulwolf also talked about the difficulty in knowing how much a nursing baby is taking in, and recommended early and frequent weight checks. Rosen stressed the importance of a pediatrician visit on the third day of a baby’s life. “Many mothers don’t see a pediatrician until two or three days after they get home from the hospital,” when the baby is four or five days old, “and a lot can go wrong in that time,” she said.

If you have low supply, supplement with breastmilk or formula

“If someone has low supply, we say first feed the baby, then protect the milk supply and enjoy the baby,” said Melissa Morelli-Walsh, I.B.C.L.C., C.N.M., a board-certified lactation consultant and certified nurse midwife at New York University Langone. You can supplement your baby’s intake with your own breastmilk (through pumping), donor milk or formula. “Babies always leave a little milk behind after nursing. Pumping can get it, while also stimulating the body to make more milk,” said Rosen. NYU has recently started offering donor milk to newborns needing supplementation. Formula is also an option, and can actually help breastfeeding, said Wisner, pointing out that a very hungry baby will not breastfeed as well as one who is nourished. A 2018 study showed that very early formula supplementation, before the onset of mature milk production, does not interfere with exclusive breastfeeding at 1 month.

In order to preserve the breastfeeding relationship, supplemental milk should be offered in small amounts, after a nursing session, perhaps using the technique of paced bottle-feeding (slower feeding with a wide bottle nipple that incorporates plenty of holding and bonding, similar to the nursing experience). Dr. Schulwolf recommended using formula strategically. “You can use formula in the middle of the night — the partner enjoys bonding with the baby by feeding a bottle, and the mom enjoys a good four-hour stretch of sleep,” she said.

[How to feed a combination of breast milk and formula]

Treat medical issues and up demand to increase supply

If you have low supply, you should first treat any suspected medical issues, said Wisner. You may need to start medication if you have a thyroid problem, or change medication if you have P.C.O.S. or diabetes. Retained placenta, which can interfere with supply, may be discovered and need to be removed. If you have I.G.T., a lactation consultant can help determine what a realistic milk supply might be for you.

Next, increase supply by frequent nursing followed by pumping. “It’s classic supply and demand,” said Morelli-Walsh. Pumping removes any leftover milk, and thus creates additional demand for it. In some cases, low supply is caused and further exacerbated when a baby does not remove milk well. The baby may have a tongue tie, a condition in which a band of tissue attaches the tip of the tongue to the bottom of the mouth, impairing sucking; a tongue tie can be corrected by a procedure in which the tissue is cut. A poor latch or simply weak sucking ability can also create problems. Pumping two to three ounces after a nursing session is a likely sign your baby is not sucking well, said Rosen, and is something a baby born before 39 weeks’ gestation is at higher risk for.

A skilled lactation consultant can help you make a plan to increase supply and supplement your baby, taking into account the specifics of your situation. Weighted feeds, over a 24-hour period, can show exactly how much your baby is taking in, said Rosen.“You need much more support and involvement than a five-minute visit with a lactation consultant in the hospital,” said Rosen.

An established supply may diminish if nursing sessions decrease, which might happen when a mother goes back to work or a baby starts sleeping for longer stretches at night. Devon Clement, a postpartum doula and founder of “Mama’s Best Friend,” a newborn care services company, said that when this happened to one of her clients, “we added a pumping session before mom went to bed, and in the early morning before the baby woke up,” and her supply returned. As for lactation cookies, teas and herbs? There is no evidence they help, but also no evidence they can hurt, unless a mother prioritizes drinking lactation tea over frequent nursing sessions. “Every mom should have a treat when she sits down to pump,” said Rosen. “If it’s a lactation cookie, that’s great, but it’s not going to have a major impact on supply.

Resist an all-or-nothing mindset around feeding

Nursing, pumping and then supplementing on top of recovering from giving birth can be a daunting regimen for mothers and should be seen as a short-term remedy to increase supply. “If a two-week all-out effort doesn’t result in a full supply, then exclusive breastfeeding probably isn’t going to work,” said Rosen. Feeling pressured to increase supply may contribute to postpartum depression, said Dr. Schulwolf, as additional pumping further reduces a mom’s sleep and time with her baby. She recommends pumping after nursing when you can, but not at the risk of mental health.

“You have to ask yourself, what are your goals?” said Rosen. “Breastfeeding does not have to be all or nothing. Even if you are feeding 90 percent formula, and 10 percent breastmilk, if that is meaningful for you, that is good for your baby.” Wisner voiced similar sentiments and relayed an anecdote about a woman who had a breast reduction prior to becoming a mother, and at her maximum supply, was feeding her baby about 75 percent formula, and giving the rest through nursing. “Breastfeeding was a way for her to connect with her baby,” Wisner said. “It does not have to be exclusive.”

When to Worry

Serious health complications can result from inadequate milk intake in a newborn, including dehydration, failure to thrive, prolonged jaundice and hypoglycemia. While frequent weight checks and close contact with a pediatrician should prevent dangerous complications, there are some warning signs parents can look for. Dr. Schulwolf described two different sets of alarming behavior in the first three weeks: the baby who is “too good” — sleeps well, has to be woken up to feed and is lethargic — and the baby who cries nonstop between feedings and cannot be put down for a minute. These behaviors, along with a dry mouth and not enough wet diapers, can indicate feeding problems. If you have any doubts that your baby is getting enough to eat, schedule an appointment with your pediatrician right away.

Susan Reslewic Keatley holds a Ph.D. in chemistry, blogs at I Love a Good Story and is the mother of two children.