By Teresa Pitman.
Teresa Pitman is an award-winning author whose articles on parenting and maternal infant health have appeared in Today’s Parent, Great Expectations, Mothering, Chatelaine, Leaven and New Beginnings. Teresa is also the author and co-author of 18 books on parenting and breastfeeding related topics, including the updated 8th edition of the Womanly Art of Breastfeeding and LLLI’s new book, Sweet Sleep.
As a long-time La Leche League Leader and author, I’ve helped many parents with their concerns about feeding their babies. And one of the most common questions I hear is “I’m worried that I’m not making enough milk.”
Baby behaviour: not always a good indicator
While it’s a common concern, often as we talk about WHY they are worried, it turns out that their milk production is just fine. Yes, the baby seems to be nursing frequently, but frequent feedings are normal for young babies. Yes, the baby is more wakeful than they’d been led to believe babies usually are, but that’s normal too. And yes, the baby wants to be held and carried around and kept close – also perfectly normal (and very beneficial) behaviour.
Something else that is not a great indicator: how your breasts feel. Some women feel a strong let-down and see a noticeable difference in how full and firm their breasts are before and after a feeding. Others notice little change and rarely feel the sensation of the milk “letting down.” This can also change over time, which sometimes freaks people out and makes them worry about their supply for no reason. Research confirms that we are pretty bad at judging our own milk supply (Galipeau et al., 2017).
Of course, there are times when the baby really is not getting enough milk. It’s important to check some of the other indicators to be sure.
Better indicators of milk production
When we look at signs that are better indicators of the baby’s milk intake, it’s easier to see if there really is an issue or not. The best indicator is the baby’s weight gain. If an exclusively breastfed baby is gaining as expected, following the curve on the growth chart (using a growth chart based on breastfed babies, not one based on babies fed with formula as the curves can look quite different), there’s no need to worry about milk production.
In between weigh-ins, another generally reliable indicator is the number, size and frequency of poops. What should a parent expect to see?
In the first few days, the baby is clearing out the meconium, which is the technical name for the poop stored in the baby’s intestines while it is still in the uterus. Meconium is dark in colour and sticky. Generally, the baby will have one poop on the first day, two on the second, and continue to increase throughout the first four or five days. The poops should change colour over this time as well – from the very dark brown meconium, through medium brown (may look greenish) and eventually to yellow.
After that, for at least the first six to eight weeks, a baby should have several poops per day. They should be loose and yellow in colour. After this stage, some babies will poop less frequently, while still gaining weight well. There are varying opinions about whether this is normal, but it is known to be a common pattern.
How can hand-expression help in the first week?
In the first few days after a baby is born, there’s a lot going on in the breasts. How often and how well milk is removed during that first week or so will influence future milk production. But many factors can influence how those first days go.
If a baby is premature or not able to feed well for other reasons, or if the parent who has given birth is not well and has to be separated from the baby, then stimulating milk production can be a problem. And hand-expression can make a big difference here.
Sometimes people suggest a breast pump in these situations but using a pump can be problematic. Many people are giving intravenous fluids during labour; these fluids often migrate to the breast after birth and can cause engorgement. Using a breast pump tends to pull more fluids into the breast area, making the engorgement worse and not removing much milk.
A pump is also not very helpful in the early days because the first milk (known as “colostrum”) is produced in small amounts. When a breast pump is used, the colostrum often gets lost in the tubing – there just isn’t enough to add more than a drop or two to the container.
So this is a time when hand-expression is a great choice. Hand-expressing frequently in the first few days will not increase engorgement – in fact, it can relieve it. It also makes it easy to collect the colostrum so that it can be fed to the baby. This is important because colostrum is high in antibodies and essential nutrients that help to get the baby off to a good start.
How can hand-expression help with milk production later?
For some parents and babies, that first week doesn’t go well, and milk production is not enough to meet the baby’s needs. The parents may be supplementing with formula or donated milk and wondering if they’ll ever make enough.
In many cases, the answer is yes – and once again, hand-expressing can help. Even though the milk supply was initially low, it’s the removal of milk from the breasts that signals the breasts to make more. When the milk ducts inside the breast are full, milk production slows down; when they empty, milk production speeds up. (Each parent has a limit on how much milk can be produced at any one time, how much can be stored, and the total amount per day, however, and for some that is not enough to meet the baby’s needs even at the maximum. This changes, though, from one baby to another, as new milk ducts grow during each pregnancy.)
So the key is keeping the milk ducts as empty as possible by removing milk frequently. Hand-expression is an easy way to do this. After the baby feeds, several minutes of hand-expression can remove more milk, signaling the breasts to make more milk in the future. Any milk that is collected, even if it is a small amount, can be fed to the baby with the next feeding. Note that if you are still learning hand expression you might want to practice it before a feed. This makes it a bit easier to find milk and figure out how to squeeze it out (see next paragraph).
If the baby sleeps for a long period of time, or is having some feedings of formula, hand-expression can be used at those times as well.
Usually, parents can expect to see an increase in milk production within two or three days.
Every breast is different, so learning to hand-express often involves some trial and error. Milk is made in the alveoli near the chest wall, and then moves into ducts behind the nipple in response to various things – the baby crying, the baby nuzzling at the breast, the baby suckling. So before you begin to hand-express, it often helps to stimulate the breast with gentle massage, including some rubbing of the nipples. Pleasant sensations encourage the milk to “let down.”
The ducts that will fill up with milk are (more or less) in a circle around the nipple, so your goal in hand-expression is to compress those ducts to send the milk out through ducts towards the nipple pores. Usually, what works best is to have your thumb on top and fingers underneath, and gently squeeze. Try not to slide your thumb on the skin as this can cause bruising and pain. You may want to roll your thumb towards the nipple, though, to push the milk out.
If you get some milk doing this, you know you have found a duct and are doing it right! Only apply a comfortable amount of pressure. When the milk flow slows down, move your hand slightly and try again. Over time you will figure out where your ducts are and become more efficient.
Still not enough milk?
If you have been working on breastfeeding techniques and using hand-expression to increase milk production, but the baby is still not gaining well, it’s important to talk to your doctor/ health care provider and to a breastfeeding expert. They will be able to examine your baby and your breasts and assess the situation – and help you find a solution.