Inadequate+Milk+Supply

=Inadequate Milk Supply=

What it is
Increasingly, mothers of premature babies being cared for in neonatal intensive care units are asked to provide expressed human breast milk for their babies. Most mothers express a strong desire to provide breast milk for their infant and verbalize positive feelings about being able to do something to help their ill baby. However, many mothers of very preterm infants find it difficult to provide adequate amounts of expressed breast milk to meet their baby's needs over prolonged periods of time. Stress related to the hospitalization, concerns related to the increased risk of mortality and morbidity, separation, and lack of infant suckling may contribute to decreased milk production. Decreased milk production among mothers of very preterm infants expressing breast milk can occur as early as two weeks postpartum, although such problems typically peak between four and six weeks postpartum.

One of the most common reasons women give for weaning their baby from the breast is an inadequate milk supply. While this can be a perceived rather than a real problem, some women find it difficult to initiate and maintain a milk supply sufficient to totally nourish their baby. Ensuring correct positioning and attachment, increasing the number of breastfeeds and other breastfeeding management suggestions are usually sufficient to increase a woman's milk supply. However, there is still a group of women who struggle to produce enough milk. Galactagogues are substances that are claimed to increase milk supply. It is often difficult to know what can be offered in the way of galactagogues to women.

Lactogenesis II, or the initiation of copious milk secretion, occurs following delivery of the placenta and the sudden drop in progesterone. Although the hormone prolactin is important for the initiation of lactation, local or autocrine control takes over after a few days. A peptide present in milk (feedback inhibitor of lactation) inhibits further milk production. It is the continual removal of breast milk and this peptide that stimulates the breasts to keep producing milk.

Genuine insufficient breastmilk has a number of possible causes: - inadequate positioning or attachment; - the infant is not feeding frequently enough or is not given enough time to feed, and the milk is not being removed from the breast – after several days the milk supply will start to diminish; - using dummies, which reduce sucking time at the breast, may eventually lead to a reduction in milk supply - reduction mammaplasty (breast reduction) and other breast surgery, while not precluding breastfeeding, may hinder full lactation – some areas of the glandular tissue which are no longer connected to the nipple ducts will become hard when the milk comes in, but this is temporary because these sections of the breast will gradually cease to make milk, due to the effect of local autocrine control.
 * Risk Factors**
 * **Factors affecting milk supply** ||
 * Maternal health || Anaemia, postpartum haemorrhage, smoking(moderate/heavy - nicotine reduces prolactin levels, adrenaline rush may interfere with let-down reflex via oxytocin) ||
 * Mammogenesis || Insufficient breast tissue, breast surgery (reduction) ||
 * Lactogenesis || Retained placenta, delayed breastfeeding ||
 * Galactopoiesis || Inadequate breast drainage, infant tongue-tie ||
 * Milk intake || Restriction of frequency or duration of feeds ||
 * Infant factors || Infant medical problems (eg. congenital heart disease, urinary tract infection) ||

Symptoms

 * **Reliable signs of low supply ** || **Common misconceptions of low supply** ||
 * Weight gain less than 500 g/month; <150g/week || B reasts feel softer ||
 * Baby weighs less than birth weight at 2 weeks || Baby feeds more often ||
 * Passing small amounts of concentrated yellow, strong smelling urine, <6/day || Baby takes less time to feed ||
 * Infrequent small amounts of hard, dry, green stools || Baby is unsettled ||
 * Lethargic, sleepy, weak cry || Baby settles better on infant formula ||
 * Dry skin and mucous membranes, poor muscle tone || Growth slows after 3 months ||

How to Treat
In low milk supply or failed lactogenesis II (i.e., the milk coming in), an attempt should be made to establish the underlying etiology. Certainly, if insufficient breast stimulation and/or inadequate milk removal is the most likely and primary etiology of an inadequate milk supply, it should be corrected by using proper breastfeeding techniques (shown below).

__Strategies__ Low breast milk supply is usually a temporary difficulty and only occasionally becomes an ongoing problem which requires supplementation of the breast milk supply.

Increasing the milk supply: - check positioning and attachment; - feed more frequently; – offer the breast between the usual feeds – offer the breast as a comforter instead of a dummy – wake the infant and offer an extra feed before the mother goes to bed - encourage the mother to allow her baby to finish the first breast before offering the second breast; - always offer the second breast after finishing the first; - express between feeds; - encourage good maternal nutrition and rest; – recommend a healthy well balanced diet – discourage excessive exercise and weight loss diets – ensure adequate fluid intake by drinking when thirsty - encourage rest and relaxation

If the infant requires supplementation this can best be achieved by using a supply line or supplementary nursing system available from NMAA; a supply line consists of a plastic container of expressed breast milk or formula hung around the mother’s neck with a fine tube leading from it which is taped to the mother’s nipple; as the infant sucks on the breast she gets both breast milk from the breast and expressed milk or formula from the supply line. - the supply line avoids the possibility of ‘nipple confusion’ which can result if a bottle and teat is used, and encourages milk production by ongoing stimulation of the breast. Mothers discharged from hospital using a supply line need specific follow - up and referral to an appropriate health professional.

However, laboratory tests should be ordered prior to or concurrent with treatment with galactagogues if any of the following conditions exist: 1) a coexisting etiology is known or suspected, 2) an inadequate milk supply persists or is present despite correct breastfeeding, or 3) a severe insufficiency is ascertained or there is an outright failure of lactogenesis II.

Laboratory tests to consider ordering are the following: - a complete blood count to evaluate for anaemia - thyroid-stimulating hormone to evaluate for hypothyroidism - testosterone levels to evaluate for gestational ovarian theca lutein cysts - human chorionic gonadotropin to evaluate for retained placenta - prolactin levels to evaluate for pituitary diseases.

When galactagogues are indicated, the clinician is cautioned to use them only in conjunction with adequate milk removal via correct breastfeeding technique and/or a hospital-grade, double, electric pump. The rationale for this is that milk stasis inhibits milk production via a local feedback mechanism. Consequently, milk removal is imperative for milk production to occur or increase.

Other advice
**Guidelines to Assess for Correct Breastfeeding Technique, Adequate Breast Stimulation, and Effective Milk Removal** 1. Mother is breastfeeding frequently at the first signs of hunger. Newborns usually feed 8 to 12 times per 24 hours. 2. When latching, the infant’s mouth opens and the tongue extends past the lower gum line. 3. Once latched the infant’s lips are flanged and covering at least 1 to 11⁄2 inch of the surrounding areola. 4. The infant sucks rhythmically without causing nipple discomfort and swallowing is heard. 5. While nursing, the infant is positioned ventrally with head, shoulders, and hips in line without rotation. 6. At each feeding, at least 10 minutes of active sucking occurs, the feeding is not timed or limited, and both breasts are offered. 7. Breast compression and massage can be used to assist with milk removal during feedings or while pumping. 8. If the infant is feeding, sucking, or latching inadequately, feeding less than 8 times per 24 hours or unable to breastfeed, the mother usually must double pump 8 to 10 times per day for 15 to 20 minutes with a hospital-grade, electric pump fitted with a flange for each breast.

- At least 6 to 8 very wet cloth nappies in 24 hours provided no other fluids or solids are being given. A very young baby will usually have 2 or more soft bowel movements a day for several weeks. An older baby is likely to have fewer than this. Small quantities of strong, dark urine or formed bowel motions do suggest that the baby is in need of more breastmilk. - Good skin colour and muscle tone. - Your baby is alert and reasonably contented and is not constantly wanting to feed. Your baby may still wake for night feeds - some babies sleep through the night at an early age while others wake during the night for some time. - Your baby has appropriate weight gain when averaged out over a four week period, bearing in mind that infants lose five to 10 per cent of their birth weight, so using an appropriate growth chart is recommended – after two weeks they should return to their birth weight and should then follow a pattern of weight gain which averages out over a four week period of: – birth to three months – 150 g/week – three to six months – 100 g/week – six to 12 months – 70 g/week
 * If your baby shows two or more of the signs below then it is probable that you do have enough milk.**

Additional Resources
[|AMH - Domperidone] [|Resources for Clinicians - Galactagogues] [|Pharmacoepidemiology and Drug Safety - Use of herbal drugs in pregnancy] [|RCHM - Medications and herbal preparations to increase breastmilk production] [|Breastfeeding: The healthy term newborn] [|RACGP - Breastfeeding: Managing 'supply' difficulties] [|Australian Breastfeeding Association - Increasing your supply] [|eMedicine - Counselling the breastfeeding mother]