Protocol to Increase Intake of Breastmilk by the Baby ("Not Enough Milk")
By Jack Newman, MD, FRCPC

Here is the way I suggest mothers proceed for "insufficient milk supply" (actually, most mothers have lots or could have had lots, but the problem is that the baby is not getting the milk that is available).

1. Get the best latch possible. This needs to be shown by someone who knows what they are doing. Anyone can look at the baby at the breast and say the latch is good. The accompanying diagram, or the one available at the websites below shows how to get a good latch. If a mother has plenty of milk, the latch does not have to be perfect. But, if the milk supply is decreased, the baby will get more milk if he is latched on better. Get good “hands on” help. Videos can be seen at www.thebirthden.com/Newman.html that show you how to best latch a baby on.

2. Know how to know the baby is getting milk. When a baby is getting milk (he is not getting milk just because he has the breast in his mouth and is making sucking movements), you will see a pause at the point of his chin after he opens to the maximum and before he closes his mouth, so that one suck is (open mouth wide--> pause-->close mouth). If you wish to demonstrate this to yourself, put your index or other finger in your mouth and suck as if you were sucking on a straw. As you draw in, your chin drops and stays down as long as you are drawing in. When you stop drawing in, your chin comes back up. This pause that is visible at the baby's chin represents a mouthful of milk when the baby does it at the breast. The longerthe pause, the more the baby got. Once you know about the pause you can cut through so much of the nonsense breastfeeding mothers are being told—such as “Feed the baby twenty minutes on each side”. A baby who does this type of sucking (with the pause) for twenty minutes straight might not even take the second side. A baby who nibbles (doesn't drink) for 20 hours will come off the breast hungry. You can see this “pause” on the videos at www.thebirthden.com/Newman.html

3. Once the baby is no longer drinking on his own, use compression to increase flow to the baby. Compression can be particularly helpful, but don't forget trying to get the best latch possible first. Babies tend to pull at the breast when the flow of milk is slow, so it is useful to know how to know the baby is actually getting milk and not just sucking without getting milk. When the baby no longer seems to be getting milk, and is sucking without getting milk, this is when to start compression, while the baby sucks, but does not drink. Keep the baby on the first breast until he doesn't drink even with compression. See handout #15 Breast Compression. You can see this how to use compression on the videos at www.thebirthden.com/Newman.html

4. When the baby no longer drinks even with compression, switch sides and repeat the process. Keep going back and forth as long as the baby gets reasonable amounts of milk at the breast.

5. Try fenugreek and blessed thistle. These two herbs seem to increase milk supply and increase rate of milk flow. There is more information on the handout #24 Cabbage Leaves, Herbs, Lecithin.

6. In the evening when babies often want to be at the breast for long periods, get help to position the baby so that you can feed lying down. Let the baby nurse and maybe you will fall asleep. Or rent videos and let the baby nurse while you watch.

7. It is not always easy to decide if a baby needs supplementation. Sometimes applying this Protocol for a few days gets the baby gaining more rapidly. Sometimes more rapid growth is necessary, and it may not be possible without supplementation. If possible, get banked breastmilk to use as a supplement if you can. If not available, formula may be necessary. However, sometimes slow but steady growth is acceptable. The main reason to worry about growth is that good growth is one sign of good health. A baby who grows well is usually in good health, but this is not necessarily so. Neither is a baby who grows slowly in poor health, but physicians worry about a baby who is growing more slowly than average. Growth charts are frequently interpreted poorly. A baby who follows the 10 th percentile line is growing as he should be. Too many people, including physicians, believe that only babies on the 50 th percentile or higher are growing normally. Not true. Growth charts were developed on information based on information gathered about normal babies. Somebody has got to be smaller than 90% of all other babies. Somebody normal.

8. If it is decided to supplement, the best way is at the breast with a lactation aid. Introduce the supplement with a nursing supplementer (lactation aid), not bottle, syringe, cup or finger feeding. See handout #5 Using a Lactation Aid at the website below. Supplement only after steps 3 and 4 above and the baby has nursed on at least both sides. Why is it better to use the lactation aid?

• Babies learn to breastfeed by breastfeeding
• Mothers learn to breastfeed by breastfeeding
• The baby continues to get your milk
• The baby won't reject the breast
• There is more to breastfeeding than the breastmilk

9. If the baby is older than three or four months, and supplementation appears to be necessary, formula is not necessary and extra calories can be given to the baby as solid foods. First solids may include: mashed banana, mashed avocado, mashed potato or sweet potato, infant cereals, as much as the baby will take, and after the baby has nursed, if he is still hungry. Even at this age giving bottles when the baby is not getting much from the breast will often result in breast rejection. If you must give formula, mix it with the baby’s solids. Giving solids at three or four months if everything is going well is not recommended, and even if the weight gain is slow, there are several ways of getting the baby more breastmilk that can be tried before adding solids. Solids should normally be started when the baby is showing interest in eating solids (usually around five or six months of age).

10. If your baby was gaining well for a few months and now is not gaining well, see the handout #25 Slow Weight Gain After the First Few Months. Reasons for a decreased milk supply are listed there. Fix what you can, and then follow this Protocol.

11. Domperidone is a possibility. It is not a panacea (a magic bullet). Check the handouts on Domperidone.

Handout B: Protocol to Increase Breastmilk Intake by the Baby; Revised: January 2005; Jack Newman, MD, FRCPC. (c) 2005