Low Milk Supply

Low milk supply is milk production that does not meet the infant's needs, shown by poor weight gain, few wet nappies and an infant who is unsatisfied after feeds. True low supply is less common than perceived low supply.

It results from infrequent or ineffective milk removal, poor latch, infant tongue tie or weak suck, hormonal causes (hypothyroidism, Sheehan syndrome, polycystic ovary syndrome), retained placental tissue, breast surgery, anaemia, oestrogen containing contraception, smoking, stress and some drugs. It matters because poor intake causes infant dehydration and slow growth, and it is a common reason for stopping breastfeeding early.

• Risk factors: first baby, caesarean section, preterm birth, separation of mother and infant, scheduled feeds, supplementation with formula, obesity, diabetes, breast hypoplasia or previous breast surgery, postpartum haemorrhage.
• Milk supply works on demand: more removal gives more milk.
• Infant weight loss above 10 percent of birth weight, or birth weight not regained by 14 days, signals inadequate intake.

Mothers report that the breasts do not feel full and that the infant feeds very often, is restless or sleeps too much. Signs of inadequate intake in the infant are fewer than 6 wet nappies daily after day 5, dark urine, infrequent or green stools, dry mouth, jaundice and poor weight gain.

• Infant weight gain below 150 g per week in the first 3 months.
• Little change in breast size in pregnancy, or absent breast changes, in some women with true insufficiency.
• Differential diagnosis: perceived low supply with normal growth, delayed lactogenesis, infant tongue tie, infant illness (infection, cardiac or metabolic disease), poor latch with normal supply, Sheehan syndrome, hypothyroidism, retained placenta, maternal drugs (oestrogen, pseudoephedrine, bromocriptine, cabergoline).
• Complications: infant dehydration, hypernatraemia, hypoglycaemia, jaundice, failure to thrive, early weaning, maternal distress and depression.

The approach is to separate true from perceived low supply by weighing and observing a feed, then to look for a cause.

• Infant weight against birth weight and growth chart; wet nappies and stools; hydration; jaundice; examination of the mouth for tongue tie and palate.
• Observation of a full feed for latch, suck, swallowing and breast softening; test weighing before and after a feed where a scale is available.
• Maternal history of haemorrhage, breast surgery, drugs and contraception; haemoglobin, thyroid stimulating hormone, glucose; prolactin if galactorrhoea or Sheehan syndrome is suspected; pelvic ultrasound for retained placental tissue.
• Infant sodium, urea and bilirubin if weight loss is above 10 percent or the infant looks dehydrated.

The principle is to increase effective milk removal, correct the cause, feed the infant adequately in the meantime and use a galactagogue only after these steps.

• Supportive:
  • Skin to skin contact; feed 8 to 12 times in 24 hours with night feeds.
  • Offer both breasts at each feed and switch sides when swallowing slows; breast compression during feeds; correct latch and position.
  • After feeds express both breasts for 10 to 15 minutes using hand expression or a pump (about 8 times daily for 1 to 2 weeks).
  • Rest, fluids and a balanced diet; stop smoking; stop oestrogen containing contraception.
• Pharmacological:
  • Infant supplementation when intake is inadequate: expressed breast milk first, then formula, 150 mL/kg/day in 8 feeds (given by cup, spoon or syringe), reduced as supply improves.
  • Domperidone 10 mg oral 8-hourly for 7 to 14 days (maximum 30 mg daily; avoid with prolonged QT interval or interacting drugs such as erythromycin and fluconazole).
  • Or metoclopramide 10 mg oral 8-hourly for 7 days then tapered over 1 week (maximum 30 mg daily; avoid in depression or epilepsy).
  • Ferrous sulphate 200 mg oral 12-hourly for 3 months for anaemia.
  • Levothyroxine 50 micrograms oral once daily on an empty stomach, increased by 25 micrograms every 4 to 6 weeks to normalise thyroid stimulating hormone, for hypothyroidism.
  • Contraception change to levonorgestrel 30 micrograms oral once daily or a copper intrauterine device.
• Procedures: frenotomy for infant tongue tie; evacuation of retained placental tissue with antibiotics; none otherwise.
• Special groups:
  • Women with Sheehan syndrome (failure of lactation after severe haemorrhage with fatigue, hypotension and low cortisol) need hydrocortisone 20 mg oral in the morning and 10 mg at midday and levothyroxine 50 micrograms oral once daily (started after hydrocortisone) under specialist care.
  • Women with depression or epilepsy avoid metoclopramide.
  • Women with prolonged QT interval avoid domperidone.
• Red flags: infant weight loss above 10 percent, fewer than 4 wet nappies daily, jaundice, lethargy, hypernatraemia, fever in the infant, maternal fatigue with hypotension after haemorrhage, breast engorgement that does not soften after feeds.
• Follow-up: infant weight every 2 to 3 days until weight gain is 150 g per week or more; review of feeding at 1 week and 2 weeks; stop the galactagogue after 2 to 4 weeks if supply is adequate; review at 6 weeks with infant growth chart.