Some Common and Not So Common Causes of Low Milk Supply (with solutions that may be helpful)

By Kelly Bonyata, BS, IBCLC

Is your milk supply really low?

First of all, is your milk supply really low? Often, mothers think that their milk supply is low when it really isn't. If your baby is gaining weight well on breast milk alone, then you do not have a problem with milk supply.

It's important to note that the feel of the breast, the behavior of your baby, the frequency of nursing, the sensation of let-down, or the amount you pump are not valid ways to determine if you have enough milk for your baby.

What if you're not quite sure about baby's current weight gain (perhaps baby hasn't had a weight check lately)? If baby is having an adequate number of wet and dirty diapers then the following things do NOT mean that you have a low milk supply:

Your baby nurses frequently. Breastmilk is digested quickly (usually in 1.5-2 hours), so breastfed babies need to eat more often than formula-fed babies. Many babies have a strong need to suck. Also, babies often need continuous contact with mom in order to feel secure. All these things are normal, and you cannot spoil your baby by meeting these needs.

Your baby suddenly increases the frequency and/or length of nursings. This is often a growth spurt. The baby nurses more (this usually lasts a few days to a week), which increases your milk supply. Don't offer baby supplements when this happens: supplementing will inform your body that the baby doesn't need the extra milk, and your supply will drop.

Your baby nurses more often and is fussy in the evening.

Your baby doesn't nurse as long as she did previously. As babies get older and better at nursing, they become more efficient at extracting milk.

Your baby is fussy. Many babies have a fussy time of day - often in the evening. Some babies are fussy much of the time. This can have many reasons, and sometimes the fussiness goes away before you find the reason.

Your baby guzzles down a bottle of formula or expressed milk after nursing. Many babies will willingly take a bottle even after they have a full feeding at the breast.. Of course, if you regularly supplement baby after nursing, your milk supply will drop (see below).

Your breasts don't leak milk, or only leak a little, or stop leaking. Leaking has nothing to do with your milk supply. It often stops after your milk supply has adjusted to your baby's needs.

Your breasts suddenly seem softer. Again, this normally happens after your milk supply has adjusted to your baby's needs.

You never feel a let-down sensation, or it doesn't seem as strong as before. Some women never feel a let-down. This has nothing to do with milk supply.

You get very little or no milk when you pump. The amount of milk that you can pump is not an accurate measure of your milk supply. A baby with a healthy suck milks your breast much more efficiently than any pump. Also, pumping is an acquired skill (different than nursing), and can be very dependent on the type of pump. Some women who have abundant milk supplies are unable to get any milk when they pump. In addition, it is very common and normal for pumping output to decrease over time.

Who to contact if you suspect low milk supply

If you're concerned about your milk supply, it will be very helpful to get in touch with a La Leche League Leader or a board certified lactation consultant. If your baby is not gaining weight or is losing weight, you need to keep in close contact with her doctor, since it's possible that a medical condition can cause this. Supplementing may be medically necessary for babies who are losing weight until your milk supply increases. If supplementing is medically necessary, the best thing to supplement your baby with is your own pumped milk.

Potential causes of low milk supply

These things can cause or contribute to a low milk supply:

Supplementing. Nursing is a supply & demand process. Milk is produced as your baby nurses, and the amount that she nurses lets your body know how much milk is required. Every bottle (of formula, juice or water) that your baby gets means that your body gets the signal to produce that much less milk.

Nipple confusion. A bottle requires a different type of sucking than nursing, and it is easier for your baby to extract milk from a bottle. As a result, giving a bottle can either cause your baby to have problems sucking properly at the breast, or can result in baby preferring the constant faster flow of the bottle.

Pacifiers. Pacifiers can cause nipple confusion. They can also significantly reduce the amount of time your baby spends at the breast, which may cause your milk supply to drop.

Nipple shields can lead to nipple confusion. They can also reduce the stimulation to your nipple or interfere with milk transfer, which can interfere with the supply-demand cycle.

Scheduled feedings interfere with the supply & demand cycle of milk production and can lead to a reduced supply, sometimes several months later rather than immediately. Nurse your baby whenever she is hungry.

Sleepy baby. For the first few weeks, some babies are very sleepy and only demand to nurse infrequently and for short periods. Until baby wakes up and begins to demand regular nursing, nurse baby at least every two hours during the day and at least every 4 hours at night to establish your milk supply.

Cutting short the length of nursings: Stopping a feeding before your baby ends the feeding herself can interfere with the supply-demand cycle. Also, your milk increases in fat content later into a feeding, which helps baby gain weight and last longer between feedings.

Offering only one breast per feeding: This is fine if your milk supply is well-established and your baby is gaining weight well. If you're trying to increase your milk supply, let baby finish the first side, then offer the second side.

Health or anatomical problems with baby can prevent baby from removing milk adequately from the breast, thus decreasing milk supply.

Increasing your milk supply

Milk production is a demand & supply process. If you need to increase milk supply, it's important to understand how milk is made - understanding this will help you to do the right things to increase production.

To speed milk production and increase overall milk supply, the key is to remove more milk from the breast and to do this frequently, so that less milk accumulates in the breast between feedings.

OK, now on to things that can help increase your milk supply:

Make sure that baby is nursing efficiently. This is the "remove more milk" part of increasing milk production. If milk is not effectively removed from the breast, then mom's milk supply decreases. If positioning and latch are "off" then baby is probably not transferring milk efficiently. A sleepy baby, use of nipple shields or various health or anatomical problems in baby can also interfere with baby's ability to transfer milk. For a baby who is not nursing efficiently, trying to adequately empty milk from the breast is like trying to empty a swimming pool through a drinking straw - it can take forever. Inefficient milk transfer can lead to baby not getting enough milk or needing to nurse almost constantly to get enough milk. If baby is not transferring milk well, then it is important for mom to express milk after and/or between nursings to maintain milk supply while the breastfeeding problems are being addressed.

Nurse frequently, and for as long as your baby is actively nursing. Remember - you want to remove more milk from the breasts and do this frequently. If baby is having weight gain problems, aim to nurse at least every 1.5-2 hours during the day and at least every 3 hours at night.

Take a nursing vacation. Take baby to bed with you for 2-3 days, and do nothing but nurse (frequently!) and rest (well, you can eat too!).

Offer both sides at each feeding. Let baby finish the first side, then offer the second side.

Switch nurse. Switch sides 3 or more times during each feeding, every time that baby falls asleep, switches to "comfort" sucking, or loses interest. Use each side at least twice per feeding. Use breast compression to keep baby feeding longer. For good instructions on how to do this, see Dr. Jack Newman's Protocol to manage breast milk intake. This can be particularly helpful for sleepy or distractible babies.

Avoid pacifiers and bottles. All of baby's sucking needs should be met at the breast (see above). If a temporary supplement is medically required, it can be given with a nursing supplementer or by spoon, cup or dropper.

Give baby only breastmilk. Avoid all solids, water, and formula if baby is younger than six months, and consider decreasing solids if baby is older. If you are using more than a few ounces of formula per day, wean from the supplements gradually to "challenge" your breasts to produce more milk.

Take care of mom. Rest. Sleep when baby sleeps. Relax. Drink liquids to thirst (don't force liquids - drinking extra water does not increase supply), and eat a reasonably well-balanced diet.

Consider pumping with a hospital grade pump if available. Adding pumping sessions after or between nursing sessions can be very helpful - pumping is very important when baby is not nursing efficiently or frequently enough, and can speed things up in all situations. Your aim in pumping is to remove more milk from the breasts and/or to increase frequency of breast emptying. When pumping to increase milk supply, to ensure that the pump removes an optimum amount of milk from the breast, keep pumping for 2-5 minutes after the last drops of milk. However, adding even a short pumping session (increasing frequency but perhaps not removing milk thoroughly) is helpful.

Consider a galactagogue. A substance (herb, prescription medication, etc.) that increases milk supply is called a galactagogue. We recommend Fenugreek and Blessed Thistle 3 capsules of each, 3 times per day. Or you can purchase a herbal blend made by Mother Love called “More Milk Plus” All found at health food stores like Good Earth and Amazon.

BREASTFEEDING AND LOW SUPPLY: COMMON AND SURPRISING CAUSES AND SOLUTIONS

Low milk supply is always listed as a top reason why mothers quit breastfeeding and switch to formula. Experts often claim that the percentage of women who can't produce enough milk is extremely small (usually numbers under 5% are quoted, without any specific source being given). However, the number of women who say they tried everything and still couldn't make enough milk seems to be on the rise. This article explores some of the possible reasons for that, including polycystic ovary syndrome (PCOS), diabetes and pre-diabetes, and mammary hypoplasia (insufficient glandular tissue).

Why do so many mothers struggle to make enough milk?
In Bangladesh, where infant formula isn't readily accessible, affordable or safe for most families, 98 percent of babies are breastfed and the average age of weaning is 33 months (source: WHO Global Data Bank on Infant and Young Child Feeding). In Norway, a country well known for having created perfect conditions for breastfeeding, around 80 percent of babies are still being breastfed at six months of age (source: Suzanne Barston, Bottled Up). Norway's 80 percent is significantly higher than in countries like Canada, the United States, and the United Kingdom,  but it is also a far way off from the 98 percent in Bangladesh.

So what is the difference? I think part of it is certainly choice. Although formula feeding may be frowned upon in Norway, ultimately, women still have the option not to breastfeed. Infant formula is accessible and Norwegians generally have the financial means to be able to afford it. Some women may simply not want to breastfeed or may find it too difficult and they have the freedom to make that choice. A mother in Bangladesh, however, would have to grit her teeth and push through. 

Beyond the issue of choice, another element that is worth considering is that there are certain medical conditions that are more prominent in Western developed countries that can have an impact on a woman's ability to produce enough milk. In particular, many medical conditions that create fertility challenges for women can also cause low milk supply. While there have been advancements in fertility treatments in the Western world, allowing women with fertility challenges to have babies, those same women may not be aware that they could have trouble breastfeeding as well.

In developing countries, some of the conditions that can cause infertility are less common than in the developed world. Additionally, women facing infertility in developing countries are probably much less likely to end up having a baby because they don't have access to the same types of medical treatment we do in the Western world. So our advancements in the area of fertility treatments may unintentionally be increasing the percentage of mothers who will struggle to produce enough breast milk. Unfortunately, health care providers and other sources of breastfeeding information are not preparing mothers who struggle with infertility for the fact that they may struggle to breastfeed their baby. 

Common Causes of Low Supply

Before we get into the medical conditions that can cause low supply, it is important to note that there are a number of fairly common and well known causes of low milk supply that primarily have to do with breastfeeding management. These factors are generally easily to control and don't require much more than a good understanding of breastfeeding best practices and the law of supply and demand.

At a very basic level, when milk is removed from your breast, that sends a signal to your body to make more. The more milk that is removed, the more milk your body makes. The less milk that is removed, the less milk your body makes.

• Scheduling or timing feeding: If you're getting advice from an older generation or from misguided baby training books, you may think that you should be trying to get your baby on a schedule or that you should be feeding for a specific amount of time at each feeding. This is not the case at all. Scheduled or timed feeds can make your baby go hungry and tamper with your milk supply. The best way to establish and maintain a strong milk supply is to breastfeed your baby on demand. You can't nurse too frequently, but you can nurse too infrequently. Newborns should be nursing 10 to 12 times per day. If you're not sure what signs to watch for, check out the information on Hunger Cues on kellymom.com. It can sometimes be hard to read those cues during the early days, so when in doubt, put the baby to your breast. 

• Skipping a feeding or supplementing: Breastfeeding can be overwhelming and all consuming. Sometimes moms just want to get a bit more sleep or want to go out for a bit without the baby. So they leave their partner or someone else in charge of giving a bottle. Unfortunately, if the mom doesn't then pump during the time when that bottle is being given, it will send signals to her body to make less milk and that can decrease her supply. If giving a bottle (without pumping to replace it) becomes a regular habit (e.g. once per day, several times per week), it can significantly impact the mom's ability to produce enough milk. The early days of breastfeeding are especially critical for establishing a strong milk supply and nursing frequently and not skipping feedings is very important.

There are numerous other possible causes of low supply including some medications, hormonal birth control, retained placenta, poor latch, nipple confusion and more. For more information on getting established with breastfeeding, check out the article Breastfeeding Your Newborn on kellymom.com. 

Lesser Known Causes of Low Supply

What if you're doing everything right and your body still isn't making enough milk? In addition to the common reasons for low supply, there are a number of lesser known causes of low supply that often catch new mothers by surprise. Many of these seem to be more prevalent in the developed world than in the developing world, which may be one reason why such a large proportion of mothers seems to struggle with low supply in the Western world. All of the causes described below have the potential to impact a mother's milk supply, but it doesn't do so consistently. Some mothers with these medical conditions will struggle with breastfeeding and others will have no problem at all. But all women with these conditions apply should be aware that it could impact their ability to breastfeed their baby. 

The first three conditions that can impact milk supply are, in many cases, related. Women who have one of these are often prone to the others as well. 

Diabetes and Pre-Diabetes

Scientists have discovered a link between insulin and breast milk production. Mothers who have low levels of insulin may also have trouble producing enough milk. This will be of interest and concern to mothers with diabetes, of course. However, it may be an even bigger problem for mothers who have pre-diabetes or undiagnosed diabetes. If they do not have a formal diagnosis and are not doing anything to control their insulin levels, this could unknowingly make it difficult for them to produce enough milk. Diabetes rates have doubled in the past 12 years, in particular among young women. As diabetes rates increase (and especially as the number of undiagnosed cases of pre-diabetes and diabetes increases), the number of women who have trouble breastfeeding their babies is likely to increase too. 

Polycystic Ovary Syndrome (PCOS)

Polycystic Ovary Syndrome (PCOS) is one of the most common female endocrine disorders and can affect a woman's hormone levels, periods, ovulation, fertility and ability to produce enough milk when breastfeeding. According to research by Dr. Charles Glueck, MD Medical Director of the Cholesterol and Metabolism Center at he The Jewish Hospital - Mercy Health, PCOS affects around six to eight percent of Caucasians, eight to 10 percent of African-Americans and 10 to 12 percent of Latinos and Native Americans. Lisa Marasco, MA, IBCLC, notes that PCOS is related to a number of possible reasons for lactation problems, including hyperandrogenism (can inhibit mammary development and milk synthesis), insulin resistence, hypothyroidism, and possibly too much estrogen. She notes that "PCOS is a collection of different pathologies. A woman with one or more of these problems may or may not have a diagnosis of PCOS, but can still be affected." According to Dr. Anita Swamy, Medical Director at the Chicago Children's Diabetes Center at La Rabida, there is a strong link between PCOS and diabetes: "While type 2 diabetes risk factors such as insulin resistance and glucose intolerance are often seen in patients with PCOS, PCOS itself confers a significant risk, up to 10-fold versus the normal population, for development of type 2 diabetes."

Mammary Hypoplasia / Insufficient Glandular Tissue (IGT)

Some women do not have enough glandular tissue to nourish a child. According to noteveryonecanbreastfeed.com, "women with Insufficient Glandular Tissue may have experienced a lack of breast changes during puberty and/or pregnancy, no engorgement, and a low milk supply."  According to The Breastfeeding Answer Book (referenced on LLLI), 1 out of 1000 mothers experiences primary lactation failure. This can be due to hypoplasia or other causes. However, like with diabetes and PCOS, assisted fertility and hormonal support to conceive babies is leading to an increase in the number of cases of babies born to mothers with hypoplasia. Not a lot is known about the causes of mammary hypoplasia, but there is likely a genetic link (women who have it often say that no one in their family was able to breastfeed).

Breast or Nipple Surgery

Another possible cause of low supply is breast or nipple surgery, which can include breast augmentation, breast reduction and other types of breast or nipple surgery. According to BFAR.org (a website dedicated to providing information and support for breastfeeding after breast and nipple surgeries), there are many factors that affect how much milk a mother can make after surgery: "The condition of her ducts is very important, however, that the state of the nerves that affect milk release is equally critical.   Fortunately, the ducts and nerves can regenerate through processes known respectively as recanalization and reinnervation, which are critical to the impact of breast surgery upon milk production and release." Mothers who have had breast or nipple surgery are often able to breastfeed, but may not be able to establish a full supply. This doesn't mean that it isn't worthwhile and, as the book on breastfeeding after reduction surgery by Diana West, IBCLC is titled, you should Define Your Own Success.

Solutions for Low Supply

If you have a newborn and are worried that your baby isn't getting enough milk, first check kellymom.com's page on Low Supply, in particular the section called Is your milk supply really low? (which is at the beginning of this article.)

If you are a mom with one of the conditions discussed above, there are some things that you can do to help prepare for breastfeeding. I know people with these conditions who struggled significantly with breastfeeding their first child, but were able to successfully breastfeed their second child because they were more informed and more prepared.

• Gather Your A-Team: If you want to breastfeed, having the right people around you in the right environment is critical. This requires doing the same things every mother should do to get breastfeeding-friendly prenatal care, hospital and pediatrician, but it may also mean seeking out certain specialists who have experience working with mothers with your condition and knowing how you can access them for support and expertise before and after your baby arrives.

• Learn More About Your Condition: Women should do research into their own individual situation to find out what their chances of being able to breastfeed are and to learn about possible solutions. Consult your healthcare provider and experts in the field who are knowledgeable about lactation. For example, as it relates to PCOS, Lisa Marasco, MA, IBCLC suggests: "Be aware of your individual PCOS issues. Insulin resistance? Androgen problems? Do everything in your power to address these, before conception preferably but even during pregnancy. Have someone assess overall breast development, especially if the mother herself has any concerns. Seek a consultation with a lactation consultant if breasts are unusual or are not growing/changing during the pregnancy."

Once your baby arrives, you will want to get breastfeeding started as quickly and as well as possible. This includes doing the same things any mother would do for good breastfeeding management (nursing frequently, on demand, etc.), but may involve doing a bit more.

• Remove as much milk as possible in the first two weeks: BFAR.org suggests removing as much milk as possible from your breasts in the first couple of weeks. This is because the supply of breast milk is determined by demand, so the more you remove the more you make. This certainly involves breastfeeding as frequently as possible, but could also involve some pumping with a high quality, hospital grade, double electric pump. Being able to pump hands-free will make it easier for you to get through those times and not feel chained to the pump (you can read, eat, use the computer, tickle the baby, etc. while pumping hands-free). Lisa Marasco, MA, IBCLC suggests offering the breast right from the start and keeping the baby skin to skin during early days to encourage more nursing. 

• Address any concerns immediately: If you have latch problems, plugged ducts, or other breastfeeding problems, address them right away. The longer you wait, the more likely these regular nursing problems are to have an impact on your supply that may not be easy to recover. If the baby is sleepy or not latching well, pump after feedings to ensure you're removing more milk from the breast.

• Identify and address your risk factors: When working with mothers with PCOS, Lisa Marasco, MA, IBCLC tries to identify and address their risk factors. For example: "Metformin, for instance, reduces insulin resistance. This in turn can help reduce androgens. Normalizing the hormonal milieu during and after pregnancy is going to give mom the best chance. I also may suggest specific herbal galactogogues—for instance, goat’s rue is reputed to stimulate mammary development and milk production. It has anti-diabetic properties and is the herb that metformin was developed from, making it especially appropriate, I think, for PCOS. Fenugreek has similar properties, and I also like saw palmetto, goats rue, and fennel for both mammary stimulation and anti-androgen action on top of stimulating milk production." DO NOT USE FENUGREEK IF YOU HAVE THYROID DYSFUNCTION.

• Medications that increase milk supply: Depending on where you are located, there may be certain medications you can access to increase your milk supply. For example, in Canada many doctors will prescribe Domperidone according to the recommendations of renowned breastfeeding expert Dr. Jack Newman. Domperidone isn't easy to access everywhere though, so speak to your lactation consultant and physician to find out what options are available to you.

• Supplementing at the breast: No matter how much milk you make, there are benefits to you and your baby for feeding at the breast using a system such as Lactaid.  Feeding at the breast boosts the baby's immune system through skin-to-skin contact, better develops the jaw muscles, and fosters that wonderful bonding experience that every new mother and baby pair need and crave.   You can use your own pumped milk, donor milk, infant formula, or some combination thereof. Yes, You CAN Breastfeed Successfully No Matter How Much Milk You Make