This post was prompted by a woman who wrote that her four-month-old baby was gaining weight too slowly, and that she had decided to stop breastfeeding exclusively because of worries about her milk supply. I am hoping that this information will be helpful to mothers who google "four-month-old baby with slow weight gain" or "sliding down the growth charts 4 months" or "milk drying up four months." I don't provide as much hands-on breastfeeding support as I used to, so shoot me an email if you catch any errors, please.
1) Less in the breast means more in store. Hm, maybe I was
trying too hard to make a catchy rhyme and wound up obscuring my point.
Here is the fundamental law of milk supply: the breast makes milk
fastest when it's emptiest, slowest when it's fullest. To increase milk
supply, empty your breasts more completely and more often. (If you want more detail, take a look at this article.)
2) Human children grow most appropriately when fed human milk. It's not surprising, if you think about it, that kids grow at different rates depending on their diets. Breastfed children put on weight more rapidly in the first few months than formula-fed children (causing some jumpy doctors to expatiate about overfeeding and obesity epidemics), and more slowly from about 3-4 months through the end of the first year (causing many more doctors to dispense dated advice that leads straight to iatrogenic supply issues and premature weaning). This does not mean a mother has a milk supply problem. It does not mean she needs to supplement with artificially modified cows' milk so that her child will grow like all the other babies receiving artificially modified cows' milk. In the absence of other symptoms, it for sure doesn't mean the baby needs a workup for various scary pathologies.
Growth charts, just in case you were unclear, do not proceed from the mouth of God. They reflect the way a group of children did grow, not the way yours should grow. Growth charts from formula-fed populations do not reflect the species norm for growth patterns in infancy, but lots of doctors don't know this. If your doctor's office is still using the CDC charts instead of the free downloadable WHO charts normed on breastfed infants, I suggest you bring your own.
3) Breasts come in all sizes. This is not news, you are
thinking, but I'm talking about storage capacity and not cup size. You
can be an A cup with a large storage capacity, or a DD with a teeny
tiny storage capacity. Women with small storage capacities can make
just as much milk for their babies, but they have to remove it more
frequently. In this culture, we're all about the large storage
capacity. Is he sleeping through the night? Are you able to leave him
with someone else for a few hours and not worry that he (or you) will
need to nurse? That's much easier for the woman who can store more
milk. Small storage capacity means you may be vulnerable to supply
downturns when baby sleeps all night, or goes longer without nursing
during the day. (Small storage capacity also has advantages, I feel
compelled to say. Off the top of my head: longer average duration of
amenorrhea, which is at least partially responsible for the diminished
risk of ovarian cancer and premenopausal breast cancer seen in mothers
who breastfeed; more frequent hits of the happy-making hormones
prolactin and oxytocin; and perhaps more comfortable babies, who get
frequent small snacklets instead of giant stomach-distending meals.)
1) Nurse that baby. To make more milk, empty your breasts more thoroughly and more often. Throw out the schedules; streamline your life for a few days and focus on nursing whenever your baby seems remotely interested. Before you nurse, use breast massage briefly to increase the volume and fat content1 of the milk available during that feeding. While baby is nursing, use breast compression to assist with breast emptying, and to settle a baby who seems to want more milk pronto. Even if they're not part of your usual routine, short-term babywearing and co-sleeping will increase the frequency of nursings, which is good for milk supply.
2) What's changed? Don't just think about what's going on with the baby -- what's going on with you? Are you taking medications? Hormonal birth control is a frequent culprit -- even progestin-only preparations can interfere with milk production in sensitive women. Stopping the hormones can often reverse the problem. (I was going to recommend LAM as an easy free effective alternative, but I don't know if there are concerns about relying on LAM after synthetic hormone use. Alicia? Anybody? Does a woman have to be more systematic about NFP in that case?)
Cold medicine, particularly pseudoephedrine (the active ingredient in Sudafed), can also cause problems. Some women hear that it's considered safe for the baby, but learn the hard way that it can cut a mother's milk supply by 24%. Many times the milk supply will rebound, but if it doesn't, I highly recommend the resources at http://bfar.org. Much of the information there is helpful for any woman with supply concerns, not just those who've had surgery.
Has your baby recently started pulling away and looking around during nursing? Some mothers interpret this as a complaint about the milk supply, but it's normal four-month-old behavior. Try reducing stimulation, perhaps by nursing in a sling or other baby carrier so that a) there's nothing to see except breast and sling fabric and b) if baby tries to turn around mid-nursing, he won't be able to take your nipple very far (ouch). Has your baby seemed unhappy? Teething, an ear infection, a UTI -- any of those could lead to a miserable baby who's not nursing as effectively. Is there a chance you could be pregnant? Sometimes a reduction in milk supply is the first symptom for a nursing mother.
3) Pump it up. Pumping can be a quick and effective way to boost milk supply. Unfortunately, it is also kind of a drag. There is some great advice on the web about making pumping tolerable, so I will just stress two things. First, do not borrow your sister-in-law's old Pump In Style for short-term pumping. The PNS is a) an open-system pump, designed so that your SIL's milk may still be floating around in there no matter how carefully she cleaned it, and b) only guaranteed to last a year. Breast function is more robust than breast pump function, but so many mothers think that their limited response to a flagging breast pump means their milk supply is flagging. Rent a good pump for a week. Really. It's cheaper than formula and you'll thank me later.
My second piece of advice: power-pump. If there were a Nobel Prize for clinical breastfeeding support, it would go to the LCs who came up with power-pumping. Power-pumping eliminates the need for a big chunk of time in which to sit motionless in front of a breast pump (while your older children "redecorate" and perhaps give the dog a fetching new haircut) and simplifies the cleanup. Power-pumping takes advantage of the anti-microbial properties of human milk, which can be left at room temperature for ten hours and have FEWER bacteria at the end than at the beginning.2 To power-pump, find a corner where you can leave your breast pump set up for a while (maybe 4 hours, if you're pumping for a healthy full-term baby). Whenever you have a few minutes, sit down and pump -- a little bit here, a little bit half an hour later, a little bit forty-five minutes after that. You can stop and rescue the cat from his impending coronation with a headpiece crafted from Play-Doh and cold spaghetti. You don't have to do all your pumping in one fell swoop, and you don't have to clean all the bits and pieces in between mini-sessions. Genius.
Oh, wait, I have a third suggestion and it is this: pump right after you nurse the baby. You'll get very little in the collection containers, but you'll send a powerful message to your body: More milk. Right away, please. Remember, the emptier the breast, the louder the call for more.
4) Think about your options. My intent in this post is not to dictate how long anyone ought to breastfeed, or breastfeed exclusively, or to tell anyone what remedies she ought to try. Different mothers prioritize breastfeeding differently; different mothers have different hassle thresholds. One mother's weekend of extra cuddling and nursing and pumping is another mother's purgatory, and I am not attempting to shove the latter into the former's camp. But I find it absurd that the solution routinely proposed for slow weight gain in breastfed babies is the introduction of a potent allergen with a high potential renal solute load, a substance associated with increased risks of health problems both short- and long-term. If a mother wants to keep breastfeeding her baby, there's usually a way to make it happen.
If your baby's growth is a concern, vigilance is appropriate; panic and one-size-fits-all action plans are not. You have choices in addition to formula supplementation. If your baby's weight is in the normal range, he is meeting developmental milestones, and he is reasonably happy, you might just watch and wait. This week's weight could be a blip that will level out two weeks from now. Or it could be part of a trend that will be clearer in a month. With a healthy baby you can take a little time to figure things out, as long as you stay alert for signs of trouble. If you opt for milk-based supplementation, the World Health Organization recommends your own expressed milk as the first choice, pasteurized donor milk as the next option (I know -- good luck with that one in this part of the world), and finally formula. For a baby four months or older, you could also consider the introduction of nutrient-dense solids such as mashed avocado (not rice cereal, which supplies bulk with few calories).
Saying "I don't have enough milk" can be a self-fulfilling prophecy. "I didn't have enough milk for my first baby either" overlooks the reality that many women with a history of milk supply problems can do just fine nursing subsequent babies: milk production usually gets more efficient. Keep in mind that in many cases, a little bit of trouble-shooting coupled with a few days or a week of extra milk removal can turn things around, setting you up for months of harmonious nursing, if that's your goal. Get input about the problem from an experienced LC or volunteer breastfeeding counselor; get some temporary help with your other responsibilities. Other people can cook your dinner or bring you takeout, but only you can build your milk supply. Good luck!
1Stutte PC, et al. (1988) The effects of breast massage on volume and fat content of human milk. Genesis, 10, 22-25.
2Barger, J. and Bull, P. (1987). A comparison of the bacterial composition of breast milk stored at room temperature and stored in the refrigerator. Intl J Childbirth Ed, 2, 29-30.