When a newborn baby is not putting on as much weight as expected, or has lost more than about 8% of birth weight by day 5, mothers are often advised to “top up” after feeds. A typical pattern is to spend a set amount of time attempting to breastfeed and then offer baby additional expressed or formula milk from a bottle, while the mum is asked to express to protect or boost her milk supply. This can, of course, be a brilliant way to get baby feeding and putting on weight. The drawback is that parents don’t know how or when to stop it, and how to wean their baby off the top ups. It is also relentless and exhausting, especially for a new mother who had a rough birth experience and really needs time to rest to recover.
When new parents ring me for support in this situation, there is quite a lot to unpick. From my side, I want to know what has happened up to this point. I need to know whether there is likely to be a short or longer term reason why milk supply might not be sufficient. It equally important to know whether the baby can effectively access the milk that is there. Only by understanding all this, and watching a baby through a whole feed, can we have an idea about what to do next.
Is there sufficient milk?
First, is there a reason why the mother’s milk supply has been low? If yes, is this a temporary issue, and has it been resolved? For example, a woman who has lost more than an average amount of blood during or after the birth, might not have made enough milk for her baby in the early days as her body has struggled to recover. This problem often, but not always, sorts itself out when mum gets better. Were mum and baby separated after birth for any length of time? When a mother has been too unwell to feed or express, it can take her supply a while to catch up. Sometimes a lack of effective breastfeeding or expressing in the early days can have a permanent impact on milk supply for that child. It seems that some women’s supply is more sensitive than others, it is an under-researched area. If this applies to you then I am so sorry, please call me or another professional to talk it through.
Next I would also ask whether the mum is taking any medications or has any health conditions that could impact on her supply. Conditions such as an underactive thyroid, polycystic ovaries, diabetes or pituitary issues, can all impact on the hormonal controls needed in the “milk factory”. A mother might not know exactly what has happened, but needing IVF can sometimes hint at an underlying hormone issue. Previous breast issues such as not developing breasts as a teenager, growing breasts that appear misshapen or tubular or undergoing breast surgeries, could also have serious implications on milk supply. I have met many women in my clinics in these situations. They often leave with a huge sense of relief when they understand that what is happening is not their fault.
In any case where a woman wants to breastfeed, we need to work with what we have to boost milk production and top up the baby when necessary. As breastfeeding works by supply and demand, regularly taking milk out the breasts by baby feeding and/or expressing at least eight times a day, will help to drive up the supply. It is important for the woman not to leave gaps of more than 3-4 hours between feeds at this time. Lots of skin to skin contact and unrestricted access to feeding makes a big difference, and it is so helpful if mum gets plenty of support with everything else.
Can baby feed well at the breast?
If we are sure that there is milk there for the baby to drink, we need to think about whether baby can get it out. A tiny, premature or jaundiced baby, for example, might not have the capacity or energy to breastfeed effectively for a while. For these little ones there is little point them spending energy repeatedly trying to latch if they can’t. They need expressed or formula milk from a bottle, nursing system or cup until they are big and strong and well enough to feed directly at the breast.
It is possible that a baby is healthy but unable to get milk from the breast because of problems with achieving a comfortable and effective latch. A good latch should not cause the mum pain or nipple damage. If you can see your little one swallow, their jaw drops and there is a little pause, and they make a tiny huff from their nose, then it is working. Please contact me or another lactation professional to help to achieve the best possible latch for your baby. If baby has a latch without much breast in their mouth, or they are tugging the nipple away from where it belongs, they will not be well fed. Tongue-tied babies can face challenges with this. Laid back feeding positions help in a lot of cases, as can “nipple sandwich” shaping techniques for flatter nipples and sometimes nipple shields if all else fails. Long term use of shields is also implicated in low supply, so use watchfully.
Some babies have birth injuries or physical problems that make it harder for them to feed. Some, like instrumental birth bruises or sore necks, will go with time. Others need more investigation. If you are worried that your baby is not doing well, please seek specialist support.
So how can you stop the cycle of top ups?
In the end, we need to be guided by baby’s behaviour at the breast. If your little one is in a situation where he or she latches comfortably, clearly sucks and swallows milk, gets offered both sides, comes off looking relaxed and sleeps for a bit before waking up hungry, then you might well have cracked it! Look for wet and dirty nappies appropriate for the age of your baby. By the end of the first week, at least six heavy wet nappies and at least two big poos a day would be a reasonable guideline. Even if everything is now looking great, I rarely advise new parents to ditch all the top ups at once. If baby has been having considerable top ups, it would be unreasonable to expect the breasts to pick up all the slack immediately. Pay close attention to your little one. There might be several feeds in a day when baby seems content afterwards. This is most likely in the midnight to midday stretch. Great, perhaps don’t offer a top up then. Monitor their behaviour and their nappies. Continue to boost supply with frequent expressing especially if your baby has not had a good breastfeed at a particular time of day. Offer the expressed milk as a top up. There is no rush.
Parents who have had a worrying time with their little one might still appreciate the certainty of some bottle feeds each day until their confidence has really improved. This is totally understandable. Softly does it. With time things tend to improve. And if they don’t, and your baby still needs top ups to be sufficiently fed, please try not to blame yourself or them. Sometimes these things just happen. If you have done everything you can to investigate and change the situation and it still isn’t working, accept that your baby needs extra milk and they will still thrive in your loving care. Be kind to yourself.
For any women wanting chapter and verse on these issues, I highly recommend “Making More Milk” 2nd edition (2020), by Lisa Marasco and Diane West
There are also many evidence based articles on the excellent site www.kellymom.com