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Thread: Another "please help": low milk supply & risk of over-supply

  1. #1
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    Default Another "please help": low milk supply & risk of over-supply

    Background: Mother to two children. With this one, we've had latching issues from the start. At the hospital they recommended we bottle feed her. She was bottle fed from Day 2. At the beginning the pain was too intense from me. They suspected she might have lip tie, but no-one could confirm it. I contacted a local LLL leader but she wanted me to pay her to talk more (she is a ICLBC also) and I didn't know where to turn so I read a lot online, and also asked my MD for prescriptions.

    My baby is now no longer willing to take the bottle (any bottle) so I am having to EBF her. It feels hard as my milk supply is low. The doctor gave me a prescription of APNO although she should have told me that it has cortisone and I would have used it less. But I can now put her back on my breast, especially stressful as she won't take a bottle.

    Strategy:

    Domperidone 3-4 x 2 tablets, Fenugreek, Blessed Thistle, Mothers Milk, pumping after BF

    RISK:

    The real question is pumping.

    I pump after each BF to try to stimulate supply, BUT the baby usually wants to eat every 1.5 hours. I think she is underfed each time because of my milk supply and her inefficient latch.

    Questions:

    1. Should I be pumping and BF at the same time for every feed?
    2. As a result, the baby hardly gets enough to drink (she is very unhappy) - only one feed at night is she satisfied. The rest, between pumping and drinking, I never have enough for her. Should I stop pumping and just focus on feeding her?
    3. Is there a risk if I stop that my supply further dwindles?
    4. If I DON'T stop pumping, is there a risk of over supply in future?

    Please help - I am so stressed and confused.

    I'd be very grateful for any perspectives and help.

    B

  2. #2
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    Default Re: Another "please help": low milk supply & risk of over-su

    Hi bunnyears, I am sorry you are having this difficulty.

    First, an LLL leader, whether she is an IBCLC or not, should never be charging a breastfeeding mother who called her for help as an LLL Leader for talking to her. Ever. Many LLL Leaders are also IBCLC's and it can be hard sometimes to keep the two "hats" separate, but that is not your problem, it is hers. Please report this LLL Leader and whatever she said to you up the chain at LLL. If you cannot figure out how to do that (it is confusing and is different depending on where the person is) you can PM me and I can try to help you figure out where to go with complaints.

    Also please do not let this unfortunate encounter sour you on LLL Leaders OR IBCLCs. LLL Leaders are almost always going to be your best source for breastfeeding support and information. For the most part they are wonderful, dedicated people who sacrifice a lot to be Leaders and they do it because they have a passion for helping mothers and babies.

    A properly trained and educated IBCLC is usually going to be the best bet for a mom who is facing real, clinical breastfeeding barriers like ongoing latch pain or low milk production that is so severe the mom has considered/tried pumping and bottles instead of nursing. They are professionals and yes they will ask to be paid for their services like any other professional. But there are often ways to make it more affordable. Costs can vary quite a bit, many insurances cover services, and sometimes there are free or low cost clinics available. You may have to look beyond this one person to get the help you need. Again if you want to PM me I can try to find out what local services might be available to you.

    Whenever a mom is dealing with a low milk production concern, it is first important to figure out if production is really low and how low. How are you determining that your milk production is low? Low production can be accurately determined only by weight gain issues or by doing multiple before and after nursing weight checks.* A baby seeming "not satisfied" is not an accurate way to determine milk production. Newborn babies fuss lots and nurse lots even when they are getting plenty of milk.

    Latch pain usually indicates an issue with latch, and a poor latch might also be causing baby to be having a hard time transferring milk efficiently. *This would be a different concern than low milk production but it would also be determined by looking at gain and in particular, at several before and after nursing weight checks. (Of course, such a situation could lead to low milk production.)

    A baby wanting to eat every hour is usually normal in the newborn period. However most babies do take longer breaks here and there. If baby is nursing every 1.5 hours, that would mean baby is nursing 16 times in 24 hours. Believe it or not, sometimes even that kind of high frequency could be normal, but it would help to know more specifically how many times in 24 hours baby usually nurses.

    Also it would help to know:

    How old baby is now
    How baby has been gaining (day of life and each weight check number)
    from when to when baby got bottles and how many baby got each day total, how many ounces each day total in bottles, and how often you pumped also.
    What kind of pump are you using and about how much you could pump at a time and overall.

    I would need the above info to help you more, but I will try to answer your questions generally.

    1) If your baby is getting enough to eat by nursing at the breast, there is probably no reason to pump. A newborn can be expected to nurse about 10-15 times in 24 hours.
    2) I do not understand. Are you pumping before baby nurses or after? How do you know there is not enough?
    3) If your baby is not able to stimulate your milk production normally, and/or baby needs supplemental feedings (anything not at the breast) to gain normally, then yes, there is a risk that your milk production will reduce or not increase as needed if you stop pumping entirely. But you may be able to pump less often safely. It just depends on exactly what is happening.
    4) If at this point you think your production is low, I would suggest do not worry about OP concern. Severe OP can be a problem (mostly due to concerns for mom's health) but low production is much more of a problem and usually much more difficult to solve. Of course again, if baby is gaining normally just nursing, there is no need to pump. Also, if you are really worried about OP taking domperidone etc. is going to be the more immediate concern there, not pumping.
    Last edited by @llli*maddieb; August 21st, 2017 at 09:01 AM.

  3. #3
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    Default Re: Another "please help": low milk supply & risk of over-su

    First of all, thank you, MaddieB, I must admit I felt quite disheartened and reluctant to contact the LLL after that experience, so thank you for that. I will PM you separately and now respond to your post:

    Baby is 8 weeks
    Baby is gaining well according to the last 3 weigh ins (only once she dropped in weight) - BUT in the last times she was weighed, she was being fed formula by bottle as well as some BF
    Since 10 days or so ago, she has suddenly refused the bottle, and my only option now is to BF her. She even refuses expressed milk in a bottle. I have not weighed her since this time.
    Baby was getting bottles since Day 2 to 10 days ago. We didn't measure at the beginning but my records show me that in Week 3 she was receiving between 285-470mL by bottle with some intermitten BF.
    In Week 4, after the doctor told us we were underfeeding her, due to weight loss, we upped bottles to about 500-650.
    Since August 11 she has refused the bottle (she looks disgusted or spits the milk back out, or plays with it with her tongue - unless she is very hungry) - she has received 50-210 mL of expressed milk by bottle

    1. How are you determining that your milk production is low?

    a) History of baby with ineffective latch

    Baby has suspected lip tie, although no-one can confirm definitively (doctors nurses dentist). I'm told she has a small mouth, I have a big nipple and that she has a little bit of a lip tie but not much. Her latch strength is very strong, and basically she usually latches, and then "adjusts" herself back to the nipple where she starts sucking. From the start, when she unlatches, my nipples look like lipsticks and there is a strong white ridge.

    So the problem with latching is known. I considered lip tie laser but as noone seems sure if it really is lip tie, I don't want to put her through laser. And my doctor thinks she will outgrow the problem as her mouth gets bigger.

    b) Pumping history

    I was advised by hospital LC to start bottle from Day 2 but I was NOT diligent with the pumping - I really didn't know so much about this stuff back then and was quite traumatized after my delivery. Since then I've realized what I have done so as the nurse said, I now need to "catch up". I have now been pumping for at least 5 times a day since Week 3. I started taking Domperidone at the end of July.
    My supply started increasing a bit since August but one day, a doctor told me to reduce my pumping from 15-20 minutes to 5 minutes and I got intense pain (sharp pains) and I got scared and stopped the Domperidone. Anyway I restarted again 9 August but my supply seems low again. I'm very confused about how to approach the pumping.
    The other issue is, since August 11, when the baby refuses to take the bottle, I can no longer pump with peace of mind as I'm constantly also having to BF her, and worry she is not getting enough.

    c) Baby

    Most times baby is on the breast for a long time and I usually unlatch her, she hardly unlatches herself. At times when I have just pumped, I think and realize there is no milk because
    baby basically looks frustrated and acts frustrated on the breast. She writhes around and attacks my breast from all angles, pulling the nipple as well. I also think that sometimes there IS milk but she is not good at taking it out.
    At night time, after a 5 hour sleep my breasts are full and I notice the baby just sucks and sucks and seems content afterwards. The breasts at that point are fuller and harder and she can latch just on to her preferred location AT the nipple (not best practice but I no longer try the other way as she just clicks on the breast) - and get full

    1) If I was confident she is drawing adequately from the breast I would think this is best. Because of her latch issues, I'm scared that if I just let her nurse my milk supply will fall again. Also, sometimes when I pump after she nurses, I still get 50 mL out from both breasts.
    2) I pump after she nurses, but she usually wants to BF again very soon. e.g. she eats at 11am - nurses until 11:30am. I pump at 11:45am for 15 minutes to 12pm. She wants to eat again at 12:30pm. I am in trouble
    3) Yes maybe I need to get her weighed, I really don't know what is happening
    4) Thank you

    Thank you again, very much, maddieb.

  4. #4
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    Default Re: Another "please help": low milk supply & risk of over-su

    Ok, I know I asked lots of questions but I do need those answers to help more. I am still not hearing exactly how baby is gaining. It would help to know. I do not need whole weight gain history, just the highlights. I am particularly curious what the gain was when you were told baby was gaining poorly and to increase supplements. If you can use pounds and ounces for everything that would help but if not I will convert.

    Also, how many times a day (24 hours) does baby nurse currently?

    Is baby currently getting any supplements at all? It is unclear.

    Have you ever sat with an IBCLC or anyone else who knows how to do it, and had breastfeeding fully assessed? I think it is important this happen if at all possible. Here is info on what this would consist of: http://www.cwgenna.com/lconsult.html I would suggest perhaps not getting the lip tie treated without having an IBCLC assess things first and to help you with follow up after.

    If baby is latching better on a fuller breast, that could indicate a few issues but guiding you there is above my knowledge. However, it may be that in this case, the pumping is causing poor transfer due to the breast being less full from the pumping when baby nurses. Of course a baby should be able to nurse just fine on a soft breast, so again this need for a full breast to get a good latch indicates a problem that will need to be addressed. But in the meantime, perhaps try pumping only when you are fairly sure baby is down for a while, or pump a bit less out at a time, or pump on one side only so the other side is more full when baby nurses?

    As far as how baby latches exactly, I suggest worry more about how it feels rather than how it looks. Many babies "nipple nurse" and it is just fine unless of course it is causing mom pain or injury.

    I will add more later, have to run.

  5. #5
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    Default Re: Another "please help": low milk supply & risk of over-su

    Quote Originally Posted by @llli*maddieb View Post
    Ok, I know I asked lots of questions but I do need those answers to help more. I am still not hearing exactly how baby is gaining. It would help to know. I do not need whole weight gain history, just the highlights. I am particularly curious what the gain was when you were told baby was gaining poorly and to increase supplements. If you can use pounds and ounces for everything that would help but if not I will convert.
    Thank you Maddie B. I will try to answer the questions:


    Also, how many times a day (24 hours) does baby nurse currently?
    During the day, she nurses between 1.5 hours an 2.5 hours generally - and at night now she sleeps 4-5 hours and then 3 hours during the night. I would say she still nurses 10 times a day.

    No, I have not sat with an IBCLC. Most in my area seem to charge hourly rates. I will try to find one I can trust.

    But in the meantime, perhaps try pumping only when you are fairly sure baby is down for a while, or pump a bit less out at a time, or pump on one side only so the other side is more full when baby nurses?
    OK I will try to do this. I am just scared, but I will adjust.

    Thank you!
    Last edited by @llli*lllkaren; August 26th, 2017 at 09:56 AM. Reason: added quote tags for clarity

  6. #6
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    Default Re: Another "please help": low milk supply & risk of over-su

    Week 3 she was receiving between 285-470mL by bottle with some intermitten BF.
    In Week 4, after the doctor told us we were underfeeding her, due to weight loss, we upped bottles to about 500-650.
    Ok real quick- 285-470 upped to 500-650 milliliters per bottle? a 500 milliliter bottle is 17 ounces! Or is this what baby was getting per day? Also, how much about do you pump when you pump if it is not after nursing? Pumping 50 mils after baby nurses sounds normal to me.

    Most times baby is on the breast for a long time and I usually unlatch her, she hardly unlatches herself.
    Long as in how long? Generally it is normal for a baby to want to nurse long periods. Some nurse a long time and others nurse shorter. What I mean is long sessions are not necessarily indicative of a problem.

  7. #7
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    Default Re: Another "please help": low milk supply & risk of over-su

    I would say she still nurses 10 times a day.
    It is normal for a two month old to nurse at least 10 times a day. Your baby's nursing pattern as far as frequency sounds entirely normal to me. In fact the night nursing is a little on the lower end of normal. Many babies wake more often than that at this age to nurse.

    Some IBCLCs charge an hourly rate and others charge a per consultation rate, but in the long run this amounts to the same thing. Again these are trained professionals who had to pay to be trained and educated and continue to pay to get the continuing education they need and the testing to remain certified. They have to carry insurance and have all the other overhead costs any other professional would have, even if they do home visits (do not have an office) they have many such costs. I would suggest read the article I posted above, then call a few and get a feel for what their experience is, their process is, etc before booking a consult.

    The weights are very wonky. Am I reading that correct? they indicate fairly fast gain up to 2 weeks, then actual loss!!!??? for the next two weeks, and then from 4 weeks to 6 weeks baby gained 3 pounds!!!????! Normal gain for this whole period (2 weeks to about 3-4 months) is average about one pound (or a little less) every 2 weeks. If baby really gained 3 pounds in 2 weeks, part of that may have been catch up, but it would overall indicate overfeeding.

    Overfeeding is not some terrible thing, it routinely happens when a baby is bottle fed. For the breastfed baby and mom, the worst thing about overfeeding is it makes mom think she does not make enough milk when she actually does, or think baby cannot nurse normally, or makes mom think that a baby should behave like an over fed baby and not like a regular baby.
    Last edited by @llli*maddieb; August 21st, 2017 at 12:20 PM.

  8. #8
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    Default Re: Another "please help": low milk supply & risk of over-su

    285-470 upped to 500-650 milliliters per bottle? a 500 milliliter bottle is 17 ounces! Or is this what baby was getting per day? Also, how much about do you pump when you pump if it is not after nursing? Pumping 50 mils after baby nurses sounds normal to me.
    That is a per day count

    Pumping not after nursing - depends - on a per day count I started around 300mL, now I think it is around 500mL (with a few BF sessions thrown in)

    Long as in how long? Generally it is normal for a baby to want to nurse long periods. Some nurse a long time and others nurse shorter. What I mean is long sessions are not necessarily indicative of a problem.
    When there is little milk, I feel she can stay there for hours, but she generally falls asleep and when I put her down she cries or wakes up and cries and wants to eat again.
    Last edited by @llli*lllkaren; August 26th, 2017 at 09:56 AM. Reason: added quote tags for clarity

  9. #9
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    Default Re: Another "please help": low milk supply & risk of over-su

    I would suggest read the article I posted above, then call a few and get a feel for what their experience is, their process is, etc before booking a consult.
    Thank you. I don't mind paying of course, it's more the quality I care about.

    The weights are very wonky. Am I reading that correct? they indicate fairly fast gain up to 2 weeks, then actual loss!!!??? for the next two weeks, and then from 4 weeks to 6 weeks baby gained 3 pounds!!!????! Normal gain for this whole period (2 weeks to about 3-4 months) is average about one pound (or a little less) every 2 weeks. If baby really gained 3 pounds in 2 weeks, part of that may have been catch up, but it would overall indicate overfeeding.
    I believe the weight loss factor was incorrect, as the doctor's office didn't calibrate it properly. Therefore, I don't know how accurate these measurements are. However, that said, when she gained weight, she was bottlefed up to 120mL (4 ounces). She was weighed today and since 2 weeks, she has gained 0.63 pounds.

    Overfeeding is not some terrible thing, it routinely happens when a baby is bottle fed. For the breastfed baby and mom, the worst thing about overfeeding is it makes mom think she does not make enough milk when she actually does, or think baby cannot nurse normally, or makes mom think that a baby should behave like an over fed baby and not like a regular baby.
    I believe, imo, a large part of the issue is baby doesn't seem to extract milk well. Sometimes she will go to the nipple part (where she seems most comfortable) and pull there. I have tried holding her head at the areola but I don't think I'm supposed to hold her head and she also often just stops and starts sleeping then. I think that the biggest stress is this to me.

    Thanks
    Last edited by @llli*lllkaren; August 26th, 2017 at 09:56 AM. Reason: added quote tags for clarity

  10. #10
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    Default Re: Another "please help": low milk supply & risk of over-su

    Hi again.
    I believe, imo, a large part of the issue is baby doesn't seem to extract milk well.
    I get it that you are thinking baby cannot nurse properly...but you really do not know if that is the case, it is at this point a suspicion, unless I am misunderstanding something here. And this is actually a very common suspicion that is often unfounded, and when a baby has been bottle fed and/or mom is pumping, the vast differences between pumping and bottles v. nursing at the breast tend to increase this suspicion. The concern that baby is not getting enough to eat at the breast, whether due to low production or some other issue, is one of the most common reasons moms stop nursing. But in fact often baby is transferring milk just fine and there is no problem with production, or when there is any issue, it is much more minor and more easily addressed than mom thinks.

    Here is how you tell a baby is getting enough to eat. Weight gain, accurately measured, is all the info you need. If a baby is gaining normally exclusively breastfed, there is almost certainly no problem. (Unless nursing hurts mom, that is the other main problem when it comes to breastfeeding.) You do not have to see an IBCLC to get properly done weight checks. Properly done weight checks means:

    Checks are done on the same digital, professional grade infant scale. It has to be the SAME SCALE each time, and if the scale is recalibrated between weight checks, you need to know that.
    Baby is naked or in a dry diaper
    Check is done carefully by someone who has the patience and knowledge to accurately weigh a squirmy baby.
    Number on scale is checked and rechecked and if something seems odd (like weight loss recorded in a 4 week old) the baby is weighed again and the scale checked out.
    Any math conversion is checked and rechecked.
    Weight checks are a reasonable time apart. Since babies do not gain exactly the same each day, but rather in fits and starts, the longer time elapse between two checks the more overall accurate your check will be. But of course when there is a concern baby is not getting enough, checks may need to be more often...just be sure to remember that gain in fits and starts is normal and try to look big picture.
    Conversions math is checked and rechecked

    The other way to measure how well a baby nurses is to do before and after nursing weight checks. What you want to see is that baby can transfer 2 ounces or more over about 20-30 minutes with baby nursing both sides in that time. That is the rule of thumb for indicating normal transfer when this type of check is done. The problem with before and after nursing checks is 1) you need to use a very accurate scale and know how to use it to do them properly and 2) sometimes baby is perfectly capable of getting enough milk but just not that hungry or for some other reason not nursing well when the check is done. So it really helps to have several of these done, unless of course your result is very good the first time.

    Sometimes she will go to the nipple part (where she seems most comfortable) and pull there. I have tried holding her head at the areola but I don't think I'm supposed to hold her head
    Have you tried adopting a more laid back nursing position? You leaning back (as little or as much as you like, but not flat on your back) and baby kind of on top of you? This often helps with "slippage"
    As far as holding baby's head, it is true that applying pressure on the back of baby's head can cause baby to reflexively push back into your hand or arm or whatever, and consequently this causes baby to pull away from the nipple and can cause baby to have a shallow latch or to pull on the nipple or to pop off. But in my experience it often does help to prop baby's head a bit with a hand or arm or whatever, maybe without pressing on the back if that is causing a problem. breastfeeding positioning is not about following the rules but about playing around and finding what works for you.
    she also often just stops and starts sleeping then.
    Well this is only a problem if baby is not getting enough to eat because baby is sleeping too much and nursing too little. It is normal for baby to fall asleep when nursing.
    If you think baby is falling asleep because baby is shutting down because they are not getting enough milk, there are many ways to "rev baby up"- Breast compressions may help (search jack newman breast compressions) you can try stroking baby, pumping hand or foot, jiggling baby's chin, etc.

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