Concerns about low breast milk supply are common reasons for early cessation of breastfeeding.This guideline outlines the diagnosis and management of low breast milk supply.

Staff at GHB will provide appropriate management and support for women with concerns about low milk supply.

Low supply: a mother is unable to produce enough breast milk to meet the nutritional requirements of her baby.

Galactogogue: a substance that increases breast milk production

RWH: Royal Women's Hospital (Melbourne)

GHB: Grampians Health Ballarat

Please refer to section 2.1 for contraindications to the use of Domperidone for low milk supply.

Breast milk production

For initial milk production (lactogenesis) to occur a woman requires adequate glandular tissue, correct hormonal balance and stimulation by a baby's sucking or breast milk expression.

Continued milk production requires frequent, regular and effective removal of milk from the breast. The more milk that is removed from the breasts, the greater the increase in milk production. Situations that interrupt milk removal may result in delayed or decreased supply.

Many mothers may perceive their baby's need for frequent feeding as a sign of low supply. Awareness of normal, frequent feeding patterns and growth, and the developmental stages of babies can help mothers to be more reassured about their baby's feeding behaviour. Thorough assessment of breastfeeding is required to determine if concerns about low supply are real or perceived.

Causes of low milk supply (Source: Victorian Breastfeeding Guidelines (2014) page 42-43

The most common cause of low milk supply is insufficient removal of milk from the breasts leading to a reduction in milk production. This is associated with:

• Poor attachment

• Insufficient breastfeeding

• Restricting breastfeeds

• Sleepy baby

• Mother-baby separation

• Unresolved engorgement

• Inappropriate use of infant formula, teats and pacifiers

• Ankyloglossia (tongue-tie) and other oral cavity abnormalities.

• Insufficient or ineffective expressing techniques if prolonged expressing is required (e.g. preterm baby)

Other reported causes of low milk supply may include:

• Maternal smoking, overuse of caffeine and other substance use

• Maternal alcohol consumption may slow the milk ejection reflex, thus reducing breast drainage and milk production

• Maternal medical problems; for example, retained products, severe postpartum haemorrhage, Sheehans Syndrome, serious maternal illness, severe anaemia, maternal diabetes, obesity, maternal medications, hypothyroidism, polycystic ovary syndrome, hormonal imbalance, inverted nipples

• Menstruation and/or subsequent pregnancy - some women perceive a reduction in milk supply during menstruation or early pregnancy

• Some maternal medications e.g. combined oral contraceptives, pseudoephedrine

• Excessive exercise

• Infant medical problems interfering with breastfeeding; for example, congenital abnormalities, cardiac problems, prematurity, illness, oromotor dysfunction

• Early introduction of solids

• Insufficient glandular tissue. May be:

  • Primary; for example, hypoplastic breasts or

  • Secondary; for example, surgery such as reduction mammaplasty.

  • Disguised by the presence of breast implants.

Signs and symptoms of low supply

Low supply may be indicated by the following clinical signs. However, a careful history, breastfeeding assessment and physical examination is necessary, as the presence of some of these may not necessarily indicate low supply

• Fewer than 3 wet nappies/24 hours by day 3

• Fewer than 5-6 heavy wet nappies/24 hours after day 5

• Concentrated urine

• No change to normal breastmilk stools by day 3-4 and scant stools thereafter (less than one dirty nappy per day)

• Dry mucous membranes

• Weight loss greater than 10% of birth weight

• Further weight loss after day 3-4

• Less than 20gm weight gain/day after day 3-4

• Failure to regain birth weight by 2 weeks of age

• Limited evidence of milk transfer during feeds

• Prolonged or continuous feeding with little evidence of satisfaction

• Persistent jaundice

• Persistently sleepy or lethargic baby

• Excessive crying, weak cry

• The baby appears unwell or shows signs of hypoglycaemia/dehydration (jittery, sleepy, sunken fontanelles)

• No signs of lactogenesis 2 by day 3-5 (breast fullness and heaviness)

• Breasts remain soft in between feeds (normal after around 3 weeks).

1. General Management

1.1 Assess breastfeeding.

• Refer to Appendix 1. Assessment of Breastfeeding.

• Assess for presence of oral abnormalities such as tongue-tie or palate abnormalities.

• Consider referral to a Lactation Consultant.

• Consider the need for referral to a medical practitioner for medical examination and treatment of medical conditions.

• Consider the need for referral to an Allied Health Practitioner such as Speech Pathologist, Dietician.

1.2 Implement plan to increase supply - if baby is attaching and feeding at the breast

• Increase the number of breastfeeds - for baby less than 6 weeks old, encourage at least 8-12 feeds per day, wake baby more often if necessary.

• Increase skin to skin contact.

• Encourage night feeding to maximise milk production.

• Teach the mother how to recognise infant hunger and satisfaction cues and effective milk transfer.

• Advise to minimise or avoid use of dummies and non-medically indicated formula where possible.

• Encourage switch-feeding if baby is sleepy change baby from one breast to the other several times during a feed to keep baby alert during feeding.

• Try gentle breast compression to increase milk transfer while feeding.

• Increase breast stimulation and drainage through regular expressing after or in-between breastfeeds. Expressed breastmilk can be fed to baby as a top-up feed if required.

• Encourage good maternal nutrition, hydration, extra rest and domestic support if possible.

• Reduce smoking, caffeine, use of alcohol and other substances.

• Treat any underlying maternal or infant medical conditions identified.

• Ensure regular follow-up support and monitoring until adequate supply is established.

• Provide the mother with a copy of the RWH Consumer Health Information Fact Sheet 'Low Milk Supply' - see Appendix 2.

• Provide other relevant written information and contact numbers to breastfeeding support agencies

  • Breastfeeding Service at GHB and Parent Place

  • Australian Breastfeeding Association

  • Maternal Child and Health Nurse.

1.3 Implement plan to increase supply - if baby is not attaching and feeding at the breast.

• Refer to Appendix 3. 'Tips to increase breast milk supply when expressing for a preterm or unwell baby.'

• Suggest that the mother to keep a record of amounts expressed using the Expressing Journal (Appendix 4.) or use a mobile App so that progress can be observed.

2. Pharmacological management

Medicines that may increase milk supply should only be recommended following a thorough assessment of breastfeeding and appropriate physiological management to increase milk supply has been implemented. Lactation management to increase milk supply should be continued even if medicines are commenced. Prior to commencing medication a breastfeeding assessment should be conducted by a Lactation Consultant if possible.

Commonly available galactagogues include:

• Domperidone (Motilium)

• Metoclopramide (Maxolon, Pramin) - now not commonly prescribed due to the risk of neurological adverse events - see below

• Herbal preparations

2.1 Domperidone (Motilium)

Domperidone is the drug of choice. It is a peripheral dopamine antagonist which blocks dopamine receptors in the gastrointestinal tract and the brain-stem. It does not enter the brain compartment as it does not cross the blood brain barrier. It is generally used for the treatment of nausea, vomiting and gastroparesis. However domperidone also increases the level of prolactin and is used to increase breast milk supply.

The amount of domperidone ingested by the infant through the breast milk is reported to be extremely low (less than 0.2 microg/kg/day) and side-effects in infants of breastfeeding mothers have not been reported.

Use of domepridone including potential maternal side effects must be discussed with the woman and a copy of the RWH Consumer Health Information fact sheet 'Domperidone for increasing breast milk supply' provided to her (see Appendix 5).

Side effects include:

• Common - dry mouth, headache

• Uncommon - urticarial rash, insomnia

• Rare - loss of balance, palpitations, swelling of feet, restlessness, extrapyramidal side effects

• Very rare - allergic reactions, anaphlaxis (<1/10,000)

Domperidone is available as 10mg oral tablets and must be prescribed by a medical officer. The woman should have ongoing medical supervision from her own GP, as long as she remains on domperidone.

2.2 Metoclopramide (Maxolon, Pramin)

Metoclopramide is a central dopamine antagonist. It has an effect in the gastrointestinal tract and in the brain. It is a widely used antiemetic and gastroprokinetic medicine. Metoclopramide increases prolactin levels and breast milk supply. However, the use of metoclopramide has been associated with an increased risk of neurological adverse events, including extrapyramidal disorders and tardive dyskinesia. A risk of rare cardiac conduction disorder has also been identified. Cases of depression associated with metoclopramide use have been reported. Other adverse effects of metoclopramide include restlessness, drowsiness and fatigue, and therefore is no longer usually recommended for treatment of low breast milk supply.

Metoclopramide may be prescribed when Domperidone is contraindicated. The dose is 10mg TDS.

For further information on the use of metoclopramide, please contact a BHS pharmacist or Lactation Consultant, or contact The Women's Medicines Information line on (03) 8345 3190

2.3 Herbal preparations
Many herbal preparations such as hops, fenugreek, fennel seed, blessed thistle and alfalfa have traditionally been used to increase breast milk production. However, there is little published research to support their effectiveness in increasing milk supply or their safety to mother and infant, therefore GHB is unable to recommend their use in management of low breast milk supply.