Protocol to Manage Breastmilk Intake
Most mothers have lots of milk or could have had lots of milk if they
had gotten off to a good start and had good hands-on help. The problem
is often that the baby is not getting the milk that is available.
Sometimes mothers seem to have a lot of milk which flows very quickly
at the beginning of a feeding, but the baby fusses or falls asleep when
the flow slows down later in the feeding. Although the following
symptoms are not necessarily due to the baby’s not getting enough milk
flow from the breast, this Protocol can be used to help resolve
- The sleepy or “lazy” baby. Babies are not lazy,
incidentally. They respond to milk flow and if flow is slow, they tend
to sleep at the breast especially if they are under a few weeks of age.
Babies also seem to want to “use the mother as a pacifier”. Yes,
sucking is pleasurable for the baby, but if the baby gets better milk
flow and is truly “full” often the baby won’t want to just suck at the
- The baby who pulls or fusses at the breast.
- The baby who is fussy or “colicky” (see also the
information sheet on Colic in the Breastfed Baby).
- Frequent or long feedings or the baby who does not seem
to wake up for feedings.
- Jaundice (see also the information sheet on Jaundice
- A too-rapid milk flow, “Over-active letdown”, babies
choking or coughing at the breast or breasts that don’t seem to drain
To Ensure the Baby Drinks as Well as Possible:
Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond.
- Get the best latch possible. In order to
accomplish this it is best to get help from someone who knows how
to help mothers with breastfeeding. Anyone can look
at the baby at the breast and say the latch looks good. We tend to
teach the latch differently from most others. Naturally we think our
approach is very effective and often is. A baby latched on well is on
the breast asymmetrically, covering more of the areola with his lower
lip than his upper lip, with his chin in the breast but not his nose,
and his head is slightly tipped backwards compared to the rest of his
body. When the baby is latched on well, the mother has no pain, and the
baby gets milk well from the breast. See the information sheet When
Latching and the video clips at the website nbci.ca.
Get good “hands-on” help.
- Know how to know a baby is getting milk.
When a baby is getting milk, he will have an open mouth wide - pause -
close mouth type of suck. He is not getting milk just because
he has the breast in his mouth and is making sucking movements.
When he is sucking and not getting milk his chin moves down and up
rapidly with no pausing of the chin at the maximum opening—this means
“I am not getting milk flow into my mouth”. If you wish to demonstrate
this to yourself, put your index finger into your mouth and suck as if
you were sucking on a straw. As you draw in, your chin drops and stays
down as long as you are drawing in. When you stop drawing in, your chin
will come back up. This pause that is visible at the baby’s chin
represents a mouthful of milk when the baby does it at the breast.
Actually the baby does this pause when he gets milk from finger feeding
or a bottle too. The longer the pause, the more milk the baby got, so
it is obvious that the frequently advised “feed the baby 20 minutes on
each side” makes no sense. A baby who drinks very well (as
opposed to sucking without drinking) for say, 20 minutes straight, will
likely not take the other side. A baby who nibbles (doesn’t drink) for
20 hours will come off the breast hungry. You can see video
clips of babies drinking (or not) at the website nbci.ca.
Note that when baby stops sucking, “taking a break”, this
is not the pause we are referring to. Note also that it is normal for
babies not to suck continuously without a break. Just ensure that when
he begins to suck again he is also drinking.
- Compressions. Once the baby is sucking
use the technique of breast compression to increase the flow of milk to
the baby. Babies react in two ways to slow flow. They either fall
asleep at the breast or they pull at the breast. Some babies do one
thing at one feeding and another at another feeding. Some will both
fall asleep and pull at different times during a single feeding. When
the baby is sucking without drinking, start compression, but be sure to
do them while the baby is sucking but not drinking. Keep the baby on
the first breast until he doesn’t drink even with compressions (so that
there is no pausing-type of suck even when you compress). See the
information sheet Breast Compression. You can also
see a mother using
breast compression at the website nbci.ca.
- Switch sides. When the baby no longer
drinks even with
compression, switch sides and repeat the process. Keep going back and
forth as long as the baby gets reasonable amounts of milk. Of course
once the baby has fed well, there is no harm in letting him “nibble” at
the breast until he pulls off.
When the above techniques don’t work well enough…
- Herbs. Take fenugreek and blessed
thistle. These two
herbs seem to increase milk supply and increase the rate of milk flow,
which is actually more important. Because herbs are not standardized,
we recommend mothers take enough fenugreek that she notices its scent
on her skin. Often 3 capsules each of fenugreek and blessed thistle (or
20 drops of the tincture) taken 3 times daily will help and should work
within 24-72 hours. If they have not worked by 72 hours and the mother
smells of fenugreek, they probably won’t work. For other herbs that may
help increase milk supply, see the information sheet Herbal
Remedies for Milk Supply.
- Lying down to breastfeed. In the
evening, when babies
often want to be at the breast frequently and/or for long periods of
time, get help to position the baby so that you can feed him lying
down. (Note: mothers have less milk in the evenings, but less does not
necessarily mean “not enough”). Let the baby breastfeed and maybe you
will fall asleep. Babies who fuss at the breast when the flow is slower
in the evening may be content to suckle at the breast when lying side
by side with the mother. Or rent videos and let the baby breastfeed
while you watch. See the information sheet Safe Co-sleeping.
Still having difficulty?
- Domperidone. This is a medication that
rate of milk flow to the baby by increasing the milk supply. It is not
a magic bullet and won’t cure all problems. It must be used in
conjunction with the other steps in this Protocol. Sometimes it can be
useful even if your milk supply is already substantial (as when the
baby does not yet know how to latch on). See the information sheets (2)
- Supplementation. It is not always easy
to decide if a
baby needs supplementation. Sometimes applying this Protocol for a few
days and continuing with it will get the baby gaining more rapidly.
Sometimes more rapid growth is necessary and it may not be possible
without supplementation. If practical, get banked breastmilk to use as
a supplement (for more information see www.hmbana.org). If not
available, infant formula may be necessary. However, sometimes slow but
steady growth is acceptable. The main reason to worry about growth is
that standard growth is a sign of good health. A baby who grows well is
usually in good health, but not necessarily so. Neither is a baby who
grows slowly necessarily in poor health, but physicians worry about a
baby growing more slowly than average. Growth charts are, however,
frequently interpreted poorly. A baby who follows the 10th percentile
is growing normally and as he should. Too many people, and surprisingly
even some physicians, believe that only babies on the 50th percentile
and above are growing normally. This couldn’t be more false.
charts were developed on information gathered on normal
Somebody has to be smaller than 90% of all other
babies (on the 10th
- Lactation aid. If it is decided that
necessary, the best way to do it, even if you are supplementing with
breastmilk, is with a lactation aid at the breast. Our lactation aid is
made with a #5 French, 36 inch or 93 cm long feeding tube leading from
a bottle of supplement and it is used once the baby has fed only after
doing steps #3 and #4 above and the baby has fed on at least both
sides. Why is a lactation aid better than a bottle, cup, syringe, or
- Babies learn to breastfeed by breastfeeding.
- Mothers learn to breastfeed by breastfeeding.
- The baby continues to get milk from the breast thus
helping to increase the milk supply.
- The baby won’t reject the breast.
- There is more to breastfeeding than breastmilk.
- Solids. If the baby is older than about 3 or 4 months
and supplementation appears to be necessary, formula is not necessary
and extra calories can be given to the baby as solid foods. Yes, you
can give solids to a baby of 3 or 4 months of age. The statement by
Health Canada, the Canadian Paediatric Society, the American Academy of
Pediatrics, UNICEF, the World Health Organization, and almost all
paediatric societies around the world encourage exclusive breastfeeding
to about 6 months. This means that if the baby needs extra calories and
is also getting formula he is still not exclusively breastfed. Formula
is basically a liquefied solid. But it’s not the formula that is the
biggest problem. It’s the bottle. If the baby gets bottles when the
milk flow from the breast has slowed because of a decreased supply, he
will figure out pretty quickly where the food comes from and start
rejecting the breast. Bonding is important, but hunger comes first. So
formula can be given, but mixed with the baby’s solids. This works
fine. First solids can include mashed banana, mashed avocado, mashed
potato or sweet potato etc—as much as the baby will take without
forcing. Note however, that giving the baby solids at 3 or 4 months of
age when everything is going well and the baby is gaining well is not
recommended. Solids should normally be started when the baby is showing
a definite interest in eating solids (usually around 6 months of age,
but not always, sometimes this occurs before six months and sometimes
after). See the information sheet Starting Solid Foods.
- Late onset slow weight gain. If your baby was gaining
weight well for a few months and no longer is, see the information
sheet Slow Weight Gain After Early Good Weight Gain. Reasons for a
decreased milk supply are listed there. Fix what interfering factors
fit your situation and follow this Protocol
To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002.
Protocol to Manage Milk Intake, 2009©
Written and revised (under other names) by Jack Newman, MD, FRCPC,
Revised by Jack Newman MD, FRCPC, IBCLC and Edith Kernerman, IBCLC,