Insights Into Milk Production

Overview
Insights into Milk Production • Milk production norms
− Key dynamics
Nancy Mohrbacher, IBCLC, FILCA − 1st 2 weeks
− Gauging adequate
milk intake
− Supplements?
• Engorgement
• Multiples
• Oversupply
• Pump-dependent
families
• Relactation &
induced lactation

Disclosure: I have a competing

interest that could be
perceived as having a Milk
bearing on my Production
presentation
Norms:
~
I earn royalties & profits
Key Dynamics
from sales of books & apps

~
that cover these topics

~
I receive speaker fees
for talks like these
2

Knowing how
CHICAGO
milk production works
clarifies what
can be ignored &
what needs attention

c2021 Nancy Mohrbacher, IBCLC, FILCA 1

Insights Into Milk Production

Early Milk Intake Peak milk intake averages

~25-30 oz/750-900 mL per day
Day 1
5-7 mL/feed
From 1 to 6 mo
= 50 mL/day nursing babies
Day 2 need ~same amount
of milk per day
15 mL/feed
= 150 ml/day
Because babies’
Day 3 growth rate slows
25 mL/feed
= 250 mL/day
Nielsen, et al. Pediatrics 2011; 128(4):e907-14

2 Basic Milk Production Dynamics

1st 40 days,
milk ↑quickly
• Day 1:
1 oz/30 mL
• 5 wk: ~30 oz/
900 mL

Milk removal #1 Degree of fullness: Drained glands make

is main driver milk faster, full glands make milk slower
of supply (FIL + pressure)
#2 Storage capacity
Daly, et al. Exp Physiol 1996; 81:861-75
Hill, et al. J Hum Lact 2005; 21(1):22-30

#2 Storage Capacity

A nursing baby’s Based on

milk intake: volume of milk
in the glands
↑Increases from at their
Birth to Week 5 fullest time
Hill, et al. J Hum Lact 2005; of the day
21(1):22-30

↔ Plateaus til 6 mo
Nielsen, et al. Pediatrics Not about
2011; 128(4):e907-14
gland size
↓Decreases when other Daly, et al.
foods started Affects # milk removals per day
Exp Physiol 1993;
78:209-20 needed to build & maintain supply

c2021 Nancy Mohrbacher, IBCLC, FILCA 2

Insights Into Milk Production

Language of Milk Removals

On average, Same Volume, Different Feeding Patterns
babies take
Large Small
~2/3 of the Storage Capacity Storage Capacity
milk Volume of milk 150 mL 90 mL
available available per feed 5 oz 3 oz
Number of feeds per 6 10
To increase day needed to reach
900 mL
supply,
Longest sleep 8 hours 4 hours
babies take
stretch before milk
more milk production slows
more often
Kent, et al. JOGNN 2012;
41: 114-21

With
Large capacity: unlimited
Takes more time for refills,
glands to get so full which
that milk-making slows size
pitcher
Small capacity: better
Takes less time for satisfies
glands to get so full your
that milk-making slows thirst?

Storage Capacity
Influences
• One side or two
• Number feeds/day
• Night feeds
Concept: Jeanette Panchula, BSW, RN, PHN, IBCLC

c2021 Nancy Mohrbacher, IBCLC, FILCA 3

Insights Into Milk Production

Critical Period: 1st 2 Weeks Over Time, Prolactin Levels Drop

More Lactation Stage Baseline After Nursing
feeds/day (ng/mL) (ng/mL)
boost
Not PG/lactating 2-20 N/A
prolactin
1st 10 days 200 400
and milk
levels 1 mo 100-140 260-310
2 mo 100-140 195-240
Upregulation 4 mo 60-80 120-155
of prolactin 6 mo 50-65 80-100
receptors:
7-12 mo 30-40 45-80
Key during
first 2 weeks de Carvalho. Pediatrics 1983; 72:307-31 Marasco & West. Making More Milk. New York: McGraw-Hill, 2020

Hormones and receptors Milk Removal:

like a lock and key Major Driver of Milk Production

Removing milk more often

raises prolactin levels; less
often lowers prolactin

Prolactin Lactation Curve

• Hormone secreted by Dynamics of a Good Start
anterior pituitary with
major milk-making role
• Release during nipple
stimulation varies
− Lowest in am ~2-3 hr
after waking
− Highest during sleep

• Prolactin release
delayed 10-20 min,
lasts ≥1 hour

Ignacak, et al J Physiol Pharmacol 2012; 63(5):435-43 Marasco & West. Making More Milk. New York: McGraw-Hill, 2020

c2021 Nancy Mohrbacher, IBCLC, FILCA 4

Insights Into Milk Production

Boeing Starliner Failure American Academy of Pediatrics

December 20, 2019 Encourages Nursing on Demand

Goal: Dock with

the International
Space Station

Never reached
orbit due to
programming
errors

AAP. Pediatrics 2012; 129(2):e827-41

Early, Often, Effective Milk Removal

• Goal: nurse ≥ 8-12 /day
• Offer both sides
• Okay if one side

When Nursing, No need to

What Interferes? focus on:
• Feeding
• Scheduled or length
infrequent feeds (except if
• Regular baby falls
supplements asleep at
latch)
• Regular use of
• One side or
soothers
both
(pacifiers,
• Intervals
swings)
between
feeds

c2021 Nancy Mohrbacher, IBCLC, FILCA 5

Insights Into Milk Production

Ingredients Needed for Ample Milk

Sufficient
Gauging Adequate Milk Intake
• Milk removals
• Glandular tissue
• Intact nerves and
milk ducts
• Hormonal levels and
receptors upregulated
• Lactation-critical
nutrients

And no lactation
inhibitors
Marasco & West. Making More Milk. New York: McGraw-Hill, 2020

Parental Red Flags

 Hypoplastic glands
 Hx endocrine problems
 Hx bilateral
breast surgery
 Conditions that delay
milk increase
-- Diabetes
-- Long, difficult labor
 Heavy blood loss Is Average Weight
 Retained placenta Loss After Birth
 Hx low milk production
5% to 7%?
Thulier. J Hum Lact 2016; 32(1):28-34

Infant Red Flags

56% of healthy
 Illness/infection
 Prematurity
term nursing
 Tongue-tie newborns
 Cleft palate lost >7% of
 Cardiac birth weight
problems
 Airway
Mean weight loss
abnormality
 Neurological 8%
issues

Photo: Kirsten Hedberg Nyqvist, RN, PhD DiTomasso & Paiva. J Hum Lact 2018; 34(1):86-92; N=135

c2021 Nancy Mohrbacher, IBCLC, FILCA 6

Insights Into Milk Production

What Other Than

“Weight loss in the
Milk Intake Affects range of 8% to 10%
Weight Loss? may be within normal
limits.
• Birth weight
• Type of birth If all else is going well
& the physical exam
• Gestational age
is normal, it is
• Baby’s gender an indication for
• Country of birth careful assessment &
• Parent’s possible breastfeeding
fluid balance assistance.”

Kellams A, et al. Breastfeed Med 2017; 12(4):188-98

Chantry, et al. Pediatrics 2011; 127(1): e171-79
ABM Clinical Protocol #3 at bfmed.org/protocols

Excess IV fluids ≤2 hr
before birth increase
birth wt & act as diuretic
• ↑urination & ↑wt loss Diaper
during 1st 24 hr
Output?
• # wet diapers in
1st 24 hr predict wt loss

For accuracy, calculate

wt loss from 24-hr wt

Noel-Weiss, J, et al. Int Breastfeed J 2011; 6:9

Use 24-Hour Weight

as Reference Many Use as a Gauge
No increase during Day 1: ≥ 1 wet & stool
hospital stay in Day 2: ≥ 2 wets & stools
• Maximum weight loss
Day 3: ≥ 3 wets & stools
• Length of stay
• Bilirubin levels Day 4: ≥ 4 wets & stools
• Infants losing ≥10% BW
But research found
Reduced use of formula “…diaper counts are not a reliable
supplements enough indicator to serve as a screening
• 43.6% (pre-intervention) tool for breastfeeding inadequacy.”
• 27.4% (post-intervention) --Nommsen-Rivers, et al. J Hum Lact 2008; 24(1):27-33
Deng & McLaren. Breastfeed Med 2018; 13(2):128-34; N=667

c2021 Nancy Mohrbacher, IBCLC, FILCA 7

Insights Into Milk Production

What Do We Know No significant difference in number of

from Diaper Output? stools & voids/24 hr among newborns
Baby’s stools: who lost more or less weight
Meconium (Day 1-3)
 Early stool color change
to yellow linked to
less weight loss
Shrago, et al. Pediatr Nurs 2006;
32(3):195-201

Transitional (Day 3-4)

 Red flag: <4 stools Day 4
AND Mom feels milk
not yet increased
Nommsen-Rivers, et al.
J Hum Lact 2008; 24(1):27-33

Breast milk (Day 4-5) Photos: The Breastfeeding Atlas DiTomasso & Paiva. J Hum Lact 2018; 34(1):86-92; N=135

Other diaper counts unreliable:

Weight Gain: Gold Standard
• Too many
false positives After baby starts
• Too many gaining weight
false negatives • 1st 3 mo: average
1 oz./day
Alternative Message: • Over time, healthy
“Expect daily wet weight gain slows
diapers and stools. • Baby follows
Baby’s stool growth curve
should change color
from black to green
and finally yellow by
Day 4.”

Change in Diaper Diary

What About
Supplements?

c2021 Nancy Mohrbacher, IBCLC, FILCA 8

Insights Into Milk Production

Supplement
When

• “When a medical Spoon feed

indication exists”
Another option
– High bilirubin levels
– Low blood sugar
before
with frequent feeding milk increases
• >10% weight loss &
not feeding well

Kellams A, et al. Breastfeed Med 2017; 12(4):188-98

Photo: The Breastfeeding Atlas
ABM Clinical Protocol #3 at bfmed.org/protocols

Supplement
What

Cup feed
In order of priority
1. Expressed milk After milk
2. Donor milk increase
3. Infant formula (Day 2 & 3)

Photo: The Breastfeeding Atlas

Supplement
Feeding-Tube Devices
How

Syringe feed
Before
milk increase
(Day 1 & 2)
• Less lost
• Looks like more
to parents

Photo: Jack Newman, MD, IBCLC

c2021 Nancy Mohrbacher, IBCLC, FILCA 9

Insights Into Milk Production

Bottle-feed Role for

Hand
If parent prefers: Expression
• Hold baby upright
• Tap lips with nipple &
wait for open mouth
• Hold bottle horizontal,
tip down end of bottle
every few sucks for
breathing breaks

Kassing. J Hum Lact 2002; 8(1):56-60

Supplement Safe to learn and

How Much practice hand
expression during
last month of low-risk
Volume Is Key pregnancy

Lactation Norms DAME RCT followed

635 women with
Day 1: 7 mL/feed gestational diabetes
Day 2: 15 mL/feed
Day 3: 25 mL/feed Found no risk of
complications

Photo: The Breastfeeding Atlas Forster, et al. Lancet 2017; 389(10085):2204-13

Protocol to supplement healthy, term babies

firstdroplets.com
Volume per feed
1st 24 hr: 2-10 mL
24-48 hr: 5-15 mL
48-72 hr: 15-30 mL
72-96 hr: 30-60 mL

ABM. Breastfeed Med 2017; 12(3):188-98 Morton. Breastfeed Med 2019; 14(5):295-97

c2021 Nancy Mohrbacher, IBCLC, FILCA 10

Insights Into Milk Production

firstdroplets.com
Last 4 weeks
of pregnancy,
1-2x/day
express milk Engorgement
and
Goals to:
• Learn this
Milk
skill before
birth
Production
• Collect and
store milk to
use as a
supplement,
if needed
Morton. Breastfeed Med 2019; 14(5):295-97

firstdroplets.com
After birth, follow nursing by hand-expressing milk
into spoon, feed baby this “dessert”

Goals to prevent:
• Excess weight loss
• Exaggerated jaundice
• Delayed milk production

Some fullness, heaviness is normal as

milk increases but engorgement usually
Morton. Breastfeed Med 2019; 14(5):295-97 Photo: firstdroplets.com
means nursing is not going optimally

Those who hand-

expressed during Cause: Too Little Milk Removal
pregnancy After birth, extra
• Felt more confident blood and
they could exclusively
nurse
lymph travel to
Casey, et al. Aust N Z J glands to aid in
Obstet Gynaecol 2019; milk making
59(6):811-18
• More confidence linked
to less perceived If milk is not
insufficient milk (PIM)
Sandhi, et al. Int Breastfeed removed well
J 2020; 15(1):65 and often,
• After birth, excess milk
supplemented less with
formula Demirci, et al.
adds to fluid
Mat Child Nutr 2019; buildup in
15(4):e12824
glands

c2021 Nancy Mohrbacher, IBCLC, FILCA 11

Insights Into Milk Production

Severe Engorgement True or False?

• Usually starts 2nd to
4th Day (earlier with “Draining glands more fully
2nd baby) increases milk production,
• May include: making engorgement worse.”
− Throbbing
− Warmth (fever to
101°F)
− Pain
• May extend from
areola to Tail of
Spence in the armpit

Engorged True or False?

mothers and
those leaking “Draining glands more fully
milk less likely increases milk production,
than others to making engorgement worse.”
report perceived • Completely FALSE
insufficient milk • Removing milk lets other body
fluids drain more easily,
relieving engorgement faster

Cooke M, et al. J Hum Lact 2003; 19(2):145-56

To Prevent Engorgement

Multiples and
Milk
Production

• Keep nursing couple together

• Nurse long and often
• If not nursing well, express milk often

c2021 Nancy Mohrbacher, IBCLC, FILCA 12

Insights Into Milk Production

Multiples Are Often Born Early

Pregnancy with
multiples Even with
produces excellent
more placenta prenatal
nutrition and a
Releases more healthy lifestyle,
mammary- multiples at
stimulating higher risk for
hormones, which • Cesarean
grows & develops section
more milk-making • Preterm
glandular tissue delivery

Multiple Possibilities Many Ways to Position 2 Babies

Parents have fully

nursed quadruplets
• Milk removal key
• Nurse all babies at
all feeds or express
• Some nursing better
than none
Berlin CM, et al. Breastfeed Med 2007; 2(2):125-26

Oversupply
and
Milk
Production
Nurse healthy Nurse all babies
term multiples 8 or more times
within 1st hour or each day
two after birth

c2021 Nancy Mohrbacher, IBCLC, FILCA 13

Insights Into Milk Production

Oversupply Oversupply: Common Causes

Hyperlactation, hypergalactia

• Making much • Self-induced:

more milk than Nurse often +
baby needs pump often +
galactogogues
• Often feels full,
even with • Bad advice,
effective nursing cultural beliefs
• May need to • Naturally large
pump for comfort milk producer
• Many plugs,
mastitis Johnson HM, et al. ABM Clinical Protocol #32 (2020)
www.bfmed.org/protocols

Oversupply: Baby Symptoms Oversupply: Managing Nursing

• Very fast weight gain • Use starter
(2x average) positions so
• Struggles with fast baby has
milk flow (often pulls more control
off to catch breath) of milk flow
• Fussy between feeds • Avoid
pumping
• Constant feed cues
before
• Explosive watery, nursing
green, bloody stools (boosts
• Reflux disease supply)
NaturalBreastfeeding.com

Cause of Baby’s Gut Symptoms Oversupply: Before Reducing Milk

Too much high-
lactose, low-fat milk If baby’s weight
• Gut can’t digest all gain is not
sugar, causing gas,
mucusy, frothy,
≥2 lb/mo, rule out
bloody stools other possible
• Baby can’t get to
causes
fatty milk, feel full • Allergy
• Parents may assume • Reflux
“not enough milk” • Other health
issues
• May be confused
with allergy

c2021 Nancy Mohrbacher, IBCLC, FILCA 14

Insights Into Milk Production

Oversupply Treatments
Hormonally Challenged?
• Use “full glands
make milk • Less body contact
slower” dynamic • Plastic feel of milk
to slow milk removal, not soft,
production warm baby, moving
− Restrict baby to mouth and tongue
one side per feed
− Full drainage/block • No love
feeding by the • To meet goals,
clock or more
intuitively optimize all key
• Drugs, herbs milk-making
dynamics: early,
often, effective
van Veldhuizen-Staas. Int Breastfeed J 2007; 2:11

Oversupply Prevention Milk Volumes (mL) Day 1 to Week 6

• Follow baby’s
cues
• Finish the 1st
side 1st feeding
strategy
• If baby nurses
effectively,
pump only to
comfort as
needed
Parker LA, et al. J Perinatol 2012; 32:205-09; N=20 VLBW
Parker LA, et al. Breastfeed Med 2015; (10)2: 84-91; N=40 VLBW

The Magic Number

Pump-Dependent Total # of milk
removals per day
Families needed to maintain
production
long term

Main factor:
Storage Capacity

Mohrbacher. Clinical Lactation 2011; 2(1):15-18

c2021 Nancy Mohrbacher, IBCLC, FILCA 15

Insights Into Milk Production

Clues to Storage Capacity Definitions

# Milk Removals Largest Large Medium Small Smallest
per Day Needed Capacity Capacity Capacity Capacity Capacity
Relactation: Process of increasing milk
to: production in a parent who was pregnant
Increase milk 4-5 6-8 8-10 10-11 ≥12
Induced lactation: Process of stimulating milk
Maintain milk 3-4 5 6 7 8 production in a parent who was never pregnant
Decrease milk 2 3 4-5 6 7

Largest Large Medium Small Smallest

Capacity Capacity Capacity Capacity Capacity

Yield at 1st 15 oz 10-14 oz 8-9 oz 6-7 oz 4-5 oz

am pump
Max 10-12 hr 8-10 hr 7-8 hr 6-7 hr 4-5 hr
longest
stretch

Boosting Milk: Outside 1st 2 Weeks

If number of Same gland

milk stimulation affects
removals/day hormonal levels
drop below less
Magic
Number, Requires much
milk more time and
production effort to boost
slows milk production

Marasco & West. Making More Milk. New York: McGraw-Hill, 2020

How Long Does It Take?

Relactation If relactating,
and allow same
amount of time
Induced since had
significant milk
Lactation
If inducing
lactation, allow
3 to 4 weeks to
see any milk

c2021 Nancy Mohrbacher, IBCLC, FILCA 16

Insights Into Milk Production

Consistent Stimulation Over Time

Affects speed of
milk-making:
• SHORT TERM: Questions?
Less FIL & pressure nancy@nancymohrbacher.com
makes milk faster
• MEDIUM TERM:
Faster milk making
~
www.NancyMohrbacher.com
speeds metabolic
www.NaturalBreastfeeding.com
activity of key enzymes
• LONG TERM: Facebook.com/NancyMohrbacherIBCLC
Stimulates growth of Pinterest.com/nancymohrbacher
milk-making tissue @BFReporter
Czank C, et al. Hale & Hartmann’s Textbook of Human Lactation, 2007
www.YouTube.com/NancyMohrbacher

My story at:
bit.ly/BA2-Magical

Overview
• Milk production norms
− Key dynamics
− 1st 2 weeks
− Gauging adequate
milk intake
− Supplements?
• Engorgement
• Multiples
• Oversupply
• Pump-dependent
families
• Relactation &
induced lactation

c2021 Nancy Mohrbacher, IBCLC, FILCA 17