Session Objectives
On completion of this session, participants will be able to:
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| 1. Discuss concerns about “Not enough milk” with mothers. | 10 minutes |
| 2. Describe normal growth patterns of infants. | 5 minutes |
| 3. Describe how to improve milk intake/transfer and milk production. | 10 minutes |
| 4. Discuss a case study of “not enough milk”. | 20 minutes |
| Total session time | 45 minutes |
Materials
Slide 9/1: Picture 2 Mothers in bed talking to nurse.
Slide 9/2: Case study.
For the case study, you will need:
To ask 3 participants to help with the role play and to prepare and practice.
Chairs that can be brought to the front of the room.
A doll or bundle of cloth to act as the ‘baby’.
Further reading for facilitators
Not enough milk Update No. 21, March 1996, WHO.
RELACTATION: A review of experience and recommendations for practice. WHO/CHS/CAH/98.14
1. Concerns about “Not enough milk”
10 minutes
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Show slide 9/1: picture of 2 mothers in bed talking to nurse
Miriam felt that she did not have enough milk for her previous baby and she gave regular supplements from the early weeks. During this pregnancy, she has heard that exclusive breastfeeding is important for her baby. Miriam believes that it is important, but she is not sure that she can give only breast milk with nothing else.
The most common reason for mothers to stop breastfeeding, or to add other foods as well as breast milk, is they believe that they do not have enough milk.
Ask: What signs might make a mother think she does not have enough milk, even if the infant is growing well?
Wait for a few responses.
A mother, her health worker or her family may think she does not have enough milk if there are signs such as:
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baby cries often;
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baby does not sleep for long periods;
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baby is not settled at the breast and is hard to feed;
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baby sucks his or her fingers or fists;
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baby is particularly large or small;
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baby wants to be at the breast frequently or for a long time;
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mother (or other person) thinks her milk looks ‘thin’;
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little or no milk comes out when the mother tries to express;
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breasts do not become overfull or are softer than before;
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mother does not notice milk leaking or other signs of oxytocin reflex;
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baby takes a supplementary feed if given.
These signs may mean a baby is not getting enough milk but they are not reliable indications.
Ask: What are reliable signs that the mother can see for herself that show that her young baby is receiving sufficient breast milk?
Wait for a few responses.
Reliable signs of sufficient milk intake are:
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Output – milk must be going in, if urine and stools are coming out.
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After day 2, six or more wet diapers in 24 hours with pale, diluted urine. If drinks of water are given in addition to breast milk, urine output may be good but weight gain low.
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Three to eight bowel movements in 24 hours. As babies grow older than 1 month, stooling may be less frequent.
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Alert, good muscle tone, healthy skin and is growing too big for his or her clothes.
A consistent weight gain is a sign of sufficient milk intake; however the mother may not be able to have her baby weighed often. If there is doubt about the infant’s milk intake, weigh the baby each week, if possible
Knowing these signs will build the mother’s confidence – point out the things that she is doing well and suggest ways that she can get support in mothering.
Causes of low milk production
The common reasons for low milk production are related to factors that limit the amount of milk the baby removes from the breast. If the milk is not removed, less milk is made. These factors include:
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infrequent feeds;
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scheduled feeds
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short feeds;
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poor suckling;
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poor attachment.
Low milk production may be also related to psychological factors:
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The mother may lack confidence; feel tired, overwhelmed, worried, or find it difficult to respond to her baby.
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Physiological factors may lead to too little or ineffective breastfeeding practices. A mother who is in a stressful situation may feed less frequently or for a short time, be more likely to give supplementary feeds or a pacifier, and may spend less time caring for the baby.
Causes of low milk transfer
The mother may have a good supply of milk but the baby may not be able to remove the milk from the breast. Low milk transfer may result if:
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The baby is poorly attached to the breast and not suckling effectively. The baby may seem restless during a breastfeed and may pull away or tug at the breast.
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Breastfeeds are short and hurried or infrequent.
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The baby is removed from one breast too soon, and does not receive enough hindmilk.
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The baby is ill or premature and not able to suck strongly and for long enough to obtain the milk the baby needs.
Milk transfer and milk production are linked. If the milk is not being removed from the breast, the milk production will decrease. If you help the baby to remove milk more efficiently then sufficient milk production will usually follow.
2. Normal growth patterns of babies
5 minutes
Miriam has listened to what you said about signs of sufficient milk. However she is concerned about what the baby should weigh. With her previous baby even though she thought the baby looked well and seemed to be getting bigger, she was told that the baby was not gaining enough weight when the baby was weighed.
Ask: What is a normal growth pattern for a baby?
Wait for a few responses.
Most babies start to gain weight soon if they are exclusively breastfed from soon after birth, are well attached and feed frequently.
Some babies lose weight in the first few days after birth. This weight loss is extra fluid that the baby has stored during uterine life. A baby should regain birth weight by two weeks.
Babies usually double their birth weight by five to six months; and triple it by one year. Babies also grow in length and head circumference.
A properly and regularly completed growth chart can show the baby’s pattern of growth. There is a range of normal growth. There is not one ‘correct’ line that all babies should follow.
Do not wait until the weight gain is poor to do a careful breastfeeding assessment. Start and continue with good breastfeeding practices.
Practising the Ten Steps to Successful Breastfeeding helps to assure an abundant milk supply:
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Discuss the importance of breastfeeding and basics of breastfeeding management during pregnancy (Step 3).
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Facilitate skin to skin contact after birth (Step 4).
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Offer the breast to the baby soon after birth (Step 4).
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Help the baby to attach to the breast so the baby can suckle well (Step 5).
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Exclusively breastfeed: Avoid feeds of water, other fluids or foods; give only breast milk (Step 6).
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Keep baby near so feeding signs are noticed (Step 7).
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Feed frequently, as often and for as long as the baby wants (Step 8).
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Avoid use of artificial teats and pacifiers. (Step 9).
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Provide on-going support to the mother and ensure that mother knows how to find this support (Step 10)37.
3. Improving milk intake and milk production
10 minutes
Improving milk intake/transfer
Increasing milk production
Monitoring and follow-up
Follow-up the mother and baby to check that the milk production/milk transfer is improving. The frequency of follow-up depends on the severity of the situation.
Monitoring means more than just weighing the baby. Look for signs of improvement that you can point out to the mother – increased alertness, less crying, stronger suck, more urine and stooling, and changes in her breasts such as fullness and leaking.
Monitoring also gives you an opportunity to talk with the mother and see how the changes are working. Build her confidence and encourage things that she is doing well.
If the baby’s weight was very low and supplements were needed, reduce supplements as the situation improves. Continue to monitor the baby for a few weeks after supplements have stopped to ensure milk supply is sufficient.
4. Discuss a case study
20 minutes
Ask three participants to role-play the Case Study below in front of the class. This role-play should reflect what the midwife will do now and how she will follow up. Follow up the role-play with a discussion among all the participants.
Characters:
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Show slide 9/2 with the key points of the Case Study
Case study
Anna gave birth to a healthy boy in the hospital two weeks ago. Today she, the baby, and her mother-in-law are returning to the hospital because the baby is "sleeping all the time" and has passed only three stools this week. When the outpatient clinic midwife weighs the baby, she finds him 12% under birth weight.
The midwife asks about the events of the last week, using good communication skills and learns that:
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Anna and the baby were discharged on the second postpartum day.
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Anna received very little instruction on breastfeeding while she was in the postpartum ward.
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Anna feels that her baby is refusing her breasts.
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Yesterday, the mother-in-law began offering tea with honey in a bottle twice a day.
Questions that the midwife might ask include:
Can you tell me a little about the first day or two after the birth?
How did the baby feed in the first few days?
How do you feel the baby is feeding now?
Does the baby get anything other than breast milk?
The midwife also observes a breastfeed and sees that the baby is held loosely and that he must bend his neck to reach the breast. The baby has very little of the breast in his mouth and falls off the breast easily. When he falls off the breast, he gets upset, moves his head around, crying and has difficulty getting attached again.
Discussion questions: (with possible answers)
What are the good elements in this situation that you can build upon?
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They have looked for help, the mother-in-law is caring, and the bottle has been given only for one day.
What are three main things this family needs to know now?
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How to position and attach the baby for effective feeding.
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To feed frequently (2 hourly or more often), waking the baby if necessary.
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To avoid giving water (or honey and tea) using a bottle and teat. If needed, how to express breast milk and give to the baby by cup.
Also useful to know:
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To use plenty of skin to skin contact to help the baby learn that the breast is a comfortable place to be and to help stimulate prolactin release.
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To allow the baby to finish one breast before going to the other breast.
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The removal of milk makes more milk.
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The signs of having enough milk.
What follow-up will you offer?
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See the mother and baby in 1–2 days if possible to check if feeding and weight gain has improved.
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Continue assistance and follow-up until baby is feeding and gaining well.
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Ask if there are any questions. Then summarise the session.
Session 9. Summary
Concerns about “Not enough milk”
A mother or her family may lack confidence in breastfeeding and think that she does not have enough milk. Explain to mothers the reliable signs of enough milk: passing urine and stools, and seeing the baby as alert and growing. Weight gain is a reliable sign if there is an accurate scale available and consecutive weight checks are on the same scales.
Build the mother’s confidence in her ability to breastfeed.
Most common reason for low milk production is not enough milk is removed from the breast so less milk is made.
Common causes of low milk transfer are:
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Poor attachment, poor suckling; short or infrequent feeds; baby ill or weak.
Normal growth patterns of infants
Infants may lose 7 – 10% of their birth weight in the first days after birth but should regain birth weight by 2 to 3 weeks.
If they start breastfeeding exclusively soon after birth, they may lose very little weight or none at all.
Babies generally double their birth weight by 6 months and treble it by 1 year old.
The practices of the Ten Steps to Successful Breastfeeding help to ensure an abundant milk supply.
Improving milk intake and milk production
Use your communication skills to listen, observe, respond, and build confidence.
Address the cause of low milk transfer, offer possible solutions:
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Improve attachment; increase frequency and duration of feed; avoid supplements and pacifiers.
Increase milk production:
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Breastfeed more often and for longer, express between feeds; talk with family about support.
Monitor and follow-up until weight gain is adequate and mother is confident.
Session 9 Knowledge Check
Keiko tells you that she thinks she does not have enough milk. What is the first thing you will say to her? What will you ask her in order to learn if she truly does have a low milk supply?
You decide that Ratna's baby Meena is not taking sufficient breast milk for his needs. What things can you do to help Ratna increase the amount of breast milk that her baby receives?
Additional information for Session 9
Causes of low milk production
Uncommon reasons for low milk production
Medication of the mother – contraceptives that contain oestrogen can reduce milk supply. Diuretic therapy may also reduce milk supply.
Alcohol and smoking may reduce milk supply.
Breast surgery, which cuts milk ducts or nerves to the breast.
If a mother becomes pregnant again, she may notice a reduction in milk supply.
Very rare reasons for low milk production
Retained pieces of the placenta affect the hormones needed for milk production.
Inadequate breast development during pregnancy, so that few or no milk producing cells develop.
Severe malnutrition – milk is made from what the woman eats plus what is stored in her body. If a woman has used up her body stores, then it may affect her milk supply. However, she needs to be severely malnourished, and for a long time, to reach this state. A very restricted fluid intake may affect milk supply.
Weight gain
Breastfeeding ensures healthy, normal weight gain for infants. Many breastfed babies are leaner (less fat) than artificially fed babies.
Test weighing before and after one feed does not give a good indication of milk intake or production. The amount that a baby takes varies from feed to feed. Test weighing may worry the mother and can reduce her confidence in breastfeeding, tempting her to give supplements.
A baby who is not gaining weight with good breastfeeding and good milk transfer may have an illness. If the baby is feeding poorly or showing signs of illness, refer for medical treatment. However, if the baby seems willing to feed and has no signs of illness, then poor weight gain can be the result of not getting enough milk, which is often due to poor feeding technique. This baby and mother need help with feeding.
A baby with a condition such as congenital heart disease or a neurological difficulty may be slow to gain weight even if there is sufficient milk supply and transfer.
There is a need for weight monitoring for all children including those who are not breastfeeding.
Relactation
Relactation definition: Re-establishing milk production in a mother who has a greatly reduced milk production or has stopped breastfeeding.
If a mother has stopped producing breast milk and wishes to breastfeed, the health worker can help her to relactate. Relactation may be needed because:
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The baby has been ill and not able to suck.
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The mother did not express her milk when her baby was unable to suck.
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The baby was not breastfed initially and now the mother wants to breastfeed.
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The baby becomes ill on artificial feeds.
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The mother was ill and stopped breastfeeding.
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A woman has adopted a baby, having previously breastfed her own children.
A woman who wishes to relactate should be encouraged to:
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Let her baby suckle at the breast as often as possible, day and night for as long as the baby is willing.
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Massage and express her breasts in-between feeds, especially if the baby is not willing to suckle frequently.
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Continue to give adequate artificial feeds until the milk supply is sufficient to her infant’s growth.
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Seek support from her family, to ensure that she has enough time to spend relactating.
Drug therapy is sometimes used to increase or develop a milk supply. It is only effective if there is also increased stimulation of the breasts.
It is easier to relactate if:
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The baby is very young (less than 2 months of age) and has not become accustomed to using an artificial tea.,
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The mother gave birth recently or stopped breastfeeding recently.
However relactation is possible at any age of baby or time since breastfeeding stopped. Grandmothers may even relactate to feed their grandchild.
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See Session 11: If a baby cannot feed at the breast.
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