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Supplementation Guidelines

Figuring out how much supplement to give your baby means finding the right balance between enough and not too much. You want to be sure that your baby is getting sufficient food, but you don’t want to give him too much supplement. Too much supplement may make him less interested in the breast, and the less he breastfeeds, the less milk you will produce.

First Determine the Total Amount Needed

Unfortunately, there is no clear-cut way to determine the total amount of milk your baby needs each day. Until recently, babies’ human milk requirement was calculated using an equation that was based on the intake of formula-fed babies. The general rule was that babies’ caloric needs would be satisfied by two to three ounces of milk per pound of body weight per 24 hours. This was often shortened to an average of 2.5 ounces per pound of baby’s body weight with the understanding that the actual amount would vary. The amount needed per feeding was the total amount for 24 hours divided by the average number of feedings per day.

This basic equation assumes that a baby’s milk intake continues to increase in proportion to his weight, regardless of his age, which is true for formula-fed babies. However, this is not normal or natural for exclusively breastfed babies, whose intake of human milk appears to plateau in the early months and then remain fairly constant. Babies are also growing more slowly toward the end of the first year, so that the same amount of milk is able to meet their needs, even though they are bigger.(1), (2), (3), (4) The old general rule also ignores the fact that little babies may need more than the equation indicates, while large babies may need less.

A better, though still imperfect, variation of the mathematical approach is one that has been used successfully by Linda Pohl, IBCLC. She breaks down the estimate of milk intake by age and related rate of growth:

  • 2.4 ounces per pound of body weight per day from 2 weeks to 3 months of age
  • 1.8 ounces per pound of body weight per day from 3 months to 5 months of age
  • 1.6 ounces per pound of body weight per day from 5 to 7 months of age

 

Normal Feeding Amounts for Exclusively Breastfed Babies

Research has shown that the milk intake of exclusively breastfed babies reaches a plateau of about 23 to 40 oz (680 to 1183 ml) of human milk per day in the first month or so, depending on growth rate and sex (baby boys tend to take a few ounces more).(5), (6), (7) Each baby has unique nutritional needs, so these amounts are only general guidelines and must be considered in the context of your unique circumstances. 


Does this all seem complicated? Most of the time, it’s not necessary to do a lot of math to figure out how much supplement to give your baby. You can use your observations of your baby along with your intuition to know if he is getting enough, while keeping in mind the general ranges of normal presented below. The truth is that estimating the amount of supplementary milk needed is more of an art than a science, and that the baby himself needs to play a role in this process. Some basic issues to consider include:

  • Approximately how much milk the baby is currently removing from the breast on average. (You will know this if you performed test weights using a sensitive electronic scale.)
  • How much milk you are producing. (You will know this if you used the test pumping method to measure your milk production.)
  • Most importantly, if the baby has been losing weight, staying about the same, or gaining. If gaining, about how much per week?

Most babies take only one and a half to three ounces per feeding the first two weeks, and then two to four ounces per feeding thereafter (though they can certainly take more if the mother’s breasts have a large storage capacity). If you know that your six-week old baby has been getting two ounces at the breast but hasn’t been gaining any weight, you can probably expect him to want at least an additional ounce per feeding. Offer him this much and watch carefully to see if he wants less or more. Give him whatever he will take, but don’t force him to take more than he is really wants. Also keep in mind that babies, like adults, may vary in how much food they want from one feeding to the next.  If a baby is gaining weight, but doing so at a slow rate, a half ounce of supplement per feeding (or even every other feeding) may be a more appropriate starting place. The more weight he is gaining, the less supplement you need to offer; the less weight he is gaining, the more supplement you will need to offer.

The Significantly Underfed Baby
 
While we usually trust babies to tell us how much food they need, some circumstances do require parents to take over for a while. The baby who has been seriously underfed (and who may have misled you with his passive behavior) may not show strong hunger cues, or may quit nursing before he has had enough to eat. Such a baby’s diaper output is usually low. In times like this, you can fall back on milk intake averages and offer baby the amount of supplement at the high end of the range for his age, while carefully watching his diaper output. A baby who hasn’t been getting enough to eat, especially for several days or more, may become weak, and feeding at the breast will be tiring for him.  He needs to be given some food up front prior to breastfeeding, at least one-half ounce. If supplementation is not occurring at the breast, then put him to the breast only for as long as he is willing. If the baby begins to show stress cues or loses interest in nursing, then offer the rest of the supplement immediately.  Some babies can be supplemented at the breast but others cannot, at least not at first. Babies who have been seriously underfed need to be given milk in the least energy-expending way until they are stronger.  It will be important for you to pump after your baby has finished feeding at breast so that all of the available milk can be removed to keep your production as high as possible.

Adjustments

It is especially important to watch your baby’s behavior after beginning supplementation.  He may or may not need to be supplemented after every feeding, and the amount that he needs each time may vary. If he seems full and content before he has taken the amount you think he needs, and if he has had good diaper output, then don’t force him to finish his supplement. If he seems ravenous and he was not feeding too quickly, don’t hesitate to give him a little more than you planned.  Adjust the amount you offer your baby upward or downward in one-half ounce increments (unless it’s obvious that your estimate was really far off and you need to make a larger adjustment). If the change works, stay with it until it isn’t working, then adjust again.

The key to making adjustments lies in balancing three factors: 1) good diaper output, 2) good weight gain, and 3) baby’s satisfaction.

  • If weight gain and baby’s satisfaction are good but the diaper output seems off, you are probably still okay.
  • If diaper output and weight gain are good but the baby isn’t acting satisfied, he may need more milk, he may be having a growth spurt, or he may be unhappy for other reasons; try other soothing techniques and diaper changes before offering more milk.
  • If diaper output seems to be good and baby seems satisfied but he is not gaining well, he may not be getting enough milk, and you may need to ask your pediatrician to help determine what is going on. The baby can have a mild deficit in one of these three areas and still be fine, but if there is a strong deficit in any one area, an investigation and change is almost always in order.
  • If diaper output <I>and<I> weight gain are both low, most likely there is a problem and the baby needs more milk.

References

(1) Arthur, P., Hartmann, P., Smith, M.  Measurement of the milk intake of breast-fed infants.  J Pediatr Gastroenterol Nutr 1987 Sep-Oct; 6(5):758-63.

(2) Cox, D., Owens, R., Hartmann, P. Blood and milk prolactin and the rate of milk synthesis in women. Exp Physiol 1996 Nov; 81(6):1007-20.

(3) Allen, J., Keller, R., Archer, P., et al. Studies in human lactation: milk composition and daily secretion rates of macronutrients in the first year of lactation. Am J Clin Nutr 1991 Jul; 54(1):69-80.

(4) Neville, M., Allen, J., Archer, P., et al. Studies in human lactation: milk volume and nutrient composition during weaning and lactogenesis. Am J Clin Nutr 1991 Jul; 54(1):81-92.

(5) Cox, D., Owens, R., Hartmann, P. Blood and milk prolactin and the rate of milk synthesis in women. Exp Physiol 1996 Nov; 81(6):1007-20.

(6) Neville, M., Allen, J., Archer, P., et al. Studies in human lactation: milk volume and nutrient composition during weaning and lactogenesis. Am J Clin Nutr 1991 Jul; 54(1):81-92.

(7) Allen, J., Keller, R., Archer, P., et al. Studies in human lactation: milk composition and daily secretion rates of macronutrients in the first year of lactation. Am J Clin Nutr 1991 Jul; 54(1):69-80.

 

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