Lack of adequate milk removal

Are my breastfeeding problems caused by not breastfeeding or expressing enough?

Inadequate (infrequent or ineffective) breastfeeding may initially result in overfull breasts. Mothers may notice their breasts are uncomfortable or develop plugged ducts or mastitis. In the longer term, the breasts will make less milk. Breasts respond to a baby’s feeding behaviour. If the baby removes more milk from the breast, more is produced. If the baby removes less milk, less is produced. This is referred to as “supply and demand”. Babies may breastfeed infrequently when given unnecessary milk supplements or because of sleeps that are longer than five hours. Babies may breastfeed ineffectively when they are premature or weak or have a latching problem. Mothers may keep babies from feeding by offering a pacifier frequently or not offering the second side. Expression can also be ineffective.  

A) The importance of regular milk removal from the breast

A baby needs to feed well enough and often enough to grow well. This will maintain the milk supply and is called adequate milk removal. When a baby fails to do this, it is called inadequate milk removal.

The breasts and the baby work together. The baby removes milk by breastfeeding and the breast responds by producing the required amount of milk. This relationship is called “supply and demand”.

If the baby needs a little more milk, the baby will breastfeed longer and more often and the breast responds by making more milk. 

If the baby takes less milk from the breast, the unused milk remains behind, causing fullness and even breast pain. Within a few days, the breast will make less milk. The less completely and frequently milk is removed from the breast, the less milk the breast makes (De Carvalho 1983). 

B) How inadequate milk removal is thought to reduce milk production

There are a number of theories about how not removing milk from the breast results in less milk being made.

One theory is that pressure from the increased amount of milk in the milk sacs (alveoli) slows further milk production.

Some researchers (Peaker 1996) have suggested that a substance they called the feedback inhibitor of lactation (FIL) reduces milk production. The FIL, which may be produced by the breast, is thought to accumulate in the alveoli as the milk collects there. The more FIL in the alveoli, the less milk is produced. The FIL has not been isolated from milk and remains theoretical.

C) Reasons for inadequate milk removal

Milk supply decreases if milk is not adequately removed from the breast.

1) Reasons for inadequate milk removal that lie with the baby

Milk may not be removed regularly or effectively because the baby:

2) Reasons for inadequate milk removal that lie with the mother

Mothers may notice a decrease in milk supply if they:

D) Effect of inadequate milk removal on the baby

When there is inadequate milk removal, babies may not grow well. Over time the milk supply will decrease, increasing the risk of the baby being reluctant to breastfeed or even rejecting the breast. These babies need to be supplemented with extra milk until the milk supply has recovered and they can breastfeed effectively (Daly 1993). 

Inadequate milk removal may produce overfull breasts and hardening of the nipple root, making it difficult for the baby to latch and breastfeed. This is especially likely to occur with a premature, sleepy newborn, or sick baby. 

E) Effect of inadequate milk removal on the mother

Inadequate milk removal initially causes milk to build up in the breasts, making the mother uncomfortable or ill. Mothers may notice:

In the longer term, without adequate milk removal, the mother’s milk supply will decrease.

Her body may even act as if the baby is weaning and start preparing for the next baby by restarting her periods. This can further decrease milk supply. The mother may also become pregnant, which dramatically reduces the amount of breast milk.

F) Managing inadequate milk removal

Mothers in this situation need to:

  • Ensure the baby can latch properly and that the nipple root is not firm.
  • Ensure effective breastfeeding or expressing.
  • Ensure the baby does not go more than 5 hours at night without breastfeeding.
  • Supplement their babies with milk if there are signs that the baby is not getting enough milk.
  • Review the tools to increase their milk supply.
  • Treat any breast fullness and engorgement.

Mothers should work with their health-care providers during this time.

References

Daly SE, Owens RA, Hartmann PE. The short-term synthesis and infant-regulated removal of milk in lactating women. Exp Physiol. 1993 Mar;78(2):209-20
 
De Carvalho M, Robertson S, Friedman A, et al. Effect of frequent breast-feeding on early milk production and infant weight gain. Pediatrics. 1983 Sep;72(3):307-11
 
Peaker M, Wilde CJ. Feedback control of milk secretion from milk. J Mammary Gland Biol Neoplasia. 1996 Jul;1(3):307-15