Establishing and maintaining milk supply when baby is not breastfeeding

By Kelly Bonyata, BS, IBCLC

It is important to express your milk to establish and maintain milk supply if your baby is not nursing at all or not nursing well. By expressing, you will also have your milk available to feed baby – every bit of moms’ milk that baby gets (even the tiniest amount) is like liquid gold.

When should mom start pumping?

• If baby does not nurse immediately postpartum, mom should begin pumping within 6 hours of baby’s birth — starting early makes a difference for future milk production.

What pump is best?

• If baby is not nursing, seriously consider renting a hospital-grade pump (a multiple-user double pump such as those made by Ameda, Hygeia or Medela) that will allow you to pump both breasts at the same time. A hospital-grade pump is the best choice for maintaining or increasing milk supply.
• If you are not able to rent a hospital-grade pump, consider buying a pump (preferably a quality double pump) and/or hand expression.

How much milk should mom be pumping if baby is not nursing?

• Aim for pumping 750-800 mL (25-27 oz) per day by 7-10 days postpartum. If you have twins or higher order multiples, aim for pumping 800-950 mL (27-32 oz) by 14 days postpartum.
• It’s useful to evaluate mom’s 24 hour pumping output at 10 days. If supply is borderline (350-500 ml / 11-17 oz) or low (less than 350 ml / 11 oz), then galactagogues (prescription meds or herbs to increase supply) or other interventions should be considered.
• The research tells us that milk production at 2 weeks is an indicator of breastfeeding outcome, so it is important to get a good start. Even if milk production doesn’t start out well, however, don’t get discouraged–many moms will see an increase (even as late as 9-15 weeks after birth) if they continue with regular pumping.

How often should mom pump?

• 8-10 times per day: Until supply is well established, it is important to get at least eight good nursing and/or pumping sessions per 24 hours. Ten sessions per day is better, particularly if you have twins or higher order multiples.
• These sessions don’t need to be evenly spaced, but you should be nursing/pumping at least once during the night in the first few months or anytime you notice a decrease in supply. Avoid going longer than 5-6 hours without pumping during the first few months.
• When pumping during the night, milk yield tends to be better if you pump when you naturally wake (to go to the bathroom or because your breasts are uncomfortably full) than if you set an alarm to wake for pumping.
• If you are having a hard time getting in enough pumping sessions, adding even a short pumping session (increasing frequency even if milk is not removed thoroughly) is helpful.

How long should mom pump at each pumping session?

• If baby does not nurse at all:
  • The first few days, before mom’s milk comes in, hand expression is often the most effective way to express colostrum. Double pump for 10-15 minutes per session for additional stimulation.
  • Once mom’s milk is in, pump for 30 minutes per session, or for 2-5 minutes after the last drops of milk.
• If baby nurses but does not soften the breast well
  • Double pump for 10-15 minutes after nursing.
• Empty the breast as thoroughly as possible at each session. To ensure that the pump removes an optimum amount of milk from the breast, keep pumping for 2-5 minutes after the last drops of milk. Use breast massage prior to pumping, and massage and compressions during pumping to better empty the breasts and increase pumping output.

Additional tips

• Rest & relax as much as possible.
• Skin-to-skin (Kangaroo care) can make a significant difference in pumping output.
• One study has shown that the moms of hospitalized babies who listened to guided relaxation or soothing music while pumping had an increased pumping output. When mom listened to a recording that included both music and guided relaxation while pumping, in addition to looking at photos of her baby,  pumping output was increased even more. In this study, the interventions led to moms producing 2-3 times their normal pumping output. Milk fat content also increased for these moms in the early days of the study. (Reference: Keith DR, Weaver BS, Vogel RL. The effect of music-based listening interventions on the volume, fat content, and caloric content of breast milk-produced by mothers of premature and critically ill infants. Adv Neonatal Care. 2012 Apr;12(2):112-9.)
• If double pumping is difficult to coordinate in the beginning, then single pump, alternating sides. Move to double pumping as soon as you can.
• Avoid any medications that might interfere with milk supply (hormonal birth control, pseudoephedrine, ethanol/alcoholic beverages, bromocriptine, ergotamine, cabergoline)
• If supply is not increasing as expected by 7-10 days after birth, consider the use of galactagogues. Fenugreek, metoclopramide (Reglan) or domperidone (Motilium) can be helpful for increasing milk supply.

See Got Milk? for more information on milk supply.

References and additional information

Note: Premature infants are certainly not the only breastfed babies who have problems nursing at the breast, but much of the writing and research in this area involves premature babies and their mothers. Talk to your lactation consultant about adapting these guidelines for older babies.

@KellyMom

• Pumping & Bottle Feeding
• Let-down Reflex: Too slow?
• I’m not pumping enough milk. What can I do?
• Links: Breastfeeding a Premature Infant
• Links: Exclusive Pumping
• Help — My Baby Won’t Nurse!

@ other websites

• The ‘Magic Number’ and Long-Term Milk Production by Nancy Mohrbacher
• Maximizing Milk Production with Hands On Pumping by Jane Morton, MD

References

Mohrbacher N. Cutting Edge Breastfeeding Trends, Orlando, FL, June 9, 2004.

Wight NE. La Leche League International Conference Session–The Premature Infant and Breastfeeding: Myth, Reality and Evidence-Based Practices, San Francisco, CA, July 5, 2003.

Furman L, Minich N, Hack M. Correlates of lactation in mothers of very low birth weight infants. Pediatrics. 2002 Apr;109(4):e57.

Meier PP. Breastfeeding in the special care nursery. Prematures and infants with medical problems. Pediatr Clin North Am. 2001 Apr;48(2):425-42.

Hill PD, Aldag JC, Chatterton RT. Initiation and frequency of pumping and milk production in mothers of non-nursing preterm infants. J Hum Lact. 2001 Feb;17(1):9-13.

da Silva OP, Knoppert DC, Angelini MM, Forret PA. Effect of domperidone on milk production in mothers of premature newborns: a randomized, double-blind, placebo-controlled trial. CMAJ. 2001 Jan 9;164(1):17-21.

Hill PD, Aldag JC, Chatterton RT. Effects of pumping style on milk production in mothers of non-nursing preterm infants. J Hum Lact. 1999 Sep;15(3):209-16.

Bier JA, Ferguson AE, Morales Y, Liebling JA, Archer D, Oh W, Vohr BR. Comparison of skin-to-skin contact with standard contact in low-birth-weight infants who are breast-fed. Arch Pediatr Adolesc Med. 1996 Dec;150(12):1265-9.

Anderson GC. Current knowledge about skin-to-skin (kangaroo) care for preterm infants. J Perinatol. 1991 Sep;11(3):216-26.