It seems that in all societies, mothers’ confidence in their ability to meet their babies’ needs (unaided) is easily undermined. They need active support if they are to breastfeed successfully. Usually where a mother perceives her milk to be insufficient, her baby is getting all the milk that he needs.
Almost all mothers can produce enough breastmilk for one or even two babies, provided the baby suckles effectively and breastfeeds as often as he wants. The amount of milk the breasts produce is determined by the amount that the baby takes, and increases when the baby takes more. Even in societies were women are on marginal diets, most are able to produce breastmilk in amounts that are adequate for good infant growth.
There are however occasions when a baby does not get enough breastmilk. In most cases, this is because he is not suckling enough, or he is not suckling effectively. There are only very few situations in which a mother is unable to produce enough because of poor mammary gland development or hormone disturbance.
Mothers who think that they do not have enough milk need the help and support of a skilled person. A practical approach for health workers is described in the following three steps.
Mothers give a variety of reasons why they think that they do not have enough milk. There are however only two signs which show reliably that a baby is not getting enough. These two reliable signs are: poor weight gain or passing small amounts of concentrated urine.
A growth chart is a useful tool to establish whether or not a baby has gained weight satisfactorily. Growth charts however are not always available. A useful rule of the thumb is: if a baby gains less than 500 grams a month during the first 6 months of life or if he is below his birth weight after 2 weeks, he is not gaining enough weight. In order to establish that weight gain has been poor, at least two weights need to be compared. A minimum useful interval is 1 week, in which a baby should gain 125 grams or more.
If a baby urinates less than 6 times a day, and the urine is yellow and strong smelling, this also indicates that he may not be getting enough breastmilk. This sign is useful for monitoring a child’s breastmilk intake on a daily basis, while waiting for information about weight gain. Urine output should be used as a guide, not a rule. It is not helpful if the baby is dehydrated from diarrhoea, if he is having other fluids besides breastmilk, or if very absorbent nappies are used which make estimates of urine output difficult.
There are other signs which may mean that a baby is not getting enough milk. These are possible signs:
However, there are other reasons why a baby may cry. For example, he may go through a growth spurt. Sometimes a baby gets upset by certain foods that a mother takes. Some babies cry a lot because they need to be held and carried more than others. Another common reason for crying is what is called ‘colic’. A colicky baby usually cries continuously at certain times of the day. He may pull up his legs as if he has abdominal pain. Colicky babies grow well and their crying usually becomes less after 3 months.
If a baby passes infrequent small stools he may not be getting all the breastmilk that he needs. The frequency of stools of breastfed infants is quite variable. Some babies do not pass stools for several days, while others have eight or more stools a day. However, a breastfed baby’s stool is usually large and semi-liquid. It is rare that a mother is not able to produce enough breastmilk. However, when a mother observes no changes at all in her breasts during or soon after pregnancy, or if she can not express any milk some days after delivery, it may indicate that she can not produce enough breastmilk. So when a mother reports one of these possible signs, one cannot be sure and there is a need to check for reliable signs to confirm that her baby is actually not getting enough breastmilk.
Reasons why a baby may not get enough milk:
If it has been established that a baby is not getting all the breastmilk
that he needs, the cause needs to be identified. ‘Breastfeeding factors’ and ‘Mother: psychological factors’ are common. Psychological factors often underlie breastfeeding factors, for example lack of confidence causes a mother to give bottle feeds. A tired mother may feed her baby less often. One should look for these common reasons first.
‘Mother: physical condition’ and ‘Baby’s condition’ are not common. One should think about these reasons only if no common reason can be identified.
Breastfeeding factors: Breastfeeding factors are usually related to the baby’s attachment to the breast or the amount of time that he suckles. Poor attachment is a cause of many early breastfeeding difficulties, including not removing the milk effectively. This may result in the baby not getting enough milk and so failing to gain weight. Or it may result in the baby not being satisfied and crying often, though he gets enough milk because he suckles often or for a long time at each feed. Either way, it becomes a problem for his mother, who is likely to think that her baby needs complementary feeds. If a baby is well attached, the following signs can be observed:
Early complementary foods – even drinks of water – satisfy a baby’s hunger and thirst, so he suckles less. Bottles and pacifiers also reduce a child’s desire to suckle. In response, his mother produces less milk so she seems not to have enough.
Psychological factors of the mother:
Mothers often worry about their ability to provide enough breastmilk for their baby. They easily believe that it is they who are at fault if their babies are not satisfied. Mothers who are young, who lack support from family or friends, or who have a bad experience breastfeeding a previous baby are particularly likely to lack confidence. Promotion of infant formula and giving free samples also makes mothers doubt the adequacy of
their milk supply. These different conditions may lead a mother to give complementary feeds too early. A mother who dislikes breastfeeding, who is tired, or who rejects her baby may have difficulty in responding to him. She may not hold him close enough
so he does not attach well, or she may feed him infrequently or for a short time.
Acute stress can temporarily reduce the flow of breastmilk, so that it appears to ‘dry up’. There is however no evidence that chronic stress reduces the milk supply long term, and with support a mother can continue breastfeeding.
Physical conditions of the mother or baby:
These factors are less common. Think about these if no common reason can be found, and if giving the mother the usual kinds of help and support is not successful, and her baby continues not to gain weight adequately.
How to help a mother whose baby is not getting enough milk:
If it has been established that a baby is not getting enough breastmilk, the mother should get help to gain confidence that she can produce enough milk and to reestablish her breastmilk supply. The following steps will help a health worker to care for the mother and baby:
Conclusion:
Breastfeeding is an intrinsically vulnerable process. Mothers anywhere in the world are in need of consistent and continuous support to successfully breastfeed their baby. In some societies traditional networks have a major influence. Where these are less strong, there is a need to establish other sources of support. Health workers can play a key role in this regard.
The approach outlined is based on the principles of breastfeeding counselling. Adequate breast-feeding counselling can help mothers to establish and maintain optimal breastfeeding practices. Two studies to evaluate its impact in the health care system confirm its effectiveness. Attendance at a lactation support clinic at the island of Guaruja, Brazil was associated with significantly greater prevalence of exclusive breastfeeding at 1 month (54% vs 31%) and 4 months (43% vs 18%). Preliminary results from the evaluation of the Lactation Management Clinic of the Children’s Hospital in Islamabad, Pakistan also demonstrate that, whereas ‘not enough milk’ was the most com-monly reported difficulty (41%), exclusive breast-feeding rates increased from 1% at the first visit to 69% three months later amongst those babies who attended the clinic compared to an increase from 0% to 19% amongst those who did not attend.
The above findings support that breastfeeding counselling should become an integral part of health care services. The WHO/UNICEF package "Breastfeeding counselling: A training course" is an appropriate tool for health workers to acquire the necessary knowledge and skills to fulfil this task. WHO and UNICEF strive for this kind of training to be introduced in all countries as part of an overall plan for breastfeeding training for health workers at different levels.
For further information, contact: The Director, Division of Diarrhoeal and Acute Respiratory Disease Control,World Health Organization, 1211 Geneva 27, Switzerland, Email: hempel@who.ch
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Last updated January 21, 1999