Most new moms are unaware that many of the variables affecting breast milk supply are under their control. Author, nurse, and lactation consultant Stacey H. Rubin explains how to optimize your breastfeeding routines in her book The ABCs of Breastfeeding.
Your body was made to nourish your baby. During pregnancy, your breasts prepare colostrum with the assumption that you will breastfeed your newborn. After birth, this early milk gradually evolves into mature breast milk. As this occurs, the decisions that you make influence the development of your future milk supply. In the first few weeks following birth, a breastfeeding mother can take concrete steps that will lead her toward a strong milk supply.
I recently had a home visit with Marla, who was concerned about her low milk supply. After meeting with her and her three-week-old son, Henry, I concluded that Marla’s milk supply was indeed low. The cause of her trouble was clear; Henry was being cared for by a live-in baby nurse. This nurse had been keeping Henry with her during the night and for long periods during the day. Although he periodically breastfed, he was often pacified with artificial nipples and supplemented with formula bottles.
Marla was young, healthy, and capable of breastfeeding. Unfortunately, frequent separation from her baby and missed breastfeeding opportunities inadvertently gave her body the message that she did not intend to breastfeed, and Marla’s initially strong milk flow slowed to a mere trickle.
With so many variables affecting a mother’s milk supply, most new mothers are unaware that many of these variables are under their control. Had Marla understood that separation, pacifiers, and bottle-feeding would have a negative impact on her milk supply, she might have decided to keep Henry with her and breastfeed him more frequently so that her milk supply could fully develop.
What Are the Signs that My Body Is Making Milk?
Colostrum is available to satisfy your newborn’s thirst and hunger immediately after birth. Small amounts of thick yellow colostrum are high in protein, minerals, and some vitamins. Interestingly, colostrum contains cholesterol. Learning to metabolize cholesterol as a newborn may help your baby’s body develop healthy cholesterol levels later in life. Although small in volume, these early feedings are rich in immunities that work to protect your newborn from illness. With each successive feeding, your early milk prepares your baby’s stomach and intestines for the arrival of your high-volume mature milk.
“When Will My Milk Come In?” Timing varies, but new mothers can expect their mature milk to “come in” three to five days after giving birth. You will know that your mature milk has arrived because your breasts will feel different, your milk will look different, and your baby will feed differently. As your early milk changes, so will your breasts. Your breasts will become bigger, heavier, and warm. Many mothers describe feeling hot or developing a transient low-grade fever when their mature milk arrives. This entire process is called primary engorgement.
Your newly full breasts will begin to leak, and your mature milk will have a different look from your colostrum. The color of your early milk will gradually shift from yellow to white. Compared to your early breast milk, your mature milk will be copious in volume and look watery. Even though the breast fullness of primary engorgement happens overnight, it is normal to take several days for the color of your milk to shift from bright yellow to creamy white.
Finally, you will know that your mature milk has arrived by the way your baby feeds. Compared to early breast milk, your mature breast milk is higher in volume and sweeter tasting. Like your colostrum, mature breast milk is full of living cells that work to protect your baby from illness. As your baby feeds from your newly full breast, you will hear frequent swallowing and gulping as your baby takes in larger volumes of breast milk. In response to this greater intake, your baby should have a greater output of wet diapers and bowel movements. Your baby’s increasing diaper count is a sure sign of a healthy milk supply.
What Is Normal Engorgement?
Just as the hormones of pregnancy signal your breasts to produce colostrum for your baby’s first meal, the shifting hormones brought on by childbirth lead to the experience of primary engorgement. This usually occurs three to five days after birth even if a mother doesn’t intend to breastfeed. How a mother contends with the onset of primary engorgement can affect her milk supply and her entire breastfeeding experience.
Tara, a second-grade teacher and new mother, handled this important phase in the development of her breastfeeding relationship just right. Tara taught up until her labor started on a Friday afternoon. Her labor quickly progressed and Carla was born early Saturday morning. Tara breastfed Carla in the delivery room and by Monday morning the new family was home. So far, Tara and Carla had sailed through their initial days as a breastfeeding couple. Suddenly, things changed. On Monday night, both of Tara’s breasts became very full. It seemed that from one hour to the next, Tara’s breasts grew bigger than she thought possible. Carla noticed the change and had difficulty attaching to the new shape of her mother’s breast. Instinctively, Tara massaged and softened her breasts to help Carla get a better attachment. Tara breastfed Carla often, and Tara could hear Carla swallow milk as she breastfed. When Carla detached after feeding, Tara was happy to see that there was breast milk in and around her daughter’s mouth.
Even with frequent feeding, Tara felt uncomfortably full. To further soften her breasts, Tara expressed a little bit of milk so that she was more comfortable. By the end of the first week following Carla’s birth, Tara’s breasts were full but soft. She frequently leaked breast milk and began wearing disposable nursing pads. By following her excellent intuition, Tara was able to navigate through this period of primary engorgement with her strong supply of mature breast milk intact. The uncomfortable swelling resolved and Carla was now able to easily feed from both breasts.
Tara’s experience of primary engorgement was normal, or physiologic. By breastfeeding Carla frequently, Tara prevented her breasts from becoming overly distended. However, even with frequent feeding, Tara experienced the sensation of uncomfortable fullness. Overabundance at this time is normal as your body learns to predict exactly how much milk your baby needs. As Tara experienced, your body will err on the side of too much milk as opposed to not enough. As expected, within a few days, Tara’s body self-regulated, and this period of engorgement passed.
What if Normal Primary Engorgement Goes Untreated?
Unfortunately, mishandling primary engorgement can lead a mother to experience unnecessary pain and disappointment. Because of the misinformation that Marta received when she became engorged, she ended up losing her milk supply. Marta required general anesthesia during the cesarean section birth of her son Julio. When she woke up, Julio was already in the newborn nursery. Once they got together, Marta and Julio had difficulty breastfeeding. Over the next few days, their breastfeeding troubles continued, and Julio was given formula supplements. By her fourth day in the hospital, Marta’s breasts filled with milk and became very firm. However, Julio was still unable to breastfeed and therefore unable to receive Marta’s milk. Throughout her hospitalization, none of the doctors or nurses recommended that Marta pump her breasts. In fact, she was told to wear a tight bra and to avoid pumping for fear of worsening her engorgement and creating more breast milk. By the time she was discharged from the hospital, nearly six days after Julio’s birth, Marta’s breasts were soft, and her milk seemed to be going away.
Marta really wanted to breastfeed, but Julio was unable to attach, and she didn’t seem to have any milk. Once she was discharged from the hospital, Marta called and requested my help because she wasn’t sure what to do next. By the time I met Marta, she had passed through her natural period of primary engorgement without ever removing any milk from her breasts. The build-up of milk coupled with the lack of regular breast stimulation caused her to lose her milk supply. Marta’s body thought that she did not intend to breastfeed.
“How Can Pumping Help with Mishandled Engorgement?” In order to preserve her milk supply and help her through the engorgement phase, hospital staff should have advised Marta to use a double electric breast pump every three hours. Not only would regular pumping serve to lessen the symptoms of painful engorgement, but Julio could have been fed his mother’s pumped breast milk instead of formula. Sadly, Marta was incorrectly counseled that pumping during the early stages of engorgement would worsen her condition. This is simply not true. Early engorgement is hormonally driven, and pumping to relieve over engorgement will not worsen a mother’s condition. In Marta’s case, pumping would in fact have protected Marta’s milk supply until Julio could learn to breastfeed. Frequent breastfeeding or pumping in the days following birth awakens receptors sensitive to the hormone prolactin, a key player in the production of mature breast milk.
Marta’s story has a happy ending. Marta told me she still wanted to breastfeed Julio and was eager to do whatever was necessary to recapture her lost milk supply. Marta began using an electric breast pump every few hours. She refused to be discouraged when at first her efforts produced not even a drop of milk. In the meantime, Julio continued to be supplemented with formula. Slowly, Marta’s body began to respond, and she made measurable amounts of milk with each successive pumping. This motivated Marta to try a prescription medication to help restimulate her supply. Julio began breastfeeding, and, to my amazement, Marta went on to develop a very strong milk supply. (Learn more about balancing breast milk and formula.)
What Is Abnormal Engorgement?
Most mothers experience the breast fullness and warmth of primary engorgement three to five days after giving birth. This is a good sign! Breast fullness harkens the arrival of your mature milk and is an indication that your body is working well. It is important to know how to navigate through this sometimes troublesome period so that you can sail smoothly into the future with your baby. Left unchecked, the normal symptoms of primary engorgement can develop into a full-blown problem.
What started out as normal engorgement for Robin quickly progressed into over engorgement. By the time Robin called me for help, she was in so much pain that she had difficulty talking. Robin’s breasts were so swollen and so engorged that when I touched them during my exam, my fingers left visible indentations on her breasts. Robin explained that her milk had come in the day before and that her son Ray had been breastfeeding irregularly overnight. Robin’s breasts became rock hard with no discernable nipple, making it virtually impossible for her son to attach for feeding. Robin also had a low-grade fever, a sign that her whole body was responding to the severe inflammation of her breasts.
Over the next hour, we alternated cold and heat treatments. Once the swelling abated a bit, Robin was able to pump some milk with an electric breast pump. To minimize pulling her already distended breast and nipple tissue, I instructed Robin to keep the suction on the pump low. Finally, Robin’s baby was able to attach and effectively breastfeed using a nipple shield. Afterward, we once again iced Robin’s breasts. Robin continued this plan until her breasts healed from the over engorgement.
Part of the reason Robin experienced such exaggerated engorgement was that Ray was her second child. Experienced mothers can expect their mature milk sooner and in greater volume than first-time mothers. Whether you are having your first baby or your fifth, it is important to know how to treat your symptoms of engorgement well before the engorgement develops into an excruciating problem.
How Do I Treat Engorgement?
During this phase of engorgement, avoid wearing a bra. A bra may compress your breasts and make your swelling worse. Sometimes clients ask me about cabbage leaves as a treatment for engorgement. Certainly, there is no harm in wrapping your breasts in cabbage, but I prefer the treatment described next. Whatever treatment you choose, it is important to repeat the regimen every two or three hours day and night until your engorgement abates and your milk is freely flowing. Until your engorgement is under control, avoid any preparations that could potentially increase your milk production and worsen your engorgement, such as herbal teas or supplements that contain the herb fenugreek.
Cold treatment: If your breasts feel very hard and full, chances are it’s not just trapped milk volume that is causing the swelling. During engorgement, your breast tissue becomes over distended and painful just like a sprained wrist or ankle. It is important to reduce the swelling so that milk flow can resume. The treatment for the breast swelling of early engorgement mimics the treatment for a sprained ankle. Before doing anything else, my treatment of choice is cold treatment. When working with an engorged mother, I insist on real ice in quart-size plastic bags. The ice can be cubed or crushed. I then wrap the bags in a thin receiving blanket and cover the mother’s swollen breasts with the wrapped ice bags. (I don’t recommend putting ice directly against bare skin.)
Most mothers experience a noticeable reduction in swelling after fifteen to twenty minutes. Of course, the ice bags can be placed back in the freezer and reused. The cold treatment will need to be repeated until the engorgement is resolved.
Heat treatment: Sometimes a heat treatment is necessary to loosen a tight full breast. A heat treatment works best by getting into the shower and allowing warm water to soak the breast. The shower should be warm enough so that steam rises. Be careful not to burn your sensitive breast or nipple tissue. If you find heat helpful, then try wetting the inside of a disposable diaper with warm water and wrapping one around each swollen breast. Remove the diapers when the heat dissipates. Repeat the heat treatments frequently until your breast milk is freely flowing, and your engorgement is resolved.
Milk removal: Milk can be removed from your engorged breasts after the swelling is reduced by cold or heat treatments. Frequent milk removal is key to the healthy resolution of engorgement. Breastfeeding your baby often will help prevent your breasts from becoming over engorged. For this reason, it is important to keep your baby close to you, so you can easily breastfeed. Avoid substituting formula supplements in place of breastfeeding. Supplementing will reduce the number of times your baby breastfeeds and worsen your engorgement.
Engorgement can significantly change the shape of your breast and nipple, making it difficult for your baby to breastfeed. This can occur even when your baby has successfully breastfed prior to the development of primary engorgement. If you find yourself in this situation, then a nipple shield may help your baby reattach and effectively breastfeed. You can stop using the nipple shield once your engorgement resolves. If you are unable to breastfeed your baby, use a double electric hospital-grade breast pump every few hours. Pumping will protect your milk supply as it lessens your engorgement. Save all of your milk to feed your baby.
How Do I Build a Strong Milk Supply?
Brenda wanted to see me for a prenatal consultation because she was worried that she might not develop a strong milk supply for the baby she was expecting. Brenda was having an excellent pregnancy. Early on, Brenda’s breasts felt sore, her nipples darkened, and her breasts became noticeably larger in size. Brenda was healthy and had never had breast surgery or any other risk factors that could predispose her to a low milk supply.
After talking with Brenda, I assured her that the breast changes she described meant that her breasts were ready to make plenty of breast milk for her baby. After our appointment, Brenda was able to trust her body. Once her son Finn was born, Brenda followed some simple steps designed to send her body the message that she intended to breastfeed. Sure enough, Brenda developed plenty of breast milk right on schedule.
Chances are that you will build a strong milk supply to nourish your baby. Your body is well suited for motherhood, and as your milk supply matures, your body will err on the side of abundance. As I explained to Brenda, there is no shortcut to developing a strong milk supply. By putting forth effort during your baby’s first few weeks of life, you and your baby can enjoy a strong milk supply later. The steps described next are designed to help you develop a full supply of mature breast milk.
Breastfeed at birth: Breastfeed as soon as possible after birth. These early feeding experiences give you a head start on your way to developing a full milk supply. Breastfeeding in the delivery room or the recovery room after a cesarean section gives your baby your early breast milk and lays the hormonal groundwork for your future supply of mature milk. Keeping your baby close to you makes getting an early start easier.
Breastfeed frequently: Breastfeed your new baby as frequently as possible. Frequent breastfeeding sensitizes your hormonal receptors to prolactin, the hormone that helps build your milk supply. Once your baby is born, pregnancy hormone levels decline, and prolactin levels rise. This is a crucial time in the development of your future milk supply.
Breastfeeding your baby during this hormonal shift enables you to capture the crest of this prolactin wave. If you become separated from your baby or your baby is unable to breastfeed, then pump your breasts with an electric breast pump every three hours. Pumping will send your body the message that you intend to breastfeed.
Cope with engorgement: About three to five days after giving birth, your breasts will swell with the arrival of your high-volume mature milk. This signals a turning point in your breastfeeding relationship. By now, your colostrum or early milk has prepared your baby for your mature breast milk. It is important to navigate smoothly through this period of primary engorgement.
Take your bra off while you are engorged to prevent compression of your breasts. If your breasts become swollen and painful, plan to use cold or heat treatments as previously described. Softening your breasts with repeated ice or heat treatments will enable your milk to flow and allow for milk removal. Breastfeed your baby or pump to prevent milk stasis and escalating engorgement. Reducing the swelling of your breasts and removing milk will preserve your future milk supply.
Is There Anything That Will Interfere with My Milk Supply?
Because so many variables impact a mother’s milk supply, the cause of a low supply is not always obvious. Sometimes the origin of a mother’s difficulty remains a mystery and cannot be traced back to any one cause. Of course, having a history of surgery such as breast reduction will affect a mother’s potential to produce a full supply; however, she can still breastfeed. Although some factors that affect milk supply are outside a mother’s control, many factors are within her control.
Consider Marla, whom we met at the beginning of this article. Most likely, she would have developed a full milk supply if she had breastfed baby Henry early and often during the first weeks of his life instead of having him under the care of a hired baby nurse. Missing out on these early feeding opportunities suppressed Marla’s milk supply.
A variety of situations or conditions have the potential to delay the arrival of a mother’s mature milk. Having a difficult birth or a cesarean section may delay a mother’s experience of primary engorgement. Diabetics may also experience delayed primary engorgement. Even being a large-size woman can put a mother’s milk supply at risk. Experiencing greater than expected blood loss while giving birth or having a retained placenta inside the uterus after birth can lead to milk supply problems. Of additional concern are hormonal birth control measures that are prescribed or administered too early in the postpartum period. Birth control hormones can short-circuit a new mother’s ability to establish a full milk supply.
The ABCs of Building a Milk Supply
To review, pregnancy prepares your breasts for breastfeeding. In fact, your body assumes that you will breastfeed and prepares early breast milk for your baby’s first meal. After giving birth, the hormonal landscape shifts within your body and culminates with the arrival of your high-volume mature milk. It is important to navigate smoothly through this time to protect your future milk supply. Once this phase of engorgement passes, your body will be ready to learn just how much milk your new baby needs.
Assume that you will easily build a strong supply of mature milk for your baby. Keep a positive breastfeeding mindset, and don’t be discouraged if you have a risk factor that may predispose you for a delay in the arrival of your mature milk. I have worked with many new mothers who had multiple risk factors for delayed primary engorgement. Many of these mothers welcomed the arrival of their mature breast milk right on time. Assume you will be a breastfeeding success story, and chances are you will be.
During pregnancy, your breasts will grow larger, and the color of your nipples may darken. Your breasts will prepare colostrum for your baby’s first meal. This early breast milk will be available even if your baby is born earlier than expected. About three to five days following your baby’s birth, your breasts undergo more changes with the arrival of your mature breast milk. Primary engorgement is a turning point in your breastfeeding relationship. Your breasts will become larger, fuller, and warmer. The color of your breast milk will gradually change from yellow to white. Finally, your baby will respond to this high volume milk by swallowing frequently during feedings, and you may notice breast milk in and around your baby’s mouth after feeding.
In the hours, days, and weeks that follow your baby’s birth, it is important to send your body the message that you want to breastfeed your baby. By clearly communicating your intention, your body will respond by making a strong supply of breast milk. Begin by breastfeeding after birth. Keep your baby close to you so that you can breastfeed frequently. Breastfeeding after birth and breastfeeding frequently sensitizes your body to the hormones that regulate your future milk supply. Manage the swelling that can accompany primary engorgement by applying cold or heat treatments to your breasts. Reducing the swelling of your breasts will facilitate milk removal and help you to remain comfortable.
Excerpted from The ABCs of Breastfeeding: Everything a Mom Needs to Know for a Happy Nursing Experience by Stacey H. Rubin, M.N., APRN, IBCLC. Copyright © 2007 Stacey H. Rubin, M.N., APRN, IBCLC. Published by AMACOM Books, a division of American Management Association, New York, NY. Used with permission. All rights reserved. www.amacombooks.org.