Milk Supply and Let Down

Evidence 

https://journals.sagepub.com/doi/full/10.1177/0973217920922398 

Sneha Gupta and Tushar Parikh  

Mothers of babies who are admitted in NICUs are faced with multiple challenges as they strive to practice exclusive breastfeeding. In stressful situations, mothers may have difficulty with milk let-down. The low frequency of milk expression (<6 times per day) is a common cause of low milk supply. The first 2 weeks after a baby’s birth are a critical period for the establishment of good milk production. 

Education 

Breast milk is important for all babies but for premature and sick newborns, it provides vitally important health benefits and acts like a medicine that only a mother can provide. 

When babies are sick or premature it often takes them longer to be able to breastfeed. It may take weeks or even months. This is very normal. In the first few days or weeks you will be asked to express your milk until your baby can coordinate their sucking, swallowing and breathing effectively and the doctors have given the green light to start breastfeeding.  

Milk production is driven by supply & demand. The more milk that is removed from your breasts, the more milk your breasts will produce. During the first few days after birth, it is common to express only a few drops to a few millilitres of colostrum. As your milk matures, the quantity increases. 

Expressing breast milk is a skill that takes time to learn. Please don’t get discouraged; remember that each drop is like a medicine for your baby, and it is helping get them off to a healthier start. 

It’s extremely important to have an effective pumping schedule which involves starting within a few hours of birth and pumping 8-10 times per day, roughly every 2-3 hours. Using a hospital-grade electric breast pump and hand expressing afterwards to extract any remaining milk can maximise milk production. 

Nighttime expression is important for continued milk production. There is a surge of a hormone called oxytocin during the night, which helps in milk let-down. You should express milk just before sleep, at least once during night, and again after waking up in the morning. 

Your milk supply may be low if you’re unwell or feel under stress, or if you have a pre-existing medical condition. Some medications, including cold and flu treatments, can impact milk production. 

If you have concerns about your milk supply, consult your healthcare team or GP, a lactation consultant in the NICU or an Australian Breastfeeding Association counsellor. 

Tips to Increase Milk Supply 

• Skin-to-skin contact, known as Kangaroo Care, can help your baby feel secure and stimulate your milk supply, preparing both of you for breastfeeding. 

• Rest and Nutrition: Rest when possible and consume healthy foods.  

• Stay Hydrated: Drink water when thirsty; keeping a water bottle handy can help. 

• Sit near your baby or look at a photo, and the smell of your baby can enhance milk flow. 

• Popping a cover over the collection bottle helps to distract you from worrying about how much milk is coming out.  

• Gentle breast compressions –smoothing down your breast towards the nipple  

• Listening to calming music may help you to relax and increase your milk production.  

• Giving your milk via tube feeds while holding your baby allows you and your baby to learn to breastfeed together without a feeling of pressure. Your baby can feel that full feeling while in your arms and or when near the breast.  

Miracle Babies Foundation offer a Milk Express Pack for mothers who are expressing breast milk for their baby in neonatal care.  Be sure to ask your baby’s nurse for your resource pack. 

Let-down Reflex 

When your baby latches on to your breast to nurse or when you use a pump to express your milk, it stimulates nerves that trigger the release of two hormones, prolactin and oxytocin, into your bloodstream.  

• Prolactin is responsible for making more breastmilk.  

• Oxytocin causes the let-down reflex so your milk flows.  

The milk-making cells in your breast contract and squeeze out the milk, pushing it down the ducts towards the nipple. Oxytocin also makes the milk ducts widen, making it easier for the milk to flow down.  

This pushing out of milk is known as the let-down reflex or the milk ejection reflex.  

This could feel like: 

• A tingling sensation either before or during a feeding 

• A feeling of sudden fullness 

• Milk dripping from the breast you’re not nursing or expressing from 

• Baby changes from a suck-suck pattern to a constant suck-swallow  

• Cramping due to your uterus contracting, which is more common in the first few weeks of nursing a newborn 

• Feeling thirsty 

Let downs often happen more than once while you feed or express milk, but most of the time you only notice the first one. If you’re expressing milk, it can be a bit harder to notice a let-down.  

Let-down may also not be achieved for several reasons including stress, fatigue, tension, pain and even being cold. 

Some challenges with your let down could be: 

• Delayed or slow let-down due to stress or anxiety 

• Overactive let-down causing milk to flow too quickly  

• A painful let-down (especially in the first few weeks postpartum. This is because your milk ducts constrict to force milk out towards your nipple) 

Some women may also experience Dysphoric Milk Ejection Reflex (D-MER), or a whole roller coaster of negative emotions such as sadness or anger, at the same time. These feelings usually disappear along with the pain within ten minutes after you start feeding. As your body becomes more used to breastfeeding/expressing, these negative sensations should disappear. 

If those feelings don’t disappear or you have any concerns, it’s important you reach out for support.  

COPE – Centre for Perinatal Excellence 
https://www.cope.org.au/getting-help/e-cope-directory/ 

Panda - Perinatal Mental Health 
https://panda.org.au/ 

Beyond Blue  

https://www.beyondblue.org.au/mental-health/parenting/caring-for-a-baby

For When 

https://forwhenhelpline.org.au/ 

Other challenges that can affect your let down and/or your milk supply include:  

• Positioning/size of the breast pump flanges or your baby’s latch. 

• A yeast infection  

• Engorgement  

• Blocked Milk Duct/Mastitis  

In the early days of expressing or breastfeeding, your milk may let down within a few seconds, or it could take a few minutes. If it's taking a little while to get the milk flowing, don't worry. As the days and weeks go on, your body will learn to recognise the signs, and you will notice that your let down comes more quickly.  

Empowerment  

For many mothers, expressing breast milk and feeding is one of the most beneficial and rewarding things they can do for their baby. This is a time when relationships are formed, and bonds are forged. 

Struggling with a low milk supply can be very upsetting and frustrating. Remember that any amount of breastmilk you provide your baby is valuable. 

Some level of anxiety is normal in when you begin breastfeeding or expressing your milk, especially when your baby is in the Neonatal Unit, however if you find that you are anxious most of the day, several days a week for more than 2-3 weeks then this can be signs that anxiety is becoming more of a problem for you.  If it is impacting on your ability to continue your normal life, then you may wish to seek further help from your GP or Social worker at the hospital – every Neonatal/Special Care Nursery will have one. Your healthcare team and GP should both be checking on your mental health at each appointment even if you do not feel you need help yet, if you are starting to feel anxious or low you can still discuss it with them so that they know to check up on you in the future. 

Useful Links 

The Royal Women’s Hospital, Victoria  

https://thewomens.r.worldssl.net/images/uploads/fact-sheets/Helping-your-baby-to-breastfeed-in-the-NICU-200319.pdf 

Australian Breastfeeding Association   

https://www.breastfeeding.asn.au/resources/increasing-supply 

https://www.breastfeeding.asn.au/resources/let-down-reflex-and-your-milk-flow 

Pregnancy, Birth and Baby  

https://www.pregnancybirthbaby.org.au/increasing-your-breast-milk-supply 

Miracle Babies Foundation 

https://www.miraclebabies.org.au/content/breastmilk/gk7wm8 

https://www.miraclebabies.org.au/content/expressing-breastmilk/gjsd7c 

COPE – Centre for Perinatal Excellence 
https://www.cope.org.au/getting-help/e-cope-directory/ 

Panda - Perinatal Mental Health 
https://panda.org.au/ 

Beyond Blue  

https://www.beyondblue.org.au/mental-health/parenting/caring-for-a-baby 

For When 

https://forwhenhelpline.org.au/ 

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