"Low supply", "over supply", "overactive let down", "supply and demand", "slow gaining infant", "no weight gain" & the role of the baby in these phenomena!

The landscape of breastfeeding discussions has changed. I have been in breastfeeding conversations now, actively, for 12 years. The conversations I am having now do not resemble the conversations I have had in the past. I cringe now when I think about many of those conversations, knowing what I know now. What is that saying? When we know better, we do better…YES, yes we do. 

One of the primary changes to the conversation is that we no longer can look solely at what is happening with the mother of the breastfeeding dyads, but we are looking at the baby also. I don’t mean positioning. I don’t mean skin-to-skin. I don’t mean early and often feeding. I mean, just as in how we look at a mothers ability to produce milk, we need to look at the babies ability to extract that milk. We know production of milk is primarily about supply and demand. Demand needs to be present first; this is the baby. Expulsion of the placenta stimulates the start of milk production & then the baby needs to drive it from there. If we are seeing something not working as expected, we need to assess both mother and baby. Often what appears as not working is “mom hasn't started to produce, her milk is not in yet, she just can’t produce milk or she cannot produce enough”. However, we then also say, and I am sure you have heard this, that very few women truly do not produce milk or produce lower amounts of milk. We use completely contradicting statements, loosely, but they are taken as hard, fast truths. Or we will say, “No, no, you are making enough for your baby. Of course, you are making perfect milk for your baby. Your body knows what your baby needs. Some babies are just slender. That is how breastfeed babies are. They feed all the time. They are slender. Babies on formula weigh more. Don't worry about it. Just keep feeding," Or have you heard about the mothers being told their breastmilk is made of water. They just don’t make “cream” like their friends. How confusing! 

When the new growth charts came out, we expected to prove some of these theories .The new charts were based on breastfed babies, internationally, in favourable living environments. There is lots of history to read on the development of the WHO growth charts. In short, people expected to see breastfed babies being slender and slower gaining and waited to be able to say, “we, told you so”. Well, the laugh was on us. The new charts show that under favourable environments and feeding conditions, breastfed babies do weigh more than their formula fed counterparts and on the new charts breastfeeding concerns show up even sooner than previously. For example, it is common at a 4 month check up to see a baby on the old chart to not be gaining on the curve anymore. Now, with the new growth charts, that same baby would show up with less than ideal growth earlier, perhaps at 3 or 4 weeks. Growth failure was being seen as a normal negative deviation and being missed! It appeared almost as if advocates of breastfeeding were trying to downplay growth failure, because they so truly believed breastfeeding is the way to feed an infant and didn’t want to admit when it wasn’t working. I was fascinated by the charts and wanted to know why the data spread that way. (That could be my former career as a Medical Laboratory Technologist shining through). 
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About the same time I started looking at breast-feeding failure with my new set of lenses; the lenses that looked at mom and baby, not just a mother seemingly making too little milk, with pain or maybe without pain, with a screaming baby or maybe a sleepy baby, maybe a baby gaining weight but seemingly hungry all the time, maybe a baby with slow weight but seemingly content. I wanted to know more about all the babies & was learning more about babies. (What you seek you shall receive) I was introduced to the idea that babies cannot always function at the breast well, and therefore, the demand is not put on the mothers supply. Without demand, there is no supply! But can’t a mother just offer the breast more, get into bed for 24 hours for a breast-feeding vacation, do skin-to-skin, put baby in a wrap and walk and feed as baby needs and get that supply up? That is exactly what I was taught. Mom just needed to try harder and get supply up, drink more water, rest, take some fenugreek, drink lactation tea and eat lactation cookies. But, you know what?  That wasn’t always working. Not with the cases I was seeing.

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​If the baby cannot function fully at the breast no amount of time at the breast is going to drive supply. At the same time, we also learnt the breast doesn’t function like we thought it did. The new science tells us we make more milk by emptying the breast more, NOT by letting it get full and empty every 4 hours. Hold on, what? But babies don’t like when the breast isn't full, they scream and protest or fall asleep. They are happy when it is full, let-downs come easy and milk leaks into their mouths. We now understand this all as a compensation for babies inability to function and realize that this routine of feeding can, in fact, cause (secondary) low milk supply down the weeks of feeding. If we address the babies issues, we can have proper feeding, proper demand and proper long term supply. We are starting to make progress with this and changing the idea of low supply. 

What i am not seeing is a change is how we see the idea of oversupply or overactive let down. If the idea of low supply is often being perceived incorrectly should we not consider the idea of overactive let down or oversupply isn't a true phenomena either? Could oversupply also point back to the baby? Is this another function consideration?  I certainly think so. I would like to ask that we consider the let down and supply as normal flow, but, too fast for that particular infant. The infant, for varying reasons (and an assessment would be needed to determine the reason) is having a hard time controlling the flow of the milk. They choke, cough, sputter, leak milk, etc. They might have fast feeds, gain well and seem to adapt to this "overactive let down". As time goes on, supply decreases (we respond saying milk supply is now regulated as nothing was wrong anyway) and soon, the same mom with overactive let down, is saying she has low supply. WHY? Because the baby could not feed correctly from the beginning. They had difficulty at the breast, relied on that fast letdown and now without correct feeding behaviours, just like the low supply moms I talk about above, the demand is not there and so the supply goes down. 

Something else we now know, that we used to say the opposite of, is that a hungry baby will cry and a content baby cannot be hungry, Regardless of weight gain plateauing on the curve, being slow gaining, so long as baby seemed content, no one worried. What we know how is that as milk supply goes down, appetite of the baby goes down. That appetite is the demand we need! So without the demand, we again will have no supply. This is quite a different tale than has been told in history! 

Let's keep chatting! If you think you need some hep navigating your breast-feeding I am happy to book a time to see you and your little one.