What are the options to increase milk supply during breastfeeding?

Increasing Milk Supply During Breastfeeding

The most effective strategy to increase milk supply is frequent breastfeeding or milk expression 8-12 times per day combined with ensuring proper latch and complete breast emptying. 1

Primary Evidence-Based Strategies

Frequent Feeding and Breast Emptying

• Breastfeed or pump 8-12 times per 24 hours (approximately every 2-3 hours) to stimulate milk production through frequent breast emptying. 1, 2
• Frequent feeding (8-10 times daily) decreases newborn weight loss, reduces supplement needs, and lowers hyperbilirubinemia risk. 3, 2
• Proper latch and positioning are crucial for effective breast drainage—incomplete emptying signals the body to reduce production. 1
• For mothers of premature infants, pump 8-12 times daily to establish adequate supply. 1

Optimize Breastfeeding Technique First

• Before considering supplements or medications, optimize breastfeeding technique and frequency. 3
• Ensure continuous rooming-in with on-demand feeding to support milk production. 3, 2
• Early skin-to-skin contact promotes milk production through hormonal responses and helps establish successful breastfeeding. 1, 2

Pharmacological Options (Galactagogues)

Domperidone and Metoclopramide

• Both domperidone and metoclopramide can increase milk supply by elevating prolactin levels. 1
• Domperidone: When taken orally, levels in milk are low due to first-pass metabolism; used specifically as a galactagogue. 3
• Metoclopramide: Also functions as a galactagogue and may increase milk supply. 3
• Ensure access to a breast pump if there is any delay in feeding the infant when using these medications, as they may increase milk production. 3

Important caveat: These medications should be considered only after optimizing frequency and technique, as the AAP recommends avoiding supplements unless breastfeeding has been optimized first. 3

Behavioral and Supportive Interventions

Relaxation and Stress Reduction

• Relaxation and visual imagery techniques can significantly increase expressed milk volume—one study showed a 63% increase in milk expression compared to controls, with a 121% increase among mothers of ventilated infants. 4
• Music, warmth, and relaxation interventions have been shown to increase milk quantity obtained. 5

Breast Massage and Warmth

• Breast massage when pumping increases fat content and milk volume obtained. 5
• Warming the breasts before expression can increase milk quantity. 5

Hand Expression Combined with Pumping

• Hand expression can be as effective or more effective than electric pumps for some outcomes. 5
• Combining hand expression with pumping may optimize milk removal. 1, 5
• Hand expression provides higher protein content than manual pumps and higher sodium with lower potassium compared to electric pumps. 5

Pumping Strategies

Timing and Frequency

• Initiate pumping sooner after birth when the infant cannot feed at the breast. 5
• Increase pumping frequency to stimulate greater production. 5
• Most mothers experience lactogenesis II (copious milk production) by the third to fourth day after delivery. 3

Equipment Considerations

• Ensure proper breast shield size, as appropriate sizing increases milk volume obtained. 5
• A breast pump should be available to reduce mastitis risk if there is prolonged separation. 3
• Low-cost interventions and lower-cost pumps may be as effective as large electric pumps for some outcomes. 5

Common Pitfalls to Avoid

• Avoid formula supplementation unless medically necessary, as it reduces breastfeeding frequency and subsequently decreases milk production. 1, 2
• When supplementation is necessary, use expressed breastmilk rather than formula when possible. 1, 2
• Do not rely on increased fluid intake beyond physiological needs—there is insufficient evidence that extra fluids improve milk production. 6
• Avoid test weighing (weighing before and after feeds) as a measure of milk production due to lack of precision. 6

Monitoring Effectiveness

• Track infant weight gain to assess milk intake adequacy. 1
• Monitor diaper output: 6-8 wet diapers per day indicates adequate intake. 1
• Breastfeeding 9-10 times per day is associated with lower bilirubin concentrations, while fewer than 7 feedings daily correlates with higher bilirubin levels. 2

Special Populations

Very Low Birth Weight Infants

• For infants <1500g, mother's expressed milk provides critical benefits including reduced necrotizing enterocolitis, late-onset sepsis, and improved neurodevelopment. 2
• Pasteurized donor human milk is recommended when mother's milk is unavailable or as a supplement. 3

Professional Support

• Skilled lactation support should be readily available in maternity care facilities and accessible after discharge. 3
• Staff trained in breastfeeding support should be available to help with expressing milk during prolonged separation. 3
• Most maternal medications are compatible with breastfeeding—consult LactMed to avoid unnecessary disruption. 3