I'd also like to add my 0.2 ml worth in here.  How can the mother 
know if the baby is taking all the milk she's making, ie 
breastfeeding effectively?  Firstly, a baby who isn't doing very well 
will usually go to the breast, take a very few gulps/swallows with 
eyes open, and then as soon as the flow reduces, close the eyes and 
mainly flutter-suck, only to wake and protest if taken off the breast 
(when mom assumes the baby has had enough and _that's_ why he's going 
to sleep.....).  If the mom puts the baby back to the breast the same 
thing happens again - a few swallows, then he just hangs out at the 
breast again.  This can go on for hours, with the mom assuming that 
the baby is "breastfeeding", but he's really not .....  So at the end 
of the breastfeed, when the mom perceives that the baby has finished, 
she can "test" whether the baby has taken a good quantity of milk by 
expressing a drop or two of milk by hand.  If there are jets of 
watery looking milk, then the baby has _not_ finished - he simply 
doesn't have the energy to breastfeed effectively.  On the other 
hand, if there are only a few creamy-looking drops of milk left, then 
that's the sign that the baby has breastfed effectively and taken 
most of what mom is making.

So I would usually suggest the following management plan to a mother 
wanting/needing to increase her breastmilk supply (the mother who has 
jets of milk left _after_ breastfeeding .....)

1.  Breastfeed for no more than 20-30 minutes, using alternate 
massage and switch-nursing and stimulating the baby to stay awake and 
keep swallowing - the _stop_ breastfeeding (allowing baby lengthy 
times at the breast when there is little swallowing going on is 
simply wasting everyone's time).
2.  Immediately after breastfeeding, feed the baby any previously 
expressed breastmilk as a top-up, in the quickest, easiest possible 
way (no slow-flow teats, use the fastest teat the baby can cope with)
3.  "Settle" the baby - this can be done by putting baby back to 
breast, and allowing him to comfort/flutter-suck and go to sleep.
4.  As soon as possible after feeding, pump/express both breasts 
perhaps twice each, using massage too, to maximize let-downs and 
output.  Store any EBM, no matter how small the quantity, for the next top-up.
5.  Breastfeed again and repeat the above when the baby wants to feed 
again, but breastfeed/drain the breasts thoroughly at least every 3 
hours around the clock (if the baby is sleeping and can't be woken, 
then the mom can pump/express instead, keeping the EBM for top-ups 
later in the day).

It's the frequent, thorough drainage of the breasts which will 
re-stimulate breastmilk production.  When a baby is breastfeeding 
very ineffectively, his weight gain may be very low, or remain 
static, or he may even lose weight.  As he becomes weaker, his 
breastfeeding performance becomes worse and worse, so that drainage 
of the breasts becomes more and more ineffective, and it is this, 
more than anything else, which suppresses the mom's milk supply.  The 
above protocol can reverse everything if the mom can be persuaded to 
keep on keeping on.  When she first starts, the quantity of milk 
expressed/pumped after breastfeeds may be very low - but really good 
drainage of the breasts very frequently can kick-start the whole 
process, and I've seen this work soooo well!   I usually suggest moms 
keep a chart of the times of breastfeeds, urine/stool output, EBM 
expressed, top-ups given (both EBM and if necessary ABM), daily 
totals of everything, so that - over time - she can see that her milk 
production is starting to increase a little, and later, a lot!   This works!

Pamela Morrison IBCLC
Rustington, England

Rachel writes,
>Cathy Genna writes, in response to this question:
>"If the baby is not feeding effectively, and that's the likely 
>reason for low supply, I encourage moms to pump right after bf. If 
>the baby is taking pretty much everything mom can make, then I 
>encourage her to pump about 45-60 mins after the feeding, so she can 
>spike her prolactin again and remove milk to stimulate the breast."
>
>I would add that if the baby is taking pretty much everything mom 
>can make, *and* is willing and able to feed effectively again 45-60 
>minutes later, I encourage mother to skip the pumping and let the 
>baby earn its keep by doing the dreary, tiresome work of stimulating 
>milk supply itself.  The quicker mother and baby can get together 
>without a pump in between them, the happier we (mother, baby and me) all are.

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