Milk Flow It’s at the Heart of Breastfeeding

By Beverly Morgan, IBCLC | Written for MOBI Motherhood International

Beverly’s note: This article contains information crucial to all breastfeeding mothers. It includes ways to “watch the baby” that you may not have heard before. I foresee this information helping you to enjoy, marvel at, and respect your special little person even more.

It will be helpful if you read this article from beginning to end first to get an overview, and then return to the sections that seem to apply to your situation.

When people think about milk flow and breastfeeding at all, it is often in relation to a mother not having enough milk. Fast flow can be of concern, too. In this article, we will explore both.

If you have concerns about your milk flow, seek help. An IBCLC can help diagnose the problem, work out a management plan, and refer you to an appropriate therapist if necessary. Some babies have shaky breastfeeding feeding skills that can cause extra challenges. They can benefit by additional support.

A word of caution: If your newborn baby is fussing and fretful while feeding at the breast, or if he shows a lack of interest, or is falling asleep at the breast, look for help today.

A baby reacts to his mother’s milk flow

A friend of mine, while nursing her verbal child, asked him why he was massaging her breast while he nursed. He popped off her breast to say, "Cause it makes the milk come faster."

Milk flow is at the heart of feeding and its impact is far reaching. As an IBCLC, I became aware that many mothers are not conscious of the interplay between milk flow and the baby. A baby’s response to his mother’s milk flow shapes his nursing behavior. Consequently, his feeding behavior also affects his mother’s milk flow.

If the baby is always struggling with a flow that is too fast for him to handle, or continually tugging at the nipple because the flow is too slow, this can be confusing or disturbing to the mother. The quality of the nursing relationship is affected by a mother’s milk flow and her baby’s reaction to it.

Variable flow rate throughout the nursing session

Throughout a nursing session the general trend in milk flow is from faster to slower. However, it is not a straight line decrease. Like the tide, there is an ebb and flow. Let me explain.

If you’ve done any pumping, you will have noticed that when you start there is a delay before the milk flows. Once the milk ejection begins, the milk flows faster. The milk might even spray, especially if your breasts were firm when you started. The flow will then be steady for a time, gradually decreasing, and temporarily stopping. If your baby keeps nursing, or if you continue pumping, you will have another milk ejection. The flow will rise again with the next “wave” of milk, but unlike the tide, the flow of milk does eventually stop. Each milk ejection is less forceful and has less volume than the one before. This means that a baby has faster flowing milk at the beginning of a session, when he has a strong appetite, and slower flowing milk at the end, when he is full and sucking more for comfort. Keeping this variable flow rate in mind, the baby’s behavior at the breast becomes a bit easier to read.

Reading your baby’s behaviour cues

• If he pulls back and milk is flowing out of the breast, it may be that his swallow is temporarily challenged and he is trying to get breathing space.
• He may have learned from experience that the first letdown is too fast and strong for him to handle comfortably, so he pulls away and waits for it to pass.
• He may pull off the breast once the flow starts. He may have been nursing more for comfort; this extra milk was not what he wanted.
• If he pulls his head back and tugs on the nipple of the first breast in a feeding, and you can tell that that breast feels soft now, he will likely be happy to change to the second breast for a faster flow.
• If he tugs or fusses right from the start he may be impatient for the flow to start. He may want the other breast if he knows it is the faster flowing breast.

As you get to know your baby and your milk supply, you can make educated guesses on what he is trying to tell you.

Variable flow from breast to breast

Milk flow varies from one breast to the other, and it changes throughout the nursing session and throughout the day. I consider this variable flow as nature’s way of providing different flow rates for different babies. Often, tuning in to which breast flows faster, and learning what the baby prefers, can add an extra level of enjoyment to breast nurturing.

When working with mothers, I share “Morgan’s Rule of Thumb for Milk Flow”: The firmer the breast, the faster the flow—the softer the breast, the slower the flow.

Bottle nipple manufacturers and people who bottle-feed a baby have also discovered how important milk flow is to a baby. There are a variety of flow rate nipples available and a mother may need to try many to find the one that flows best for her baby.

Side preference

Not all children have a side preference and there are reasons other than milk flow that can induce an infant to favor one side. For example, a baby may have a broken or cracked clavicle from birth. If so, he will prefer to nurse on the side that does not put pressure on his sore shoulder. If a baby seems distinctly uncomfortable on one side, a therapist may be in order. He may be happy to use both breasts once the restriction or pain that caused his preference is resolved.

For the sake of our discussion here on milk flow, we will assume that there is no underlying physical condition causing the side preference, and that the preference is due to the most obvious cause: the baby’s preference for a faster or slower milk flow.

Supply and demand

Interestingly, the favored side can change from time to time, sometimes because the baby’s flow preference changes. A baby who was having trouble keeping up with a fast flow can now handle it better, and suddenly he prefers the faster flowing breast. A baby who likes a slow flow may nurse on the slower flowing breast more effectively, so that with time both the volume and flow rate increase in that breast. This baby may now switch his preference to the other breast that has become slower flowing in comparison.

Sometimes, the preference for one particular breast remains for the entire duration of the nursing relationship. This preference may be consistent from child to child, or may vary depending on the child. One possible reason for the preference could be that one breast produces the larger portion of milk, and the mother’s children respond to that with a preference.

The more often the baby chooses one breast, the more stimulation and milk removal that breasts experiences. This milk removal and stimulation induces that breast to produce more milk. Some mothers offset the baby’s preference for the faster flowing breast by pumping in addition to nursing on the slower-flowing breast for a time to increase its flow. If the flow rate is too fast for the baby on one side, making him reluctant to take that breast, mother might use a nipple shield on that breast to slow the flow. Strategies such as these can assure that there is demand to drive the supply on both breasts.

Baby’s cues: watch those little hands

Let’s assume the baby is nursing effectively and is generally comfortable with the flow of milk from both breasts. Let’s also assume that mom has the milk he needs. Now look at his hands. Here are some things you might notice.

• Think of his fists and arms as a gas gauge. His arms are up and his hands are in fists when he needs a fill up. His arms are down and his hands open when he feels satisfied!
• Anticipating the nursing session, his hands are held in fists near his face
• They remain fisted during the pre-milk ejection and the first milk ejection phase
• As he's becoming satisfied and the milk flow slows to the post-ejection rate, his hands gradually uncurl and drop down from his face
• If he has gas or is startled out of his relaxed state, his hands may go part way up again. However, his hands will usually not go as far as his mouth and they will usually start to drop again more quickly then at the beginning of the feeding.

Tailored Breastfeeding

You have now been introduced to baby-watching, an important aspect of “Tailored Breastfeeding.” Tailored breastfeeding is not “off the rack” but specifically designed for each mom and baby. I coined the phrase “Tailored Breastfeeding” as a shorthand way of referring to a breastfeeding relationship that is interactive.

Rather than a specific set of rules such as “switch breasts after 15 minutes,” or “the baby must spend at least 20 minutes nursing,” Tailored Breastfeeding uses the baby’s behavior as cues to guide the breastfeeding dance. A mother uses her knowledge of how each of her babies reacts to her milk flow and makes feeding decisions that are “tailor made” to each of her babies. The rules then become less important than the immediate experience for the breastfeeding couplet.

FAST MILK FLOW
Fast Flow Management with “Tailored Breastfeeding”

Baby behaviors related to wanting slower flow

If the baby perceives that his mother’s milk rate is consistently too fast, every nursing session will seem challenging for mom and baby. When coping with milk flow that is too fast, the baby will show signs that he is working hard:

• He may tug at his ear while nursing
• He may scratch at his face
• He may squirm
• He may try to roll his body out away from the breast
• He may push against his mother
• He does not look as if eating is restful, but more as if it is an athletic event.

In an attempt to decrease the rate of milk flow, a baby may:

• Take the breast into his mouth with a shallow latch especially if the breast is full
• Clamp on the nipple with his jaws especially when the breast is firm with milk
• Bunch up the back of his tongue, pinching the nipple to protect his airway
• Role away form the breast, so his head is facing the breast but his chest is rolled away from mom

Baby’s ease of breathing and swallowing

I have found that when a baby has difficulties with milk flow, his mother often takes the “blame.” A mother may think she has an oversupply of milk, or milk flow that is too fast or too slow. Actually, her supply and her flow may be average, but her baby may need extra time and support to learn, coordinate and manage the suck/swallow/breathe process. Simply put, a baby’s unease in breathing and swallowing often show up as difficulties handling milk flow.

Breathing difficulties

If a baby has breathing difficulties, fast flowing milk will challenge him. Taking the breast deep into his mouth causes the milk to squirt out of the breast, and pushes the baby to swallow. He may struggle to find time to breathe.

If your baby has breathing difficulties, you will likely recognize some of the behavior you saw in the list above on too-fast flow. More signs include:

• He may gulp the milk so fast it looks as if he was starving. He may be swallowing fast to clear his airway to breathe. A pattern might be gulp, gulp, gulp, gulp, gulp, gulp, and gulp, gasp, breathe, pause, gulp, gulp, and gasp and so on. A more controlled pattern might be suck, suck, suck, swallow breathe.
• He may drip milk out of his mouth throughout the nursing not just at the end when he is full or the very beginning with the first letdown on an extra firm breast.
• He may fuss if pulled in close to the breast, as he needs breathing room.
• He may pull back and clamp on the nipple to control the flow.
• He may use the back of his tongue, curling it up and pinching the tip of his mother’s nipple to protect his airway.
• He may fuss if his head is held in to the breast, as he does not have the freedom to pivot his head.
• He may nurse more comfortably when he is held with his bottom down and his head up so he can breathe better than if he were in a side lying position.
• He may want to turn his body away turning his head so he can take a controlled breath and then swallow.

Swallow issues

If a baby has a difficult time swallowing he will be challenged by a fast milk flow. He might share many of the same behaviors as the baby with breathing issues.

• He may gulp with each swallow, but it will not be a series of rapid swallows. His swallows will not seem effortless.
• He is likely to drip milk out of his mouth throughout the nursing session. (He may also drool so that his bib or clothing is usually wet.)
• He may tip his head back to help his swallow.
• He may turn his head to the side to swallow

WHAT YOU MIGHT TRY
Managing fast flow

Each child is unique. What one baby considers too fast may be just right for another baby. The first step in management is therefore to discover what makes the milk flow too fast for this baby. Management will be different if the baby has breathing or swallow issues, than if the problem lies in the mother’s over abundant fast-flowing milk supply.

Modifying Baby's Breastfeeding Position

Even small changes in positioning can be a big help for babies struggling with flow issues. Watching your baby’s cues for his physical comfort is an important first step to discovering these subtleties.

In experimenting with positions to help your baby handle fast flow, it can be helpful to reevaluate so-called “good positioning”. You’ve probably read that good positioning means the baby is tummy to tummy with mom, that he does not turn his head away to swallow, that he opens his mouth wide to nurse, flanging his lips, and that he takes the nipple deep in his mouth.

Here is new information for you. What we in the Western world have come to view as “good positioning” is actually “maximum flow positioning.” The baby receives the flow directly to the back of his mouth, and he has no way to avoid, deter, or lower the flow to his comfort level. While this works for most babies, it is not the best position for all babies.

Many times mothers find that to help a baby deal with fast flow they need to break the rules of "good positioning.” Babies with suck, swallow and breathe issues, or babies with GERD-reflux, are examples where this is the case. Even babies with effective breastfeeding skills have times when they prefer the option of a slower flow, for instance, when a mother’s breasts are heavy with milk.

To find your baby’s preferred position, watch his cues and be open to assist him as he shifts and adjusts himself--even if the adjustment is unorthodox.

Remember, while the principals of "good positioning" are useful in resolving some breastfeeding difficulties, being locked into a form and not being mindful of how the baby reacts to it can cause problems. At times, we focus so much on an "effective” nursing position that we don’t get the baby’s subtle message that he is finding it challenging.

Let the baby control the position and latch

• Let the baby choose to turn his head to the breast but keep his tummy turned out if he wants that. Don’t keep turning him back to the tummy to tummy position. Turning his body away from the breast allows him to have a more controlled swallow. The milk will not squirt so deep into his mouth. He may feel less challenged to protect his airway.
• Let the baby pull off the breast whenever he wants to. Some babies want to take a breather when the milk is coming fast.
• Let him stop if he cues you for a break. He may want to burp or pass gas and then resume nursing again.
• Let the baby test the waters. Babies may bob with their heads off and on the breast before they settle in to nurse. They will often bob three times before they settle.
• Let the baby put his little mouth on the nipple and lick with his tongue. Babies do this to assess how fast they expect the milk to flow. Is the nipple wet and spraying or dry and not yet flowing?

The baby will choose how deep to take the nipple and how close to turn into the breast from the feel of the breast and the nipple, based on his experience. Allow him to take the nipple in only as deep as he wants. This is a real leap of faith for a mother who has had her nipple in the vice of a baby’s jaws! He may now start sucking stronger and more rhythmically or be more gentle on the nipple. If he can control the position and latch, a mother may be surprised that he no longer clamps, or pushes his tongue up against his pallet to squish mom’s nipple. He no longer needs these behaviors to manage milk flow.

However, if letting the baby take the lead does not result in less clamping, a mother should look for expert help in perfecting his ineffective suck, such as a Feeding Therapist, CranioSacral Therapist or Chiropractor.

Nipple shields can help to handle milk flow

Sometimes changing the nursing position is simply not enough to fix the underlying challenge. Using a nipple shield can be an additional help because it slows down milk delivery. There are a variety of reasons to use a nipple shield. In this case, we will exclusively explore issues of milk flow. An International Board Certified Lactation Consultant can help you discover if this tool will work for you and your baby. As with other tools, there is a learning curve to use it, and it is not always the right tool for every situation.

A nipple shield is a thin, soft, flexible silicone nipple. It is placed on mother’s breast over the nipple area. The shield can help to hold the flow of milk back if the milk is coming too fast for the baby. The milk can flow into the baby's mouth only as fast as the holes in the nipple shield allow.

Without a nipple shield, the milk will drip and flow away when the baby pulls off the breast. If the baby pulled off and stopped sucking because of a too-fast flow, he may be timid when he begins to suck again. Concerned about triggering another fast flow, he may not suck vigorously enough to start the milk flow.

With the shield in place, if the baby pulls off the breast or stops sucking, the milk will remain in the shield. Once the baby takes the nipple again and starts to suck the milk in the shield will flow right away and he can control the flow. Many babies feel less overwhelmed and challenged, and will begin to suck vigorously again.

A mother’s overabundant milk supply can create special challenges

Having "too much" milk can cause some difficulties. Mothers with an overabundant milk supply are prone to plugged ducts and breast infections from inadequate drainage. Babies can become stressed because they are not getting their comfort needs met. Every time the baby sucks, he gets a lot of milk that he has to struggle to deal with. He may signal that he wants to nurse, but then fuss and become unhappy once the milk lets down. What should have been peaceful nursing session turns into a fretful time.

Even though having too much milk presents problems, the mother may find that others do not recognize her challenges, and that dealing with her issues is a lonely road to travel.

About oversupply

A mother’s milk supply can be overabundant for many reasons. A mother may arrive at oversupply because she originally overused the strategy of pumping to relieve engorgement. The removal of much more milk than her baby could comfortably hold can result in building a supply too large for her baby's needs. Once a mother gets into a cycle of pumping, she may find it hard to break. The good news is that changes in breastfeeding management can bring the milk supply under control.

Some mothers find that their supply swings from too much to not enough. The mother may find, if she does not sleep enough, eat and drink just the right foods to support lactation, or has more stress than usual, her supply responds with a drop in volume. This rollercoaster can make for a stressful ride.

On the other end of the spectrum, some mothers have hormonal issues such as Polycystic Ovary Syndrome (PCOS), which can cause supply issues. About a third of mothers with PCOS have overproduction, while another third has low supply.

A mother speaks

One mother, Shannon, whose baby was sleepy with a "lazy suck" spent hours on the breast with little weight gain. She wrote, "Beverly, it's amazing! I wanted to try the nursing hold you described, just to see.... well it's amazing! She was able to take long drawing sucks rather than gulp, gulp, gulp like she has been. She also kept sucking that way past the let down for a bit! She even sucked well on the other side when I switched breasts doing it this new way... it's so amazing!"

SLOW MILK FLOW
Slow Flow Management with Tailored Breastfeeding

Baby behaviors related to wanting faster flow

When milk delivery is slower than baby wants:

• He may tug at the nipple pulling back his head while holding his mother's breast in his mouth.
• He may clamp down then release then clamp down again chewing at the nipple to get squirts of milk by compression.
• He may appear uncomfortable at the breast, squirming or whimpering.

In an attempt to increase the rate of milk flow, a baby may:

• Massage or knead the breast with his fist or fingers
• Stimulate the other nipple with his fingers to increase milk flow, twiddling the other nipple
• Tug at the breast while arching his back
• Nuzzle his head into the breast rolling his head into the breast like a little goat

Breast stimulation to increase the flow

Breast stimulation is a time-honored method of increasing milk flow. When a baby signals that he wants a faster flow, for instance, during the time of the day when a mother’s supply is lowest, a mother can stimulate one or both breasts to increase the flow. With her free hand, a mother can gently compress the breast the baby is feeding on. She will notice that he begins swallowing more quickly again. A mother can also pump the second breast while the baby is nursing, or stimulate her other nipple to increase the body’s production of oxytocin, the hormone for milk ejection.

It is important to watch the baby to be sure he likes the resulting increase in milk flow. If baby reacts negatively to the increased milk flow, avoid pumping or stimulating the other breast when the breast is full and the flow is the heaviest.

In general, early in the nursing session when a baby’s appetite is heaviest, he will appreciate faster flow. He may want to switch to the other breast even though the first breast has not softened all the way in order to continue having a strong flow. Watch the baby’s behavior to know when to use breast compression to increase his milk flow or when to switch to the faster-flowing breast.

Breast compression can help a baby whose feeding skills are not yet established. When the milk flows more easily, he feels more successful at the breast. Switching the baby from breast to breast, and using breast compression, can help him get more milk then he would without his mother’s help, and build his confidence for feeding.

Breast pumps

Pumps that can be set to pump one breast at a time are good for pumping while nursing when a mother needs to increase her volume of breastmilk to the baby:

• A piston driven electric breast pump such as the SMB or Lact E pumps by Ameda/Hollister, or the Classic™ or Symphony® pumps by Medela
• a battery pump such as the Whisper Wear Pump;
• a hand breast pump such as the One Hand Pump by Ameda/Holister or the Harmony™ by Medela

Building a supply

A piston driven electric breast pump such as the SMB or Lact E pumps by Ameda/Hollister, or the Classic™ by Medela are my recommendations for building a milk supply.

Slow flowing milk can be a frustration to you and your baby. Slow flow often goes hand in hand with low supply.

Discovering whether it is your baby’s technique that is causing slow flow, or if you are having difficulties manufacturing the quantity of milk your baby needs can be frustrating and frightening. It is a typical chicken or egg question. Which came first? Is the baby not breastfeeding effectively so mother has a lowered milk supply, or is a mother’ milk supply not developing well resulting in a baby who is not nursing well?

Building milk supply involves learning many new things. Entwined in each learning step are strong and sometimes difficult emotions. For instance, mothers must learn about pumping. They may feel saddened at being plugged into a pump rather than snuggling their new baby. Through trial and error, they learn which pumps work for them, and they watch the precious drops of milk fill the container. Mothers struggle to discover how often and for how long they need to pump—there are no rules that apply to all mothers. They learn about storing milk and sterilizing bottles, and about which bottle nipples flow fast and which slow. They learn about herbs such as fenugreek to build a milk supply, and goat’s rue to grow breast tissue. They learn about mother food that can help support milk supply, and they explore the differences between the medications domperidone and Reglan for enhancing their milk supply. They learn about PCOS and other hormonal issues that can have an impact on milk supply, and they learn about supplemental feeding devices.

It makes many families sad that the quantity of mother’s milk their baby needs is not available. If you are having breastfeeding challenges, we send you hugs. You are not alone.

Importance of recognizing milk flow issues

If milk flow problems are not recognized and addressed, serious problems can develop for the mother and the baby.

• Ultimately, a mother’s milk supply can suffer, and if she does not realize that she is producing less milk, her baby may not get enough nourishment.
• A baby may fall asleep at the breasts in response to a too fast or too slow milk flow. This may be his way of coping.
• He may cry and fuss even before he is at the breast because he anticipates the difficulties to come. It is painful for the whole family and mother often feels rejected when a baby is going through breast refusal.
• His stamina at the breast is reduced when a baby does not gain weight well. Eventually, he may go on a breastfeeding strike.
• When a baby finds a way to feed less than he needs to grow, his reduced feeding can lead to his mother having a reduced milk supply.

Problem resolution with "Tailored Breastfeeding"

Every nursing mother has times when her milk flow does not match her baby’s wants. A mother’s milk flow can change, and may be temporarily too fast or too slow. Perhaps a baby who can usually handle his mother’s milk flow now has a cold and the faster flow is troubling him. Perhaps his appetite is building and he wants more milk. It may also be that he was not feeling well, nursed more for comfort, and built his mother’s milk supply beyond what he wants.

If your baby nurses well some of the time, tugs at others, and he is gaining well without supplements, then the solution for you may be as straightforward as letting him decide when to change to the other breast. While “switch nursing” is a time-tested way of building a milk supply, this is switch nursing with a twist. Instead of insisting that the baby stay on the first breast for a given amount of time, or until he has completely drained the first breast, the mother follows the baby’s cues for switching. This is part of “Tailored Breastfeeding.”

Sometimes the baby’s appetite for fast flowing milk is greater than the fast flowing volume in the breast he is currently using. He will happily settle on the second breast even though he did not drain the first breast yet. He may want to move back to the breast with less milk as his tummy fills. He may move back and forth from one breast to another in each feeding. He may want to move from the first breast to the second even though the milk has not totally drained. Think again of Morgan’s Rule of Thumb for Milk Flow: The firmer the breast the faster the flow.

Generally, later in the day the milk flow is less copious than in the earlier hours of the day. A baby may want to move back and forth twice during late afternoon or early evening nursings, but only want one breast in the morning if his mother’s breasts are super full and fast flowing.

If your baby has drained both breasts and still tugs and wants more after you have let him switch back and forth twice, you can distract him by changing activities for at least 20 minutes. Mom can have a glass of water and a lactogenic snack. If he still wants to breastfeed, the delay and moms energy boost will have allowed for some breast fill-up time. He will be happy to have some faster-flowing milk and will be less likely to tug, but will settle down for some unwind time.

A mother speaks

A mother, Demetra, wrote to me after we spent some time working through her nursing problems and sore nipples. "…I have learned from you to have a more open attitude about what may work and I am willing to troubleshoot until we find a more comfortable position. You have given me a greater appreciation of Lola’s communication skills."

Chronically frustrated babies may refuse to breastfeed

If the milk flow situation becomes chronically frustrating to the baby, he may refuse to breastfeed because he does not feel successful. Sometimes using special feeding devices such as the Lact-Aid® or the Supplemental Feeding System™ (SNS) ™ by Medela can help the baby feel successful while the underlying problems are addressed.

Recognizing the importance of milk flow to your baby and discovering his preferred milk flow can help you and you baby tailor the breastfeeding relationship. Tuning in to your baby’s body language as it relates to milk flow can help you discover new ways of communicating with your baby. What a great adventure that is!