Breastfeeding challenges are common, especially for first time pregnant women and new moms. There are some known risk factors for having breastfeeding problems, which are important for both pregnant people and their healthcare practitioners to recognize ahead of time. Risk factors for problems with milk supply can be mother-related, pregnancy-related, or newborn-related. Knowing you might have problems with breastfeeding and milk supply ahead of time can help you to prepare and try to prevent breastfeeding issues.
Risk Factors for Breastfeeding Problems
Maternal Risk Factors for Breastfeeding Problems:
- History of Prior Breast Surgery
- Advanced Maternal Age (35 years or Older)
- Previous Breastfeeding Problems
- Lack of Breast Enlargement During 3rd Trimester
- History of Infertility
- Underlying Health Problems
- Including High Blood Pressure, Anemia, Diabetes, Thyroid Disease
- Polycystic Ovarian Syndrome (PCOS)
Pregnancy & Delivery Risk Factors for Breastfeeding Problems:
- Gestational Diabetes
- Multiple Gestation (Twins or Triplets)
- C-Section Delivery
- Excessive Blood Loss During Delivery or Postpartum
- Retained Placental Fragments (When Placenta Pieces Remain in Uterus)
- Anesthesia Use During Labor
- Use of Vacuum or Forceps
- No Skin-to-Skin Contact During 1st Hours After Birth
Newborn Risk Factors for Breastfeeding Problems:
- Low Apgar Scores
- Meconium Aspiration
- Prematurity (born before 37 weeks)
- Need for Neonatal Intensive Care Unit (NICU) Admission
- Small for Gestational Age (Below 10th Percentile for Weight)
- Large for Gestational Age (Above 90th Percentile for Weight)
- In Utero Exposure to Illicit Drugs
- Tongue Tie
- Birth Defects
- Including Cleft Lip/Palate & Congenital Heart Disease
If you read through this list and identify that you have risk factors, don’t worry! This does not mean that you will run into problems, just that you should prepare for breastfeeding (and possible lactation challenges) ahead of time.
Preparing to Breastfeed
The first way to prepare is to learn as much as you can about breastfeeding. You can do this by attending newborn care and breastfeeding classes, joining breastfeeding support groups, attending La Leche League meetings, and consulting with a breastfeeding specialist, such as a certified lactation consultant, while pregnant. One of the best ways to actually learn about breastfeeding is to spend time with family members and friends when they are breastfeeding. Don’t be afraid to observe and ask questions!
Get a good lactation support system in place ahead of time. Let your partner and other household members know that you plan to breastfeed. Plan what equipment you will need (i.e. nursing pillows, pumps, etc.) and where you will sit or lie while you breastfeed (such as a certain chair or couch for breastfeeding positions). Be sure that your family members receive breastfeeding education and brainstorm how they will help you be successful with breastfeeding, get enough nutrition and rest, and participate in baby care.
Breastfeeding can be the equivalent of having more than two full-time jobs (80+ hours per week), so please keep your expectations low in terms of being able to be “productive” while you are establishing breastfeeding and your milk supply. This can seem stressful for breastfeeding moms so be prepared to ask for (and need) help!
Hand expression of colostrum and milk during the first postpartum week can help increase your milk supply. Lactation consultants, your OB/GYN, doula, or midwife should be able to provide you with education and instruction regarding hand expression. There are also many excellent hand expression instructional videos online, including this video from Stanford Medicine of Dr. Jane Morton’s hand expression technique.
Antenatal (prenatal) hand expression, which is done prior to delivery, is becoming an increasingly popular way to help mothers who might be at risk for having a low breast milk supply. Hand expression should never be done before 36 weeks, and only started if your OB/GYN okays it – this is due to a small risk of labor being triggered by breast stimulation. Women who are at high risk of having a premature birth should avoid hand expression during pregnancy.
Once your baby is born, you will need to monitor your breast milk supply and newborn’s feeding patterns. Per the Children’s Hospital of Philadelphia, signs that breastfeeding is going well include the following:
- During the early days or the first few days after giving birth you should be producing a small amount of early breast milk, or colostrum.
- By the end of day 10-14, you should be making between 16-32 oz of milk per day.
- Your breasts should feel softer after feedings.
- Babies should breastfeed between 7-19 times per day. Babies may not feed off of both breasts each time, so this range includes feeds from only one breast, too.
- You should feed your newborn whenever he or she shows signs of hunger, even if it has not been very long since the last breastfeed. Some newborns may have periods of feeding every 1-2 hours as their mothers’ milk supplies are being established.
In addition to monitoring your breast milk supply, as above, it’s also important to keep tabs on baby needs and how your newborn baby is doing. Signs that a newborn might not be getting enough milk include losing too much weight (dropping 8% or more below birth weight), not having many wet or dirty diapers, developing jaundice, being inconsolable, and/or not starting to regain weight by the time they are about 4-5 days old.
As a rule of thumb, exclusively breastfed newborns should have at least 8 breastfeeds per day that are at least 10 minutes long, several yellow, seedy stools per day, and at least 6-8 wet diapers per day by the time they are a week old, and be back to his or her birth weight by the time they are two weeks old.
All breastfeeding newborns should be seen by their pediatrician for a weight and jaundice check within 1-2 days of discharge home from the newborn nursery, or within a day or so of a planned home birth. Some newborns need to be seen on a regular basis in the early weeks until their mothers’ breast milk supplies are fully established and they have good weight gain.
If your newborn does need supplementation, options include pumped breast milk, pasteurized donor breast milk and infant formula. Supplemental feedings can be given by bottle, finger (syringe) feeding, droppers, cups, or supplemental nursing systems. The Academy of Breastfeeding Medicine has evidence-based guidelines for when to supplement and how much supplemental breast milk or formula should be offered per feed.
Tips to Increase Breast Milk Supply
- Increase Feedings: Sometimes increasing milk supply is as simple as feeding your baby more frequently. Breastfeeding helps with milk supply If you are scheduling feedings or allowing your baby to go more than about two hours between feedings during the day, start waking your baby up and offering the breast more often.
- Get Help with Latching: If you are experiencing pain, feel like your baby’s latch is too shallow, or are hearing a lot of clicking noises as you nurse, chances are your baby has a bad latch. This limits the amount a baby drinks and can lead to a low milk supply. Talk to an IBCLC to get help on successful breastfeeding techniques.
- Pump After Feedings: Since breast stimulation and milk removal is the key to increasing milk production it is often helpful to begin pumping after feedings to signal to the body to make more breast milk. To make pumping easier, we recommend using a hands-free pumping bra as your regular nursing bra to double pump.
- Try Power Pumping: Power pumping is when you set aside one hour every day to pump in intervals. To begin you will pump both breasts simultaneously for 20 minutes. After 20 minutes, turn your breast pump off and take a 10-minute break from pumping. After the break, resume pumping for 10 more minutes. Take another 10-minute break followed by another 10 minutes of pumping. Continue doing this once a day for 5-7 days in a row to mimic what it is like when your baby is going through a growth spurt and cluster feeding.
- Use Your Hands: Use your hands to massage your breasts as you nurse or pump. “Breast compressions” increase milk flow leading to increased milk transfer when breastfeeding and more milk output when pumping. The most effective way to do breast compressions is to start massaging near the back of the breast/chest wall and gently working your way down the breast towards the nipple.
- Drink More Water: Breast milk is made up of water and fat. While breastfeeding or pumping you may notice an increase in thirst. This is because making breast milk requires lots of water. It is recommended that breastfeeding and pumping moms drink at least 100 ounces of water per day.
- Consider Herbs & Supplements: There are a few supplements,or galactogogues, that can help moms produce more milk. Some of the most popular supplements for increasing milk production are goat’s rue, blessed milk thistle, brewer’s yeast, moringa, and fenugreek. Remember, though, that simply taking supplements or herbs will not provide you with a significant increase in milk production if you are not also increasing breast stimulation and milk removal.
For more information and details on increasing your breast milk supply, visit our article on the best ways to increase milk supply.
- ACOG Committee Opinion. Number 820. Committee on Obstetric Practice Breastfeeding Expert Work Group. Obstetrics and Gynecology. 2021. 137(2): e42-e52.
- Flagg, J. and Busch, D. Utilizing a Risk Factor Approach to Identify Potential Breastfeeding Problems. Global Pediatric Health. 2019. 6: 1-5.
- Kellams, A., Harrel, C., Omage, S., et al. ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017. Breastfeeding Medicine. 2017. 12(3): 1-11.
- Meek, J. and Noble, L. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics. 2022. 150(1): e2022057988.