QUESTION: My identical triplet girls are 3 weeks old and living at the NICU for the next several months. I am having very significant problems getting my milk supply to increase from approximately one teaspoon or so per breast per pumping. I am pumping 7 to 10 times per day and believe I am doing everything correctly. I really want to provide the benefits of breast milk to my tiny daughters but am getting a bit discouraged. I have been pumping for several weeks. Could there be a medical explanation for my small output? Any advice would be greatly appreciated.

What kind of breast pump are you using? Most Lactation Consultants (LCs) recommend using a hospital grade, piston driven breastpump like a Medela Classic or Ameda-Egnell Elite; and pumping both breasts at the same time (double pumping). There may already by one in the NICU at your baby's hospital, and you will want to rent one for your use at home.

It is important that you follow specific guidelines for pumping for your baby: (1) wash your hands thoroughly before expressing your milk; (2) each mother uses her own personal collection kit (the tubes and bottles); (3) all the parts of the collection kit that touch the milk need to be cleaned after each use with hot soapy water and thoroughly rinsed then placed on a clean paper towel, covered with another clean paper towel, and allowed to air dry; (4) the expressed milk should be labeled with the date, the baby's name, the baby's hospital ID number, etc; (5) the milk from each pumping should be kept in its own container and not mixed with milk from other pumpings; (6) milk should be stored in feeding sized portions.

You should be pumping every 2 to 3 hours during the day and once or twice at night. You may be pumping more than your babies are eating right now, and that is okay. Your babies will grow quickly, and soon be placed at your breast for their first nursings!

Remember that your milk let-down response (MER) is crucial to your milk expression. Stress, tension, fatigue, etc. can produce hormones which can reduce your MER. Try to set up a milk expression routine, so that your MERs are more productive. Here are some ideas: (1) Allow enough time so you don't feel rushed; (2) Try to express milk in a familiar and comfortable setting - privacy and comfortable seating promotes relaxation, which enhances your MER; (3) try to minimize distractions - take the phone off the hook, etc.; (4) follow a pre-expression routine - use warmth to relax and stimulate milk flow by applying heat to your breasts or putting a warm wrap around your shoulders - stimulate your breasts and nipples through massage - relax with deep breathing and visualizations; (4) think about the baby - look at their picture, smell the blanket that they were wrapped in recently - imagine them at your breast while you are expressing your milk; (5) interrupt your pumping several times to pause and massage your breasts.

The important thing is to establish a daily routine and stick to it. Pump at least 10 to 15 minutes, and pump every 2 to 3 hours during the day and 2 to 3 times at night. Some women find that they only need to pump once at night. It is important to listen to your body and do what feels right to you. If you drop to once per night, and your breasts become overly full, you may want to consider increasing to twice a night. Some women find that if they only express the small amount that their baby needs, their breasts begin to revert to their pre-pregnancy state, and milk supply is difficult to increase later.

And there are medications that are known to increase milk supply -- Reglan (metoclopramide) and Motilium (domperidone). Please ask your physicians about them.

The easiest way to increase your milk is to nurse your baby more frequently, and to pump more frequently. Think of it this way - Your total capacity of milk production = 100%. What your baby takes on a day to day basis is about 80%. That leaves a "residual" of about 20%. As a baby eats more solids and slowly weans, he takes less than the 80%, so the mother's supply decreases slowly. You are trying to increase your milk, so you will need to dip into that 20% residual with extra pumpings.

I encourage you to contact a La Leche League Leader (LLLL) or International Board Certified Lactation Consultant (IBCLC) in your area. You can find an LLL Leader and LLL Group in your area by calling 1-800-LALECHE or at their web site - www.lalecheleague.org.. To find an IBCLC in your area, call your local LLL Leader and ask for a referral, or contact the International Lactation Consultant Association (ILCA). Try to look for an IBCLC with a background as an LLL Leader -- they really are the best in the business!

Congratulations again on the birth of your daughters. They are such a lucky little girls to have such a dedicated mother willing to provide her milk for them!

Andrea Eastman, MA, CCE, IBCLC

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