Case 1:

Will it ever be more?

On milk production and getting the time

Case 1: Will it ever be more?

On milk production and getting the time

Ariana called because, despite working terribly hard, she did not have enough milk for her son. Bram was now 14 days old and with pumping she was getting a maximum of 50 to 60 cc at a time. She didn’t latch him anymore because it was too stressful. But the combination of breastfeeding, pumping and supplementary feeding was really not feasible in terms of time now that she was alone with Bram most of the day. 

Chris, her partner, had made the appointment because he was worried about Ariana: this was not sustainable. Besides, they had heard that if you don’t have enough milk by day 12, it will never work again.

Was that true?

Bram had been born at home at 3320 grams at 40 weeks and 2 days after a long labour. During first hour he had done well at the breast but after that feedings had become increasingly difficult. He had trouble grabbing the nipple and then quickly fell asleep. After 3 days, he had lost 8% weight and Ariana’s nipples had become too painful to feed. When she started pumping on day 3 she was getting barely 10 cc per breast and so now, 10 days later, it had increased but still not enough to feed Bram fully.

Because she never knew how much her son was getting from the breast (and thus how much extra he would need) she had switched to full pumping. She pumped both breasts for at least 15 minutes at each feeding, double ended with a good pump. Even at night, although sometimes she would skip 1 x because she was too tired. All in all, she pumped 7 to 9 times per 24 hours without the results she was hoping for.

Could breastfeeding still work out?


There are two bottlenecks here: latching on and milk production. For the connection between them, see the video below this block (video is in English).

Always ask what is most important for this mother at this moment: child at the breast or (certainty of) enough milk. Because if you know that then you can start tailoring policies.

If she doesn’t know, ask, for example, “What should I conjure up for you: child at the breast or enough milk? Then the answer usually comes and you can tailor your policy to her question.

The assumption is often that every mother will be able to get optimal production going by pumping. And with that comes the underlying assumption that what a person pumps is comparable to what the baby can drink.

In practice, we see that some women are indeed able to pump very easily and thus stimulate production.

But there are also women who hardly give milk for a pump, and for a baby they do (see case study 15). If pumping is not easy then it is certainly useful to see where the pumping itself can be improved. But also keep in mind that some women don’t seem to make milk for a device.

If latching is most important then your policy may be: latch on short and well, supplement as needed with donor milk or formula, and based on weight and feeling see if and how quickly the supplemental feeding can be phased out.

If the milk itself is most important, as it is for Ariana and Chris, then pumping may be the best solution

Approach and result

For Ariana, milk production was the most important thing. She was fine with pumping as long as there was more milk. For the next two weeks, Chris still did not work and was able to feed the bottle while she pumped.

Ariana seemed to sit tense while pumping, staring at the bottles. When she lowered her shoulders, took a deep breath and said with tears in her eyes, “I so hope this works”, THEN the milk began to flow.

She pumped every time Bram would feed, roughly every 3 hours because that’s what they had heard was the normal frequency.

The tricky thing is that her body missed the information that not enough milk was coming in. A well-fed baby will feed 7 to 10  times in a 24-hour period. And pumping tends to stimulate a little less than latching. So there was no incentive to produce more milk by pumping 7 times.

The plan became:

Cluster the pumping times like a hungry baby would cluster:

» Between 8 a.m. and noon, pump briefly every 1 to 1.5 hours: place the pump by the sofa and pump for 5 to 10 minutes each time.

» Then take a break from 12pm to 4pm: sleep, cuddle, eat….

» From 4pm to 9pm, pump again every 1 to 2 hours.

» And at night only when Bram woke up.

That way she was suddenly pumping 10 times a day and Ariana had time to rest. And, most importantly, to cuddle with Bram.

Pumping more playfully

Sitting more comfortably and relaxing while pumping helps milk flow. For Ariana, this meant leaning forward from time to time to let the milk out, but she actually liked it: it meant she could see that the milk was really coming.

She pulled Bram’s socks over the bottles so that she could concentrate less on the result and more on herself and her breathing.

She started alternating between one-sided and two-sided pumping: she started with two-sided pumping, and after the first big wave of milk, she pumped both breasts a little more one-sided, with some gentle compression.

Double-sided pumping stimulates prolactin and therefore milk production. But one-sided pumping with tea or chocolate in the free hand is often nicer. And gentle massage with your free hand will help you produce thicker milk.

More cuddles

Bram was now always put in his cot between feeds, and much of his sleeping time was spent by Ariana and Chris cleaning the pump. Breastfeeding and breast milk should not be at the expense of direct (skin) contact between parent and child.

Bringing an extra pump and some extra bottles made cleaning much more efficient. As a result, there was more time to cuddle with both parents. And during part of the cluster sessions, Ariana just stayed on the couch with Bram against her.

The result

After 3 days, Ariana was expressing over 100 cc in the morning and about 80 cc at the end of the day. Enough to feed Bram completely.

Chris and she liked knowing exactly how much Bram was getting, so they decided to keep pumping and not take any more feeds. After 6 days the production was so stable that cluster pumping was no longer necessary. 

Ariana pumps after every feed and spends a total of about 40 minutes per feed: 10 to 15 minutes with the bottle and then another 20 minutes of double pumping while chatting and cuddling with Bram.


Ariana and Chris were shocked that Bram had lost so much weight. But in itself, 8% weight loss is still within normal limits.

Giving parents information in advance about normal weight loss in the first week increases the chance that parents dare to continue breastfeeding.

Using a good monitor for weightloss in the first week can help, like the NEWT or the Dutch TNO curve for the first 10 days.

The 1st week

It seems so logical when there is not enough milk: latch on and then after-pump and then supplementary feed. But this triple-feeding is a heavy burden for parents.

It can be a temporary solution to give the baby enough nutrition and get milk production going. But it is only viable if the mother is not alone with the baby and if she is motivated and fit. 

For the night, it is then definitely worth considering 2-of-the-3:

  • either pumping and supplementary feeding
  • or breastfeeding and supplementary feeding

Then the amount of supplementary feeding can be tailored to what is needed during the day.

The first 3 months

When pumping full time it is important that the pumping itself is as pleasant as possible. Create a pumping ‘station: a ‘sidetable, tray or basket with all the pumping equipment and very important:  nice, pleasant things for the mother such as biscuits, something nice to drink, the charger of her phone, and if possible a vase with a flower or something?

Once milk production is well underway, a professional pump is usually no longer necessary. Any good double-sided electric pump can then be effective enough. See what fits within the family’s budget. Contrast the cost of the pump with several months of full artificial feeding, for example.

When fully pumping, the investment in a hands-free pump may be worthwhile.

For the first 3 months, milk production will probably require at least 1 pump at night too.

After 3 months

Even with slightly older babies, some women choose to pump completely. All the tips above are helpful then:

  • Make pumping as pleasant as possible with a ‘pumping station’ or bag.
  • Pump playfully: alternate single- and double-sided pumping, breathe, move.
  • Consider buying a hands-free breast pump.
  • Night sessions can be important for maintaining milk production, often one feeding time can be skipped without milk production falling too far.