An exploration of common infant behaviour misinterpretations that can lead to a perception of low milk supply

01 January 2016

Lyndsey Hookway explores how misinterpretations of infant behaviour can led to mothers believing they have a low milk supply.

Pile of books

Lyndsey Hookway BSc RNC HV IBCLC
Infant Feeding Lead – CSH Surrey, International Board Certified Lactation, consultant in private practice


Many breastfeeding mothers are anxious about their milk supply – but it is actually quite unlikely that there is a fundamental reason for low milk supply. Only about 5 per cent of women have a medical or surgical reason that means they are unlikely to produce enough milk (Neifert et al, 1985). Perceived low milk supply, as opposed to actual low milk supply, is often cited as the most common reason for cessation of breastfeeding or the early introduction of formula supplements (Brown et al, 2014; Li et al, 2008; Odom et al, 2013). According to a review of 20 years of evidence in the lactation field, perceived low milk supply is the most common reason for weaning, and is bound up with complex cultural, socio-economic and psychological factors (Wambach et al, 2005). Numerous studies have found that a major reason for a perceived low milk supply is the misinterpretation or lack of preparation regarding normal infant behaviour (DaMota et al, 2012; Wagner et al, 2013; Palmer et al, 2015). Breastfeeding initiation is now on the rise, but many women worldwide lack the basic knowledge about how normal breastfed infants behave (Palmer et al, 2015). This article will outline how community health visiting teams can allay women’s fears by providing evidence-based information about their infant’s behaviour.

Misinterpretation of infant cues

Misinterpreting infant cues is a common reason women doubt their milk supply – in fact, in many lactation consultants’ experience, it is the number one reason why women begin to feel under-confident and begin to supplement (Li et al, 2008). A study in California found that in a sample of nearly 100 mothers who had all expressed a desire to breastfeed, nearly all of them requested formula in the first week. The most common reason was that the mothers believed that their infant’s crying and frequent waking was an indicator of hunger (DaMota et al, 2012). In a large study of nearly 3000 women, again, the top concern associated with supplementation or cessation of breastfeeding was a belief that certain infant behaviours, including frequent feeding, was a sign of insufficient milk – these beliefs extended beyond the first week and continued to be of concern to mothers in later weeks, when in the UK they would be in contact with health visiting teams (Wagner et al, 2013).

A newborn baby knows no other reality than his mother. He has been used to being tightly held, rocked, protected from light, noise and temperature variation. In utero, babies are surrounded by white noise, drip fed from the placenta, and are never apart from their mothers. Based on the findings of numerous studies, there is a clear need for health professionals to prepare parents antenatally, at the new birth visit and at opportunistic postnatal contacts to better understand the adaptation from womb to world and accurately read infant cues in the first few weeks (UNICEF, 2012).

Many babies prefer to be in close contact with their mother, for numerous reasons. Colostrum smells very similar to amniotic fluid (Contreras et al, 2013), and the mother’s breast is near her heart, which they have heard and felt beating for many months. Infants typically exhibit a predictable sequence of behaviour when in skin to skin contact, culminating in sleep in the early hours, but most infants will become more wakeful after this period of sleep on the first day (Widstrom et al, 2011). Maintaining this close contact between infants and mothers has been shown to reduce infant stress, improve breastfeeding attachment and improve infant calmness (Svensson et al, 2013).

In addition, after this initial period of rest in the first few hours after birth, some babies cry a lot (DaMota et al, 2012), which can undermine maternal confidence. In some cases – it is not clear why they are crying, but it is known that infants tend to stop crying when held close with their mother and allowed to breastfeed as often as they like (Hunziker and Barr, 1986). Palmer et al (2015) found that when women receive positive responses from their infant in the breastfeeding relationship, they feel that their infants’ behaviour confirms their efficacy as a mother, and similarly, that positive behaviour confirms the mother’s confidence in her ability to make milk. This is borne out in clinical practice, many mothers perceive infant crying as a demand for feeds and become disheartened that their baby is seemingly unsatisfied at the breast. Mothers need to be reassured that the only genuine signs of insufficient milk transfer are inadequate urine and stool output, excessive weight loss or failure to gain weight at normal rates (Riordan, 2005).

There are many reasons why formula-fed babies tend to sleep for longer stretches in the early days. Recent studies have sought to answer whether or not this continues to be true in the longer term – and a very large study concluded that there was no statistical difference in the amount or quality of sleep or the level of maternal fatigue experienced between mothers who were breastfeeding, formula feeding or combination feeding (Montgomery-Downs et al, 2010) One reason for the differences in early sleeping behaviour is that the larger volumes commonly given to formula-fed babies will overfill the newborn’s tiny stomach. Another reason is that human milk protein is far more easily digested than cows milk protein found in formula (Riordan, 2005; Minchin, 2015). The response to being overfull is either vomiting, or falling asleep – much like adults do after over-eating. It is not necessarily a sign of contentment – just a physiological response to the large volume of liquid that the baby now has to digest. Numerous studies including Martens and Romphf (2007) have found that formula-fed infants receive larger volumes of milk than is physiologically normal. This study also expands on the harm done by rapid weight gain, increased caloric and protein intake, insulin production and metabolic imprinting with formulafeeding (Martens and Romphf, 2007). So there is clear harm of over-feeding when supplements of formula are used, and yet it is still common practice, in part fuelled by the misconceptions of both health professionals and mothers of infant behaviour (Gagnon et al, 2005).

It is important to note:

  • Babies often want to feed frequently in the first 3-5 days, after a period of sleep (Svensson et al, 2013).
  • Women often feel under-confident about their milk supply – and lack of understanding of infant behaviour, and the genuine signs of milk insufficiency ie reduced urine output and change in stool colour and frequency often leads them to reach the conclusion that their baby is not satisfied on their breastmilk.
  • Our society is very used to seeing bottle fed babies. Many health professionals are highly skilled in helping mothers to initiate and maintain breastfeeding, but occasionally both health professionals and mothers have reported low confidence that early milk volumes are sufficient for healthy term babies (Gagnon et al, 2005).

Differences in required milk volumes

Formula-fed babies drink more milk than breastfed babies. In fact, even babies fed with breastmilk in a bottle drink greater volumes than directly breastfed babies (Li et al, 2012). There are three main reasons for these variations.

Firstly, breastmilk is highly bio-available (Riordan, 2005). That means that babies can extract nearly all the nutrients from it. In turn, this means that volumes are generally lower, and also more consistent than for formula milk.

The initial volumes are much smaller than the amounts commonly fed to formula fed babies (Martens and Romphf, 2007), and in practice, women often compare their expressed milk volumes unfavourably with formula quantities. These small amounts gradually increase during lactogenesis II.

A little known fact is that after the initial establishment of a mature milk supply, which takes about 2-4 weeks, a breastmilk supply will remain at relatively constant volume all the way through to starting solids at about 6 months (Neville et al, 1988; Kent et al, 2006). Babies naturally grow more slowly from about 12 weeks, and the nutritional composition of breastmilk adapts as the baby matures, meaning that they don’t need to keep drinking greater volumes of milk as they get older and bigger. This is in direct contrast to the nutritional needs of formula-fed babies, who need higher volumes of milk as they get older and larger.

This is part of the reason formula-fed babies are approximately 1kg heavier than breastfed babies by the age of one year. This has come to be a sign of health and privilege – but actually being heavier at age one is associated with an increased risk of diabetes and obesity, so far from being a good thing, it is actually harmful (Alves et al, 2012).

The second reason for increased volumes is due to the mechanism of bottle feeding. When infants drink from a bottle, they cannot regulate the flow of milk as well. Bottle fed babies will therefore drink more milk simply because it keeps flowing into their mouths. This is also true of babies who are fed expressed milk in a bottle. Li et al, (2012) suggested that one reason for this is that during a bottle feed, the carer is in control of the style of the feed, and the infant plays a less active role in determining their intake. There is much that health professionals and parents alike need to know about how to bottle feed slowly and responsively to an infants cues to help them pace the feed and moderate their appetite. It is a positive step that the UNICEF baby friendly initiative now includes guidance on how to practice paced and responsive bottle feeding (UNICEF, 2012).

The third reason is that when breastfeeding, babies receive an increasing proportion of fat as the feed progresses.

They also receive increasing amounts of an appetite-regulating hormone called leptin (Miralles et al, 2006; Li et al, 2012). Leptin causes the baby to feel satisfied and full at the right time so that the baby does not overeat. It chemically signals the baby to finish feeding. When a baby is bottle fed expressed milk, Li et al (2012) point out that there is no gradual increase in fat content throughout a breastfeed, which signals the infant to spontaneously release the breast. No such mechanism exists for bottle fed babies as the composition of the milk is homogenised.

So, two of the most common reasons women doubt their milk supply are due to the misinterpretation of infant cues, and misunderstandings about the fundamental physiological differences in milk volumes between breast and bottle fed babies (Wagner et al, 2013; Palmer et al, 2015).

Summary of key positive interventions by health professionals

Of course, any perceived low milk supply can become an actual low milk supply problem if mothers begin to supplement their infant with formula – because the breast will be emptied to a lesser degree, which will cause the down-regulation of milk production (Riordan, 2005), so it is important to address maternal concern about low supply,not just to prevent unnecessary formula supplementation but also to preserve and increase her feelings of self-efficacy (Palmer et al, 2015). Therefore the following strategies may be helpful:

  • Ensure infants are correctly attached at the breast so that they can effectively transfer milk (Riordan, 2005)
  • Help mothers to understand what effective feeding looks like, and also to understand the objective signs that their infant is receiving enough milk – appropriate urine and stool output and normal weight gain (Palmer et al, 2015)
  • Educate mothers antenatally about normal infant behaviour, particularly about cluster and frequent feeding (Wagner et al, 2013)
  • Offer practical and evidence based information about infant sleep, and suggestions about how to cope with night feeds (Montgomery-Downs et al, 2010)
  • For mothers who choose to bottle feed either exclusively or partially, ensure that they have information about paced bottle feeding and how to bottle feed responsively to reduce the risk of overfeeding and physiological stress (Li et al, 2012)
  • Refer mothers with conditions such as polycystic ovary syndrome, fertility problems, obesity, breast hypoplasia, thyroid dysfunction and diabetes - which can lead to a primary low milk supply - to specialist breastfeeding support (Wambach et al, 2005).


Increasingly we live in a society of comparison. It is really important that any comparisons made are with the understanding that breastfeeding is the biological norm. The behaviour of breastfed babies should be taken as the benchmark against which we compare all infant behaviour. This will normalise many aspects of infant feeding which are perceived as problematic by mothers, and occasionally - health professionals. Only by perceiving breastfed babies’ behaviour as normal can women hope to have any sense of selfsufficiency and confidence. When we can do this across all sectors of society – the media, health professionals (Burns et al, 2010), popular parenting literature – maybe then women will have more faith in their own to make plenty of milk for their babies.


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