Reliable signs:

• Poor weight gain: less than 500 g per month for the first six months.
  
• Small amount of concentrated urine: infant urinates fewer than 6 - 8 times per 24 hours.
  

Possible signs:

• Infant dissatisfied after breastfeeds.
• Frequent crying (look for other reasons why the infant is crying).
• Very frequent breastfeeds.
• Very long breastfeeds.
• Infant's refusal to breastfeed.
• Hard, dry, or green stool in the infant.
• No milk when the mother tries to express.
• No breast enlargement during pregnancy.
• No milk "coming in" after delivery.

Reasons Why Infant May Not Get Enough Breastmilk

Breastfeeding factors:

• Delayed start.
  
• Infrequent feeds.
  
• No night feeds.
  
• Short feeds.
  
• Poor attachment.
  
• Use of bottles or pacifier.
  
• Complementary feeds.
  

Psychological factors in mother:

• Lack of confidence.
  
• Worry or stress.
  
• Dislike of breastfeeding.
  
• Rejection of infant.
  
• Tiredness.
  

Mother's physical condition:

• Combined oral contraceptives in the first six months post-partum.
  
• Severe malnutrition.
  
• Smoking and alcohol.
  
• Retained piece of placenta (rare).
  
• Poor breast development (very rare).
  

Infant's condition:

• Illness.
  
• Abnormality.

Management of "not enough milk":

• Withdraw any supplement, water, formulas, or tea.
  
• Feed infant on demand, day and night.
  
• Increase frequency of feeds.
  
• Make sure infant latches on to the breast correctly.
  
• Correctly position infant.
  
• Wake the infant up if he/she sleeps throughout the night.
  
• Reassure mother that she can produce sufficient milk.
  

Kinds of refusal to breastfeed:

• The infant may attach to breast but not suckle or swallow or suckle very weakly.
  
• The infant may cry and fight at the breast when the mother tries to breastfeed.
  
• The infant may suckle for a minute and then come off the breast choking or crying (may do this several times during a single feed).
  
• The infant may take one breast but refuse the other.
  

Reasons Why an Infant May Refuse to Breastfeed

• Infant:
  
  • Illness.
  • Pain.
  • Blocked nose or sore mouth - Sedation.
• Poor breastfeeding technique: possible causes:
  
  • Feeding from a bottle or suckling on a pacifier.
  • Not getting enough milk because of poor attachment.
  • Mother holding and shaking the breast interferes with attachment.
  • Restricting breastfeeding (e.g., breastfeeding only at certain times).
  • Too much milk coming too fast because of oversupply.
  • Early difficulties in coordinating suckling (some infants take longer than others to learn how to suckle effectively) - Infant refusing one breast but not the other.
• A change may have upset the infant:
  • Infants are very sensitive and may refuse to breastfeed if upset.
    
  • Infant 3 - 12 months old may not cry, but simply refuse to suckle (sometimes called a "nursing strike"). Possible causes of upset:
    
    • Separation from the mother (e.g., when she starts to work away from home).
    • New caregiver.
    • Change in family routine.
    • Illness of mother or breast infection.
    • Change in mother's smell (e.g., from different soap or different food).
    • Family stress.
• Management of refusal to breastfeed:
  • Reassure mother and build her confidence for breastfeeding to continue.
  • Help mother identifies the cause and treat accordingly.