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8.4 Insufficient breastmilk

Before you can understand and problem-solve breastmilk insufficiency you must first be confident in your knowledge of normal initiation and maintenance of lactation.

How is breastmilk production regulated?

A quick reminder of how lactation commences ....

Secretory differentiation (Lactogenesis I)

  • commences during pregnancy
  • causes growth of functional breast tissue and begins colostrum production
  • is an endocrine function dependent on hormonal control

Secretory activation (Lactogenesis II)

  • commences soon after birthing
  • is seen clinically as a copious production of breastmilk
  • is an endocrine function

Factors that interfere with normal hormonal status of the mother can impact early lactogenesis:

  • sub-optimal glucose metabolism, 1 retained placenta, 2 3 obesity, 4 5 diabetes, 6 7 severe hemorrhage, 8 stress, 9 10 hypothyroidism 11
  • breast hypoplasia

Forewarned is forearmed

If you can be alerted early to the possibility of low supply you can implement measures immediately to prevent an inevitable poor outcome.

Lactogenesis III (Maintenance)

Lactogenesis III is the maintenance of milk synthesis.

This is an autocrine function, meaning milk production is under local control at the breast. Simply explained, milk must be removed from the breast for more milk to be made. Each breast is independent of the other in regards to milk production.

Researchers have described the following mechanisms, which both work together.

  1. Feedback Inhibitor of Lactation (FIL)

    FIL is a small whey protein that is found in breastmilk. It works on an inhibitory basis. The more milk present in the breast, the more FIL is present to be absorbed, slowing milk production. Conversely, as the breastmilk volume in the breast drops there is less FIL and production of breastmilk is more rapid. 12 13

  2. Prolactin receptors:

    The hormone prolactin is necessary to form the substrate of breastmilk. Prolactin must pass from the bloodstream through the alveolus and into the milk.
    Prolactin receptors on the alveolus control how much prolactin can move into the milk. (Imagine the prolactin receptors to be like keyholes, and prolactin is the key. The keyhole must be the perfect shape to allow the key to fit into it.) As the the breast is filling the alveoli become increasingly distended and the receptors become distorted preventing prolactin moving in, which slows milk production. 14 As the alveolus empties of milk, the receptors regain their shape allowing prolactin to bind and pass through them and into the milk increasing the rate of milk production again. 15 16

What was that again?

Simply put:

  1. Full breast = lots of milk in alveoli = lots of FIL = slow breastmilk production

  2. Full breast = distorted receptors = slow passage of prolactin = slow breastmilk production

Two very good reasons to ensure frequent, effective milk removal for adequate milk production.

Workbook Activity 8.8

Complete Activity 8.8 in your workbook.

Breast storage capacity and rate of breastmilk production

Breastmilk storage capacity is unique to each mother, and each breast.

  • A mother who has a small storage capacity will find that her baby must feed frequently, removing most milk at each breastfeed. This mother's rate of breastmilk production will be high most of the time. If she is told not to feed baby as frequently her breasts will remain full for longer, breastmilk production will slow and she will not be able to produce enough milk for her baby.

  • A mother with a large storage capacity will have higher degree of breast fullness for longer. Her infant may need only one side per feed or may feed less frequently. Breastmilk production during this time will be slow, increasing as the available milk is removed.

Over a 24-hour period both babies may take very similar amounts of milk, but one baby may have to breastfeed many more times per day to achieve it.
Every mother and baby is unique.

Warning: It takes sophisticated technology to determine breastmilk storage capacity, ie large breasts don't necessarily mean large storage.

Perceived breastmilk insufficiency

Along with nipple pain, this is the most common breastfeeding problem which women experience and a reason mothers give for introducing artificial infant formula and weaning prematurely. "Not enough milk" is reported by women, but often their perception does not match reality.17,18

To help prevent this misunderstanding and unfortunate outome always include education about:

  • normal infant behavior (all crying or unsettled behavior isn't from hunger),
  • normal infant breastfeeding frequency, (which is different for every mother and baby),
  • normal infant output (which shows the mother how much her baby is consuming).

Output is the most obvious and reassuring way for a mother to know her baby is being well fed. Remind the mother: If it's coming out, it must have gone in!

Confirmed breastmilk insufficiency

  • delayed onset: absence of noticeable fullness/heaviness of the breasts within 72 hours. 19
  • persistent insufficiency: lactation never reaches levels sufficient to meet infant's needs, or gradually declines to be inadequate over time.

Diagnosis of insufficient breastmilk supply is generally made by observing the condition of the baby. As mentioned in Topic 7.5 , it may not be low supply that has caused failure to thrive, which is why a pediatric review is always indicated.

Management

As always: determine and treat the cause! If it is a medical issue refer the mother for assessment, diagnosis and treatment by the appropriate health practitioner. A team approach may be required depending on the cause. Insufficient milk may be temporary or permanent.

Your role will be to guide the mother on how to increase her production, assisting her to effectively and regularly remove breastmilk, improving breastmilk production.

  1. The breastfeed - assess a breastfeed as discussed in Topic 5.3
    • Observe for good positioning, deep latch, effective suckling, swallowing. Believe it or not this very first step is one often neglected, particularly by health professionals whose specialty is not breastfeeding.
      • Correcting a poor latch may be all that's required to solve the mother's lactation insufficiency.
    • Breast compression during breastfeeding increases milk transfer. Breast compression involves holding the breast in the hand and gently squeezing it. Hold the compression until the baby's sucking pattern changes then release. Repeat.
    • Switch feeding can also be effective. When the infant stops nutritive sucking on the first breast, swap to the other breast. Repeat this on each breast to encourage infant's interest and promote milk synthesis.
  2. Breastfeeding frequency
    • There are many misconceptions about breastfeeding frequency. Remember that the frequency of breastfeeding depends on:
      • how much milk is available in the breast (breastmilk storage capacity)
      • how hungry the baby is (is he given water or supplements between/after feeds)
      • BREASTFEEDING FREQUENCY WILL BE UNIQUE FOR EVERY MOTHER AND BABY
    • Infrequent or 'spaced out' breastfeeding causes milk production to slow and therefore decrease.
    • Teach mothers about milk synthesis and breast storage capacity giving them confidence to breastfeed as their breasts and baby require.
  3. Additional stimulation - milk removal between breastfeeds
    • Fact: The more frequently milk is removed from the breast the more rapidly the breast will produce breastmilk.
      The fuller the breast, the slower the breast will make breastmilk.
    • Additional milk removal after or between breastfeeds will increase total breastmilk produced in that period. Use this milk as a supplement later.
    • Use a tube-feeding device at the breast when supplements are necessary. If possible commence the breastfeed without the supplement flowing to encourage good drainage of the breast first. When nutritive sucking stops allow the supplemental milk to flow. Review Topic 7.5.1
  4. Galactagogues - discuss the pros/cons and types available
    • A galactagogue is a substance that increases the volume of breastmilk produced.
    • Effective galactagogues include domperidone and metoclopramide, as well as the herbals fenugreek, blessed thistle and goat rue. Discuss with mother's doctor.
    • Galactogogues will only be successful if combined with clinical measures that ensure frequent, effective milk removal.
  5. Counselling the mother - sensitivity and caring will be needed to assist this mother.
    • Reassure her that your recommendations won't be detrimental to the baby (and make sure they aren't - baby must receive adequate nutrition, preferably all breastmilk, but may include artificial infant formula) .
    • Carefully assess her understanding of the feeding and lactation plan.
    • Be sensitive to her feelings; some people have probably criticised her decision to breastfeed, and she may see this problem as justification of their criticism.
    • Be careful that she doesn't perceive you to be unapproachable if she does decide to artificially feed. She's still going to need lots of support to help her through possible emotional and guilt reactions.

When is the best time to pump breastmilk?

Assume a mother has an insufficient milk supply. Her baby latches effectively and drains both breasts well each breastfeed but it is not enough for him. When will you tell her to pump?

Immediately after breastfeeding?? This is what is frequently advised. Mother breastfeeds, then pumps and gets only a few mls, or maybe nothing. That's understandable: the baby had just breastfed effectively.
Mother feels disheartened - it proves her inability to provide for her baby.
Breastmilk production will not be increased because the breast was already as empty as possible.

However, if she waits for an hour then pumps, breastmilk production would have been at maximum rate for the majority of that time, beginning to slow now as more milk accumulates in the breast.
Pumping may produce 30ml (1 ounce) from each breast (depends on individual rate of milk production). The breast will be emptied again, milk production will be back to maximum rate once again increasing overall volume produced, and the mother will feel positive about her ability to produce breastmilk.

This is an example of applying your knowledge of physiology to a problem.
Warning: if the baby is unable to remove all breastmilk at each breastfeed, pump immediately afterwards (and again in another hour - it needn't take long!)

Workbook Activity 8.9

Complete Activity 8.9 in your workbook.

Did you know?

Women are able to relactate having prematurely weaned their baby, and also induce lactation, if they did not previously go through pregnancy. Always offer this as an option for mothers who weaned prematurely or are adopting a baby.

What should I remember?

  • That lactogenesis III is the maintenance of milk synthesis and is an autocrine function.
  • Breastmilk production is increased when breastmilk is removed more frequently and effectively.
  • Be able to describe the 2 mechanisms of autocrine control of milk synthesis at the breast level.
  • Understand why breastfeeding frequency is unique for every mother and baby.
  • The FIVE important steps in the management of low supply.

Self-test quiz

Notes

  1. # Nommsen-Rivers LA et al. (2012) Timing of stage II lactogenesis is predicted by antenatal metabolic health in a cohort of primiparas.
  2. # Pieh-Holder KL et al. (2012) Lactogenesis failure following successful delivery of advanced abdominal pregnancy.
  3. # Anderson AM (2001) Disruption of lactogenesis by retained placental fragments
  4. # McGuire E (2013) Breastfeeding and high maternal body mass index.
  5. # Amir LH et al. (2007) A systematic review of maternal obesity and breastfeeding intention, initiation and duration
  6. # Finkelstein SA et al. (2013) Breastfeeding in women with diabetes: lower rates despite greater rewards. A population-based study.
  7. # Matias SL et al. (2014) Maternal prepregnancy obesity and insulin treatment during pregnancy are independently associated with delayed lactogenesis in women with recent gestational diabetes mellitus.
  8. # Ramiandrasoa C et al. (2013) Delayed diagnosis of Sheehan\'s syndrome in a developed country: a retrospective cohort study.
  9. # Lau C (2002) The effect of stress on lactation--its significance for the preterm infant.
  10. # Dewey KG (2001) Maternal and fetal stress are associated with impaired lactogenesis in humans
  11. # Speller E et al. (2012) Breastfeeding and thyroid disease: a literature review.
  12. # Wilde CJ et al. (1998) Autocrine regulation of milk secretion.
  13. # Knight CH et al. (1998) Local control of mammary development and function.
  14. # Cregan MD et al. (2002, March) Milk prolactin, feed volume and duration between feeds in women breastfeeding their full-term infants over a 24 h period
  15. # DeCarvalho MD (1983) Effect of frequent breastfeeding on early milk production and infant weight gain
  16. # Zappa AA (1988) Relationship between maternal parity, basal prolactin levels and neonatal breast milk intake
  17. # Amir LH (2006) Breastfeeding--managing supply difficulties.
  18. # Lamontagne C et al. (2008) The breastfeeding experience of women with major difficulties who use the services of a breastfeeding clinic: a descriptive study.
  19. # Nommsen-Rivers LA et al. (2010) Delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding.