Abstract
Low milk production is the chief complaint in my breastfeeding medicine practice. By the time patients reach me, they’ve often endured lengthy breastfeeding sessions, power pumping, and have tried a variety of galactagogues, including baking lactation cookies, all with the belief that they must work beyond sustainable limits to produce more milk. The dominant message in media and peer-reviewed literature often downplays low milk production as a self-reported issue rather than a legitimate one.1,2 As a result, many lactating mothers experience stress, frustration, guilt, or even despair. 3 Low milk production is often not just perceived but is real, and it is crucial for physicians to recognize that low milk production is a medical problem that warrants evaluation and treatment like other health concerns. In addition, low milk production, for many women, may be a marker of future health problems, including cardiovascular risk. 4
Milk production is an intensive process that requires frequent, consistent, and effective breastfeeding and/or pumping to ensure optimal mammary gland stimulation and milk removal. 5 Supplementation with formula or donor milk, especially in the first 2 weeks postpartum, is a typical management strategy when infants need more milk. Oftentimes supplementation of “other” milk is not warranted, but if indicated due to low milk production, the mother needs a workup for diagnosis, treatment, and counseling to optimize milk production.
Consider the case of a healthy infant born at 39 weeks’ gestation to a 38-year-old generally healthy G1P1 mother with a pre-pregnancy weight of 105 kg (231 lbs) who developed mild hypertension during the third trimester and was treated with labetalol. The infant was born vaginally without complications and appeared to breastfeed well in the first few days. On day two, the infant’s weight was 6% below birthweight, and when seen by the primary care physician on day 4 of age, the weight had further dropped to 11% below birthweight. The mother was instructed to continue breastfeeding and supplement according to the infant’s feeding cues. A follow-up appointment was scheduled at two weeks postpartum, and the physician expressed confidence that the infant would thrive as long as formula was always offered after each breastfeeding session. This approach is all too common, and often no further investigation of—or explanation for—low production is provided.
The first step in supporting this mother is a careful history to determine whether milk production is truly low or if the infant is not transferring milk effectively. Lack of milk transfer can be due to many reasons, such as late preterm birth, sleepy behavior, shallow latching, ankyloglossia, or an occult palatal cleft. In many cases milk production is sufficient, and advising formula supplementation could undermine milk production. Instead, the best course of action may involve encouraging the mother to express her milk and feed it to the infant until their feeding skills mature or are actively managed. As outlined in this special issue, milk transfer measurements are an evidence-based and often-employed clinical strategy to help sort out milk transfer and milk production issues.
If low milk production is confirmed, the next step is a differential diagnosis to identify potentially modifiable factors, such as the impact of certain medications (e.g., antihistamines, early postpartum contraception, aripiprazole, decongestants, and cabergoline), thyroid abnormalities, or retained placenta. There are several maternal health factors that negatively impact milk production and are not readily modifiable, such as testosterone-secreting tumors, pituitary insufficiency, or a history of breast surgery or radiation.
However, a common but often overlooked cause of low milk production in the early postpartum period is delayed achievement of secretory activation (SA). Research increasingly suggests that insulin resistance and elevated pre-pregnancy BMI are significant risk factors for delayed or impaired SA. 4 Primary care physicians and other providers can support breastfeeding by recognizing these risk factors and referring the dyad to a breastfeeding medicine specialist. Physician breastfeeding specialists can provide anticipatory guidance during pregnancy and/or early postpartum, as well as create a feeding plan with close follow-up to ensure appropriate infant nutrition while managing SA delay and optimizing milk production.
In this issue, researchers explore how breastfeeding medicine specialists can use point-of-care measurement to objectively diagnose delayed or impaired SA achievement with ion-selective electron probes. Much-needed algorithms for the use of these instruments, including interpretation and evaluation of measurements, can guide physicians in determining appropriate next steps, whether that’s further workup, counseling, and/or treatment. In my clinical experience, mothers with delayed SA, particularly those with insulin resistance or an elevated BMI, typically experience a gradual increase in milk production over time, provided they are encouraged and managed with expert medical lactation care. Without a diagnosis or awareness that milk production will likely increase over time, these mothers often experience early, unplanned cessation of lactation.
If SA has already been achieved—confirmed by measuring milk sodium levels—and no identifiable risk factors for low production are found, the mother may be dealing with idiopathic hypogalactia. This condition, though poorly understood, is not uncommon. Based on clinical experience, women with idiopathic hypogalactia will often experience a gradual rise in milk production over the following months. Ideal support for these mothers includes evidence-based methods of optimizing milk production while protecting the mother’s mental health. This would include frequent and thorough milk removal via breastfeeding and/or pumping, along with galactagogues in certain situations. It is often not in a mother’s best interest to triple feed (breastfeeding followed by pumping and supplementing) for weeks or months when her infant demonstrates the ability to effectively remove milk from the breast. Supplementation during or immediately after feeding without additional pumping is a reasonable strategy. Likewise, these mothers need counseling on how to manage personal expectations for milk production.
We often assume that early cessation of lactation primarily impacts infant health because of the risk of childhood illnesses associated with lack of breastfeeding, such as infections, asthma, childhood obesity, childhood leukemia, inflammatory bowel disease, and infant mortality. 6 However, it is under-recognized that maternal risk for long-term, potentially modifiable health problems increases with early cessation of lactation.7,8 Research reveals a dose-response relationship between breastfeeding and long-term maternal health, including lower risks of excess visceral fat, gestational diabetes, type 2 diabetes, cardiovascular problems, hypertension, hypercholesterolemia, and stroke.7,8 Therefore, it is important to inform mothers that milk production is likely to improve over time and to provide them with personalized care that supports continued lactation.
Although research is shedding light on the risk factors for delayed and/or impaired SA, breastfeeding medicine education for physicians and providers has not kept pace, 9 which presents a challenge to incorporate this evidence into practice. Supporting lactation as a means of improving long-term infant and maternal health is low-hanging fruit compared to more challenging psychosocial and environmental determinants of health. We can and need to incorporate lactation as a key component in the diagnosis and treatment of risk factors for maternal cardiovascular and metabolic illnesses. As the curriculum coordinator for an accredited educational pathway by the North American Board of Breastfeeding and Lactation Medicine, I’ve seen a rising interest in this field among young physicians, most of whom leave residency with low self-efficacy regarding breastfeeding support and management for their patients. Academic institutions can advance long-term maternal child health by establishing departments of breastfeeding and lactation medicine for evidence-based patient care, research, and health professional education.