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Why Women Lose Their Milk: The Time-Sensitive Nature of Early Milk Production
Presented by: Barbara Wilson-Clay, BSEd, IBCLC, FILCA
Abstract:
Concerns about low milk supply and excessive early infant weight loss are among the most
frequently cited reasons women abandon exclusive breastfeeding. While lack of information
about normal breastfeeding sometimes contributes to the perception of low supply, in many
cases the problem is real. A number of well-documented factors may cause a delayed onset of
milk production and contribute to low milk production. These include long, stressful labor,
cesarean delivery, maternal overweight or obesity, metabolic or hormonal disorders (diabetes,
hypertension, polycystic ovarian syndrome), maternal blood loss, maternal infection, and poor
early stimulation by a preterm, small, injured or ill infant. What are the best practices to
protect the option to breastfeed in such cases? New research provides interventions that can
help mothers maximize their milk production, and emphasize the critical nature of the timing of
these interventions.
Objectives:
Identify causes of delayed onset of milk production and acquired low milk supply.
Identify early infant weight loss as a predictor of early supplementation and early weaning.
Describe new research about the calibration of milk production.
Discuss the time-sensitive nature of interventions to protect milk production.
Outline:
I Causes of delayed onset of milk production and acquired low milk supply
A. Birth complications
B. Medical problems of the mother and/or baby
C. Management issues
II Infant cues, stooling patterns, and excessive early weight loss
A. How the mother interprets the signals
B. Implications for exclusive breastfeeding
C. Implications for the risk of weaning
D.
Why Women Lose Their Milk: The Time-Sensitive Nature of Early Milk Production
III Best practices to protect the milk supply
A. New research: a review
B. Counseling the mother
References:
Academy of Breastfeeding Medicine Protocol Committee. ABM Clinical Protocol #3: Hospital
Guidelines for the use of supplemental feedings in the healthy term breastfed neonate.
Breastfeeding Medicine 2009; 4(3):175-182
Asztalos EV,Campbell-Yao M, da Silva OP, et al. Enhancing human milk production with
Domperidone in mothers of preterm infants: Results from the EMPOWER Trial. Journal of
Human Lactation 2017; 33(1):181-187.
Brownell E, Howard CR, Laurence RA, et al. Delayed onset lactogenesis II predicts the cessation
of any or exclusive breastfeeding. Journal of Pediatrics 2012:161(4):608-614.
Chapman DJ. Perez-Escamilla R. Identification of risk factors for delayed onset of lactation.
Journal of the American Dietetic Association 1999; 99(4):450-454.
Eckstrom A, Nissen E. A mother’s feelings for her infant are strengthened by excellent
breastfeeding counseling and continuity of care. Pediatrics 2006; 118(2):e309-314.
Flaherman VJ, Schaefer EW, Kuzniewicz MK, et al. Newborn weight loss during birth
hospitalization and breastfeeding outcomes through age 1 month. Journal of Human Lactation
2017; 33(1):225-230.
Grube M, Keitel-Korndorfer A, Bergmann S, et al. Breastfeeding in obese versus normal-weight
German mothers of various socioeconomic status. Journal of Human Lactation 2016; 32(3):546-
550.
Hackman NM, Alligood-Percoco N, Ashley M, et al. Reduced breastfeeding rates in firstborn late
preterm and early term infants. Breastfeeding Medicine 2016; 11(3):119-125.
Hall R, Mercer A, Teasley S, et al. A breastfeeding assessment score to evaluate the risk for
cessation of breastfeeding by 7 to 10 days of age. Journal of Pediatrics 2002; 141(5):659-664
Why Women Lose Their Milk: The Time-Sensitive Nature of Early Milk Production
Hill P, Aldag J, Chatterton R. Initiation and frequency of pumping and milk production in
mothers of non-nursing preterm infants. Journal of Human Lactation 2001; 17(1):9-13.
Lussier MM, Brownell EA, Proulx TA, et al. Daily breastmilk volume in mothers of very low
birhweight neonates: a repeated-measures randomized control trial of hand expression versus
electric breast pump expression. Breastfeeding Medicine 2015; 10(6):312-317.
Meier PP, Patel AL, Bigger HR, et al. Supporting breastfeeding in the neonatal intensive care
unit. Rush Mothers’ Milk Club as a case study of evidence-based care. Pediatric Clinics of North
America 2013; 60(1):209-226.
Morton J, Hall J, Wong RJ, et al. Combining hand techniques with electric pumping increases
milk production in mothers of preterm infants. Journal of Perinatology 2009; 29(11):757-764.
Morton J, Wong RJ, Hall J, et al. Combining hand techniques with electric pumping increases the
caloric content of milk in mothers of preterm infants. Journal of Perinatology 2012;32(10):791-
796.
Parker LA, Sullivan S, Krueger C, et al. Association of timing of initiation of breastmilk expression
on milk volume and timing of lactogenesis stage II among mothers of very low-birth-weight
infants. Breastfeeding Medicine 2015; 10(2):84-91.
Rassmussen K, Kjolhede C. Prepregnant overweight and obesity diminish the prolactin response
to suckling in the first week postpartum. Pediatrics 2004; 1113(5):e465-470.
Riddle SW, Nommsen-Rivers LA. A case control study of diabetes during pregnancy and low milk
supply. Breastfeeding Medicine 2016; 11(2):1-6.
Advantages of Breastfeeding: Prevention of death in children younger than age 5
Protection against a range of child infections and illnesses
Optimal development of infant gut biome
Promotion of optimal oral development
Increases in IQ
Protection against overweight and obesity
Protection against breast and ovarian cancer in mothers
Improved birth spacing
Victoria CG, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016; 387:475-490.
Fear of Low milk supply: #1 reason women abandon exclusive breastfeeding
Misinformation about what normal breastfeeding looks like may contribute to what is called “perception of low milk supply” rather than a real problem.
But! Delays in the onset of copious lactation are common –especially following cesarean birth and in obese women.
Low early milk supply contributes to excess infant weight loss.
Low infant birth weight, poor early management of breastfeeding, and infrequent feeding may cause poor initial calibration of milk production.
Maternal dietary deficiencies, metabolic, environmental, or genetic issues may contribute to poor milk production in some mothers.
Objectives: Identify causes of delayed onset of milk
production and acquired low milk supply
Identify early excess infant weight loss as a predictor of both early formula supplementation and early weaning
Describe new research about the calibration of milk production
Discuss the time-sensitive nature of interventions to protect milk production
Let’s start with a case
Mom is a smoker, very stressed with a husband recently returned from combat
Delivers on her due date by emergency c-section with general anesthesia
Baby is Small for Gestational Age (SGA) and weighs only 5 lbs owing to placental abnormalities – 2 large blood clots
Mother has larger than average nipples
What should happen following normal birth?After normal delivery, term infants left skin-
to-skin locate and begin to stimulate the nipple
Delivery of the placenta triggers what is called “secretory activation” – a complex hormonal interaction that normally results in the onset of copious lactation 30-40 hours after birth (engorgment).
During the first 2 days colostrum is available in small amounts (30 ml/day) – the primary purpose of colostrum is now being recognized as immunological rather than nutritional.
Lee S, Kelleher SL. Biological underpinnings of breastfeeding challenges: the role of genetics, diet, and environment on lactation physiology. Am J Physiol Endocrinol Metab2016; 311. E405-422.
Colostrum comes in many colors
The colostrum must be removed as if the birth were normal, and it must be fed immediately to the newborn for immunological protection, for laxative effect, and to prevent excess infant weight loss
Delayed onset of copious milk production (the milk “coming in”) occurs after 72 hours. Our c-section case mom and her tiny baby are at risk.
Delayed onset is COMMON. Dewey et al, reported that 22 percent of mothers experienced delays (Risk
factors for suboptimal infnat breastfeeding behavior, delayed nset of lactation, and excess neonatal weight loss. Pediatrics 2003; 112:607-619)
Nommsen-Rivers et al found 44 percent of women experienced delayed onset of lactation (Delayed onset of
lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding. Am J of Clin Nutr 2010; 92(3):574-584.)
What are some causes of delayed onset?
Long, stressful labor
Primiparity, multiple birth
Inadequate or delayed breast stimulation
Instrument assisted delivery, cesarean birth
Retained placenta
Hypo-androgenism, hypertension
Excessive maternal blood loss, other types of maternal illness
Maternal insulin resistance and maternal diabetes
(Chapman 1999, Dewey 2003, Hall 2oo2, and many others)
Relationship of delayed onset to weaning: Brownell (2012) reported an association between
delayed lactogenesis and cessation of both any and exclusive breastfeeding.
Delays are also significant because they are associated with suboptimal infant breastfeeding behavior (the baby gives up hoping and starts sleeping with the nipple in their mouth – they appear to be feeding but are not).
Retained colostrum contributes to down-regulation of milk production
The big driver of production is effective milk removal
Does the research support this? Parker (Breastfeeding Medicine 2015) demonstrated
that mothers of preterms who began milk expression within the first hour after birth made significantly more milk than when expression was delayed.
Morton (J Perinatology 2009, 2013) demonstrated that a combination of both hand expression and electric breast pumping produced significantly more milk and milk with higher fat content (Hands on Pumping or HOP)
Is hand expression alone adequate stimulation? A study by Lussier, et al (Breastfeeding Medicine 2015)
compared milk volumes of mothers of very low birthweightbabies using only hand expression versus electric breast pump expression.
This was a randomized, controlled trial and was not funded by a pump company.
At the end of 1 week, the mothers randomly assigned to use electric pumping were producing twice as much milk as the hand expressing mothers.
The trend of reduced milk production in the hand expression mothers persisted even after the end of the 7 day trial when they, too, began electric pumping.
What are the implications of the Lussier findings? They add to a body of evidence going back decades
that suggests that the milk supply is calibrated within the first few days to a few weeks following birth.
Milk volumes achieved during that time are likely to be maintained over the course of lactation.
If you set the thermostat too low, the mother is always trying to play catch up to increase supply – mostly unsuccessfully.
So what might happen to our case mother and baby?
In many hospitals, an SGA baby is managed like a term baby of normal weight.
SGA babies have special issues and needs. If feeding is not well-managed, growth faltering persists post-natally (resulting in both stunting and intellectual deficits – especially if the baby is female and is supplemented with formula) (Morley R, et al. Neurodevelopment in children born small for gestational age: a randomized trial of nutrient-enriched versus standard formula and comparison with a reference breastfed group. Pediatrics 2004; 113(3):515-521.)
Often disparities between small mouth and large nipples are not assessed and managed
Typically an appearance of feeding without confirmation of intake results in delayed interventions to remove colostrum and to stimulate the breasts.
This results in low milk supply and a baby who doesn’t grow well.
What did actually happen? Born in a Baby Friendly Hospital. An IBCLC at bedside as the
mother came out of anesthesia assisted in immediate hand-expression of colostrum.
The colostrum was taken to the nursery and immediately fed to the infant.
Electric breast pumping initiated within 6 hours; first breastfeed at 8 hrs.
Test weights allowed targeted supplementation with normal, reference volumes for each day postpartum. (Don’t overfeed!)
Baby was also supplemented with high cal donor milk until mother’s milk came in on Day 4.
Baby lost only 3.5% of birth weight
She was exclusively breastfed until 6 months, partially for 2 years.
Infant stooling in the first week: Absence of daily stooling in first week and delayed
transition from dark meconium to light-color stools:
Important clinical signs that an infant needs more evaluation for feeding!
They are indications that the baby is at risk for inadequate milk intake, a sign of delayed lactogenesisII, increased risk of hyperbilirubinemia, and more rarely, bowel blockage.
Here’s what normal looks like:
Meconium–Day 1 Transitional stool-Day 2 Yellow stool once milk comes in-Day 3
24 hr stool count of exclusively breastfed baby at the beginning of Day 3
When reporting stools use size
comparisons- don’t count the small ones!
After solids
Urination patterns Less useful to predict adequate calorie intake
Is important to assess from the standpoint of ruling out blockages and to document hydration status.
Red crystals in the urine (brick dust urine) may be normal on Day 1 and 2, but after Day 3 they may indicate dehydration.
Weight loss/weight gain in newborns:
Ideally newborns don’t lose more than 7% of birth weight (Academy of Breastfeeding Medicine 2009)
Excessive weight loss impacts stamina for effective feeding
Impact of maternal IV fluids during labor as a cause of infant weight loss: Increased diuesis (urination) of extra fluids by the infant appears to occur only during the first 24 hours. Continued infant weight loss Day 2 and beyond should prompt careful evaluation of milk intake.
(Noel-Weiss J, et al. An observational study of associations among maternal
fluids during parturition, neonatal output, and breastfed newborns weight loss. Int Breastfeeding J 2011;6:9.)
More about weights Babies smaller than 7 lbs are at increased risk for poor
breastfeeding.
Babies who lose > 7% of birth weight are at increased risk for poor breastfeeding. (Academy of Breastfeeding Med 2009)
By the end of 7-10 days birth weight is normally regained.
Infants who lose a lot of weight early on typically receive more formula. Tracking weight loss trajectory prior to discharge might alert staff to better assist those dyads and preserve exclusive bfg. (Flaherman VJ, et al. Newborn weight loss
during birth hospitalization and breastfeeding outcomes through age 1 month. J Human Lactation 2017; 33(1):225-230.)
More about weight: For the next 3-4 months, weight gain is typically 1
oz/day for girls and 1.5 oz/day for boys.
Weight gain typically doubles (and may triple) by 6 months, after which rate of growth typically slows unless over-feeding takes place. (WHO growth charts for
breastfed infants)
Case baby at 6 months: 17.5 lbs
Test Weighing: Why guess when you can know? “The most widely accepted method for measuring
milk production is test-weighing, in which the infant is weighed before and after feeding using an electronic scale.” (Lee S, Kelleher SL. 2016)
This requires a sensitive scale (accurate to within 2 grams).
Take home messages from the new research on calibration of milk supply and factors increasing risk of weaning:
Intervention is not a bad word when it prevents bad outcomes. (How long would you wait to feed a starving older person?)
If you carefully assess a situation and see that the mother is at risk for a low milk supply or the baby is likely unable to stimulate a full milk supply – ACT!
Give the mother full information in a calm manner so she knows that you have an evidence-based plan to manage her situation to protect her breastfeeding goals.
At risk dyads are best served by immediate steps to protect the milk supply. Early initiation of expression
Skin-to-skin holding (to calm mother & baby and facilitate breastfeeding)
Hands-on-Pumping (combine hand and pump expression)
Appropriate frequency of milk expression: 8-10 times/24 hours (at least 8 times/24 hours.)
Use own mother’s milk to supplement infants losing weight, donor human milk from a safe source, formula
Best Practices Newborn assessment should carefully identify small,
injured, preterm, ill, jaundiced babies and those with congenital malformations.
Maternal breast assessment should carefully identify women with surgical scars indicating previous breast surgery, abnormal breast and nipple anatomy, and health history should screen for hormonal conditions, obesity, nutrition.
