When lactation doesn’t work

As a newly-minted doctor and breastfeeding activist, I used to believe that all mothers could breastfeed. Now, after almost a decade of clinical experience, I know better. Sometimes, breastfeeding physiology just doesn’t work. And frankly, as medical professionals, we handle these situation poorly.

Lactation happens through a choreographed interplay of hormones that build up milk-making machinery during pregnancy and then manufacture milk and deliver it to the baby during feeding. So-called “primary lactation failure,” when a mother’s milk never comes in, may happen because the machinery doesn’t develop , or because the signals to make and move the milk are not in sync or absent altogether.

When a mother’s milk isn’t flowing, physicians should check for any medications that may be interfering with milk production, as well as assess function of the thyroid and pituitary gland, which can be damaged during childbirth after heavy bleeding. Absent milk production can also occur if part of the placenta is left behind at birth. If these tests are all normal, a few drugs can boost the level of prolactin, the milk-making hormone. ABM covers these drugs in our Protocol on Galactogogues.

Often, however, we don’t find an answer. With little knowledge and few treatment options, the physician is typically left telling a mother that she has “lactation failure.” Too often, that diagnosis is followed by some patronizing comment like, “It’s ok — I was formula fed, and I turned out fine.”

Now, I have a question: Why do we accept that malfunction of a major part of reproductive physiology is untreatable, and that the acceptable solution is a synthetic substitute and a pat on the head?

Consider that we spend more than $1 billion a year on Viagra to treat another type of reproductive malfunction. I suspect men with erectile dysfunction would not respond well to being told “We’re sorry, we don’t have a treatment for this important aspect of your reproductive and social well-being. But here’s an artificial substitute.”

This disparity in knowledge and treatment is no accident. If you search the database of federally funded medical research for “lactation failure,” there are only 9 studies listed, compared with 84 for erectile dysfunction. It seems that, as a nation, we simply don’t consider inability to breastfeed to be an important problem.

Mothers and babies deserve better. First, given the limits of current medical knowledge, we should admit that we should have better answers. And would should honor, not trivialize, her efforts to initiate and sustain breastfeeding. When we tell her, “It’s ok, I was formula fed, and I turned out fine,” we are basically saying that she’s a little crazy to have worked so hard to breastfeed, because it’s really not important, and she shouldn’t worry her pretty little head about it.

Instead, I praise the mother for all the ways she tried to make feeding work. I have even written letters to the baby, documenting for mom how hard she worked to breastfeed. Then, we talk about how breastfeeding is not simply a matter of feeding breast milk. Mom and baby can enjoy much of the bonding and intimacy of breastfeeding with skin-to-skin contact, holding and snuggling her baby, and putting the baby to breast for comfort after feeding.

We also talk about how to respond to strangers who make snide comments to bottle-feeding mothers. I’ve been assailed for nursing in a restaurant, and I was deeply humiliated when a woman stalked up and said, “For future reference, the bathroom is back there!” I can only imagine what a mother who cannot breastfeed — or decides not to — endures when strangers pass judgement on how she is nourishing her baby.

And then there are the policy issues. Physicians and nurses need training to identify moms at risk for lactation failure, provide early help and support, and prevent horror stories of dehydrated infants and devastated mothers. We need more and bigger milk banks to distribute donor human milk. And we need to encourage mothers who couldn’t make milk to transform their feelings of guilt and loss into action by writing letters to demand research funding for this all-too-common problem.

Not all mothers can make milk, but modern medicine has solved more complex problems. What we need is the willpower and resources to determine the causes of lactation failure and develop appropriate treatments so that all mother can reach their breastfeeding goals.

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician, breastfeeding researcher, and assistant professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine.