Breastfeeding Medicine

Physicians blogging about breastfeeding

How often does breastfeeding just not work?

with 45 comments

Jessica Isles posted a great question today on my blog, “When Lactation Doesn’t Work:”

I was wondering if any comparative studies have been done on the statistics of lactation failure in various cultures both developed and less developed. Please post if you are aware of any – or any statistics on how many women’s milk never comes in (in the US), with a healthy full term new born, in an environment supportive of breastfeeding. We need to help mothers who struggle with this.

That’s a great question – and a difficult one to answer. Marianne Neifert estimates that “as many as 5% of women may have primary insufficient lactation because of anatomic breast variations or medical illness that make them unable to produce a full milk supply despite heroic efforts.”   [Neifert MR (2001). "Prevention of breastfeeding tragedies." Pediatr Clin North Am 48(2): 273-97.]

We are working on a research project to try to estimate the proportion of women in the Infant Feeding Practices Survey II who experienced unplanned, undesired weaning due to physiologic problems with breastfeeding. One challenge is what to call this condition. I’ve written a draft of the paper using the term “failed lactation,” but I don’t like it.  I have problems using the word “failed” to describe mothers who have gone to heroic lengths to sustain breastfeeding. We’ve also tossed around “lactation dysfunction” or “unwanted weaning,” but those don’t quite cut it either. I want a phrase that health care providers will take seriously and moms will perceive as a lifeboat in a storm, not as insult added to injury. My personal favorite is “Lactastrophe,” but I suspect that would not make its way into the medical lexicon. What do you think we should call it when lactation doesn’t work?

We’re also finding that it’s quite difficult to tease out the issue of “a supportive environment” vs biological problems with lactation. It’s a bit like trying to tease out how much of the type 2 diabetes epidemic is caused by “biology” vs “the environment.”  Over the past two decades, the proportion of our population that is obese has sky-rocketed, in the setting of decreasing physical activity, ballooning portion sizes, neighborhoods without sidewalks, and worsening economic inequality and job insecurity. Some people who live in this country have developed diabetes, and some have not.  It’s likely that some individuals have a biological predisposition that makes them vulnerable, whereas others do not. Regardless of the precipitating factor, however, these patients need help to control their blood sugars.

Similarly, for lactation, there are some mothers who are blessed with ample milk supplies and with babies who are born with a championship suck-swallow pattern, and they would be likely to breastfeed successfully in just about any environment. And there are other dyads for whom one piece of bad advice or a nasty encounter with a stranger while breastfeeding in public is enough to throw lactation completely off track.  Furthermore, it’s likely that women who have been socialized to mistrust their bodies are more vulnerable to interpreting early feeding challenges as evidence that their bodies can’t sustain breastfeeding– and they are thus more likely to wean and attribute their decision to a physiological problem.

From a health and wellbeing perspective, however, I’m not sure that it matters whether we “count” both “biological” and “perceived” insufficient lactation together. The total burden of this problem is enormous, and mothers are suffering, whether they lack glandular tissue and or they lack self-efficacy and support.  We need mothers for whom lactation doesn’t work to know that they are not alone.  And we need to demand research to develop the tools that will identify the underlying problems and allow us to implement the appropriate treatment.

We also need to step back from assertions that every mother can breastfeed, if she just tries hard enough. As Neifert has written, “The bold claims made about the infallibility of lactation are not cited about any other physiologic processes. A health care professional would never tell a diabetic woman that ‘every pancreas can make insulin’ or insist to a devastated infertility patient that ‘every woman can get pregnant.’ The fact is that lactation, like all physiologic functions, sometimes fails because of various medical causes.”

Lactation is part of normal human physiology, and like all other human physiology, it can fail. It’s time to stop bickering about whether this mom tried as hard as that mom to breastfeed. We have too much work to do.

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. She is a member of the board of the Academy of Breastfeeding Medicine. Posts on the ABM blog reflect the opinions of individual authors, not the organization a whole.

Written by astuebe

October 15, 2012 at 3:35 pm

45 Responses

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  1. “And we need to demand research to develop the tools that will identify the underlying problems and allow us to implement the appropriate treatment.”

    Thank you, Alison, for this blog post, which will provide encouragement to the mothers who find themselves in this awful situation, and for giving voice to what needs to be done if we, as a collective profession that supports breastfeeding, are really going to help them.

    Diana Cassar-Uhl, IBCLC

    October 15, 2012 at 3:53 pm

  2. Please also consider Posterior Tongue Ties and Upper Lip Ties as factors as well. I thought my breasts were somehow inadequate until baby number 4 (FOUR) was finally diagnosed with PTT, and they all have it. These babies are unable to nurse properly because their tongues/mouths often CANNOT function properly to draw milk from the breast. I was devastated. I was able to nurse my second child for her entire first year simply because I had massive oversupply in the beginning that enabled her to get enough milk without a proper latch, but I cried and screamed for the first 8 weeks and for the rest of that year it was uncomfortable. By the time she was 3 months old, I was popping fenugreek like it was candy. I am the mom who said things like, “My nipples are too big” and had people say “Nipples are never too big or too small to breastfeed!” but then could not offer an explanation as to WHY my children could not nurse. Women have no idea it’s the baby’s mouth and not their breasts, because ‘babies are born to breastfeed.’ We are the moms who say “It just didn’t work” and get accused of not trying hard enough, or “My nipples are too big/too small” and hear “no they aren’t,” or “It just wasn’t for us” when we would have done ANYTHING to nurse that child.

    Catlin

    October 15, 2012 at 4:19 pm

    • So true Catlin, I think the current Tongue Tie stats are much lower than the reality. Many, many would go completely undiagnosed, or the connection to breastfeeding problems not made. ;-(

      mumsmilk by Naomi Hull

      October 15, 2012 at 4:23 pm

      • I agree. By the time a lot of these babies get into that first pediatrician visit, they are already on a bottle and there’s no longer a need to diagnose. Even with a diagnosis, a lot of docs will say “Well, let’s wait until he is older to fix it, let’s wait to see if it will actually cause problems or not.” They fail to see that being unable to breastfeed is indeed a problem.

        Catlin

        October 15, 2012 at 4:41 pm

      • My son went 12 days in the NICU, and two more days at home befor his regular pediatrician found his tongue tie!!! I had already had to give in to bottle feeding just so we could.go home… it felt good to know but I still made me so mad… if I hadn’t already nursed four older kids, I don’t believe I would have hung in for the three months it took to get it clipped and back to the brsast. We just found out my oldest (14!!) Is tongue tied too!!!! We only made it six monthe with her.. Under diagnosed is a massive understatement.

        Becky Kiefer

        October 16, 2012 at 12:12 am

    • The consequences of the under-diagnosis and lack of treatment of Tongue Ties, Posterior Tongue Ties and Lip Ties is heartbreaking, in my opinion. Women have had their babies hospitalized for failure to thrive, and even taken into care, all because the Health Care Providers refuse to recognize an anatomical deformity that is simple to correct. Mothers follow all the rules, nurse in agony, nurse all the time, and the babies don’t gain. Or the baby gains well, and nursing is never really enjoyable for either of them.Put a baby like this together with a low milk supply mom, and you have a disaster in the making. I watched a friend of a friend struggle with her baby with a posterior tie, who couldn’t even bottle well, and the pediatrician could “see nothing”. In the end, after mom had pumped a good milk supply, she stopped pumping because the baby would nurse by the hour on a nipple shield, and the baby lost weight for a month. So, back to formula feeding and the family GERD.
      I feel so bad for the mothers of babies with “tight” latches who I told that babies improve their suckling as they get older. In the case of PTT, not so much. Now I exam every baby I see for lip tie and tongue tie. I would definitely like to see more research in this area.

      Helen

      October 15, 2012 at 4:46 pm

      • Tongue tie is just one example of why this is not just about milk supply – lactation is a two-person organ system, and issues with baby or with mom can derail breastfeeding. The challenge is that so many mothers and babies get their care from separate providers who are not cross-trained to evaluate the other half of the dyad – so if baby is gaining and has a tight frenulum, but mom has pain, the pediatrician doesn’t perceive a problem. And conversely, if mom has mastitis from nipple trauma from the same tight frenulum, the OB provider doesn’t think to look in the baby’s mouth, and the trauma keeps happening, and the mastitis comes back. The solution, then, has to be multilayered — all physicians, PA’s and advanced practice nurses who see breastfeeding mothers or babies need to have the basic skills to look beyond their fraction of the dyad. They also need to have systems in place to seamlessly communicate with the rest of the team so that appropriate care is delivered.

        astuebe

        October 15, 2012 at 5:49 pm

  3. A few insights from our lactogenesis research:

    In our prospective study of 431 first-time mothers residing in Sacramento, CA, 44% experienced onset of stage II lactogenesis after 72 hours, but only 1.7% still had not experienced stage II lactogenesis at the end of the first week postpartum (see Nommsen-Rivers, et al, Am J Clin Nutr, 2010). In contrast, a companion study lead by Susana Matias in peri-urban Peru found that only 17% of first-time mothers experienced onset of stage II lactogenesis after 72 hours and NONE were still waiting for their milk to come in after 1 week (see Matias, et al, Mat Child Nutr, 2009). Another interesting contrast comes from rural Ghana: in a study published by Otoo, et al (JHL), in which <5% of a cohort delivering at a baby-friendly hospital in rural Ghana experienced onset of stage II lactogenesis beyond 72 hours. All of these studies used similar, validated measures of stage II lactogenesis.

    Therefore, it seems that DELAYED onset of lactogenesis is COMMON in the US (the 44% figure is in line with reports from other US settings), but not necessarily NORMAL for our species. Furthermore, FAILED lactogenesis is rare, even in the US.

    Nonetheless, we found in an earlier cohort (1999) based in Davis, CA that 33% of mothers intending to exclusively feed at the breast at least through the first 60 days postpartum ended up supplemented with their own expressed milk (more often) or formula (less common) for reasons related to either the infant not feeding well enough at the breast to gain adequately or mom not able to maintain an adequate supply, or both.

    Nommsen-Rivers, Laurie (Laurie Rivers)

    October 15, 2012 at 4:39 pm

    • Thanks so much Laurie for this context. I’m a huge fan of your work!

      astuebe

      October 15, 2012 at 5:50 pm

  4. Thank you for pointing this out, Caitlin. I would have if you hadn’t. My son too had a posterior tongue tie and an upper lip tie that caused massive pain for me. We were lucky enough to learn about it and we had it lasered at 5 weeks, though it took another 3 weeks for him to learn to use his tongue properly. Our pediatrician didn’t notice it, or think it was a problem after it had been pointed out to him. If I hadn’t been so vocal about breastfeeding before my son was born, and even then if we hadn’t figured it out, I probably would have quit. We were also lucky in that even with his awful method of sucking, he was able to get enough milk out to keep putting on weight.

    Shannon

    October 15, 2012 at 5:12 pm

    • I also want to point out that EVERYONE who looked told me that we had a great latch, including the hospital’s lactation consultant. She is the one who found the lip tie, though not the tongue tie, and she didn’t really think it was causing the problem. Nor did the ENT she recommended either. Professionals really need to learn more about the effects (both on bf and long-term) of those issues.

      Shannon

      October 15, 2012 at 5:17 pm

  5. PCOS is a medical condition that has been associated with inadequate milk supply. In spite of the use of Metformin, initiated within the first week postpartum, and use of a Pump in Style Advance. the baby has also been supplemented at the breast. My daughter has not been able to stimulate an adequate breast milk supply. As a IBCLC, I found it very disheartening, trying to help her and the baby. I know intellectually, that everything that could be done was done but it’s still difficult to be in that kind of situation. The baby is still willing to feed at the breast but my daughter is not sure how longer she will continue.

    Sharon Kraft

    October 15, 2012 at 5:16 pm

    • How about using a hospital grade pump? I have always heard that consumer grade pumps are for maintaining supply, not initiating one. Also, would Domperidone be appropriate for her? It’s being used very successfully in Canada and Europe, and I was extremely successful with it used in combination with a Madela SNS when I was misdiagnosed as being incapable of producing a full supply by an IBCLC who did not check for or discover my daughter’s posterior tongue tie. There is a lot of information on Domperidone on Dr Newman’s website, http://www.nbci.ca Good luck!

      Mary Miller

      October 15, 2012 at 10:20 pm

      • Domperidone is not FDA approved and despite it’s use by DR Jack, it is not tested or approved for use in infants. It is all ell and good to have a helpfull pill but it is important to realize that good pumping and feding practices are.far.more important including how to manually express milk as there are lots of women who don’t respond to a pump well.

        Becky Kiefer

        October 16, 2012 at 12:47 am

    • I, too, have PCOS. And was completely devastated when I just wasn’t able to maintain a sufficient milk supply. I tried for 8 weeks and still cry at the thought of having to stop (my daughter is 3.5 years old now). She just wasn’t gaining weight, no matter how often I fed her or pumped, and I was highly anxious as a result. I’m so thankful to have a happy, healthy little girl now.

      Kristen

      October 17, 2012 at 1:09 pm

  6. How about “Lactation Dysfunction” or Dysfunctional Lactation”.

    Susan Slear, RN, IBCLC, RLC

    October 15, 2012 at 6:34 pm

  7. How about preventable, non preventable, and suplementation necessary lactation complications which may be overcome in secondary or subsequent nursing pairs? -I do want (some) credit for that ;) “Kiefer Syndrome”?

    Becky Kiefer

    October 15, 2012 at 8:19 pm

  8. How about calling it a disability, which is a common term used for other conditions eg when legs or brains or arms don’t work to their normal potential?

    Barbara Sturmfels

    October 15, 2012 at 9:34 pm

    • I wouldn’t call it a disability at all nor really a “syndrome” because women have a serious chance of overcoming nearly all obstacles on subsequent attempts. Even when a woman has an inadequate amount of tissue with a first baby, she isn’t incapable completely of breastfeeding and the act itself if persistent will build new tissue that will function more fully for the next child. It is already hard enough to get women to see themselves as not as inherently broken as society has indoctrinated them to with medicalized childbirth. There is a great psychological component to breastfeeding. If you think you won’t make enough milk because your sister didn’t, your mother didn’t, your friends didn’t, the nurses say you won’t, the doctors say you won’t, you could have a very VERY difficult time doing so! And you may never know that all of them were wrong and were going by what Formula Indoctrination had taught them and simply didnt knowledge there are marked differences between how formula and breast fed babies, eat, behave, nd grow, and thus seiously misjudge a newborn need to cluster feed in order to stimulate moms milk supply and take it for starvation. It could be a tongue-tie or other issue with baby. Or inadequate teaching… there are just too many outsie forces, that can happen long long before birth even, if not during to safely call.it a disability.

      Becky Kiefer

      October 15, 2012 at 11:48 pm

      • I’d like to put in another plug for considering using ‘disability’, in the interests of getting a discussion going about it.. Disabilities in other aspects of life and health aren’t always permanent, although sometimes/often they are (although the degree of them is rarely total or an absolute), and there are often components of information, support, resources, and levels of determination involved in whether disabilities can be overcome or lessened; and how well they can be lived with or ameliorated. There are also cultural components and environmental components to the incidence of disability, and to how people with disabilities are regarded and treated. How is lactation and breastfeeding disability different to many other types of disability, in essence? Might using disability language be useful at times?

        Barbara Sturmfels

        October 16, 2012 at 1:36 am

  9. Lack of knowledge leads to weaning? Kind of long. One thing I see big time in our hospital (I’m not an LC but a staff nurse who works with a lot of BF moms) and I work 12 hour night shifts. On the 2nd day when baby is waking up and doing their 2nd day feeding frenzy as I like to call it, and the little boys have been circed, the moms think they are starving the babies because they want to nurse so much or that they are doing something wrong. I try to explain the difference between 1st and 2nd day behavior and the nursing for pain relief aspect but not many others do so moms start supplementing a lot on day 2. It shoots their confidence right off the bat.
    As far as tongue ties, I’ve seen many and have seen just as many pediatricians blow them off. Very frustrating.
    And a lot of times when I see moms back for next baby and asked them about how the last experience went they tell me about how they thought they were doing well but after about a week their milk went away and the baby was acting like they are starving. (passing of breast fullness/engorgement into growth spurt?) And since they didn’t know otherwise they started supplementing.
    Plus we do not have a dedicated lactation consultant so other than my moms, latches don’t get assessed. So to me, support and knowledge are key factors when it comes to a mom continuing to breast feed.

    Sherry Weersing

    October 15, 2012 at 10:44 pm

  10. Even Heroic efforts can -and usually do, experience catastrophic failure because skills are not known or well taught, or the people supporting the nursing pair have quite simply never actually nursed a baby themselves. They cannot teach or support skills they have never hands on, 24/7 practiced wherein they had to not only figure out inadequate to the point of idiocy instructions from a book or pamphlet or oral instructions AND had to jump in and improvise on their own while internally possessing sheer determination while fighting sleep deprivation and fighting off the mortal fear that they have one job here and it is to keep this tiny kid alive and what ehappens if they fail??? The mechanics of breast feeding not working are, IMO, far less likely than that a mother will be poorly taught or supported. Our doctors and nurses who are supposed to know what they are doing, truthfully know next to nothing. And while an IBCLC may know what she is doing technically, she may have never nursed a child at all. (Not downing IBCLC’s at all, just stating the importance of experienced support)

    Becky Kiefer

    October 16, 2012 at 12:42 am

  11. What about Lactation Deprivation? Deprivation means a loss. Being deprived of something means wanting something and being unable to have it or achieve it. Plus I feel as though it rolls of the tongue smoothly, and it rhymes, which is sorta catchy and the word itself seems to me could be used more as a technical term that health care professionals would be more willing to come to terms with as in taking that ‘condition’ more seriously. That word for me at least also doesn’t make me think failure and isn’t as negative of a word as much as say disfunction is. I really like Lactation Deprivation.

    Priscella Rivera

    October 16, 2012 at 2:00 am

  12. Great post!
    The medical profession loves going back to their greek & latin roots- what about something like “Dyslactogenia”.

    Naomi

    October 16, 2012 at 6:41 am

  13. But the problem about not calling it a disability is ins won’t cover the pump in a lot of cases nor any of the galactagouges and in dome cases we can’t afford it and are hoping that we can do it with out those things but the reality is its not likely

    Meagan

    October 16, 2012 at 6:58 am

  14. Great post… would love to see somebody collate all the information together about how many mothers and babies are unable to breastfeed for whatever reason (anatomic breast variations or medical illness, tongue tie and associated issues, medicines the mother must take for her own well-being that makes her breastmilk unsafe, etc, etc, etc) and come up with a more realistic figure of mothers who are unable to breastfeed… I’m certain it’s far higher than the oft quoted 2-5% because the proper % figure may help get rid of the uneducated claim that nearly everyone can breastfeed if you try hard enough!

    REGARDING THE NEW TERMINOLOGY to replace the deogatory use of fail, failed or failure, I’d suggest using the term ‘non-traditional success’, based on the following 3 assumptions:

    1. If breastfeeding is the normal or traditional method of feeding a baby (and who could argue against that) then any other method should be reasonably classified as ‘non-traditional’.

    2. The only failure is the failure to feed, therefore any method of feeding your baby IS a success, so it’s only fair and reasonable to refer to the successful feeding of a baby, no matter the method used!

    3. Mothering is a very difficult job and mothers need to celebrate their successes, not have them belittled by suggesting those successes are instead failures, dysfunctions, deprivations or disabilities. Call it was it is, a non-traditional successful feeding of your baby!

    NOTE: The term ‘non-traditional success’ or ‘non-traditional successful feeding’ was suggested to me today by a mother during a conversation about another matter, so if you decide to use it, please let me know so I can correctly reference the originator and the organisation she is associated with… thank you :)

    Jeff Watson

    October 16, 2012 at 11:01 am

    • I find it to be an increasing problem in america and other countries from inadequate information and lack of interest in breastfeeding research. I have a friend from russia who tells me many women do not produce milk (hypolactation maybe) because doctors tell them they need to be seperated from thier babies several days after birth. Alos I think it has alot to do will the taboo of breastfeeding in a conservative enviornment breastfeeding is viewed as sexual or “only nessary for 6 months” Formula is pushed our diets are increasingly artifical, which I have noticed affects my milk. It is just distressing on so many levels.

      Victoria Patterson

      October 17, 2012 at 9:12 am

  15. “We also need to step back from assertions that every mother can breastfeed, if she just tries hard enough. As Neifert has written, “The bold claims made about the infallibility of lactation are not cited about any other physiologic processes. A health care professional would never tell a diabetic woman that ‘every pancreas can make insulin’ or insist to a devastated infertility patient that ‘every woman can get pregnant.’ The fact is that lactation, like all physiologic functions, sometimes fails because of various medical causes.”
    ==================================================

    This is SOO important.

    But, it’s also extremely important to note that many women fail to nurse, or nurse exclusively, because lack of support. I’m talking about women who WANT to nurse, and are willing to really work at it, but are in situations that sabotage their best efforts. I’m not a researcher, but I know a lot of women who nursed or wanted to nurse, and this general issue was the most common category of reason for things not working out. I’ve gotten flack for saying this – I’ve been told that it’s insulting to women who can’t nurse and that I should stop blaming the victim. This is, in my opinion, pernicious nonsense. Refusing to recognize that circumstances can have a seriously negative impact on nursing is to demand that women be superheros who can rise above any and all circumstances. That’s just not fair, and it does nothing to encourage nursing.

    Observer

    October 17, 2012 at 12:19 pm

  16. With my first child, I was convinced I had low milk supply. He refused to latch, despite having his tongue-tie fixed (the LC said his mouth was “too small”) so I pumped exclusively and knew exactly how much I was getting. I took every possible supplement but still “dried up” at 6 weeks pp. My second child was a preemie, so I was back at the pump. This time, the LC diagnosed my true problem, one so rare I only found a one-sentence mention of it in one of the many breastfeeding books I consulted: my inverted nipples were SO inverted that the milk had an exit problem. Surgery may have fixed it, but I couldn’t have the surgery while lactating. This time I pumped for 10 weeks, but never more than 12 oz a day, before I dried up. There are definitely more obstacles to breastfeeding for some women than low milk supply, though all are discouraging and frustrating to the woman who really wants to breastfeed. If I had known ahead of time that my inverted nipples would be such a problem, I would have considered surgery, but everyone told me that inverted nipples would not stop me from breastfeeding. I feel like I was set up to fail without even knowing it.

    Laurie

    October 18, 2012 at 10:54 am

  17. To me, it can be termed “insufficient breastmilk production or transfer.” I think this covers all dysfunction either maternal or infant or combination of both.

    Susan Mocsny Thomas, RNC-OB

    October 18, 2012 at 7:50 pm

  18. I would suggest the term “unsuccessful lactation” that is more neutral than the “failed lactation”, I feel. You’re right that it’s not fair (an also not correct) to claim that every woman can breastfeed. But I do like to point out in discussions with mothers that actually 95% can. Because here in Northern Ireland, the desert of breastfeeding, women belief, that maybe 50% can breastfeed and it’s like a special talent, like singing. I hear too often, oh I tried, but it just didn’t work for me. If asked more about the trying, it was maybe holding the baby to the breast after birth and when it didn’t take it right away, they decided to give formula.

    Fanny Kernohan, Breastfeeding Peer Supporter

    October 19, 2012 at 12:14 pm

  19. As an IBCLC who had insufficient milk supply with all of my children, this subject lands very close to my heart! My firstborn twins were 12 weeks early and despite doing EVERYTHING I could not produce enough. I had hope with my 39 week girls (two years apart) but again struggled to have an adequate supply. I learned to find peace in the fact that I was able to afford donor milk to supplement in the early weeks and had healthy children despite having to mix-feed throughout their first year. Borderline PCOS and underdeveloped breasts were the likely culprits and I am so grateful for Lisa Marasco and other IBCLCs for making this subject a priority in their practices!

    I have been an advocate for those mothers who go to heroic efforts to feed their babies and are unable to, but cannot solve every problem (including my own) and that frustrates me. I have also been in tears more times than I can count at breastfeeding conferences and workshops where speakers can be very insensitive about this topic. I am all for having an official diagnosis so that these mothers can heal and realize it is not all in their control. I sometimes compare breasts that “do not work” to a pancreas that doesn’t produce enough insulin and that seems to help. I appreciate so much that this topic is being given the attention it deserves!

    Deanne Birkestrand

    October 20, 2012 at 9:18 am

  20. Helping mothers achieve their breastfeeding goals – what a challenge when misinformation is the rule and women lack the help that might develop if “breast physicians” existed. (Infertility endocrinologists can be helpful and supportive but it’s not quite the same.) A man can take his functional issues to his urologist and come away with many solutions. A woman has to endure the walk of shame (did you drink enough water? take fenugreek? breastfeed often enough? relax? eat oats?) and head for her local purveyor of herbal goodies. Talk about uneven treatment! So men can have erectile dysfunction (ED) – how about women have lactation dysfunction (LD)? Kind of analogous don’t you think? Please note I’m talking here about those very few women who do not experience milk onset: lactogenesis II does not happen – an endocrine malfunction. And those women who have stimulated their breasts optimally from day one yet have chronic low milk production (breast hypoplasia, PCOS, etc.). I’d love to see evaluation of breasts for their function during pregnancy. (which seems ethically appropriate.) This would allow a conversation about the importance of early stimulation to optimize the output of any breast – a practical guide to good supply. A stitch in time. All too often the milk boat has sailed by the time we meet that sad mother.

    Joanna Koch, IBCLC

    October 20, 2012 at 10:50 am

  21. How about using the terms primary lactation failure – for milk that simply doesn’t come in in the early postpartum? And secondary lactation insufficiency for a situation where lactogenesis II has taken place, but the milk supply is so mismanaged, by the mother herself perhaps, or as a consequence of her “compliance” with poor advice from others, the causes of which can be myriad, and need to be identified in order to be prevented or remedied? This kind of research would be so useful to all of us who work with breastfeeding mothers and babies.

    I’ve read the Niefert abstract and I agree with it completely, though I can’t access the full-text, which is reported to contain the figure of 5% for mothers who experience primary lactation failure. In my personal experience as an IBCLC who saw a little over three thousand mothers of all races in Zimbabwe (1990 – 2003) only three did not produce any milk at all – that’s 0.1%. There were a few more I worked with (possibly 10, or 0.33%) who – with the best management and motivation – produced quite a lot, but not enough to exclusively breastfeed, and needed to supplement their breastfeeding for the entire first six months, when they could then replace the formula with weaning foods and then continue partial breastfeeding in the normal way. Then there’s another percentage, probably much larger, where there are anatomical problems for the mother, or prematurity or congenital problems for the baby, that prevent feeding at the breast, but these mothers are able to exclusively breastmilk-feed for 6 months by pumping or expressing and partially breastmilk-feed for years if they wish.

    The overwhelming majority of mothers who either say or are assessed by bottle-feeding healthcare systems not to have enough milk, have received insufficient information and practical help to “manage” their own postpartum lactation. This means breastfeeding AND expressing sufficient milk from Days 4 – 9 postpartum to prevent and/or promptly resolve any degree of breast overfullness/engorgement, so that by about 10 days, when the baby’s appetite catches up, their milk producing tissue is intact and functioning well enough to produce 750 – 900ml or more each 24 hours… and to go on producing as long as there is adequate and frequent drainage – hopefully (but not necessarily) by a healthy, full-term baby. Mothers who don’t receive this information and help are badly under-served. Although, I have to say, that not all new mothers who do receive the information choose to act on it – ie some of them quite deliberately allow their milk supply to fail, and as the comments above show, many often feel they have to give up completely rather than combine some breastfeeding with some bottle-feeding. This is a shame, because _any_ quantity of breastmilk for a baby is of huge value.

    You mention obesity. Yes, this is potentially a problem, due to elevated estrogen levels. But even so, if Lactogenesis II (the milk coming in) is well managed, then these mothers can breastfeed too. I dare say they deserve meticulous preventive care to maximize milk production right from the beginning. But it is incredibly rare that a woman can be healthy enough to conceive and carry a baby to term and then not be able to breastfeed. Looking back, I can’t recall a single mother I worked with who struggled with milk production with obesity as a prime cause.

    Certainly, it will help us tremendously if the differences between primary lactation failure and secondary lactation insufficiency (whether physiological, congenital or due to marginal maternal motivation) can be teased apart. When mothers tell us, “I couldn’t breastfeed”, we need to know WHY so that the mothers who come after can be better equipped to breastfeed _their_ babies successfully.

    Pamela Morrison IBCLC

    October 21, 2012 at 1:49 am

    • Pamela, the terms you mentioned (PLF and SLI) might be the most comprehensive I’ve seen. I appreciate the fact that Secondary lactation Insufficiency encompasses all of those factors. In particular, it includes those who have been misinformed as well as those who have been informed but who have opted not to follow teaching. This can be a particular problem in this digital age as many young mothers feel that in the age of instant information they can diagnose their own breastfeeding problems and use techniques they have found online to “fix” the problems they believe they have. I absolutely agree that the critical point is to hear the mother’s story and learn what may have affected her previous breastfeeding experience or lack thereof as well as how she feels about her new opportunity to breastfeed. Thank you for your thoughtful and concise commentary! Great big thank you as well to Dr. Stuebe for addressing this issue and calling on those who have the resources to fund and carry out researchers!

  22. “Premature weining” seems to describe the subject well

    Pat Gregory

    October 21, 2012 at 5:40 am

  23. My favorite “diagnosis” is: Acute Onset Idiopathic Agalactia. It describes the sudden complete lack of milk production that so many women seem to face (be it perceived or actual).

    Jarold (Tom) Johnston

    October 21, 2012 at 10:42 am

  24. This really hit the nail on the head for me: “We also need to step back from assertions that every mother can breastfeed, if she just tries hard enough.” I slaved round the clock for the first six weeks trying to produce enough for my son (only child). We finally rented a hospital pump, which has helped tremendously, but my supply is somewhat unilateral: the left always produces about 50% more than the right, and for the second month, I noticed that it was about 20 minutes before I had let down on the right (which explained my son’s frustration on that side). Breastfeeding became much less stressful when I let myself be fine with supplementing (the important thing is that he eats), and even more so when I stopped listening to some overbearing voices telling me that breastfeeding rarely fails and that I shouldn’t even consider supplementing (passive aggressive posts on how formula-fed babies have lower IQs were not helpful). Environment did have an impact on me, but from surprising sources. Being beaten over the head with militant breastfeeding advice drove me to my breaking point.

    Once I started blocking out the negative influences, and after a few weeks of the hospital pump, things fell into place. I still have a lop-sided supply, but it’s still a supply. He gets at least one bottle of formula a day, but he is still getting mostly breastmilk. Most importantly, he is healthy and eating.

    rubyslippahs

    March 21, 2013 at 2:08 am

  25. [...] How often does breastfeeding just not work? [...]

  26. […] — and found that this is incredibly common in the U.S., but not in other parts of the world. She posted the following comment on a blog I wrote last […]

  27. […] and bottom-of-the-barrel policies for parental leave in the United States.  In other cases, a mother’s body simply can’t make enough milk for her baby, despite heroic efforts to sustain breastfeeding.  We could obviate much of the demand for online […]

  28. I don’t know if this helps – a bit of history first – In our family my mum and her mum were unable to feed any of there children – they had NO milk nothing couldn’t express any thing not a drop -unlike them I was lucky I was able to feed my Eldest for her first year when she self weaned! – Also I have been diagnosed with PCOS and consider both our children a blessing as the Doctors thought we might not be able to have any, after some chemical intervention we had our first – anyway a good diet plenty of help from our NZ midwife went a long way with feeding my eldest she feed fine – now the big one for me and the one your probably more interested in as a psychological rather then physical condition affected us- my youngest (of 2 children) latched on feed really well for the first week but created such an oversupply of milk she nearly drowned herself in the second week, after that she would not latch on we battled for 6 weeks trying to get a good feeding routine established – the child would not sleep for more then a half hour at a time and would not feed properly – I ended up with Post natal depression from about week 4 by week 6 we had given up trying to breast feed and was feeding expressed milk just to get the child to feed – we used bottles that mimicked breast feeding with the hopes of trying to get her to feed again – this did not work and by week 8 mum had dried up – so we had to move to using formula not by our choice but out of necessity !

    Adi

    October 22, 2013 at 3:40 pm


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