Breastfeeding Medicine

Physicians blogging about breastfeeding

How often does breastfeeding come undone?

with 45 comments

One afternoon in my lactation clinic, I saw two mothers who came to see me because they couldn’t make milk. One was pregnant with her second child, and the other was considering a third pregnancy. Each described how they had looked forward to breastfeeding, taken classes, put their babies skin-to-skin and birth, offered the breast on demand, and then waited, for days, and then weeks, for milk that never came in. As the second mother came to the end of her story, she said, “No one ever told me this could happen. Have you ever heard of a woman not being able to make milk?”

“Yes,” I said. “There’s one in the very next room.”

The dogma is that inability to breastfeed is rare – “like unicorns,” one blogger wrote – but I was seeing an awful lot of unicorns in my clinic. I couldn’t help but wonder – how often does breastfeeding come undone?

We set out to try to answer that question in a study published this month titled, Prevalence and Risk Factors for Early, Undesired Weaning Attributed to Lactation Dysfunction. We used data from the Infant Feeding Practices Study II, which followed more than 2000 mothers from pregnancy through one year postpartum. This approach offered us a window into the size and scope of this problem. It also meant that we had to triangulate “breastfeeding coming undone” from the data that were available.

Here’s what we had to work with: During pregnancy, moms were asked how long they planned to breastfeed. If they weaned before the study ended, they were asked whether they breastfed as long as they wanted to. We used these two questions to define whether weaning was early or expected, and whether it was desired or undesired. Moms also indicated, from a list of options, what they considered to be important reasons for weaning.

Nearly half of women in the study – 45% – reported early, undesired weaning. Among these moms, we wanted to find those for whom lactation fell apart – those who struggled with multiple breastfeeding problems. We defined disrupted lactation as early, undesired weaning among moms who attributed weaning to at least two of three problems – pain, low supply, and latch difficulties. We found that one in eight mothers met our definition. Among moms with symptoms of depression, one in five met our definition, underscoring the need to screen women with breastfeeding difficulties for depression and anxiety. We also found that women who were overweight or obese were more likely to experience disrupted lactation than normal weight moms.

Both our definition and our study design are imperfect measure of how often breastfeeding falls apart. Multiple factors affect whether a mom is able to achieve her breastfeeding goals, including maternity care, uneven lactation training for health professionals, lack of maternity leave and requirements to return to work. Better systems and quality lactation support might have allowed more of these moms to achieve their goals. We also don’t know whether mothers reporting low milk supply were physically unable to meet their baby’s needs, or were influenced by other factors, such as unrealistic expectations for infant feeding and sleep, which led them to perceive normal physiology as “not enough milk.” We will need prospective studies with clinical evaluation of moms and babies over time to tease out such questions.

Nevertheless, our study suggests that breastfeeding comes undone quite frequently, and the moms in this study who reached out for solutions had trouble finding them. Two-thirds of moms with disrupted lactation sought help from a health professional, but only 1 in 4 said the advice that they received was helpful. While 88% of women with undisrupted lactation had positive feelings about breastfeeding, only 58% of those with disrupted lactation rated their breastfeeding experience as favorable.

In my clinical experience, the unraveling of breastfeeding can take an enormous toll on mothers. Some moms have been told to “Just keep trying!” despite telltale signs of insufficient glandular tissue on physical exam, with widely-spaced, tubular breasts and no breast growth during pregnancy. Others describe gripping the arms of the rocking chair with each feeding to endure excruciating pain. Moms visit countless specialists, inject multiple herbal preparations, and endure every-hour pumping regimens, elaborate supplemental nursing systems, and elimination diets in an effort to achieve a normal breastfeeding relationship. Indeed, in our paper, we propose the term “lactastrophe” to describe the emotional distress some mothers experience when breastfeeding comes undone.

These experiences are real, and they are not rare. However, for too long, repairing breastfeeding has been a test of maternal determination, rather than an integral part of reproductive health care. For example, obstetricians routinely screen for breast cancer, but some have been reluctant to take responsibility for the functioning breast. Indeed, when we submitted this manuscript to an obstetrics journal, a reviewer suggested it really belonged in a pediatric journal, writing, “…the time frame covered by this paper clearly falls beyond the reach of time when most OB/GYNs are still caring for the post-partum mother.” Apparently, problems with the physiology of a woman’s breast are the responsibility of the pediatric provider, if that breast happens to be in the baby’s mouth.

Too many clinicians treat the lactating breast as a hot potato, leaving moms and babies lodged in the gap between pediatric, obstetric and lactation specialists. In an era where public health campaigns urge all mothers to breastfeed, we need to urge all health professionals treat breastfeeding management as an integral part of health care.

We also need to explore how best to support moms when lactation doesn’t work. Earlier this week, I met with a medical student, who shared that she was breastfed for 18 months, but her mother was unable to nurse her younger brother. Twenty years later, she said, her mother still worries over the fact that her son was not breastfed. We need to talk with “lactastrophe survivors,” and ask what helped them heal. And we must stop asserting that “All women can breastfeed.” As Marianne 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.

Of note, medical science has produced insulin and in vitro fertilization, restoring physiologic function for women with diabetes and infertility.   We need to invest in research that will determine how and why breastfeeding comes undone. Based on rigorous research, we can develop and test strategies that can treat such problems, and we can disseminate the approaches that repair breastfeeding, so that more mothers can achieve their infant feeding 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. She is a member of the board of the Academy of Breastfeeding Medicine. You can follow her on Twitter at @astuebe.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Written by astuebe

March 27, 2014 at 4:23 pm

45 Responses

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  1. I found this extremely interesting, I failed at direct feeding my baby, she had trouble latching and transfering milk as well as sensory issues and an undiagnosed upper lip tie, but I also suffered with PND, anxiety and am overweight, I had a lot going against my breastfeeding journey, however I recently hit my breastfeeding goal of 3 years by exclusively pumping for my daughter, she has only ever received breastmilk for 38 months, its something I am extremely proud of but I will always long for the direct breastfeeding relationship that we failed at and I will always have that guilt of wondering if I did enough, saw the right people or fought hard enough to get the help I needed.
    I completely agree that breastfeeding mothers don’t have any medical advisors to turn to when the going gets tough, most doctors, peads and even some OBGYN’s are not knowledgable in breastfeeding at all, my own daughters one pead told me that after 6 weeks formula has more nutrition and vitamins and minerals and that breastmilk is “empty” and has no calories or use other than to quench thirst. My own doctor told me I would get breast cancer from pumping long term and the OBGYN even told me it was impossible to pump for longer than 6 weeks. We can’t promote breastfeeding to moms if there aren’t knowledgable support systems to support them when they need it which is why studies like yours are so important! You can’t build a house without laying a firm supportive foundation first!

    Exclusive Pumpers SA

    March 27, 2014 at 4:44 pm

    • Wow, you are absolutely amazing!


      March 29, 2014 at 1:55 am

    • You are an AMAZING Mommy!!!


      May 30, 2014 at 9:09 am

  2. The difference is, most pancreas don’t fail to produce insulin and most infertile women don’t fail to conceive because health professionals are undermining them at every turn.

    Not saying that’s all women who can’t breastfeed, but I know I’m not the only one who was told everything looked fine and not to worry for four days (in which baby had exactly one dirty nappy and had caused incredible damage to my nipples), then immediately on day four, owing to 10% weight loss told to give formula.

    Because formula, in the opinion of practically every health professional (in the NHS anyway), is the solution to all your breastfeeding troubles. Why learn how breastfeeding works if you can easily just recommend formula?


    March 27, 2014 at 5:32 pm

  3. I am struggling with the intense pain. My LO is 8 weeks and I am that one that cries in pain everytime he latches. Getting very worn down and thinking of quitting. Everyone acts like it should be completely painless. I have extremely large breasts, so maybe it is latching issues.


    March 27, 2014 at 6:14 pm

    • Oh, Adrienne! I feel for you. I’ve been there and it sucks. If you haven’t spoken with a lactation consultant (in private practice or at your pediatrician’s office), please do. You deserve better and it can be better.


      March 27, 2014 at 7:53 pm

    • Hi Adrienne,

      I feel your pain. I had the same experience with my daughter and the first 3/4 months were excruciating. After that though it calmed down and got better so that it was eventually pain free and I feed her for 19months. There is no reward given at the end of breastfeeding as to who did it the longest and ultimately you need to look after your own mental health so that you can look after your baby. Don’t feel guilty if you stop now – don’t call it quitting as that implies you failed when in fact you’ve succeeded for 8weeks! Good on you. My advice would be to stick it out for 12 weeks and then re evaluate but don’t feel guilty if that’s not possible. I hope the pain eases quickly.

      Kate Kightley

      March 27, 2014 at 8:32 pm

    • Find a lactation consultant asap! Call your insurance company, ob/gyn, pead, local hospital, or even the WIC office to find a LC who can help you. I have pretty big boobs too (40I) & it only hurt the first few weeks. LO is 8 weeks today &i haven’t had pain in several weeks! There is probably an issue that needs to get worked out! Good luck & don’t give up til you get some help!


      March 27, 2014 at 8:41 pm

    • It could be thrush, I had it with no visible symptoms on me or the baby. Took diflucan and Dr. Newmans all purpose nipple ointment.

      mary willis

      March 28, 2014 at 8:28 am

    • Hiya, I’ve used nipple shield, my midwife didn’t like it, but it did save our beautiful breast feeding journey with both of my daughters! With my bigger one I used it for 3 month, than she was going on after her 2nd birthday without and with my second baby only needed it til three weeks, which I was so happy about!! Yeah, it can be extremely sore, but please try everything and anything but giving up! Breast feeding means so much it’s extremely big part of becoming a mother and for your relation ship and for both of your health. Please, don’t give up!!! Kindest regards, Eve x x


      March 28, 2014 at 11:57 am

      • I also used nipple shields with both of my babies for the first 2-3 months. Breastfed both babies for over a year. I have very sensitive nipples and found the nipple shields to be very helpful. I think if a nipple shield helps get more women to experience less pain when brest feeding, then by all means use it.

        Julie H.

        March 30, 2014 at 7:20 pm

    • I am so sorry to hear you are dealing with so much pain Adrienne. I am a Lactation Educator and would advise to please get help from a Lactation Consultant. We tell our moms breastfeeding should not hurt. Some moms are so super sensitive so we keep that in mind as well. I am concerned at 8 weeks you are still experiencing so much pain. One thing you can try is making sure your both tummy to tummy when feeding and nipple to nose your nipple will be at baby’s nose level so then baby will have to tilt his/her head up to get the nipple in the protected area in his/her mouth. I would start on the least painful side first. I hope this helps. I still suggest seeing a Lactation Consultant to make sure there is nothing else going on. Pain associated with breastfeeding could be a handful of things and without seeing you in person it is very hard to diagnose that.

      Donica Peer Counselor

      March 28, 2014 at 12:34 pm

    • Hi Adrienne – I’d encourage you to find a breastfeeding medicine physician in your area — where do you live? You can contact the ABM office at and they can help you find a provider near you. There are lots of causes for breastfeeding-associated pain. We’re created algorithms to diagnosis breast-feeding associated pain that are online at UNC at . I’ve also written about different causes of breastfeeding associated pain in a recent edition of the journal Obstetrics and Gynecology – see question 9 of this document. Good luck! -Alison Stuebe


      March 28, 2014 at 1:20 pm

    • I’ve been there. Definitely have someone who knows what they are doing take a look at you two nursing. Also, my midwife told me to get breast shells (NOT breast shields). They hold your bra off of your nipples and allow air circulation. Those and generous use of lanolin did finally help, and my daughter nursed till she was 3. As did my next child. My youngest is 2.5 and still going strong. And I only had the horribly sore nipples the first time around, so it does get better. Hang in there!


      March 29, 2014 at 1:31 am

    • I’m so sorry that you are experiencing so much pain Adrienne. I also had a lot of pain in the beginning, and this occurs now if I am not strict with latching. My daughter is now 22 months and still breastfed, she was diagnosed with an upper lip tie at 11 months (by myself following some research as to why I was still experiencing pain and confirmed by a specialist). We’ve chosen not to correct it due to her age when we found out, but have you had your LO checked? a painful latch can often be caused by a tongue or lip tie.


      March 29, 2014 at 1:58 am

    • Makes me think of part of my journey. Find a good LC that can help you figure out what is going on.

      For me it was raynaulds phenomenon – vasospasms – blanching of the nipples are words you can use to search for more info on the internet if you are interested. It was at week 8, day 4 that I stumbled upon the info and alerted my MW to what I had found and how I felt it related to me. Took some pics of the white nipples and sent it off to her w/ some other details about what I was experiencing, and got a diagnosis. From there on out I was able to finally “treat” the issue. This helped TREMENDOUSLY! Even more once dd2 came along.

      I am apparently logged in under my hubby’s name. I find that amusing since I’m talking about breast feeding. 🙂

      Good luck! Hang in there!

      P.s I ended up bfing dd1 for 15 months, at which time I dried up due to being 12 weeks preggers. dd2 is currently 13 months, barely eats table food, and is still nursing like crazy. Proud of how far I came and for giving it all that I could in the beginning. It was no easy thing. I feel for you right now. ❤


      March 29, 2014 at 9:53 pm

  4. My son is 7 weeks old and breastfeeding has already come apart for a variety of reasons. I’m not sure if it was poor latch because he seemed to be fine once he was on but there was excruciating pain while he was latching on, no pain while he was feeding and then extreme soreness in between feedings. I got knots in my back that seemed connected directly to my nipples so the pain came from both sides of my body. So I got a nipple shield which really helped him latch quickly and gave me some time to heal. I started using the breast pump to begin building a supply but it was infrequent at first, and then things went downhill when I got a clogged duct that quickly turned into mastitis. A week later I was hospitalized with a breast absess, given antibiotics and painkillers and since I didn’t have a supply of breastmilk my baby had to be switched to formula. Once my antibiotics are done I will try again, or at least keep pumping to either switch him back to breast milk or to use to cut back on the formula. This was completely unexpected and seems very extreme to why someone would stop breastfeeding, but everything was going so well, my son never lost 10% body weight, he was almost birth weight a week after being born and has steadily gained every week. I don’t beat myself up about it but its still a shock to the system to be completely derailed like this. Most people I know have not been successful breastfeeding for a variety of reasons but I was determined to make it work.


    March 27, 2014 at 6:18 pm

  5. I think it’s really important to continue to look at birthing practices as contributing factors to lactation failure. More research evidence is being presented on the adverse affects of artificial oxytocin and lactation supression until the artificial levels decrease. We know the affects of epidurals and the miriad side effects related to this and other drugs. Education and promoting birth as normal and not medical (in most cases) will go a long way to increasing successful breast feeding rates.

    Bonnie McKenzie

    March 27, 2014 at 6:32 pm

    • Yes, Adienne find a Board Certified lactation consultant right away. If you find a lactation consultant and she says pain is normal fire her and look for another. Pain is common but not normal and 8 weeks is far too long to try to tough it out.


      March 28, 2014 at 7:07 am

    • Hi Bonnie -sorry my comment for Adrienne ended up under your comment .

      In any case, while I totally agree with you that birthing practices will improve breastfeeding, a mere focus on birthing alone has not and never will be sufficient to overcome all the breastfeeding problems in our present age.

      To date the primary focus has been on the hospital – with campaigns to remove promotional samples of formula and campaigns to make hospitals baby friendly. Yes we do have much farther to go. Nevertheless, breastfeeding initiation rates HAVE dramatically increased and breastfeeding duration rates have not increased to nearly the same degree. At this point in time, I am finding that it is lack of support for the full duration of normal breastfeeding that is a bigger problem. If you look at staffing patterns, there has been a huge focus on building up staffing of lactation consultants in hospitals.

      Since the vast majority of women deliver in the hospital, the drop off in breastfeeding often happens after leaving the hospital. Hospitals are crowded and staffing is slim, so even with more lactation consultants, those consultants may only have a short period of time with each mother. Many hospitals are experiencing financial problems and are starting to look for less expensive short lecture courses for training lactation counselors rather than spend the money required for much more in depth training for the board certification process. Plus – the window of opportunity to assist mothers and babies is short – often only 2-4 days. Finally most out of the hospital care practitioners have little to no training in management of breastfeeding problems.

      At the same time, there has been a huge drop in IBCLCs who work in the community. Initially many IBCLCs were La Leche League Leaders with a great deal of training in counseling and understanding of breastfeeding throughout the full cycle and for a normal duration of time. Becoming a La Leche League Leader involves more than attendigng a few days of lecture and sitting through a few role plays, it involves many years of listening, observing and learning to counsel mothers – an invaluable skill especially when it is coupled with solid clinical training and supervised mentorship to become board certified. Despite the Surgeon General’s recognition that IBCLCs should be covered under the Affordable Care Act, very few insurance companies are reliably covering their services. So, there is very limited access to qualified care that goes beyond the need for reassurance that might work for someone who really has a normal breastfeeding experience.

      Why do I think this is important to have care outside the hospital environment? Because in the past there were significant problems that went unrecognized simply because more babies died and no one attributed it to real problems. Because in the past, women with insufficient glandular tissue may have felt comfortable with a family member or wet nurse, nursing their baby to make up the difference. Because now we have new problems that have arisen because of our ability to save very small and very premature infants. Because now we have new problems that have arise because of our ability to enable infertile women to conceive – some of the edocrinological problems leading to difficulty conceiving can also lead to difficulty in establishing a full milk supply. Because we do have an epidemic of obesity which means that SOME of these women have endocrinological and metabolic problems that make it more challenging to establish a milk supply. Because now we have women whose income generating activities have now been segregated to an environment that is separate from their care giving activities. Because our culture disrupted breastfeeding to the point that many people are uncomfortable with what used to be considered the normal duration of breastfeeding.

      Basically, the staffing pattern for lactation care is topsy turvey. It is as if we decided pediatric care should be predominantly provided by neonatalogists in the hospital and we decided it was rarely necessary to have pediatricians in the community.


      March 28, 2014 at 8:07 am

  6. I found this extremely interesting, educational, and encouraging… I MUST add that thyroid function plays a large role in lactation and should be looked into if mom feels there isn’t sufficient milk supply! I ran into random postpardum hypothyroid around 8 months after giving birth- my daughter weened herself at 11 months despite trying everything to make more milk for her! Stick it out moms! Advocate for yourself and your baby-there are answers


    March 27, 2014 at 6:44 pm

  7. “insufficient glandular tissue on physical exam, with widely-spaced, tubular breasts and no breast growth during pregnancy” — this is my problem. No one mentioned to me that I might have difficulties breast feeding when I had my breasts examined during my prenatal appointments. My son is 13 weeks and have managed to breast feed almost 90% of the time with just one breast… but I need to supplement in order for him to feel full at any time. When I ask questions, no one knows what to tell me. Even Leche League leaders are at a loss as to what to advise. I nurse and pump and nurse and pump on demand and there is no increase in the amount of milk I produce. Everything that I read before giving birth made me feel so confident — “Everyone can breast feed, and to increase your supply, all you have to do is nurse more often.” Its heartbreaking when you find out this isn’t true.

    Brooke T.

    March 27, 2014 at 7:19 pm

    • Ah Brooke – that is one of my pet peeves. Many health care practitioners are afraid to tell women when they see obvious signs of insufficient glandular tissue and this leaves many women with the condition feeling badly when they could flip the situation around. The notion is that women will be discouraged and therefore telling them the truth will sabotage the breastfeeding. I find actually that most women will feel empowered if you tell them they can still breastfeed, but it may not be 100% and give them realistic solutions to optimize what they can do.

      You should pat yourself on the back for breastfeeding 90% of the time with one breast. Having worked with many mothers with insufficient glandular tissue that is an accomplishment to be proud of because I KNOW how much work that can be for many mothers I’ve seen with your condition. I would suggest embracing your success, especially since it sounds like you have figured out how to get your supply up to what is considered “predominant” breastfeeding despite a major obstacle.


      March 28, 2014 at 7:28 am

  8. I was told by my obgyn that some women have to stop breastfeeding when mastitis did not clear up after antibiotics. Ended up requesting a pathology report and they refuse to continue to treat the staph infection and I had to go to another Doctor. Thankfully I continued breastfeeding through it thanks support from other moms and it being my fourth to breastfeed. I worry about new mothers.


    March 27, 2014 at 7:43 pm

  9. Thank you. Thank you for your astute observations, research, and planned research. I am one of those unicorns! I’m am still saddened by my unsuccessful experience with my dear first born over 11 years ago. I looked for help. I read. I remember asking, “What kind of doctor do I go to?” My body was not working the way my books, lactation consultant, and friends said that it should work. I hope you can help many women and children.


    March 27, 2014 at 8:00 pm

  10. Please do your readers a favor and mention that one huge factor in latching issues, low milk production, pain for the nursing mom, and poor milk transfer is tongue tie and lip tie. If the commentors above experiencing pain can be reached out to, they might have an IBCLC check for tongue tie.

    Jessica Weiss

    March 28, 2014 at 1:24 am

    • Hi Jessica – tongue tie is one of the issues that could explain the problems that moms in this population experienced. We were working with data that others had collected, and the IFPS II dataset did not ask moms about tongue tie, so we weren’t able to measure how many dyads received a diagnosis — and we certainly couldn’t measure how many dyads had un-diagnosed tongue tie. It would certainly be something one would want to capture in a prospective study of breastfeeding challenges.

      Our objective here was to measure, crudely, how many moms struggle with multiple problems and end up with early, undesired weaning. Knowing, roughly, how big the problem is allows us to build the case for finding out why, and then to identify interventions to make it better.


      March 28, 2014 at 3:36 am

  11. I am seriously disappointed that tongue tie and the inability of many practitioners to properly diagnose and treat it was so vastly over looked. It is estimated that upwards of 16% of babies with difficulty breastfeeding have this condition and too many mothers are told their children do not have it when they actually do.

    R. Kiefer

    March 28, 2014 at 1:33 am

    • See my reply to Jessica, above — it’s certainly an issue that would need to be part of solving this problem.


      March 28, 2014 at 3:36 am

  12. […] Excerpt from: How often does breastfeeding come undone? | Breastfeeding … […]

  13. I always find it difficult to read that obese mothers are more likely to suffer breastfeeding challenges. I was obese when I breastfed all three of my children, and each breastfed well past a year. I found obesity had *zero* to do with my success or failure at breastfeeding but 100% to do with the way I was treated by medical professionals, including lactation consultants. I have no solutions, only an observation of my own experience, yet I feel that it is important to raise the question — is it the weight? Or is it the way HCPs react to an overweight person?


    March 28, 2014 at 6:12 am

    • Monique – averages do not take into account individuals. So in any average of any type of grouping there will be some who are affected and some who are not.

      You are right in one sense. I see lots of women with larger breasts as a result of overweight and obesity and these women have often been instructed to lift and shape their breasts in ways that make breastfeeding much harder than it should be. And they have often received unkind comments about their breasts from other health care practitioners. In general, I find that mothers with larger breasts do much better when they work with their own body and don’t lift their breasts, but I never have a one size fits all approach to assisting mothers regardless of body type.

      In other regards you are basing your comments on your own personal experience and leaving out the fact that there are some women who are obese who are not fit and not healthy. They have endocrine and/or metabolic problems that can not only impair their own health but also impair their ability to make milk. They need help with the underlying disease to improve their milk supply.

      Just like any mother (regardless of weight) who has an easy time, embrace the joys of your own breastfeeding and have empathy for other women who encountered very real problems that did not enable them to enjoy your experience of breastfeeding for over a year.


      March 28, 2014 at 7:23 am

      • Hey Susan – I don’t think I’m right or wrong, I’m sharing the reality of my own experience. I hope you think my question is a valid one even if you assume (incorrectly) that I had an “easy” time and was healthy and without a metabolic or other disorder.


        March 28, 2014 at 10:45 am

      • I think this is one of many situations where it’s “both/and” rather than “either/or.” There have been many studies looking at maternal BMI and breastfeeding outcomes, and there is a consistent pattern of mothers with higher BMIs having shorter durations. The question that we need to sort out is what are _all_ of the reasons that this might be the case. Then how can we develop a comprehensive approach that addresses all the ways that body mass index might impact whether a mom is able to achieve her breastfeeding goals. Monique, your experience suggests one crucial issue is the way that health care professionals respond to a woman’s weight. We need to train (or retrain) health professionals to do better. We also need to sort out how to talk about the relationship between weight and outcome, and how to identify moms that are at higher risk of complications. Then we can provide them extra support and help them to overcome any obstacles that they face. There is some intriguing evidence that insulin resistance is implicated in low milk production (see my comment to Heather blow), and so it may be that moms who have high BMIs and insulin resistance are at higher risk of problems. Ultimately, a woman’s BMI is just one factor that may impact whether or not she is able to achieve her goals. My hope is that ultimately , we can identify each mom’s potential challenges for infant feeding, and the provide preemptive support so that more mothers have an “easy” time achieving the goals.


        March 29, 2014 at 6:56 am

      • Monique – I definitely think your question was extremely valuable. All too often it is easy to fall into the trap of seeing “a risk factor” and equating it with “ill health”. Your point about how people are treated when they are overweight is extremely important because it is one of those conditions where there is a lot of societal bias and health care practitioners can sometimes allow those biases to creep into their reactions to their clients. It is always important to be aware of risk factors so that a problem isn’t missed, without assuming there will always been a problem. I have seen women with all sorts of risk factors who breastfeed beautifully as well as women with those same risk factors have a really challenging time of breastfeeding.


        April 2, 2014 at 11:48 am

  14. […] How often does breastfeeding come undone? | Breastfeeding Medicine. […]

  15. Reblogged this on mamamilkandme and commented:
    This is what goes through my head on a daily basis, thank you Dr Stuebe.


    March 28, 2014 at 7:39 pm

  16. This is a very interesting article. Here is another aspect that bears looking into: I had supply issues with my youngest, and fenugreek didn’t help. What did do it for me was goat’s rue. In the process of solving my supply issues, I researched all the standard lactation herbs, and learned something interesting. Every one of the lactation herbs is also a blood glucose regulator. In fact, goat’s rue is the herb from which the diabetes drug, Metformin, was synthesized! I did not have diabetes during pregnancy or after, so I don’t know what the relationship is, but I think this relationship bears closer scrutiny.


    March 29, 2014 at 1:39 am

    • Heather – there’s actually some really interesting research looking at the issue of insulin sensitivity and milk production. Laurie Nommsen-Rivers has published that a mother’s insulin and glucose levels during her glucose challenge test in pregnancy are correlated with when her milk comes in ( ), and she led a fantastic study looking at gene expression in milk samples and milk supply ( ). In this paper, she found that mothers with milk supply issues and insulin resistance had higher levels of expression for a gene that may prevent insulin from stimulating milk production. In theory, metformin should improve milk supply for mothers with insulin resistance, although there are as yet no published studies testing this concept. It’s an area that very much needs to be studied. We also need to try to sort out systematically what galactagogues work for which mothers, so that we can guide moms to the intervention that’s most likely to work for them.


      March 29, 2014 at 6:44 am

  17. […] How often does breastfeeding come undone?, Breastfeeding Medicine — A look at how often and why women stop breastfeeding. […]

    Saturday Surfing

    March 30, 2014 at 12:33 am

  18. (I’m another Heather). Alison, your piece starts with examples of women who told you they didn’t have milk – that their milk never came in. But ‘breastfeeding coming undone’ happens for a zillion reasons. We are talking about far more than a physiological process here – as we all know!

    Infant feeding, however it’s done, is a culturally, socially, psychologically, emotionally mediated behaviour. Breastfeeding can come undone in any or all of those domains, as well as the purely physiological.

    The woman who makes no milk, literally, is very rare indeed. I have come across women who can’t easily get the milk out, and whose babies cannot easily get the milk out, and women who seem to have a physiologically low supply, without any of the cultural, social etc etc difficulties that would compound it. But women who make literally no milk ie there is no milk to get out? I have not come across this, but I gather the literature does include some examples.

    I am supporting a mother at present who bf her first 2 children for a year each (though they both gained slowly) but her third baby, at age 2.5 mths, is only 100g above birthweight. There seem to be no other reasons for this, except low intake. Breastfeeding is coming undone, at least exclusive breastfeeding is. So what happened? The baby lost a lot of weight at first and this wasn’t really taken seriously. The baby stopped asking for feeds and this wasn’t taken seriously. At just 6 weeks, the baby started going 12 hours overnight without a feed and this wasn’t taken seriously. Nobody told her she had to take the initiative and make sure the baby got to breastfeed more often – though there was plenty of clucking about the baby’s slow/non existent weight gain, and insistence on weighing the baby regularly. She got in touch with me when her baby’s weight was static, at 9 weeks, and as a result, started doing all the things we know will improve supply and intake….but it has probably begun too late to avoid supplements, even though these might be temporary.

    Reluctance on the part of HCPs to spot an incipient problem and to help the mother overcome it is to blame, here. There may be a physiological reason why her milk supply appears low – but if she’d had support in the beginning to feed often, if the baby was the sort of baby who insists on being fed (and this baby is laid back, relaxed and sunny), if she saw the overnight sleeping without waking as an alarm sign and not a sign the baby was a ‘great sleeper’, the physiological reason might have been overcome.

    Heather Welford

    April 5, 2014 at 9:22 am

  19. […] it takes a balanced stance of the challenges facing today’s mothers. Her recent post, How Often Does Breastfeeding Come Undone, caused me to look inward and examine the assumptions I make when breastfeeding doesn’t go […]

  20. […] of mothers discontinue breastfeeding earlier than they had initially planned, according to a study by Alison Steube of the University of North Carolina School of Medicine. Steube says breastfeeding is understudied because it is at a medical crossroads between […]

  21. I am very late commenting on this article, but as the birth of my 3rd child approaches I have been devouring everything I can on breastfeeding because I am one of the “unicorns.” I want to have every bit of information when I make my feeding choice. I went to see Dr. Steube for help before my 2nd child was born because of the guilt and shame I felt over not meeting my breastfeeding goals with my first. She was incredibly kind and helpful, but unfortunately I fell much harder the second time when things did not work out the way I wanted. I thought I had put everything possible into place to make breastfeeding work, but my body felt differently. I combo fed each of my children for 9 months, but I still wish I could have been an exclusive breastfeeder. I was completely torn last night over what I should do this time around because deep down I know the most loving, sacrificial choice I can make for our family is to formula feed this baby from the start. I just can’t do it. I can’t close that door. I can’t open myself up to the bullying, shame, and ridicule again. However, I know I’ll have to when my body yet again gives me no choice but to supplement (I’m not going in expecting a miracle this time because that is just setting myself up for failure).

    When my daughter was born I had more than enough support and even quit my job a month before her birth to focus solely on breastfeeding. The town I lived in at the time was so pro-breastfeeding there might as well have been someone standing on street corners handing out medals for breastfeeding, Lack of support was not my problem. My pediatrician husband was able to get a hospital grade scale for pre and post feed weighs when my daughter still had not reached birth weight by 2 weeks. At one month she was only getting 1 oz of milk after a full feeding with a perfect latch, so I was not falsely assuming I wasn’t making enough milk.

    My son was 4 years old at the time of my daughter’s birth, so I asked my mom to take him to her house for a week so I could breastfeed, pump, and rest round the clock without any distractions in hopes of upping my milk supply. My grandmother got hit by a car the day before my mom was to pick up my son and since she had to go to be with her my week of nothing but breastfeeding never happened. My grandmother was very close to death and fortunately beat all odds and pulled through. It pains me to admit I was angry at her for taking away my small chance to exclusively breastfeed. I feel such guilt over those feelings now. Breastfeeding should never take priority over someone’s life and yet a large group of breastfeeding advocates do just that when ignoring the very real breastfeeding struggles that some moms face. I have been shamed, chastised, and bullied only when I’ve taken out formula. I have also breastfed in public and never received any negative comments. but instead words of encouragement and praise. I won’t pretend that women who breastfeed don’t receive negative comments because that would be the same as people suggesting my breastfeeding struggles weren’t real. I will never pretend that my experience is the only experience because I’d like the same in return.

    I have a condition called lichen sclerosis that is rare in people my age and I don’t believe any lactation consultant I saw knew what it was, yet they all had suggestions as to how to overcome it. My nipples crack before my baby takes that first latch. An SNS is not an option as it rubs and opens me up for horrible infection, but no one seemed to understand this when I pointed it out. I screamed out in pain with each latch for 3 months until I finally got the excessive pain under control. I saw 3 different consultants and baby’s latch was perfect, so the pain was not from improper latch. Nobody in the medical field, including the therapist who was supposed to be my support line, told me to stop. The doctors at the hospital recommended I see her because she specialized in pre and post natal depression, which I was at risk for, but by some act of God never developed. In fact she told me to drink beer, something I made clear I have never done for personal reasons and was almost prescribed a medication that can bring on depression, to increase milk supply. At this point I realized I needed to return to my former therapist who had my best interests at heart. People weren’t putting me and my baby first, they were putting breastmilk first. Somebody should have told me to stop the insanity, but no one except my husband did.

    On a side note my husband has admitted many babies to the hospital for dehydration and signs of starvation because lactation consultants were terrified to mention or give formula. He’s often told he’s the first person who tells the family it’s ok and gets hugs and tears of relief when the babies “come alive” again. I’m sure this will make some advocates whince as it may seem as if he undermining breastfeeding efforts. He is pro breastfeeding, but never at the expense of a mother or baby’s health. His stance is, “if a baby has gotten to the point of hospital admission, getting milk in that baby is what matters most, and sometimes that milk needs to be formula.” What he and I always find amusing is that these babies always come from middle/upper class, well educated families. His guess is that he doesn’t admit babies who come from lower socioeconomic classes for dehydration because formula is accepted in those circles. While anecdotal, it does seem to show that this is where breastfeeding advocates should be focusing their attention. Although, not to the point where he starts admitting these babies to the hospital for dehydration as well 🙂 The group of women I fall into doesn’t need more breastfeeding advocacy (we’d have to be living under a rock to not know breastmilk is best), but instead what we need is support and compassion when problems are in fact insurmountable.

    I have visited a lactation consult in advance this time around in my new state. She put a feeding plan in place initially, but after examining me and seeing that my nipples were already fissuring said, “with your history and what I’ve seen, I will put in your chart that if you choose formula we will come in and teach you how to do a skin to skin bottle feed.” Finally, a voice of reason. I’m still going to try to breastfeed, but have promised my family that I will not breastfeed at the their expense and I will definitely not miss the newborn stage of my last child. All this is to say that compassion is what is missing from a large proportion of breastfeeding advocacy, not all of course, but a lot of it. Clearly I wouldn’t put myself through the wringer if I didn’t think there were some benefits to breastmilk. There are times I wish that every single person who shamed me could walk in my shoes for a day in order to change their outlook and approach. The first thing I do when I hear a friend is struggling with breastfeeding is reach out. I don’t offer suggestions (there are others who can do that). I want them to at least have one face of compassion in what is a very real struggle. I wish I had all the answers on how to promote breastfeeding while at the same time acknowledging and supporting the large group of women who do have real trouble. Thank you Dr. Steube for looking at the woman as a whole and for not making the issue so black and white. It is my hope that this time around I truly do what is best for me and my baby, and let the all the negativity fall to the wayside. My scars are real and deep, but maybe now the healing process can begin.


    November 5, 2015 at 9:38 pm

  22. […] Primary lactation failure is real, and if it is unrecognized, it can lead to adverse outcomes. An emphasis on exclusive lactation without adherence to recommended post-discharge follow-up in the community is a set up for bad outcomes. […]

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