Low milk supply is always listed as a top reason why mothers quit breastfeeding and switch to formula. Experts often claim that the percentage of women who can't produce enough milk is extremely small (usually numbers under 5% are quoted, without any specific source being given). However, the number of women who say they tried everything and still couldn't make enough milk seems to be on the rise. This article explores some of the possible reasons for that, including polycystic ovary syndrome (PCOS), diabetes and pre-diabetes, and mammary hypoplasia (insufficient glandular tissue).
Image credit: Daquella manera on flickr
Why do so many mothers struggle to make enough milk?
In Bangladesh, where infant formula isn't readily accessible, affordable or safe for most families, 98 percent of babies are breastfed and the average age of weaning is 33 months (source: WHO Global Data Bank on Infant and Young Child Feeding). In Norway, a country well known for having created perfect conditions for breastfeeding, around 80 percent of babies are still being breastfed at six months of age (source: Suzanne Barston, Bottled Up). Norway's 80 percent is significantly higher than in countries like Canada, the United States, and the United Kingdom, but it is also a far way off from the 98 percent in Bangladesh.
So what is the difference? I think part of it is certainly choice. Although formula feeding may be frowned upon in Norway, ultimately, women still have the option not to breastfeed. Infant formula is accessible and Norwegians generally have the financial means to be able to afford it. Some women may simply not want to breastfeed or may find it too difficult and they have the freedom to make that choice. A mother in Bangladesh, however, would have to grit her teeth and push through.
Beyond the issue of choice, another element that is worth considering is that there are certain medical conditions that are more prominent in Western developed countries that can have an impact on a woman's ability to produce enough milk. In particular, many medical conditions that create fertility challenges for women can also cause low milk supply. While there have been advancements in fertility treatments in the Western world, allowing women with fertility challenges to have babies, those same women may not be aware that they could have trouble breastfeeding as well.
In developing countries, some of the conditions that can cause infertility are less common than in the developed world. Additionally, women facing infertility in developing countries are probably much less likely to end up having a baby because they don't have access to the same types of medical treatment we do in the Western world. So our advancements in the area of fertility treatments may unintentionally be increasing the percentage of mothers who will struggle to produce enough breastmilk. Unfortunately, health care providers and other sources of breastfeeding information are not preparing mothers who struggle with infertility for the fact that they may struggle to breastfeed their baby.
Common Causes of Low Supply
Before we get into the medical conditions that can cause low supply, it is important to note that there are a number of fairly common and well known causes of low milk supply that primarily have to do with breastfeeding management. These factors are generally easily to control and don't require much more than a good understanding of breastfeeding best practices and the law of supply and demand.
At a very basic level, when milk is removed from your breast, that sends a signal to your body to make more. The more milk that is removed, the more milk your body makes. The less milk that is removed, the less milk your body makes.
- Scheduling or timing feeding: If you're getting advice from an older generation or from misguided baby training books, you may think that you should be trying to get your baby on a schedule or that you should be feeding for a specific amount of time at each feeding. This is not the case at all. Scheduled or timed feeds can make your baby go hungry and tamper with your milk supply. The best way to establish and maintain a strong milk supply is to breastfeed your baby on demand. You can't nurse too frequently, but you can nurse too infrequently. Newborns should be nursing 10 to 12 times per day. If you're not sure what signs to watch for, check out the information on Hunger Cues on kellymom.com. It can sometimes be hard to read those cues during the early days, so when in doubt, put the baby to your breast.
- Skipping a feeding or supplementing: Breastfeeding can be overwhelming and all consuming. Sometimes moms just want to get a bit more sleep or want to go out for a bit without the baby. So they leave their partner or someone else in charge of giving a bottle. Unfortunately, if the mom doesn't then pump during the time when that bottle is being given, it will send signals to her body to make less milk and that can decrease her supply. If giving a bottle (without pumping to replace it) becomes a regular habit (e.g. once per day, several times per week), it can significantly impact the mom's ability to produce enough milk. The early days of breastfeeding are especially critical for establishing a strong milk supply and nursing frequently and not skipping feedings is very important. In particular, mothers whose babies who receive a non-breastmilk supplement in hospital during those first few days after birth are much more likely to not meet their own breastfeeding goals.
There are numerous other possible causes of low supply including some medications, hormonal birth control, retained placenta, poor latch, nipple confusion and more. For more information on getting established with breastfeeding, check out the article Breastfeeding Your Newborn on kellymom.com.
Lesser Known Causes of Low Supply
What if you're doing everything right and your body still isn't making enough milk? In addition to the common reasons for low supply, there are a number of lesser known causes of low supply that often catch new mothers by surprise. Many of these seem to be more prevalent in the developed world than in the developing world, which may be one reason why such a large proportion of mothers seems to struggle with low supply in the Western world. All of the causes described below have the potential to impact a mother's milk supply, but it doesn't do so consistently. Some mothers with these medical conditions will struggle with breastfeeding and others will have no problem at all. But all women with these conditions apply should be aware that it could impact their ability to breastfeed their baby.
The first three conditions that can impact milk supply are, in many cases, related. Women who have one of these are often prone to the others as well.
Diabetes and Pre-Diabetes
Scientists have discovered a link between insulin and breast milk production. Mothers who have low levels of insulin may also have trouble producing enough milk. This will be of interest and concern to mothers with diabetes, of course. However, it may be an even bigger problem for mothers who have pre-diabetes or undiagnosed diabetes. If they do not have a formal diagnosis and are not doing anything to control their insulin levels, this could unknowingly make it difficult for them to produce enough milk. Diabetes rates have doubled in the past 12 years, in particular among young women. As diabetes rates increase (and especially as the number of undiagnosed cases of pre-diabetes and diabetes increases), the number of women who have trouble breastfeeding their babies is likely to increase too.
Polycystic Ovary Syndrome (PCOS)
Polycystic Ovary Syndrome (PCOS) is one of the most common female endocrine disorders and can affect a woman's hormone levels, periods, ovulation, fertility and ability to produce enough milk when breastfeeding. According to research by Dr. Charles Glueck, MD Medical Director of the Cholesterol and Metabolism Center at he The Jewish Hospital - Mercy Health, PCOS affects around six to eight percent of Caucasians, eight to 10 percent of African-Americans and 10 to 12 percent of Latinos and Native Americans. Lisa Marasco, MA, IBCLC, notes that PCOS is related to a number of possible reasons for lactation problems, including hyperandrogenism (can inhibit mammary development and milk synthesis), insulin resistence, hypothyroidism, and possibly too much estrogen. She notes that "PCOS is a collection of different pathologies. A woman with one or more of these problems may or may not have a diagnosis of PCOS, but can still be affected." According to Dr. Anita Swamy, Medical Director at he Chicago Children's Diabetes CEnter at La Rabida, there is a strong link between PCOS and diabetes: "While type 2 diabetes risk factors such as insulin resistance and glucose intolerance are often seen in patients with PCOS, PCOS itself confers a significant risk, up to 10-fold versus the normal population, for development of type 2 diabetes."
Mammary Hypoplasia / Insufficient Glandular Tissue (IGT)
Some women do not have enough glandular tissue to nourish a child. According to noteveryonecanbreastfeed.com, "women with Insufficient Glandular Tissue may have experienced a lack of breast changes during puberty and/or pregnancy, no engorgement, and a low milk supply." According to The Breatsfeeding Answer Book (referenced on LLLI), 1 out of 1000 mothers experiences primary lactation failure. This can be due to hypoplasia or other causes. However, like with diabetes and PCOS, assisted fertility and hormonal support to conceive babies is leading to an increase in the number of cases of babies born to mothers with hypoplasia. Not a lot is known about the causes of mammary hypoplasia, but there is likely a genetic link (women who have it often say that no one in their family was able to breastfeed). For more information see Supporting Mothers with Mammary Hypoplasia by Diana Cassar-Uhl, IBCLC on LLLI, her article on hypoplasia/IGT on kellymom.com and the website NotEveryoneCanBreastfeed.com.
Breast or Nipple Surgery
Another possible cause of low supply is breast or nipple surgery, which can include breast augmentation, breast reduction and other types of breast or nipple surgery. According to BFAR.org (a website dedicated to providing information and support for breastfeeding after breast and nipple surgeries), there are many factors that affect how much milk a mother can make after surgery: "The condition of her ducts is very important, however, that the state of the nerves that affect milk release is equally critical. Fortunately, the ducts and nerves can regenerate through processes known respectively as recanalization and reinnervation, which are critical to the impact of breast surgery upon milk production and release." Mothers who have had breast or nipple surgery are often able to breastfeed, but may not be able to establish a full supply. This doesn't mean that it isn't worthwhile and, as the book on breastfeeding after reduction surgery by Diana West, IBCLC is titled, you should Define Your Own Success.
Solutions for Low Supply
If you have a newborn and are worried that your baby isn't getting enough milk, first check kellymom.com's page on Low Supply, in particular the section called Is your milk supply really low?.
If you are a mom with one of the conditions discussed above, there are some things that you can do to help prepare for breastfeeding. I know people with these conditions who struggled significantly with breastfeeding their first child, but were able to successfully breastfeed their second child because they were more informed and more prepared.
- Gather Your A-Team: If you want to breastfeed, having the right people around you in the right environment is critical. This requires doing the same things every mother should do to get breastfeeding-friendly prenatal care, hospital and pediatrician, but it may also mean seeking out certain specialists who have experience working with mothers with your condition and knowing how you can access them for support and expertise before and after your baby arrives.
- Learn More About Your Condition: Women should do research into their own individual situation to find out what their chances of being able to breastfeed are and to learn about possible solutions. Consult your healthcare provider and experts in the field who are knowledgeable about lactation. For example, as it relates to PCOS, Lisa Marasco, MA, IBCLC suggests: "Be aware of your individual PCOS issues. Insulin resistence? Androgen problems? Do everything in your power to address these, before conception preferably but even during pregnancy. Have someone assess overall breast development, especially if the mother herself has any concerns. Seek a consultation with a lactation consultant if breasts are unusual or are not growing/changing during the pregnancy."
Once your baby arrives, you will want to get breastfeeding started as quickly and as well as possible. This includes doing the same things any mother would do for good breastfeeding management (nursing frequently, on demand, etc.), but may involve doing a bit more.
- Remove as much milk as possible in the first two weeks: BFAR.org suggests removing as much milk as possible from your breasts in the first couple of weeks. This is because the supply of breast milk is determined by demand, so the more you remove the more you make. This certainly involves breastfeeding as frequently as possible, but could also involve some pumping with a high quality, hospital grade, double electric pump. Being able to pump hands-free will make it easier for you to get through those times and not feel chained to the pump (you can read, eat, use the computer, tickle the baby, etc. while pumping hands-free). Lisa Marasco, MA, IBCLC suggests offering the breast right from the start and keeping the baby skin to skin during early days to encourage more nursing.
- Address any concerns immediately: If you have latch problems, plugged ducts, or other breastfeeding problems, address them right away. The longer you wait, the more likely these regular nursing problems are to have an impact on your supply that may not be easy to recover. If the baby is sleepy or not latching well, pump after feedings to ensure you're removing more milk from the breast.
- Identify and address your risk factors: When working with mothers with PCOS, Lisa Marasco, MA, IBCLC tries to identify and address their risk factors. For example: "Metformin, for instance, reduces insulin resistance. This in turn can help reduce androgens. Normalizing the hormonal milieu during and after pregnancy is going to give mom the best chance. I also may suggest specific herbal galactogogues—for instance, goat’s rue is reputed to stimulate mammary development and milk production. It has anti-diabetic properties and is the herb that metformin was developed from, making it especially appropriate, I think, for PCOS. Fenugreek has similar properties, and I also like saw palmetto and fennel for both mammary stimulation and anti-androgen action on top of stimulating milk production."
- Medications that increase milk supply: Depending on where you are located, there may be certain medications you can access to increase your milk supply. For example, in Canada many doctors will prescribe Domperidone according to the recommendations of renowned breastfeeding expert Dr. Jack Newman. Domperidone isn't easy to access everywhere though, so speak to your lactation consultant and physician to find out what options are available to you.
- Supplementing at the breast: No matter how much milk you make, there are benefits to you and your baby for feeding at the breast using a system such as Lactaid. Feeding at the breast boosts the baby's immune system through skin-to-skin contact, better develops the jaw muscles, and fosters that wonderful bonding experience that every new mother and baby pair need and crave. You can use your own pumped milk, donor milk, infant formula, or some combination thereof. For more information see Yes, You CAN Breastfeed Successfully No Matter How Much Milk You Make on Best for Babes. If you are supplementing via bottle, see their guide on bottle feeding.
In addition, if you are a healthcare provider working with a woman with diabetes, PCOS, hypoplasia or other conditions that impact her fertility, it is important to talk to her about the potential impact on her ability to breastfeed. Surgeons performing breast and nipple surgery should also make lactation a topic of discussion for women who are considering surgery. The more information a woman has before she gets pregnant and before the baby arrives, the better prepared she will be to make decisions about breastfeeding and to prepare herself for breastfeeding.
If you're looking for more information on low milk supply, the following articles and books provide excellent information.
Hidden Hindrances to a Healthy Milk Supply by Becky Flora, BSed, IBCLC
Increasing Low Milk Supply by Kelly Bonyata, BS, IBCLC
How does milk production work? by Kelly Bonyata, BS, IBCLC
Buy The Breastfeeding Mother's Guide to Making More Milk by Diana West, IBCLC and Lisa Marasco, MA, IBCLC on Amazon.com or Amazon.ca (affiliate links)
Did you have difficulty breastfeeding as a result of low supply? If you have diabetes, PCOS, breast reduction surgery or other conditions mentioned in this post, did your health care providers talk to you about the possible impact on your ability to breastfeed? If you breastfeed or attempted to breastfeed more than one child, was it easier the second time around?