Published in Lactation

Addressing concerns about breastmilk supply Featured

by on07 March 2013 5525 times

Simple steps to prevent premature cessation of breastfeeding

Premature cessation of breastfeeding is associated with numerous health disadvantages for mothers and children in both economically-advantaged and disadvantaged countries.

By protecting the breastfeeding relationship, the child and mother are protected from numerous acute and chronic diseases, as well as mental health problems.

Health professional knowledge, and the degree of support and encouragement they provide, is a key factor determining a mother’s decision to initiate and continue breastfeeding.

The impact health professionals make through supporting breastfeeding may be one of the most important contributions they can make to the health of current and future generations.

The World Health Organisation (WHO) recommends six months exclusive breastfeeding, followed by continued breastfeeding for at least two years. Exclusive breastfeeding means oral ingestion of only breastmilk with the exception of required medications. No water, juices, breastmilk substitutes or solid foods are given. WHO estimates that globally only 34.8% of infants are exclusively breastfed for six months. Data from the 2001 national health survey indicates that only 32% of Australian babies were exclusively breastfed. Furthermore, less than ten and five percent received any breastmilk at 18 and 24 months respectively (ABS, 2001).  

Risks associated with insufficient breastfeeding for mothers and children (based mostly on data from economically advantaged countries such as Australia, USA, Germany, and the UK)

Child

  • Otitis media (Sabirov et al., 2009)
  • Urinary tract infection (McNiel et al., 2010)
  • Lower respiratory tract infection (Quigley et al., 2007b)
  • Gastroenteritis (Quigley et al., 2007b)
  • Hospitalisation (Quigley et al., 2007b;Ladomenou et al., 2010;Smith et al., 2002)                 
  • Necrotising enterocolitis (Quigley et al., 2007a;Henderson et al., 2009;Lambert et al., 2007)
  • SIDS (Vennemann et al., 2009)
  • Maternal child abuse & neglect (Strathearn et al., 2009)     
  • Child & adolescent mental health problems (Oddy et al., 2010) 
  • Inflammatory bowel disease (Gearry et al., 2010)
  • Coeliac disease (Radlovic et al., 2010;Akobeng et al., 2006)
  • Diabetes Type 1&2 (Owen et al., 2006)
  • Childhood leukaemia (Bener et al., 2008;Smith and Harvey, 2010)
  • Cardiovascular disease (Ravelli et al., 2000;Smith and Harvey, 2010)
  • Developmental delay (Sacker et al., 2006)
  • Obesity (Smith and Harvey, 2010)
  • Dental malocclusion (Kobayashi et al., 2010;Oliveira et al., 2010;Sanchez-Molins et al., 2010;Moimaz et al., 2008)
  • Child mortality (Bartick and Reinhold, 2010;Chen and Rogan, 2004)

Mother

  • Postpartum anaemia (Bodnar et al., 2002;Rioux et al., 2006)
  • Longer duration gives greater protection against:
    • Ovarian cancer (Titus-Ernstoff et al., 2010;Jordan et al., 2010;Danforth et al., 2007)
    • Breast cancer (Shinde et al., 2010;Stuebe et al., 2009b)
    • Vascular calcification (Schwarz et al., 2010b)
    • Myocardial infarction (Stuebe et al., 2009a)
    • Type 2 diabetes (Schwarz et al., 2010a;Stuebe et al., 2005)
    • Metabolic syndrome (Schwarz et al., 2009;Gunderson et al., 2007;Gunderson et al., 2010)
    • Osteoporosis (Schnatz et al., 2010;Stuebe, 2009)
    • Rheumatoid arthritis (Karlson et al., 2004;Pikwer et al., 2009

The number one reason given by women for premature cessation of breastfeeding is perceived low milk supply (Sarasua et al., 2009;Wambach et al., 2005;Gatti, 2008). Many women will assume there are problems with their milk supply when their baby is unsettled and/or cries, when their baby wants to feed more often, when their baby wakes more frequently in the night, when their breasts feel smaller or softer, and/or when minimal milk can be expressed (Amir, 2006). While some of these things may be present when milk supply is low, none of these are clear indicators of low milk supply. 

These factors may be present when babies are unwell, in pain, and/or in a period of accelerated growth. Changes in breast fullness are often associated with the normal change from oversupply to supply matching the need of the baby that frequently occurs when the baby is 2-4 months old. The milk ejection reflex (MER) is different for a pump than it is for a baby, so pumped milk volume often does not represent milk available to a breastfeeding baby.

Unfortunately, inappropriate management of perceived lactation insufficiency often leads to true lactation insufficiency. Concern about milk supply will often lead to the use of supplementary artificial feeds (Gatti, 2008). This will threaten milk supply (Riordan J, 2010) and expose the baby to numerous health risks.

Maintaining good milk supply is dependent upon adequate removal of milk from the breast and adequate stimulation of the breast. This means frequent breastfeeds of adequate duration (and/or frequent expressing) with effective milk transfer. The breasts are under autocrine control, hence the rate of milk synthesis is directly affected by the rate of milk removal.  The baby’s latch needs to be effective to ensure adequate milk transfer. When milk remains in the breast, milk synthesis inhibitory factors accumulate and decrease milk synthesis. Removal of milk from the breast removes these inhibitors, thereby causing accelerated milk synthesis (Riordan J, 2010).

Storage capacity varies enormously between women. In a small study, Daly et al., found that breastmilk storage capacity varied from 192 to 787ml (Daly et al., 1993). However, daily breastmilk production of women with different storage capacities was similar.  Women with smaller storage capacities fed their infants more frequently and milk synthesis was more rapid. This illustrates the individuality of the mother-baby dyad. Women with smaller storage capacity will need to feed more frequently to deliver the quantity of milk needed to meet their baby’s needs. The mother-baby dyad is dependent on responsiveness to feeding cues.  It is important to remembering that crying is a late hunger cue which often hinders effective feeding due to the effects of exhaustion and elevated stress hormones.

When responding to a mothers concern about milk supply it is important to understand why she feels her milk supply is low and find out key information to assess what is actually going on in her individual case. Firstly, it needs to be determined if her baby is receiving sufficient milk through careful assessment of the baby’s stool and urination history, as well as growth and development (see Table 2; this needs to be assessed by an appropriately trained health practitioner). How often and for how long is her baby feeding? Is her baby having night feeds which are important for maintaining supply? Has she seen a qualified and experienced lactation consultant? Has the baby’s latch and other baby-related health issues that may impact milk transfer been assessed? Table 3 gives a summary of the possible causes of lactation insufficiency. 

Signs of insufficient milk intake by baby

Less than 3 stools/day in babies 4 days old or more After 4-6 wks not reliable – stool frequency varies
Less than 6 wet nappies per day in babies 6 days old or more (less than 5 very wet disposables) Strong odour and or yellow staining
Slow weight gain or weight loss May be due to illness (if this is the case, prescription of breastmilk substitutes will expose the baby to further illness risk)
 No audible swallowing from the baby  Persistent/increasingly painful nipples

Adapted from (Hurst, 2007)

Causes of lactation insufficiency

Poor lactation management (most common)    

Early postpartum care:
  • separation of mum and baby
  • lack of skin-to-skin contact
  • delayed 1st feed; ↓ frequency of feeds
  • supplementary feeds given
Ongoing care:
  • scheduled feeds (not frequent or long enough)
  • not feeding according to babies cues
  • supplementary feeds given
  • lack of appropriate support to identify and  resolve challenges

Infant related challenges (common)    

  • Poor latch (poor early lactation management; cleft palate; tongue tie (ankyloglossia); premature; Down’s syndrome)
  • Heart defect

Hormonal or Drug effects (less common)

  • Effect of birth interventions
  • Thyroid disease
  • Insulin resistance (PCOS, gestational diabetes, diabetes mellitus)
  • ↑ Progesterone (retained placenta; medication; pregnancy)
  • ↑ Glucocorticoids (stressful labour; administered in premature labour)
  • Obesity (may lower initial prolactin response; may also impact latch)
  • Pituitary disease (uterine haemorrhage → pituitary shock)
  • Other drugs (progestins, oestrogens, alcohol, nicotine, pseudoephedrine, dopamine agonists)

Structural  (rare)

  • Insufficient glandular tissue  (estimated to occur in 0.01% of women *)
  • Nipple abnormality
  • Structural due to surgery or trauma    Severed 4th intercostal nerve (interferes with milk ejection reflex)
  • Breast reduction (may affect supply - but with appropriate support many women successfully breastfeed)

(Riordan J, 2010;Amir, 2006) *Many texts incorrectly quote a figure of 5% referencing a 1938 BMJ article, or a secondary reference originating from this source (Riordan J, 2010). However, in this article the 5% figure includes cleft palate and other infant related challenges that hinder lactation success (Spence, 1938). With the rise in the use of assisted fertility technology (ART), there is the potential for an associated rise in the incidence of true insufficient glandular tissue, as some health conditions that pose as fertility obstacles are associated with insufficient glandular tissue. However one recent study found that many of the determinants of poor breastfeeding outcomes in a population of ART users were modifiable and could be overcome by ensuring consistent breastfeeding advice (Hammarberg et al., 2011).

How to increase supply

It is vital that the two most common reasons for insufficient milk intake and low supply are addressed. Firstly, inadequate feeding frequency and feeding duration which commonly occur: with scheduled feeding; when feeds are terminated before the baby lets go (reduces access to higher caloric-dense hind milk); when breastmilk substitutes are given; or when babies are drowsy due to prematurity, illness, exposure to birth medications or due to exhaustive hunger cries. Poor latch and associated ineffective milk transfer is the second factor that commonly hinders supply. Maximising skin-to-skin contact is also important. This can be encouraged by suggesting bath breastfeeds and cosy topless time with baby. Offering both breasts at each feed, when low supply is suspected, will ensure that breastmilk synthesis inhibitors are drained from both breasts.

Importance of appropriate referral

The importance of referring women who are experiencing breastfeeding challenges to experienced certified lactation consultants and breastfeeding support services cannot be emphasised enough. When challenges are addressed and resolved quickly, breastfeeding is most likely to continue. In some cases, a team approach including the involvement of a paediatrician, paediatric speech therapist, lactation consultant, and naturopath/herbalist may be indicated. The team approach works well when practitioners are aware of their area of expertise and their limitations. One of the factors hindering effective health professional support of breastfeeding women is the contradictory advice they receive, especially from practitioners with inadequate training in lactation physiology (Hauck et al., 2010;Szucs et al., 2009).

How herbal galactagogues work

Herbal galactagogues may be used to help support milk supply. It is essential to continue to address all factors that may be impacting milk supply and specifically ensure there is frequent effective removal of milk from the breast and that the breast is receiving adequate stimulation. Without these measures herbal galactagogues will have little impact.

Information on how herbal galactagogues work is of a preliminary nature and there are multiple theories. Some herbal galactagogues may enhance prolactin levels through dopamine receptor antagonism in the same way that pharmaceutical galactagogues appear to work (Capasso et al., 2009).  Others may modulate other hormone receptors, affecting sensitivity to insulin, progesterone and oestrogens.  Herbal galactagogues may work via their anxiolytic and thymoleptic actions. This may improve breastfeeding confidence, and allow effective milk ejection reflex and prolactin response by reducing inhibitory stress hormones. Components of galactagogues may enter breastmilk and alter the flavour of breastmilk, or exert carminative actions, and thereby positively influence baby feeding behaviour.

Individualising herbal galactagogue treatment allows herbal treatment to be tailored to suit the woman’s situation and improve efficacy.  The herbalist may include galactagogues with nervine properties when stress is suspected to be a significant factor or herbs that improve insulin sensitivity when impaired glucose tolerance is suspected.

 Herbal Galactagogues

Core Galactagogues
Specific information
Traditional daily dose

Pimpinella anisum

Foeniculum vulgare

Anethum graveolens

Coriandrum sativum

Carminative

P. anisum and F. vulgare contain trans-anethole which has structural similarity to dopamine and is theorised to act as a dopamine receptor antagonist (Bruckner, 1993).

15-30g crushed seed in aqueous infusion

Trigonella foenum-graecum

May also improve insulin sensitivity

Two small clinical trials have delivered mixed results (Swafford S, 2000;Damanik et al., 2006)

Possible peanut allergen cross sensitivity

3.5 -10g crushed seed

Silybum marianum

May work through dopamine receptor antagonism (Capasso et al., 2009)

Prescribing with lecithin may improve bioavailability

One study showed positive effect using micronized silymarin (Di Pierro et al., 2008)

>420mg silymarin (dose based on study)

Galega officinalis

May improve insulin sensitivity

Strong tradition of use (Bruckner, 1993)

5-20g

Cnicus benedictus

Thymoleptic

Strong tradition of use

6g

Verbena officinalis

Thymoleptic

4-6g

Supportive galactagogues

 

 

Urtica dioica

Nutritive

 

Althea officinalis

Nutritive

 

Medicago sativa

Nutritive

 

Lavandula angustifolia

Nervine, thymoleptic, carminative

May be useful when MER is diminished

 

Chamomilla recutita

Nervine, carminative

 

Nepeta cataria

Nervine, thymoleptic

 

Asparagus racemosus

Nervine, female reproductory tonic

 

Hibiscus sabdariffa

Diuretic, mild hypotensive

 

Galactagogues to use with caution

 

 

Humulus lupulus

Strong nervine traditionally used when MER impaired. Use low dose only. Avoid over-sedating mother and baby.

Up to 1g in divided doses

Vitex agnes-castus

Caution may be antigalactagogue via dopaminergic action

Caution may cause early return of menses

 

Rubus idaeus

Reported to have initial galactagogue effect followed by antigalactagogue effect when used for longer than two weeks

 

MER = milk ejection reflex (Bruckner, 1993;Humphrey, 2003;Humphrey, 2010;Swafford S, 2000;Damanik et al., 2006;Capasso et al., 2009;Di Pierro et al., 2008)
 

Relactation

Many women and health workers are not aware that relactation is possible. Relactation is the recommencement of lactation months or even years after breastfeeding has ceased (Marquis et al., 1998;Seema et al., 1997). Relactation requires regular stimulation of the breast and the support from family and health workers. Relactation is usually easier when less time has lapsed. Adoptive lactation (also called induced lactation) is also possible, where a woman who has never before lactated, can stimulate the production of milk (Gribble, 2004;Szucs et al., 2010;Wittig and Spatz, 2008;Bryant, 2006;Cheales-Siebenaler, 1999). This also requires regular stimulation and sometimes the assistance of hormonal medications and galactagogues.

Conclusion

Health professionals can play a pivotal role in determining women’s likelihood of initiating and continuing to breastfeed. Health professional knowledge of lactation physiology; the risks associated with premature breastfeeding cessation; and their ability to refer women to specialised practitioners, are key determinants in the successful promotion of breastfeeding.

Resources

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  • Find a certified lactation consultant
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  • http://www.alca.asn.au/4059/Find_a_Consultant/Find_a_Lactation_Consultant/
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Last modified on 09 June 2013
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Dawn Whitten

Dawn Whitten BNat (Hons) is a naturopath and herbalist with a passion for breastfeeding. She has been in clinical practice for 11 years and has a broad-base of clinical experience. She has a particular interest in women’s health through pregnancy and beyond, and infant and toddler health.

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