AANP 2015 presentation discussing causes, interventions, referral, and support for women who can make babies, but have difficulty producing enough milk to feed them.
3. Objectives
O Describe production and extraction factors
that contribute to low-milk supply
O List allopathic and complementary
interventions to improve supply
O Provide referral sources for corrective
interventions and psychosocial support
4.
5. Lactogenesis Essentials
O Endocrine Driven
O I: Colostrum production
O II: Progesterone withdrawal
O III: Autocrine Driven
O Feedback inhibitor of lactation
O Prolactin receptors and lactocytes
(Lawrence & Lawrence,
2010)
6. Transient or Perceived Supply
Issues
O Post-glandular
O Secondary lactation failure
O Perceived
O Engorgement, leaking, or milk ejection reflex
O Bottle preference
O Slow weight gain in infant
O Transient
O Return of menstrual cycle
O Lifestyle changes and illness
O Starting solids
O Frequent or cluster feedings
(Lawrence & Lawrence,
2010)
7. Baby-Friendly Hospital
O Skin-to-skin
O Initiate breastfeeding within an hour of
birth
O Rooming-in
O Nursing on-demand
O Avoid pacifiers and artificial nipples
O Exclusive breast-milk at the breast
O Education, support, referral
O Global initiative launched by WHO &
UNICEF (Baby-Friendly USA, 2013)
8. True Low Supply
O Primary lactation failure or insufficiency
O Inability to meet daily need
O Prevalence estimate 5-15%
O Lack of acknowledgement
O Pre-glandular
O Glandular
O Beyond “just relax,” “nurse, nurse, nurse,”
and “drink more water”
(Whitten, 2013)
9. Signs & Symptoms
O Poor weight gain, weight loss, failure to thrive
O WHO growth chart for breastfeeding infants
O Regain birth weight within 2 weeks
O >7% loss x 1/week
O Insufficient urine output
O “Marathon” nursing sessions
O Falling asleep while nursing
O Sucking without drinking
O Etiology-specific
(Whitten, 2013)
10. Risk Factors
O Pre-Partum Obesity
O Pre-partum or gestational diabetes
O Breast surgery or structural abnormality
O Congenital malformation history
O Prematurity
O Endocrine disorders: Thyroid, PCOS, luteal phase
defect, pituitary, insulin
O Hypoplasia or Insufficient Glandular Tissue (IGT)
O Pesticides, dioxins, medications, smoking, ETOH,
herbal preparations
O Retained placenta, post-partum blood loss
O Birth trauma and interventions
(Dozier et al., 2013)
11. Historical Context
“Suffice to say that ill health in the mother,
from whatever the cause, whether functional
or organic, is apt to prove a hindrance to
suckling.”
(Braithwaite, 1897)
13. Efficient Milk Transfer
O Foremilk and hindmilk sucking patterns
O Weighted feeding before and after
O Emptying breast fully
O Positioning & latch
O Bilateral & “switch nursing”
O On-demand: 1.5-2-hour day intervals, 3-
hour night intervals
O Pumping output not a reliable indicator of
intake or production
(Becker, Smith, &Cooney, (2015)
(Lawrence & Lawrence, 2010)
14. Tongue and Lip Tie
Signs and Symptoms
Mother Child
O Nipple trauma –
blistered, bleeding,
blanched, broken
O Pain or discomfort
while nursing
O Mastitis, thrush,
plugged ducts
O Sleep deprivation
from “marathon”
feeding
O Clicking noises, chewing
nipples, choking on milk,
SOA, while nursing
O Reflux, colic, or
gassiness
O Poor latch, difficulty
sustaining latch
O Prolonged feeding with
poor weight gain
(Kotlow, 2011)
15.
16.
17. Revision
O Surgical
O General or local anesthesia with incision
O Insurance coverage available
O Laser
O In-office procedure, bloodless
O Coverage varies
O Aftercare
O ACE for pain management
O Stretching QID to prevent reattachment
O Preventative
O Dental decay
O Orthodontics
O Mobility
O Speech (Kotlow, 2011)
18. Pumping for Supply
O Dual-chamber and hospital grade pump
O Pump after every feeding for 5-10 minutes
past last drop collected
O Relaxation music and breathing
O Power pumping
O Pump 10 minutes on/10 minutes off
O Stop after 1 hours
O Hand expression if non-responsive to
pumps
(Becker, Smith, & Cooney,
2015)
19. Stimulation to Promote Supply
O Supplemental Nursing System (SNS)
O Mother’s milk>donor milk>formula
O Cup, syringe, finger feeding
O Breast compression
O Warmth and massage
O On demand
O Day interval: 1.5-2 hours
O Night interval: 3 hours
O Avoid pacifiers & artificial nipples
(Becker, Smith, & Cooney,
2015)
(Whitten, 2013)
21. Hormonal
O Thyroid
O Regulation of prolactin for production
O Regulation of oxytocin for ejection
O Insulin resistance
O Hypopituitarism
O Prolactin deficiency
O Progesterone excess
O Glucocorticoid excess
(Whitten, 2013)
22. Laboratory
O FULL Thyroid panel: TSH, Free T3,
reverse T3, Free T4, antibodies
O HOMA, fasting insulin, insulin : glucose
ratio, McAuley Index, lipids
O Prolactin
O Baseline 60-110ng/ml postpartum
O Doubles 30-45 minutes after nursing
O Progesterone, Testosterone, DHEA-S,
Cortisol, CBC, Fe
23. Standard Interventions
O Hypothyroid – replacement
O Hyperthyroid – methimazole (MMI)
O Insulin resistance
O Diet & exercise
O Metformin, myo-inositol
O Postpartum hypopituitarism
O Progesterone - non-hormonal birth control
O Cortisol – stress reduction
(Karras, Tzotzas, Kaltsas, & Krassas, G. E. 2010),
(Matarrelli et al., 2013)
24. Hypoplasia/IGT
O Breast asymmetry
O Breasts >1.5 inches apart
O Breast develop stretch marks without
significant growth
O Tubular or elongated breast shape
O Large areolae in proportion to breast size
O High mammary fold
(Arbour & Kessler, 2013)
27. Domperidone
O Dopamine antagonist, antiemetic
O Second-line for gastroparesis - increases gastric
emptying & peristalsis
O Increases prolactin via inhibition of PIF on the
pituitary gland
O Hale’s lactation risk category L1
O TID dosing, total 90-120mg/day
O Weight gain, h/a, menstrual irregularities
O Not FDA approved, 2004 cardiac death in elderly
O Approved in Canada and Europe
O Compounding pharmacies
(Jones & Breward, 2011) ,
(Phan, DeReese, Day, & Carvalho,
2014)
28. Metoclopramide
O Dopamine-receptor antagonist, antiemetic
O FDA approved for gastroparesis , GERD
O TID dosing, total 30-45mg/day
O Crosses CNS
O Mood disorders, EPS, sedation
O Hale’s lactation risk category L2
(Fife et al., 2011)
(Shiva, Frotan, Arabipoor, & Mirzaaga, 2010)
29. Fenugreek
Leguminosae Trigonella foenum-graecum
O TID dosing, total of 3.5-7.3 grams/day
O Simulates sweat gland
O GRAS by FDA
O Side Effects
O GI disturbances in infant
O Hypoglycemia
O Maple syrup effect
O Contraindicated
O Thyroid disorders
O Anticoagulants
O MAOIs
(Arbour & Kessler, 2013)
(Damasceno et al., 2015)
30. Goat’s Rue
Galega officinalis
O TID-QID dosing, total of 1.2-2 grams/day
O Tincture > powdered capsule
O Increase functional breast tissue
O “Herbal metformin”
O Improves insulin sensitivity
O Contains galegin
O Side effects
O Hypoglycemia
O Blood-thinning
O Diaphoresis
(Arbour & Kessler, 2013)
(Damasceno et al., 2015)
31. Adjunctive Herbals
O Shatavari (Asparagus racemosus )
O “Herbal domperidone”
O BID 2g/day
O Estrogenic, insulin,
O Production loss reported
O Blessed thistle (Cnicus benedictus)
O Alfalfa
O Fennel (Foeniculum vulgare)
O Milk thistle (Silybum marianum)
(Arbour & Kessler, 2013)
(Damasceno et al., 2015)
32. Food Therapy
O Multi-vitamin, B-Complex, Iron
O Appropriate hydration
O Oats
O Brewer’s yeast
O Flax
O Morniga oleifera
O Aniseed (Pimpinella anisum)
O Bitter Melon (Momordica charantia Linn)
(Damasceno et al., 2015)
(Whitten, 2013)
33. Resources
O Mothers Overcoming Breastfeeding Issues
http://www.mobimotherhood.org/
O Closed Facebook support groups
O IGT and Low Milk Supply
https://www.facebook.com/groups/tonguetiebabies/#!/groups/IGTmamas/
O Tongue Tie Babies https://www.facebook.com/groups/tonguetiebabies/
O International Board of Lactation Consultant
Examiners http://iblce.org/
O Frenectomy http://ttbsg.weebly.com/provider-list.html
O Hand Expression http://newborns.stanford.edu/Breastfeeding/HandExpression.html
O Human Milk Banking Association of North America
https://www.hmbana.org
O Human Milk for Human Babies http://hm4hb.net/
O La Leche League http://www.llli.org/
O Pinterest www.pinterest.com/onednp/low-milk-supply
34. References
O Artini, P. G., DiBerardino, O. M., Papini, F., Genazzani, A. D., Simi, G., Ruggiero, M., & Cela, V.
(2013). Endocrine and clinical effects of myo-inositol administration in polycystic ovary syndrome. A
randomized study. Gynecological Endocrinology, 29(4), 375-309. doi:
10.3109/09513590.2012.743020.
O Arbour, M. W., & Kessler, J. L. (2013). Mammary hypoplasia: Not every breast can produce sufficient
milk. Journal Of Midwifery & Women's Health, 58(4), 457-461. doi:10.1111/jmwh.12070
O Becker, G. E., Smith, H. A., Cooney, F. (2015). Methods of milk expression for lactating women.
Cochrane Database of Systematic Reviews, 2(CD006170). DOI: 10.1002/14651858.CD006170.pub4.
O Braithwaite, J. (1897). The retrospect of practical medicine and surgery. New York, New York: G.P.
Putnam’s Sons
O Breastfeeding Report Card United States
www.cdc.gov/breastfeeding/pdf/2013breastfeedingreportcard.pdf
O Bodley,V. and Powers, D. Patient with insufficient glandular tissue experience milk supply increase
attributed to progesterone treatment for luteal phase defect. Journal of Human Lactation 1999;
15(4):339-43.
O Brink, C. B., Viljoen, S. L., deKock, S. E., Stein, D. J., & Harvey, B. H. (2004). Effects of myo-inositol
versus fluoxetine and imipramine pretreatments on serotonin 5HT2A and muscarinic acetylcholine
receptors in human neuroblastoma cells. Metabolic Brain Disease, 19(1-2), 51-70.
O Dozier, A., Howard, C., Brownell, E., Wissler, R., Glantz, J., Ternullo, S., & ... Lawrence, R. (2013).
Labor epidural anesthesia, obstetric factors and breastfeeding cessation. Maternal & Child Health
Journal, 17(4), 689-698. doi:10.1007/s10995-012-1045-4
O Damasceno de Aguiar Brotto, L., Diniz Brusque Marinho, N., Pinheiro Miranda, I., de Fátima Almeida
Lima, E., Caniçali Primo, F. L., & Caniçali Primo, C. (2015). Use of galactogogues in breastfeeding
management: Integrative literature review. Revista De Pesquisa: Cuidado E Fundamental, 7(1), 2169-
2180. doi:10.9789/2175-5361.2015.v7i1.2169-2180
O Fife, S., Gill, P., Hopkins, M., Angello, C., Boswell, S., & Nelson, K. M. (2011). Metoclopramide to
augment lactation, does it work? A randomized trial. Journal Of Maternal-Fetal & Neonatal Medicine,
24(11), 1317-1320. doi:10.3109/14767058.2010.549255
35. References
O Huggins, K., Petok, E., Mireles, O. Markers of lactation insufficiency: a study of 34 mothers. Current
Issues in Clinical Lactation 2000; 25-35
O Jones, W., & Breward, S. (2011). Use of domperidone to enhance lactation: What is the evidence?.
Community Practitioner, 84(6), 35-37. Karras, S., Tzotzas, T., Kaltsas, T., & Krassas, G. E. (2010).
Pharmacological treatment of hyperthyroidism during lactation: Review of the literature and novel data.
Pediatric Endocrinology Reviews: PER, 8(1), 25-33.
O Kotlow, L. (2011). Breastfeeding should be fun and enjoyable: Why does it hurt when I breastfeed?
[PowerPoint slides]. Retrieved from http://www.kiddsteeth.com/nursingbookaugfc2011.pdf
O Lawrence, R. and Lawrence, R. (2010). Breastfeeding: A guide for the medical profession, seventh ed.
Philadelphia, Pennsylvania: Elsevier Mosby
O Matarrelli, B., Vitacolonna, E., D'angelo, M., Pavone, G., Mattei, P. A., Liberati, M., Celentano, C.
(2013). Effect of dietary myo-inositol supplementation in pregnancy on the incidence of maternal
gestational diabetes mellitus and fetal outcomes: A randomized controlled trial, Journal of Maternal-
Fetal & Neonatal Medicine. 26(10), 967-972. 6p. DOI: 10.3109/14767058.2013.766691.
O Phan, H., DeReese, A., Day, A. J., & Carvalho, M. (2014). The dual role of domperidone in
gastroparesis and lactation. International Journal Of Pharmaceutical Compounding, 18(3), 203-207.
O Prime, D. K., Garbin, C. P., Hartmann, P. E., & Kent, J. C. (2012). Simultaneous breast expression in
breastfeeding women is more efficacious than sequential breast expression. Breastfeeding Medicine,
(6), 442.
O Ramsay, D. T., Kent, J. C., Hartmann, R. A., and Hartmann, P. E. (2005). Anatomy of the lactating
human breast redefined with ultrasound imaging. Journal of Anatomy, 206(6), 525-534. doi:
10.1111/j.1469-7580.2005.00417.x
O Shiva, M., Frotan, M., Arabipoor, A., & Mirzaaga, E. (2010). A successful induction of lactation in
surrogate pregnancy with metoclopramide and review of lactation induction. International Journal Of
Fertility & Sterility, 3(4), 191-194.
O Whitten, D. (2013). A precious opportunity: supporting women with concerns about their breastmilk
supply. Australian Journal Of Herbal Medicine, 25(3), 112-126.
Editor's Notes
Breast is best is great unless you can’t do it – guilt, shame, doubt over what is purported to be an essential function of motherhood.
Lactavists
“Sanctimommy” Groundwork for ppmd “all that matters is feeding your baby” loss
Progesterone inhibits prolactin
I: Half-way through pregnancy
II: Estrogen and HPL after placenta delivered; 30-40 hours after birth but may not feel milk “come in” for 2-3 days; prolacting, insulin, and cortisol, IGT
III: Supply and Demand
Slows milk formation if milk is in breast – the less FIL, the more milk
Accumulated milk block receptors – milk removal frees prolactin receptors on the lactocytes to encourage milk production
http://kellymom.com/bf/got-milk/basics/milkproduction/
Lawrence, R. and Lawrence, R. Breastfeeding: A Guide for the Medical Profession, sixth ed. Elsevier Mosby: Philadelphia, Pennsylvania. 2005:70.
Not all women experience or may change as body adapts to demand; “let down” sensation not perceived by all; growth spurts increase feeding; urine output
Ten steps to Successful breastfeeding 2013 Baby-Friendly USA, 2013
https://www.babyfriendlyusa.org/about-us/baby-friendly-hospital-initiative/the-ten-steps (WHO)
77% attempt, 49% 6-months, 27% 12-months
Crutch/excuse to stop breastfeeding
http://link.springer.com/chapter/10.1007/978-1-4615-7207-7_25#
Lactation failure is not clearly defined in the literature and has been given a variety of definitions which can be summarized as: (a) failure of the breasts to produce minimum of milk for example 200 cc per day, (b) failure to thrive in the infant i.e. failure to sustain growth in a normal infant within 2 standard deviations of the norm for that infant, and (c) failure of the mother to achieve her pre-set goal for duration of lactation (1).
Preglandular: hormonal
Glandular: IGT/hypoplasia
Postglandular:”bad start”
growth spurts, natural supply dips with menses, regulation of supply – less engourgament/leaking/let-down
Sheehans syndrome
Slow weight gain okay
Cluster feeding during growth spurt okay
Exhausted from effort of nursing
BMI >30, Waist circumference > 35 inches
PCOS may have over-supply due to prolactin (1/3rd each)
Progesterone insufficiency in first trimester cause for IGT
Retained pacental has abundence of progesterone which inhibits lactogenesis
Psydoephidrine, smoking
Pitocin, IV fluids
Poor and rich
Milk ejection reflex reduced with a pump
http://www.kiddsteeth.com/articles.php
Functinoal problems – cannot move tongue up or down, no extention
Mother’s milk – doner milk- formula
Breastfeeding without lactating
http://www.nbci.ca/index.php?option=com_content&view=article&id=8:breast-compression&catid=5:information&Itemid=17
Encourages latch
Prolongs stimulation to promote supply
Can be used in public
FBS useless; OGTT done in pregnancy; homeostatic model assessment (HOMA). It involves measuring glucose and insulin levels and then using a calculation to estimate function of the beta cells in the pancreas that produce insulin and insulin sensitivity. Fasting blood glucose (70-86 mg/dl), Fasting Insulin (2-6 microIU/mL), A1C (<5%), Oral Glucose Tolerance Test (<120)
http://care.diabetesjournals.org/content/24/3/460.full#T3
consider are a blood count for anemia, thyroid stimulating hormone (TSH) for hypothyroidism, testosterone levels for gestational ovarian theca lutein cysts (a very rare condition), human chorionic gonadotropin (hCG) for retained placenta and prolactin levels for pituitary diseases.
Myo-insitol: beans, fruit, nuts particularly with PCOS, 4g/day . OCD and depression
Tea
Choline organic compound part of B-Vitamin complex; cinnamon, eggs, organ meats, cruciferous vegetables, yogurt
Less than 3500 no effect
Physical characteristics may initiate augmentation, which is wrongly identifies as a culprit for insufficient lactation
Above 5th rib
Ultrasounds and number of milk ducts have no bearing on ability to produce
Mammary Hypoplasia Variations.
A) Incomplete development before puberty; B) Poorly developed
upper portion, scant lower tissue; C) Tubular with bulbous areola;
D) Long, bowed to outside, with extra-large areola; E) Classic wide
spaced and uneven; and F)Wide spaced with scant tissue.
Prolacton-inhibitory factor
Domperidone increases prolactin via the pituitary gland
Reglan crosses CNS – depression and EPS side effects
http://miracletrees.org/moringa-doc/moringa_breastfeeding_study.pdf
Goyal, R., Singh, J., Lal, H. Asparagus racemosus--an update. Indian J Med Sci [serial online] 2003 [cited 2005 Aug 3];57:408-14.
Goat’s rue also useful for IR
Used for goats and cows in France,
Middle Ages, first mention 1898
http://www.mobimotherhood.org/
Precusor to metformin