Low Milk Supply Risk Factors

MATERNAL RISK FACTORS FOR LOW MILK SUPPLY 

1. Maternal health issues evident before pregnancy

Previous low milk supply

• If you had a low milk supply with a previous baby, it’s wise to pay close attention this time around to make sure your milk is getting removed in the early days. Often times, primed breasts will perform better the next time around, even if there is a known risk factor for low production. 

Hypothyroidism (if poorly managed)

• If milk supply is a concern, make sure your thyroid medication is maintaining your TSH and T4 in an optimal range. 

Diabetes

• Insulin is involved in milk production. Good diabetes control will optimize your milk production.

Obesity

• Obesity can affect hormone levels, which can affect milk production.

High Blood Pressure

• Chronic hypertension increases the risk of pre-eclampsia during pregnancy, which can lead to premature birth (see below). 

Mom is over 40 years old

• There are many “older” women who produce plenty of milk. There is very little research regarding advanced age being the only risk factor for low production. Older women may have more of the other health issues that affect supply. You won't know unless you try. 

Acute illness

• If you are ill, your body uses energy for healing instead of milk production. 

Medication may affect milk supply

• Rarely, a mother may have an underlying health condition that requires a medication that affects milk supply.

Stress

• Excess stress can affect how easily your milk lets down for each feeding session. 

Theca lutein cysts

• These are very rare ovarian cysts that produce testosterone, which affects milk production.

Polycystic ovary syndrome (PCOS)

• This is a genetic condition that results in irregular periods, possible infertility issues, insulin resistance that predisposes one to future diabetes, obesity, excess body hair, scalp hair loss, and acne. Some women produce plenty of milk despite this diagnosis, but it is a red flag to monitor your baby’s weight closely. 

Infertility

• If infertility issues required hormone shots, it’s possible this will affect milk supply. However, if there are no other risk factors, like PCOS, infertility itself is not usually a problem. 

Hypoplastic breasts / Insufficient Glandular Tissue

• Some girls are born with too few cells that will produce milk some day. The size of the breasts doesn't matter, but rather the tell-tale sign is breasts that are “cone shaped” rather than rounded. Also, the cleavage is wide enough to place 3 fingers in the space between the 2 breasts. Sometimes one breast is much smaller than the other. 

Breast surgery

• Augmentation doesn’t interrupt milk ducts and cells, because the prosthesis is typically placed behind the chest wall muscle. If milk supply is an issue after augmentation, it’s likely the surgery was done because of underlying hypoplastic breasts.
• Reduction surgery often interrupts milk ducts and nerves, and reduces the number of milk producing cells. If enough cells, nerves, and ducts remain intact, there is a chance for a good milk supply. You won’t know unless you try. 

Previous mastitis or abscess with scar tissue                                                                      

• Scar tissue after mastitis infection or an abscess can interfere with milk supply. Hopefully the remaining healthy breast tissue will compensate. 

Chest radiation treatment

• This causes scarred breast tissue. 

Maternal history of sexual abuse

• Breastfeeding is known to trigger emotions in women who have been assaulted. Pumping and bottle feeding may still be an acceptable option for them.

2. Labor and delivery situations that may result in low milk supply

Prematurity

• Babies born early often lack the stamina needed to effectively stimulate the breasts to establish a good milk supply. It’s best to start pumping or hand expressing colostrum soon after delivery.  

High Blood Pressure

• Pre-eclampsia during pregnancy often leads to premature delivery (see below). Some mothers may need temporary diuretic medications, which can affect milk supply. 

Postpartum infection

• If your body is fighting an infection, there is less energy for milk production. 

Stressful and/or prolonged labor and delivery

• A long stressful labor and delivery leaves a mother exhausted, just at the time when energy is needed to make milk. Rest is important. Excess IV fluid may be used for long labors, which can exacerbate engorgement.  

C-section

• A C-section is a major surgical procedure that requires IV fluids. Recovering from surgery requires energy that is diverted from milk production.  

Retained placenta

• When the placenta detaches from the uterine wall after delivery, the hormone progesterone stops production. This is the trigger that tells the milk cells to get started.
• If a tiny piece of placenta is stuck in the uterine lining, milk production doesn’t kick in.
• The piece of placenta stuck in the uterine lining prevents the uterine wall from properly contracting down to stop bleeding from the placenta site. Thus, you’ll likely pass more vaginal blood rather than less over time, perhaps even clots. Usually the delivering provider will announce “placenta intact” when the placenta comes out, which confirms there is no retained placenta.
• If your milk doesn't come in and there's any concern about bleeding, an ultrasound can investigate this.

Postpartum hemorrhage

• There are many reasons why a mother might bleed after delivery, such as retained placenta discussed above. If the bleeding is because the uterus isn’t contracting down, you will likely get a shot of a drug called methergine, which has the side effect of temporarily delaying the milk supply from coming in.   

3. Maternal conditions evident after delivery that may result in low milk supply

Excess dieting with weight loss

• Milk production requires energy. If you limit your calories and exercise to try to lose more than 1 pound per week, your milk supply may suffer.     

High Blood Pressure

• Pre-existing hypertension or presistent pregnancy induced hypertension often requires medication to keep your blood pressure in a normal range. Blood pressure medications most commonly used while nursing don't affect your breastmilk or your baby. If a diuretic is needed temporarily, your milk supply may be affected, but hopefully temporarily. 

Pregnancy 

• Some mothers continue to breastfeed while pregnant. Growing a baby may take energy away from milk production.

Issues that affect milk removal and breast emptying

Anatomy

• Flat or inverted nipples may fail to stimulate the baby’s suck reflex at the roof of the mouth.
• A nipple shield can interfere with compression of the areola during suckling.    
• Large nipples fill the baby’s mouth, resulting in poor tongue placement.
• Engorged breast tissue is too firm and makes it difficult for baby to pull breast tissue into his mouth.
• Large pendulous breasts make it difficult to properly position the baby at the breast.

Insufficient milk “let down”

• Maternal pain, feeling cold, or emotional stress can inhibit milk flow from the breast.
• Engorgement and plugged ducts interrupt milk flow from the breast.
• Some moms leak milk, but others have a slow let down, which frustrates the baby.
• Maternal alcohol intake limits the let-down, to protect the baby from alcohol.
• Cigarette smoking limits the let down to protect the baby from nicotine.

Mom won’t allow the baby to latch

• Nipple pain from trauma, blebs, and vasospasm may be intolerable.

1. Infant conditions that result in poor milk removal

Anatomy issues

• Tongue tie can affect how the tongue functions during milk removal.
• Cleft lip and/or palate makes it difficult to achieve a proper seal during latching. 
• High palates may affect the tongue positioning and suckling movements.
• A small lower jaw requires extra attention to how the baby is positioned for the latch, so the chin is lifted, so the bottom lip can be flanged outward properly. 
• A small mouth can be challenging if the mother has large nipples. The mouth will grow! 

Sleepy baby

• Jaundice sometimes makes babies sleepy.
• Maternal narcotics can get through the milk to the baby, once the milk comes in. Avoid narcotics if possible. If you have a C-section, you should be able to wean off narcotics by the time your milk comes in. 
• Delivery medications given intravenously or in the epidural can make your baby sleepy, but they should wear off quickly.

Low energy and stamina

• Poor weight gain results in a weak baby who can't suckle hard enough and long enough to remove milk well. 
• Babies who are premature , or "small for gestational age" or have "intrauterine growth retardation" may lack the stamina to empty the breasts and stimulate the milk supply. 
• Chronic medical issues, like congenital heart diseases, may affect a baby's stamina to nurse well. 
• Acute illness may leave a baby with less energy to nurse well. 

Disorganized or weak suckle

• Various birth defects may affect a baby's ability to strongly suckle. 
• Low muscle tone, like in babies with Down’s Syndrome, may have difficulty removing milk. 
• High muscle tone, like babies with cerebral palsy, may have trouble coordinating suckling and swallowing. 

Few or no latches achieved in the first 24hrs 

• Latches may be ineffective with incomplete emptying of milk/colostrum.

Mom does not pump if the baby is not latching 

Mom does not pump if the baby is supplemented

A pacifier is used to calm the baby instead of feeding the baby.