Among lactating parents, concerns about milk supply are common and stressful. To increase milk supply, professionals will often recommend increased milk removal through pumping or breastfeeding, and sometimes galactagogues. But what about parents who don't respond to these efforts but still want to breastfeed? This article will discuss the basics of milk production, determinants of low supply, and what to do when chronic low supply is suspected.
Lactogenesis is the process in which the body develops the capabilities to produce and secrete milk and is broken down into three stages, Lactogenesis II, III, and III.¹
Lactogenesis I occurs in the latter half of pregnancy. During this period, the breasts begin to produce colostrum, but the high progesterone in the placenta prevents milk secretion.
Lactogenesis II Begins following birth and the deliverance of the placenta, causing a rapid decline in progesterone levels. This sudden drop in progesterone and the presence of prolactin and other hormones prompt the beginning of Lactogenesis II. This process typically occurs 1-3 days after delivery, and many women begin to produce larger quantities of milk and feel fuller breasts around this time.
Lactogenesis III, or the maintenance stage, is primarily controlled by nipple stimulation and milk removal at the breast. However, hormones continue to play an important role. Prolactin, responsible for breast tissue development and milk production, increases with nipple stimulation. During suckling, oxytocin is released, leading to the letdown or ejection of milk.
Milk production is also controlled by a protein in the milk called the Feedback Inhibitor of Lactation (FIL). The FIL will slow the rate of milk production when the breast is full. Conversely, if the breast is empty, less FIL is present, thus increasing the rate of milk production.² In simplified terms, the more often milk is removed, the more milk will be produced. Therefore breastmilk supply is often referred to as a supply and demand process.
It is not uncommon for parents of breastfed babies to stress over their milk production. Perceived or real concerns over low supply can often be mediated with various modifications and a professional’s help. This may include interventions like latch assessment and correction, more frequent emptying of the breasts, or ensuring proper oral motor function skills for the baby. These parents can benefit from collaborative care with a trained lactation professional such as an International Board Certified Lactation Consultant (IBCLC).
It is important to remember that some parents may not want to pursue these interventions and to work with them to find a feeding plan that meets their goals and preferences.
If the parent does not see a response to the above interventions, it may signal that they have chronic low milk supply. Chronic low supply occurs when a mother does not make enough milk to feed her infant, even when following best practices. This happens in an estimated 5-15% of lactating parents, although much more research is needed to understand the prevalance fully.³
A multitude of factors can cause chronic low milk supply: pre-existing conditions such as hormonal disruptions from conditions including thyroid disease, PCOS, or insulin resistance may lead to insufficient milk production.⁴,⁵ The breast anatomy of the parent should also be taken into consideration when assessing milk supply. Patients with a history of breast augmentation or insufficient glandular tissue may not have the ability to produce enough milk.⁶ Lastly, significant postpartum blood loss or certain medications may reduce milk production.⁷-⁸ There is no sole determinant of chronic low milk supply, so all possible causes should be explored.
A chronic low milk supply diagnosis does not mean the breastfeeding journey has to end. Clinicians should work with these parents to understand their feeding goals and what works for their family. To continue breastfeeding, they will need to provide additional nutrition through formula or donor milk supplementation. The care team should work closely with these parents to develop a feeding plan.
These parents may be experiencing feelings of shame, inadequacy, or grief about losing the feeding journey they had planned. The mismatch between parent expectations and the reality of their feeding journey can lead to postpartum mental health struggles.⁹ Working with a mental health professional to support these parents is ideal. As a provider, thoroughly explain the tools at their disposal and support the parent’s decisions.
Download our patient handout on chronic low milk supply here.
¹Pillay, J., & Davis, T. J. (2021). Physiology, lactation. StatPearls.
²Peaker, M., & Wilde, C. J. (1996). Feedback control of milk secretion from milk. Journal of mammary gland biology and neoplasia.
³Lee, S., & Kelleher, S. L. (2016). Biological underpinnings of breastfeeding challenges: the role of genetics, diet, and environment on lactation physiology. American Journal of Physiology-Endocrinology and Metabolism [Internet].
⁴Morton, J.A. (1994) The clinical usefulness of breast milk sodium in the assessment of lactogenesis. Pediatrics[Internet].
⁵Biloš, L. S. K. (2017). Polycystic ovarian syndrome and low milk supply: Is insulin resistance the missing link?. Endocr Oncol Metab [Internet].
⁶Neifert, M., DeMarzo, S., Seacat, J., Young, D., Leff, M., & Orleans, M. (1990). The influence of breast surgery, breast appearance, and pregnancy‐induced breast changes on lactation sufficiency as measured by infant weight gain. Birth, [Internet].
⁷Henry, L., & Britz, S. P. (2013). Loss of Blood= Loss of Breast Milk? The Effect of Postpartum Hemorrhage on Breastfeeding Success. Journal of Obstetric, Gynecologic & Neonatal Nursing, [Internet].
⁸McGuire, T. M. (2018). Drugs affecting milk supply during lactation. Australian prescriber, [Internet].
⁹Elder, M., Murphy, L., Notestine, S., & Weber, A. (2022). Realigning Expectations With Reality: A Case Study on Maternal Mental Health During a Difficult Breastfeeding Journey. Journal of Human Lactation, 38(1), 190-196.