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The Hows and Whys of Low Milk Supply, and the What-to-do’s. Rebecca B. Saenz, MD, IBCLC, FABM, LLLL Mississippi Breastfeeding Medicine Clinic, PLLC Madison, MS. Determine the problem. Where does the process break down? Production Transfer Utilization. Etiologies: Three-stage process.

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the hows and whys of low milk supply and the what to do s

The Hows and Whys of Low Milk Supply,and the What-to-do’s

Rebecca B. Saenz, MD, IBCLC, FABM, LLLL

Mississippi Breastfeeding Medicine Clinic, PLLC

Madison, MS

determine the problem
Determine the problem

Where does the process break down?

  • Production
  • Transfer
  • Utilization
etiologies three stage process
Etiologies: Three-stage process
  • Problems making milk (<5%)- maternal
  • Problems transferring milk (90+%)
  • Problems utilizing milk (<10%)- infant

Investigate these in reverse order.

production problems
Production Problems

Physiologic - Interference with “supply and demand” principle (>95%) - inadequate nipple stimulation and/or breast drainage


  • poor milk transfer
  • missed feedings
  • scheduled feedings / timed feedings
  • pacifier use / masked hunger cues
  • inappropriate nipple shield use
  • inappropriate supplementation
prolactin receptor theory
Prolactin Receptor Theory

There is a critical time frame after birth during which prolactin receptors must be adequately stimulated in order for full lactation to occur.

Mammary tissue shows regression after the first week or so, if unstimulated.

production problems6
Production Problems

Physiologic - Interference with “supply and demand” principle (>95%) - inadequate nipple stimulation and/or breast drainage


  • Scheduled feedings / timed feedings
  • Inappropriate supplementation
    • Failure to recognize growth spurts
  • Initiation of solids
    • Too soon
    • Too much
    • Too fast
    • Before breastfeeding, rather than after
production problems7
Production Problems


  • Retained placental fragment
  • Persistent theca lutein cyst of pregnancy*
  • Subsequent Pregnancy
  • Contraception
  • “Breast menopause”

*Hoover K, et al. J Hum Lact 2002;18(3):264-8

production problems8
Production Problems


  • Inadequate glandular tissue - congenital
    • 4 different sub-types described by Kathleen Huggins
    • augmentation is a red flag!
  • Inadequate glandular tissue 2o surgical reduction
  • Surgical denervation of nipples
  • Surgical interruption of ducts
  • Radiation therapy changes
production problems9
Production Problems

Pathologic - Hormonal

  • Panhypopituitarism
  • Sheehan’s syndrome
  • Thyroid disease
    • Hypothyroidism = decreased supply
    • Hyperthyroidism = impaired MER > engorgement > decreased supply
  • Polycystic Ovary Syndrome (PCOS)
production problems10
Production Problems

Pathologic – other

  • Interstitial edema (pathologic engorgement)
  • Anemia
  • Dehydration
    • Any acute or febrile illness
  • Mastitis
    • Inflammation
  • Plugged duct
    • Localized engorgement
  • Poorly-controlled diabetes
  • Obesity
  • Postpartum Hemorrhage (>dehydration, anemia, pituitary “shock”, Sheehan’s)
production problems11
Production Problems

Pharmacologic - Medications


Oral contraceptives

  • combination
  • Progestin-only

Injectable and implantable medroxyprogesterone

    • Depo-Provera
    • Norplant

Progestin-containing IUD’s

Estrogen vaginal cream, NuvaRing

Progesterone lollipops

production problems12
Production Problems

Pharmacologic - Medications

  • bromocriptine (Parlodel)
  • mebendazole (Vermox)
  • pseudoephedrine (Sudafed, others)
  • levodopa (Sinemet)
  • ergot alkaloids (Cafergot, Wigraine, DHE45)
  • ergonovine (Ergotrate)
  • vinca alkaloids (vincristine, vinblastine)
  • magnesium sulfate
  • antihistamines
  • diuretics
  • cabergoline (Dostinex)
production problems13
Production Problems

Pharmacologic - other

Herbal remedies

  • Sage*
  • Black Cohosh*

*both are ingredients in Avlimil

  • Ephedra / Ma Huang

high-dose vitamin B-6

Smoking - nicotine

Ethanol – impairs MER

Marijuana -

? high soy intake - phytoestrogens

transfer problems
Transfer problems
  • poor position
  • poor latch
  • impaired milk ejection reflex
  • bad mechanics
    • “disorganized” suck
    • high palate
  • inadequate nutritive suckling
if the problem is baby not breastfeeding well then fix the breastfeeding

If the problem is “Baby not breastfeeding well”, then Fix the breastfeeding!

(The What-to-do’s)

transfer problems17
Transfer problems
  • Optimize latch
  • Compression
  • Pump and feed by alternate means if necessary
    • Scheduled pumping
    • Physiologic pumping
  • Using feeding tube at breast
milk ejection reflex
Milk Ejection Reflex

Nipple stimulation causes

rise in oxytocin production in

anterior pituitary, which causes

1. alveolar myoepithelial cells to contract, squeezing milk down into sinuses

2. increase in prolactin level,

which increases milk production

impaired milk ejection reflex
Impaired Milk Ejection Reflex
  • Pain
  • Stress
  • Lack of Confidence
  • Nicotine
  • Ethanol
  • Theophylline
  • Hyperthyroidism
  • Timed / scheduled feeds
facilitating milk ejection reflex
Facilitating Milk Ejection Reflex
  • Relaxation techniques
  • Adequate pain control
  • Visual imagery
  • Bach’s Rescue Remedy
    • Homeopathic 5-flower essences
  • Oxytocin nasal spray 40u/ml
    • One spray each nostril 2-3 minutes before feeding or pumping

Galactogogues-There are currently no drugs in US that are FDA approved for use to increase breast milk production.

metoclopramide reglan
Metoclopramide (Reglan)
  • GI prokinetic agent
  • Hale = L-2
  • Increases serum prolactin levels –
    • “off-label” use
  • Contraindicated with htn, pheo, sz do, GI bleed or obstruction, depression
  • Side effects
  • Dose: 10mg QID; slow taper to stop
domperidone motilium
Domperidone (Motilium)
  • GI prokinetic agent
  • Hale = L-2; AAP approved
  • Increases serum prolactin levels
  • Contraindicated with GI bleed or obstruction
  • Side effects
  • Dose: 20mg QID; slow taper to stop
other prescription meds
Other prescription meds
  • Sulpiride
  • Chlorpromazine
  • Methyldopa (Aldomet)
  • Theophylline


  • TRH
  • GH
  • Recombinant HGH
fenugreek seed
Fenugreek seed
  • Decrease blood glucose and cholesterol, and has anti-coag effect
  • Hale = L-3, “GRAS”
  • ?blocks FIL binding site
  • Contraindicated in dm, asthma, peanut allergy, Coumadin or aspirin use
  • Side effects
  • Dose: 1800mg TID; slow taper to stop
blessed thistle
Blessed Thistle
  • Many uses
  • Hale = L-3 “GRAS”
  • ? Mechanism
  • No known contraindications
  • No known side effects
  • Dose ?
mother s milk tea
Mother’s Milk Tea

Active: Fennel fruit 560mg, Aniseed 350mg, Coriander fruit 210mg, and Fenugreek seed 35mg

“Inactive”: Spearmint leaf, Lemongrass, Lemon verbena, Marshmallow root, and Blessed Thistle

?activity / efficacy

Probably does no harm – “GRAS”

metformin glucophage in polycystic ovary syndrome
Metformin (Glucophage) in polycystic ovary syndrome
  • Type 2 diabetes, PCOS
  • Hale = L-3
  • Contraindicated in renal failure
  • Decreases insulin resistance
  • Side effects
  • Dose: 500mg qd > 1000mg BID, usually in combination with metoclopramide or domperidone
methyldopa aldomet in hypertension
Methyldopa (Aldomet) in hypertension
  • Hypertension
  • Hale = L-2, AAP approved
  • Contraindicated with depression, hepatitis
  • Centrally-acting antihypertensive
  • 250mg BID > 500mg TID
  • Primary insufficient milk supply is rare
  • Secondary insufficient milk supply is more frequent
  • Most causes are due to physiologic response:

“If you hear hoofbeats, look for horses. If there are no horses, then look for zebras.”

  • Most causes can be overcome, if treated in a timely manner.
mississippi breastfeeding medicine clinic pllc
Mississippi Breastfeeding Medicine Clinic, PLLC

Rebecca B. Saenz, MD, IBCLC, FABM

111 Depot Drive, Suite A

Madison, MS 39110


Fax 601-898-7989

Also on Facebook and Twitter (@litldoc)