AANP 2015 presentation discussing causes, interventions, referral, and support for women who can make babies, but have difficulty producing enough milk to feed them.

1. Counting Every Drop:
Navigating Low Milk
Supply
15.3.103
Jaclyn Engelsher DNP, APRN
Family, Psych-Mental Health

2. Disclosures
There are no real or potential conflicts of
interest to disclose

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

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)

12. Issues with Extraction

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)

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)

20. Issues with Production

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)

25. (Arbour & Kessler, 2013)
Hypoplasia/IGT

26. Galactogogues

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
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(2013). Endocrine and clinical effects of myo-inositol administration in polycystic ovary syndrome. A
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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
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O Bodley,V. and Powers, D. Patient with insufficient glandular tissue experience milk supply increase
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35. References
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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
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