Markers of Lactation Insufficiency:

A Study of 34 Mothers


Kathleen E. Huggins, RN, MS, CLC,
Ellen S. Petok, BS, IBCLC and
Olga Mireles, RNC, CLC

Kathleen Huggins is director of the Breastfeeding Program at San Luis Obispo General Hospital, San Luis Obispo, CA USA. She is the author of The Nursing Mother's Companion and co-author of The Nursing Mother's Guide to Weaning. Contact the author at: 644 Islay Street, San Luis Obispo, CA 93401 USA.

Ellen S. Petok is a lactation consultant in private practice and at Encino-Tarzana Regional Medical Center, Tarzana, CA USA. She is a lecturer and clinical supervisor for the Lactation Consultant Training Program, UCLA Division, and UCLA School of Nursing.

Olga Mireles is an R.N. and Certified Lactation Consultant at San Luis Obispo General Hopital, San Luis Obispo, CA. She specializes in working with Spanish speaking mothers on the post partum ward and outpatient breastfeeding clinic.

Issues in Clinical Lactation, 2000, 25-35; breast hypoplasia, breastfeeding, failure to thrive, insufficient lactation, lactation.

Abstract

In a prospective study, the relationship between breast appearance and milk production was investigated. Thirty-four women with characteristics suggestive of breast hypoplasia were evaluated. Volume of infant milk intake and breast pumpings immediately after feedings, and milk production during the first week and first month of lactation was estimated.

The majority of the women with some degree of hypoplasia and an intramammary distance of 1.5 inches or more produced 50% or less of the milk necessary to sustain normal infant growth in the first week postpartum. Many of these women also reported experiencing no breast growth during pregnancy. Sixty-one percent of the women followed were unable to produce a full milk supply within the first month.

Women at high risk for primary lactation insufficiency can be identified prenatally or in the immediate postpartum period. They need close monitoring to ensure that the infant receives adequate nutrition and to encourage optimal milk production.

Introduction

Failure to thrive is one of the most disturbing outcomes associated with breastfeeding. Typically, when infants lose weight, fail to gain adequately, or develop dehydration or life-threatening malnutrition, breastfeeding is abandoned.

Inadequate breastmilk intake may be related to improper feeding technique or routines, ineffectual suckling, illness in the infant or mother, prior maternal breast surgery, or breast abnormalities. Although much attention has focused on breastfeeding management and proper technique, few investigators have evaluated lactation insufficiency.

Neifert, et al (1990) speculate that a small percentage of women experience lactation failure as a result of insufficient milk producing glandular development of the breast. Insufficient milk producing glandular tissue is thought to be characterized by abnormal development of at least one breast, the absence of typical breast changes during pregnancy and the lack of postpartum engorgement, and inadequate milk production despite appropriate breast stimulation and drainage (Neifert, Seacat, Jobe,1985; Neifert, Seacat, 1987; Neifert et al.,1990).

What physical characteristics indicate breasts that produce low milk volume? Is it possible to identify women prenatally or in the immediate postpartum period who have these breast characteristics?

Breast deformities are reviewed extensively in the plastic surgery literature, but the focus of that literature is cosmetic surgical repair rather than breast function.

The hypoplastic disorder commonly recognized in the plastic surgery literature is the tuberous or tubular breast. The tuberous breast, first described in 1976, is characterized by hypoplasia with a lack of breast fullness in both the vertical and horizontal directions (Rees & Aston, 1976). Additional characteristics may include areolar enlargement, herniation of the glandular tissue into the nipple-areolar complex, asymmetric expression of the deformity, and ptosis.

Since 1976, this deformity has been described by others and referred to as tubular breast (Williams, Hoffman,1981), lowerpole hypoplasia (Brink, 1990), narrow based breast (Puckett, Concannon,1990) and snoopy deformity (Gruber, Jones, 1980). Several authors have attempted to classify these breast deformities into types based on the degree and location of hypoplasia or on the presence of a large areola.

In 1996, Heimburg et al described four types of tuberous breast deformities. These include (1) hypoplasia of the lower medial quadrant (Heimburg et al.,1996), (2,3) hypoplasia of the lower medial and lateral quadrants, with (2) and (3) without deficiency of skin in the subareolar region and (4) severe breast constriction with a minimal breast base.

In order to learn more about breasts that may produce insufficient amounts of breastmilk, consultants in two lactation practices, one in a hospital clinic and one a private practice, collaborated. We sought to answer the following questions: 1) What physical characteristics generally indicate breasts that produce low milk volume? and 2) Is it possible to identify women prenatally or in the immediate postpartum period who have these breast characteristics?

Identification and Classification of Breast Characteristics of Interest

We identified six characteristics that we suspected to be associated with lactation failure. These included physical characteristics and self-reported breast changes during pregnancy and the early postpartum: breast shape, noticeable breast asymmetry, stretch marks, a wide intramammary distance, and breast changes during pregnancy and in the immediate postpartum period.
We suspected that breasts that appeared underdeveloped or oddly shaped were potentially predictive of adequate milk production. Typically these breasts have a narrow transverse or circumferential base, and height of the breast from the top to the inframamary fold may cover only the 3rd through the 5th rib er than the 2nd to the 6th rib. Because the inner aspect of the breast may be underdeveloped, the breasts widely spaced.

We classified each mother's breasts based on the severity of presenting hypoplasia. A system was adapted from the classification of Heimburg et al. (See Table 1and Figure 1). Type I breasts were round in cross section with no hypoplasia in the lower medial or lateral quadrants. Type II breasts showed hypoplasia of the lower medial quadrant. Type III breasts included hypoplasia of the lower medial and lateral quadrants. Type IV breasts were severely constricted with a minimal breast base.

Other breast characteristics that we evaluated included noticeable breast asymmetry and areolar abnormalities. Breast asymmetry may be manifested by either a marked difference in size or a difference in size and shape of the breasts. Because we observed stretch marks during our evaluation of breast hypoplasia, this feature was also included.

Table 1
Breast types classified by physical characteristics. (Adapted from Heimburg DV, et al, 1996).
Type 1 Round breasts, normal lower medial and lateral quadrants
Type 2 Hypopolasia of the lower medial quadrant
Type 3 Hypoplasia of the lower medial and lateral quadrants
Type 4 Severe constrictions, minimal breast base

Characteristics of the Cases

Thirty-four mothers whose breasts had some characteristics suggestive of hypoplasia were enrolled in the study. Most of the women were identified when they were maternity patients in the hospital. Some were referred to the clinic or private practice for evaluation of a breastfeeding problem. Nearly every mother was identified and enrolled into the study within her first five days postpartum.

The mothers ranged in age from 17 to 35 years of age. Twenty-two of the mothers (65%) were Caucasian and twelve (35%) were Latina. Twenty-five mothers (76%) were primiparous and eight women (24%) gave birth to their second child. None of the mothers had been treated for infertility. All of the mothers denied having any type of breast surgery.

Thirty-three of the mothers delivered singletons; one mother delivered twins. Thirty-four of the thirty-five babies were term. One infant was delivered at thirty-five weeks gestation. All babies were appropriate for gestational age and all babies but one were healthy. All but one of the mothers initiated breastfeeding; in that case, pumping with a fully automatic piston pump using a double collection kit was begun within the first twelve hours after birth. One term infant (#15) was admitted to the Acute Care Nursery for five days.

Procedures

Upon each mother's enrollment, her breastfeeding history was taken. Previous breastfeeding history, breast growth during pregnancy, initiation of breastfeeding, frequency and length of feeds, and breast engorgement in the first week were noted.

Her breasts were examined and any characteristics of breast hypoplasia, presence of stretch marks on one or both breasts, and breast symmetry were noted. The intramammary space on the chest wall was measured with a clear six-inch flexible ruler. No breast tissue was included in this measurement.

The baby was examined and a feeding history was taken to rule out other factors that might contribute to insufficient milk intake, such as dysfunctional or disorganized sucking, oral anatomical deviations, or mismanagement of feedings. A nude weight on the infant and a pre-feeding diapered weight in grams on an electronic digital scale was recorded. Two different digital scales were used; the Medela Baby WeighTM scale (accuracy to +/- 2 grams) and the Air-Shields Vickers electronic scale (accuracy to +/- grams). Breastfeeding evaluations were timed so that at least two hours had lapsed from the time of her last pumping or breastfeeding. At each breastfeeding episode observed, the mother was assisted with her latch-on technique and positioning if needed. A nude post-feeding weight of the infant was recorded, and milk intake was calculated.

A fully automatic electric piston pump with a double kit was used for ten minutes to collect additional milk. The mother's total milk volume was then estimated by adding the baby's calculated milk intake with the amount of pumped milk collected. Adequacy of milk production was determined by comparing the mother's total milk volume with the infant's estimated milk requirements. The baby's milk requirement was assumed to be 120 calories per kilogram per day.

When the baby's intake was inadequate, recommendations were made regarding feeding frequency, the pumping of additional milk, and supplementation of the baby. Fenugreek, an herbal remedy for low milk production, was suggested as a galactogogue (Huggins, 1998; Jensen, 1992). Any questions asked by the mothor father were addressed. The mothers were re-evaluated one or more times after their initial visit.

Table 2

Case Specifications by Breast Type
Case 
Parity 
Breast
Symmetry

Breast
Changes in
Pregnancy

Stretch
Marks

Intra-
Mammary
Space

Engorgement
Milk
Production,
First Week
Milk
Production,
First Month
 
TYPE 1  4 P1 No Minimal No 1" Typical 51-99% 100%
  5 P2* Yes Minimal No 1" Typical 51-99% 100%
  14 P2** No Typical Yes 2" Typical 100% 100%
 
TYPE 2  2 P2^ No Typical Yes 2" Typical <50% <50%
  6 P2^ No Typical Yes 1.5" Typical <50% 100%
  7 P1 Yes None No 1.5" Typical <51-99% 100%
  8 P1 No Typical Yes 1.5" Typical <50% 100%
  12 P1 Yes Minimal Yes 1.5" None <50% <50%
  15 P1 No None Yes 2" None <50% 100%
  18 P1 No None Yes 2" None <50% <50%
  19 P1 No None No 2" None <50% <50%
  20 P2^^ No Minimal Yes 1.5" Minimal <50% <50%
  23 P1 No None Yes 1.5" None <50% <50%
  28 P1 Yes Minimal No 3" Minimal <50% 51-99%
  29 P1 No Minimal Yes 2.5" Minimal <50% <50%
  30 P1 Yes None No 2" Typical <50% 51-99%
  31 P1 Yes Typical No 1" Minimal <50% 100%
 
TYPE 3  3 P1 No Typcial Yes 2" Typical <50% <50%
  9 P1 Yes Minimal Yes 2" Typical <50% 100%
  10 P1 Yes Minimal Yes 1.5" Minimal <50% <50%
  13 P2^^ No Minimal No 2" None <50% <50%
  17 P1 Yes None Yes 2" None <50% <50%
  18 P2* Yes Minimal No 1" Minimal <50% <50%
  21 P2^^ No None Yes 1.5" None <50% <50%
  22 P1 Yes None Yes 1.5" None <50% ___&
  24 P1 No Typical Yes 1" Typical <50% 100%
  25 P1 Yes Typical Yes 1.5" None <50% 100%
  26 P1 No None No 2.75" Minimal <50% <50%
  27 P1 Yes Minimal No 1" Typical 51-99% 100%
  32 P1 No Minimal Yes 2" None <50% <50%
  34 P1 No Minimal No 2" None <50% <50%
 
TYPE 4  1 P2# No Minimal Yes 4" None <50% <50%
 
* Supplemented first baby ^ Did not breastfeed first baby
^^ First baby failed to thrive & No followup obtained
** First baby gained within normal limits # Twins

Table 3

Summary of physical characteristics by breast type
Breast Type
Type 1
Type 2

Type 3

Type 4

Total

 
Breast symmetry          
   Symmetrical 1 (33%) 5 (36%) 7 (47%) 0 (0%) 13 (39%)
  Asymmetrical 2 (67%) 9 (64%) 8 (53%) 1 (100%) 20 (61%)
 
Breast changes during pregnancy          
   None 0 (0%) 6 (44%) 4 (27%) 0 (0%) 10 (30%)
   Minimal 2 (67%) 4 (28%) 8 (53%) 1 (100%) 15 (46%)
   Typical 1 (33%) 4 (28%) 3 (20%) 0 (0%) 8 (24%)
 
Stretch marks          
   Yes 1 (33%) 9 (64%) 10 (67%) 1(100%) 21 (64%)
   No 2 (67%) 5 (36%) 5 (33%) 0 (0%) 12 (36%)
 
Intramammary space          
   <1.5" 2 (67%) 4 (29v 3 (20%) 0 (0%) 9 (27%)
   1.5" or more 1 (33%) 10 (71%) 12 (80%) 1 (100%) 24 (73%)
 
Engorgement          
   None 0 (0%) 5 (36%) 8 (53%) 1 (100%) 14 (42%)
   Minimal 0 (0%) 4 (29%) 3 (20%) 0 (0%) 7 (21%)
   Typical 3 (100%) 5 (36%) 4 (27%) 0 (0%) 12 (36%)


Results

Of the 34 mothers, 33 were categorized into one of four already described classifications. (See Tables 2 and 3) Mother #33 was excluded, as only one breast appeared hypoplastic and she was able to produce a full supply from the other breast.

Twenty of the mothers (61%) had marked breast asymmetry. Ten women (30%) reported no breast growth in pregnancy and 15 mothers (45%) reported little breast growth. Twenty-four mothers (73%) had an intramammary distance of 1.5 inches or more. Fourteen men (42%) reported experiencing no engorgement - the early postpartum period, while seven other mothers (21 %) reported only minimal breast fullness in the first week.

Eighty-five percent of these mothers produced 50% or less of the milk necessary for their newborns during the first week post partum. (See Table 4) Type of breast appeared to be related to the adequacy of the mother's milk production. For example, one mother with Type I breasts produced 100% of the milk required by her infant in the first week and the other mothers in this group produced more than half of their babies' required milk. However, only one of the mothers with breasts Type II, III, or IV produced all of the milk needed by her infant in the first week of life and only four (12%) produced more than half of their babies' required milk.

Evaluation of milk production in the first month, between the second and fifth week, revealed that seventeen mothers (55%) continued with low production, producing half or less of what their babies required for growth. Two mothers (6%) were producing 51-99% of what their babies needed and 12 mothers (39%) were producing all of their babies' milk requirements. All of the mothers with breast Type 1 were producing all of their babies' required milk.
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Even with the more severe types of hypoplasia, some women progress to full milk production and thus can be encouraged to keep stimulation and draining the breasts.
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Discussion

We identified 34 mothers who had characteristics of hypoplastic breasts who were likely to have insufficient lactation. Only one mother of 34 produced sufficient milk in the first week. None of the mothers classified with Type II, II, or IV breasts had sufficient lactation in the first week. This finding strongly suggests that mothers with any degree of hypoplasia may be at high risk for underfeeding their newborns. Although the sample size is small, it also appeared that the more severe the hypoplasia, the poorer the milk production in the first week postpartum. The LC should be aware that breast hypoplasia may cause low milk production. Thus early and careful follow-up to assure the infant's nutritional integrity is essential.

Breast hypoplasia may also be associated with a wide intramammary space. An intramammary space of 1 1/2 inches or greater was clearly associated with insufficient lactation when the breasts appeared to be hypoplastic. This wide intramammary space may reflect medial breast hypoplasia. Early in our study we learned that according to Jewish law, a marriage could be dissolved if a wife had bodily disfigurements including a "tefach," a handbreadth, between one breast and the other (The Shulchan Aruch). Is it possible that the association between widely spaced breasts and inadequate milk production were known in Biblical times?

Breast asymmetry was noted in a majority (61%) of the mothers. Stretch marks on the breast was another frequently occurring finding for 64% of the mothers studied. Stretch marks on the breasts occurred with greater frequency as the severity of hypoplasia increased. Asymmetrical breasts and stretch marks occurred together 75% of the time. Might stretch marks be another indication of abnormal growth on the more? While many mothers stated that they developed these stretch marks during adolescence, we did not record these findings. We also do not know the percentage of breastfeeding mothers who produce sufficient milk who also have stretch marks on their breasts.

A majority of the mothers (76%) reported little or no breast growth in pregnancy. As their degree of hypo plasia became more severe, women more commonly reported minimal or no breast changes. However, many mothers in this study who reported typical breast growth failed to produce sufficient milk.

Likewise, 63% of the mothers reported little or no engorgement in the first week and the mothers with more severe hypoplasia were less likely to report that they experienced any early post-birth breast fullness. Yet nine mothers out of 12 who reported experiencing typical engorgement failed to produce adequate milk. Breast changes during pregnancy or in the early postpartum period are subjective and thus may be a less reliable indicator of early and later milk production than other factors we have sought to identify.

The news is not discouraging for all mothers who have breast hypoplasia. While only one of the study mothers (3%) had full production in the first week, 12 of the mothers (39%) were producing sufficient quantities of milk by one month. Even with the more severe types of hypoplasia, some women progress to full milk production and thus can be encouraged to keep stimulating and draining the breasts.

Limitations

Our small sample size did not allow for statistical analysis. In the absence of a control group, we are not certain that each of the elements of breast hypoplasia that we have identified are true markers or occur with similar frequency among all women who initiate breastfeeding. Lastly, the mothers' reports of breast changes in pregnancy and post partum are limited by the mothers' memory and perception.

Implications for Clinical Practice

Mothers who appear to have breast hypoplasia can and should be identified in the prenatal or immediate post partum period. Obstetricians, midwives, and perinatal nurses, pediatricians, and lactation consultants who have contact with mothers in the immediate post partum period should be alert for and suspicious of mothers who appear to have breast hypoplasia and widely spaced breasts. Lactation consultants can be instrumental in orienting all of the health professionals who have contact with pregnant and newly delivered women to this condition and the related implications of breast hypoplasia. Mothers who have had breast augmentation procedures should be also questioned about the shape and positioning of their breasts prior to the surgical alteration.

Once mothers with possible breast hypoplasia are identified, they need to be informed that they need close follow-up after discharge to assure that breastfeeding begins appropriately and continues with an ample milk supply. They should be informed that sometimes women whose breasts are similar to theirs may have a delayed onset of milk production.

Certainly, the signs suggesting inadequate milk intake should be made clear to mothers both verbally and in writing before their discharge from the hospital. These signs should include experiencing little or no breast changes by the third post partum day, hearing little or no swallowing when the baby feeds, failure of the newborn to stool at least twice every 24 hours, dark stools on the fifth day of life, and fewer than six wet diapers by the fifth day of life. Any of these signs should be immediately reported to the pediatrician.

Additionally, we recommend that the newborns of these mothers be weighed on the third or fourth day of life to rule out excessive weight loss, and every two to three days thereafter to assure that the infant begins gaining adequately by the fifth day of life.

If signs of inadequate milk intake are evident, the infant should be supplemented with breastmilk or formula. Evaluating milk production by weighing infants on an electronic gram scale before and after a feeding and pumping the breasts to collect any remaining milk can assist the LC in recommending the amount of supplement needed to meet the infant's caloric requirements.

We suggest maximizing production by having mothers use a fully automatic electric piston pump for 5-10 minutes with a double collection kit to ensure complete breast drainage after each feeding. It is our observation that when milk production is low, many newborns fail to suckle vigorously, and may be poor stimulators of further milk production. A galactagogue such as fenugreek may also be helpful in stimulating further production. Continued follow-up to reassess production and the need for supplementation are important in encouraging maximum production as well as supporting the mother's efforts.
Many lactation consultants only encounter mothers with breast hypoplasia after discharge when they are referred with their infants in various states of nutritional compromise. Again, it is important to identify the characteristics that suggest breast hypoplasia, assess the mother's milk production, and determine the amount of supplementation that may be necessary to ensure appropriate growth.

When mothers are identified as having breast hypoplasia, they need a great deal of emotional support. Most mothers feel inadequate. Some may feel guilty or angry, especially if their infants have experienced excessive weight loss or have failed to gain weight as expected. Encouraging the mother to express her feelings may help her to work through any disappointment or sense of inadequacy.

It is important that the lactation consultant is positive and also realistic in her counseling. We have heard from many women with breast hypoplasia who felt frustrated by health professionals, lay breastfeeding counselors, and LCs who suggested that the mother would improve her poor production simply by working harder to stimulate her breasts. Helping the mother make realistic goals for breastfeeding will increase her sense of control and self-esteem as she work through feelings of disappointment.

We wrote this paper to encourage further study on breast hypoplasia. A study comparing a large control group of women with no signs of breast hypoplasia with women like those described here would likely show statistical significance for certain variables. Additional study and awareness of breast hypoplasia will give the health care professional important information to better evaluate and assist lactating women.

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