Recognizing and Treating Delayed or Failed Lactogenesis II

Nancy M. Hurst, RN, DSN, IBCLC


J Midwifery Womens Health. 2007;52(6):588-594. 

In This Article


Risk assessment is important for identifying women with potential lactation insufficiency. A clinical lactation assessment (see Appendix) performed during pregnancy is useful to identify possible cases that may require closer surveillance following delivery. A history of breast surgery (e.g., augmentation or reduction), breast hypoplasia,[33] and previous insufficient lactation and/or slow-growth breastfed infant(s) should warrant concern that delayed or failed lactogenesis may occur. Wide-spaced, tubular in shape, underdeveloped breasts have been associated with failed lactogenesis[33] (Figure 1). Assessment of nipple type and protractility will alert the clinician to possible problems related to the ability of the infant to effectively grasp and maintain attachment to the breast, which could result in suboptimal stimulation and subsequent insufficient milk volume. Following delivery, additional information relevant to lactation sufficiency as previously discussed (e.g., labor and delivery course, maternal medications, etc.) should be obtained in order to provide an overall view of potential risks for lactation insufficiency.

Figure 1.

Hypoplastic breasts: Low milk volume. Reprinted with permission from Wilson-Clay B and Hoover K.[32]

The breast is the only organ in the body that does not have a diagnostic test to measure its adequacy.[4] This fact presents clinicians with the difficult task of using indirect measures to determine lactation sufficiency. Test weighing procedures, whereby the infant is weighed pre- and postfeeding to estimate milk intake during breastfeeding and biochemical markers can both be used as measures to document the onset of lactogenesis II. However, these procedures may be impractical, costly, and cumbersome to use routinely. In a study of 60 mothers following cesarean section, Chapman and Perez-Escamilla[2] defined delayed lactogenesis II as milk transfer < 9.2 g/feeding at 60 hours and maternal perception of the lack of breast fullness, swelling, and leaking at 72 or more hours postpartum. They found maternal perception to be a valid indicator of delayed onset of lactogenesis II. Based on these findings, maternal perceptions are an effective starting point in diagnosing a delay in lactogenesis II. Once a delay is diagnosed early, and if aggressive intervention fails to result in a rapid regain in momentum of the lactation process, it should be assumed that a failed lactogenesis II exists.


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