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


The following interventions are intended to treat a suspected delay or early lactation insufficiency with the purpose of improving lactation performance. Most women are capable of producing some measurable milk volume; however, these suggested treatments are intended to stimulate the mother's full lactation potential. The challenge is determining the most effective plan of care based on the etiology of the problem, the ability of the mother to execute the plan, and at what point her full lactation potential has been reached. Treatment modalities to promote lactation sufficiency and breastfeeding success are designed to maximize breast stimulation and to assure adequate infant growth rates. Taking a "wait and see" approach may result in a delay in appropriate interventions of early breastfeeding problems. Simultaneous maternal and infant assessment to determine the possible etiologies involved will drive the proper treatment plan.

A delay in the onset of lactogenesis II warrants early recognition in order to provide timely intervention and prevent further lactation insufficiency. Recent trends prompting earlier discharge from the hospital/birthing center make it more difficult for clinicians to assess and recognize a delay in lactogenesis II and ineffective infant feeding ability. Early follow-up (during the first week post-birth) allows for the assessment of adequate milk intake and identification of possible signs of ineffective breastfeeding ( Table 2 ). The presence of two or more risk factors in Table 1 should alert the clinician to the need for closer surveillance of breastfeeding in the first few days following hospital discharge until signs of adequacy of milk intake in the infant are demonstrated by frequent patterns of urination (about five-six wet diapers) and stooling (at least three-four yellow, seedy stools). Enlisting the expertise of a lactation consultant may be useful in developing an effective plan of care, offering support and instruction to the mother, and accessing other breastfeeding equipment/supplies (i.e., hospital-grade breast pump).[34]

When lactogenesis II failure is suspected, the underlying cause will drive the plan of care. Definitive diagnosis and proper treatment of any hormonal imbalance (e.g., thyroid, pituitary, or diabetes) must occur before and/or concurrently with measures to stimulate and increase milk production. Removal of retained placental fragments[35,36] and normalizing of testosterone levels[27,28] (i.e., theca-lutein cyst) has resulted in normal onset of lactogenesis II. Depending upon the onset of polycystic ovarian syndrome and various treatment strategies, improvement of current or future lactation may be improved.[29] Early recognition of ineffective breastfeeding ( Table 2 ) and assessment of risk factors identified from relevant information obtained in the prenatal and early postpartum period (see Appendix) will alert the clinician to the need for close surveillance in the early days and weeks following birth. A treatment plan for a delay or suspected lactation failure should include the following key elements: providing adequate infant nutrition, maximizing breast stimulation and complete breast emptying, strategies to measure milk intake during breastfeeding, written record of progression of feeding plan, and recognition of when maternal lactation potential is reached.

Provide Adequate Infant Nutrition

Determining the need for supplementation is essential in promoting adequate infant growth and energy levels. An infant who is malnourished will not have the energy to breastfeed effectively; recommending that the mother simply increase the number of breastfeeds per day to improve her milk volume and the infant's milk intake will not improve the situation when failed lactogenesis II is suspected. Delayed lactogenesis II, defined as little or no maternal perception of breast fullness or leaking ≥ 72 hours post-birth, may require only minimal, short-term supplementation. Ideally, expressed breast milk or formula should be given as a complement (immediately following the breastfeeding episode) rather than a supplement (in place of a breastfeed) in order to maximize maternal breast stimulation and to maintain infant breastfeeding ability. To determine the feeding method used to provide supplement/complement feedings (i.e., bottle, cup, syringe, or feeding tube devices), careful consideration should be given to the ability of the mother and infant to use these devices. A feeding tube device allows delivery of expressed breast milk or formula while the infant is at the breast. The Lact-Aid (Lact-Aid International, Inc., Athens, TN) and Medela Supplemental Nursing System (Medela, Inc., McHenry, IL) are two commercially available feeding devices. To use these devices effectively, the infant must be able to latch onto the breast and the mother must be able to manage the device. The advantage of using a feeding tube device is the ability to simultaneously provide breast stimulation and deliver supplemental milk feedings.

Maximize Breast Stimulation and Complete Breast Emptying

Any potential infant suckling problems, such as poor latch or tight frenulum, should be assessed and corrected. When breast engorgement or nipple trauma/pain is present, proper treatment to alleviate the symptoms and promote maternal comfort and milk flow should be employed. Mechanical breast pumping with an effective hospital-grade breast pump following each breastfeeding should be initiated whenever a delay or failed lactogenesis is suspected. This practice serves to increase breast stimulation and promote complete breast emptying. Use of various galactagogues (e.g., metoclopramide, domperidone) have been shown to increase prolactin levels and milk production in some cases.[37] Although no published studies exist on the effectiveness of herbals, there are anecdotal reports of increased milk production with the use of fenugreek (1000-1500 mg three times daily).

Objective Measurement of Milk Intake During Breastfeeding

Subjective estimation of the volume of milk the infant receives during a breastfeed is inaccurate.[38] Test-weighing procedures are an important diagnostic and management tool in the early management of suspected delayed or failed lactogenesis II, and are essential in determining the infant's ability to transfer the available milk during breastfeeding and manage extra milk feedings.[39] The test weighing procedure involves weighing the clothed infant under exactly the same conditions before and after feeding with an electronic scale (accurate to at least 5 g), then subtracting the prefeed from the postfeed weight. With this procedure, 1 g of weight gain approximates 1 mL of milk intake. In situations where renting a scale is cost-prohibitive, weekly provider visits to assess breastfeeding patterns, volume of supplement, and postfeeding pumping volumes are recommended. Providing mothers with the ability to accurately measure and monitor their progress will serve to guide appropriate levels of supplementation and assessment of measures used to improve maternal milk volume.

Maintaining Feeding/Pumping Record

Having mothers maintain a simple record of daily feeding, pumping, and infant stooling and urination patterns may be useful to monitor their progress. This record can guide the plan of care to allow for modifications as breastfeeding improves (or not). For instance, the mother may see an increase in the amount of milk transferred by the infant during breastfeeding (by test weights) but no increase in postfeed pumped volume. Without the use of test weights, the mother might conclude that the postfeed pumping is not effective; however, her pumping efforts have served to stimulate milk production and breast emptying, and as a result, more available milk for the infant. As discussed previously, it is important to determine the ability of the mother to manage a specific plan of care. Whereas some mothers may find a simple feeding diary useful in monitoring her progress, others may find it cumbersome and stressful. As clinicians, it is important to recognize the most effective management strategy and individualize the plan of care based on each mother and her abilities.

Recognizing When Maternal Lactation Potential Has Been Reached

Helping the mother recognize the point at which she has reached her lactation potential is useful in providing a reassessment of her long-term breastfeeding goals. Recognizing when that potential is reached is the challenge. Assuming that the appropriate plan of care for the underlying cause(s) of a delayed or failed lactogenesis has been followed, an assessment of planned outcomes reached will guide continued management. Assessment of proportion of daily breastfeeding, supplements, and expressed breast milk volumes obtained from pumping will provide the clinician with the necessary information to determine when lactation potential has been reached. For example, when mechanical pumping postbreastfeeding and/or galactagogue administration results in no appreciable increase in milk production, the clinician can interpret that the mother has achieved her full lactation potential. Determining the extent to which each mother is able to provide her infant's feedings at breast or with expressed breast milk will give them a realistic plan as their infant develops. The clinician should be prepared for an emotional session with the mother at this point, especially for those who had a goal of exclusive breastfeeding. However, when the mother recognizes that all interventions have been exhausted and she has put forth the best effort possible, she is less likely to feel a sense of failure and loss and more likely to eventually feel successful.


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