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Breastfeeding "Failure"

When I had my first baby when I was 28 I failed at breastfeeding. I had no idea that this would happen, or really even could happen. I knew early on in my pregnancy that I would breastfeed, due to all of the known benefits of breast milk, and it never occurred to me that it would not work out.

Breastfeeding not only did not work out, it was a total disaster and left me with long-lasting feelings of guilt and shame. My beautiful daughter Grace could not latch on, even with the assistance and guidance of three lactation consultants, nipple shields, supplemental nursing systems, and trying over and over again for weeks and weeks. I ended up in a round-the-clock “triple feeding” routine (trying to feed her at the breast – then feeding with a bottle – then pumping).

Despite this, my baby continued to “fail to thrive” AND the extreme sleep deprivation I experienced from over 6 weeks of triple feeding almost killed me (I developed such severe postpartum depression that I almost took my own life). I fortunately got psychiatric help, Grace thrived on a special formula for babies with allergies, and is now a beautiful, intelligent, confident 15 year old.

I was recently asked to present at “Grand Rounds” for all of the pediatricians at the children’s hospital I work for. I decided that I would discuss “breastfeeding failure,” a problem that, although I once thought was rare, I have personally encountered in hundreds of other moms I have worked with through the years.

To my surprise, I've found that there is not very much information about breastfeeding failure out there. This is likely because there is not much research into this topic. It’s even a bit unclear what this problem-- not being able to breastfeed your baby despite trying your hardest -- should actually be called. I found all of these different alternative names for "breastfeeding failure" during an internet search:

· Lactation failure

· Delayed lactogenesis II

· Insufficient breast milk

· Breastfeeding insufficiency

· Lactation insufficiency

· Lactation dysfunction

· Failed lactation

· Lactation deprivation

· Dyslactogenia

· Lactastrophe -- I think this one, which I found on an Academy of Breastfeeding Medicine forum, is my favorite!

“Lactation failure” was coined in the 1980s by Ruth Lawrence, MD, from the University of Rochester. Dr. Lawrence is a world-renowned breastfeeding expert who is both the founder of the Academy of Breastfeeding Medicine (ABM) and is the author of the textbook “Breastfeeding: A Guide for Medical Professionals. ”

According to Dr. Lawrence:

“Lactation failure is not clearly defined in the literature and has been given a variety of definitions which can be summarized as: (a) failure of the breasts to produce minimum of milk for example 200 cc per day, (b) failure to thrive in the infant i.e. failure to sustain growth in a normal infant within 2 standard deviations of the norm for that infant, and (c) failure of the mother to achieve her pre-set goal for duration of lactation.”

So, now that we have a definition, what actually causes lactation (breastfeeding) failure?

Based on scant data, it’s estimated that some mothers will never be able to have a full milk supply due to certain medical conditions. These include insufficient glandular tissue (IGT) and breast hypoplasia. Per Marianne Neifert, MD, a breastfeeding medicine specialist, “As many as 5% of women may have primary insufficient lactation because of anatomic breast variations or medical illness that make them unable to produce a full milk supply despite heroic efforts.”

However, most women who struggle(d) to breastfeed, like me, who do not have IGT or breast hypoplasia. In most cases, breastfeeding challenges result from some combination of pregnancy, labor, and delivery risk factors and/or lack of necessary support.

The Medela website has a pretty comprehensive list of risk factors for delayed lactogenesis II (the onset of one’s breast milk “coming in” taking longer than 72 hours). Delayed lactogenesis II, which is estimated to affect 5-15% of postpartum mothers, is significantly associated with mothers being unable to exclusively breastfeed.

· Primiparity, especially older mothers. The mean age of first birth mothers rose from 24.9 years in 2000 to 26.3 years in 2014.

· Maternal obesity. 23.4% of women are obese before becoming pregnant.

· Diabetes. The prevalence of gestational diabetes mellitus (GDM) in the United States may be as high as 9.2%.

· Hypertension. Hypertension is the most common medical problem encountered during pregnancy, complicating 10% of pregnancies.

· History of breast surgery and breast hypoplasia

· Stressful labor and delivery

· Unscheduled cesarean section. The United States caesarean section rate has been reported to be 31.1%. Nearly half are unscheduled.

· Low perinatal breastfeeding frequency

· Psychosocial stress and/or pain

· Large for gestational age (LGA) infant

Although it was not listed on Medela’s website, I have also read that hypothyroidism (which I have) is a risk factor for delayed lactogenesis II.

According to a Stanford University webpage about breastfeeding failure,

“Most mothers are not prepared to experience any difficulties or problems when breastfeeding their first baby, and they are alarmed by commonplace issues.”

I know for certain that this (not being prepared to experience difficulty with breastfeeding) was true in my case 15 years ago. Based on all of the mothers and newborns I work with in the present day, I am pretty sure that the majority of women are still blindsided when breastfeeding does not work out as planned.

The first step in trying to solve this problem is to talk about the problem and increase awareness. Allison Steube, MD, the current president of the ABM, was done a wonderful job of speaking out about the problem of breastfeeding failure for a long time. Back in 2012 she stated the following:

The total burden of this problem is enormous, and mothers are suffering, whether they lack glandular tissue and or they lack self-efficacy and support. We need mothers for whom lactation doesn’t work to know that they are not alone. And we need to demand research to develop the tools that will identify the underlying problems and allow us to implement the appropriate treatment. We also need to step back from assertions that every mother can breastfeed, if she just tries hard enough.”

I am so grateful to Drs. Steube, Lawrence, Neifert, and all of the others who have discussed breastfeeding failure. It’s up to all of us to keep the conversation going. Not only to let other moms who are struggling with breastfeeding know they are not alone, but to demand that we dramatically improve support for all mothers in the U.S. via funding, research, public health initiatives, and improved maternity leave policies.

Let’s hope that we make better progress over the next 15 years than we did for the last 15 years. So that our own daughters and grand-daughters will never have to be in situations like many of us found ourselves in as first-time breastfeeding mothers and "lactastrophes" are few and far between.

Jessica Madden, MD

January 18, 2021

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