Snapshot A 28-year-old G1P1 woman presents to her primary care physician with evaluation of low supply of breast milk. She is a first time mother and had previously been evaluated by a lactation consultant. Her 8-week-old baby had been feeding and gaining weight well until the past 2 weeks, when the mother observed less wet diapers and a decreased volume of milk that she was able to pump. The woman notes that she had a normal course of pregnancy with no complications and had an unremarkable labor and delivery. Her breast examination in the clinic today is normal. Introduction Overview breastfeeding is recommended for newborn infants as breast milk provides the ideal nutrition for the baby to grow and has benefits for both the baby and the mother Physiology lactogenesis begins in late pregnancy copious milk secretion begins around day 2-3 after birth endocrine control switches to autocrine (supply-demand) control mammary gland receives hormonal signals, which ↑ in direct response to stimulation of the nipple and areola (through the infant's suckling) lactation occurs with help of 2 hormones - prolactin and oxytocin prolactin is secreted by the anterior pituitary decreased GnRH release can lead to amenorrhea oxytocin is secreted by the posterior pituitary milk production is associated with maternal well-being ↑ levels of dopamine and norepinephrine inhibit prolactin synthesis stress and fatigue may ↓ a woman's milk supply galactopoiesis occurs after 9 days after birth, maintaining milk secretion involution occurs around 40 days after last breastfeeding milk secretion ↓ with the buildup of inhibiting peptides Contraindications Active, untreated tuberculosis Active varicella infection within 5 days before delivery or 2 days after delivery Untreated brucellosis Maternal infection with HIV or Ebola Herpetic lesions of the bresat Active abuse of illicit drugs including PCP and cocaine Methadone use as part of a supervised clinic is not a contraindication Infants with classic galactosemia Epidemiology Incidence among infants born in the US in 2015, over 80% of babies started out breastfeeding Complications Inadequate milk intake possible contributing factors inadequate maternal milk production previous maternal breast surgery maternal medications that interfere with establishment of milk supply oxytocin selective serotonin reuptake inhibitors dopamine agonists (i.e., bromocriptine) estrogen-containing oral contraceptives poor infant milk extraction oral-motor, neurologic, abnormalities, or anatomic abnormalities (i.e., cleft palate) feeding difficulties due to prematurity Breast milk jaundice persistence of benign neonatal hyperbilirubinemia beyond the first 2-3 weeks of age Lactation failure jaundice lactation failure leads to ↓ neonatal fluid and calorie intake, leading to hypovolemia and weight loss, which then results in hyperbilirubinemia and jaundice late preterm infants (gestational age between 34-36 weeks) have ↑ risk of difficulty establishing successful breastfeeding compared to term infants Nipple and breast pain possible contributing factors nipple injury due to inadequate infant latch-on nipple vasoconstriction cutaneous vasospasm may occur in mothers with Raynaud phenomenon or cold sensitivity engorgement plugged ducts due to localized areas of milk stasis within the ducts that cause distention of mammary tissue nipple and breast infections lactational mastitis presents with fever and a firm, red, and tender area of one breast breast abscess often preceded by mastitis presentation similar to mastitis, with an additional tender and palpable mass excessive milk supply may be caused by drugs that ↑ milk production (i.e., dopamine antagonists and certain herbs, such as fenugreek) nipple or areolar dermatitis