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 login to view 5 more bullets milk production is associated with maternal well-being login to view 2 more bullets 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 login to view 6 more bullets poor infant milk extraction login to view 2 more bullets 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 login to view 1 more bullet engorgement plugged ducts login to view 1 more bullet nipple and breast infections login to view 5 more bullets excessive milk supply login to view 1 more bullet nipple or areolar dermatitis