Information for Providers

Definition

Chronic lactation insufficiency (CLI) or chronic low milk supply (CLMS): The production of less milk than is required to exclusively feed an infant for the duration of the breastfeeding relationship, despite following best practices and the adequate management of infant-side complications.

These best practices include support from lactation professionals including latch and positioning, frequent breastfeeding and/or pumping, and no separation of the lactating parent from the infant. Infant-side complications include issues with the infant's oral anatomy such as ties or cleft palate, prematurity, and any other issues that could affect oral motor skills and/or effective milk removal.

Prevalence

An estimated 5-15% of lactating parents experience chronic lactation insufficiency. (1)

Diagnosis

Evaluating parents with suspected CLI/CLMS (2): 

  • Rule out or manage short term issues such as:

    • Medications that can reduce supply (e.g. decongestants, estrogen, hormonal birth control, diuretics, antihistamines)

    • Pregnancy

    • Other known risk factors (see below)

  • Rule out infant-side issues, including infant health and issues of infant oral anatomy or function

  • Confirm that best practices for lactation are being followed

  • Consider conducting a weighted feed, which may be useful in estimating milk transfer. Weigh the infant before and after feeding. Do not change clothing or diaper between weights. If using a supply line, put it (with supplement) on the scale with the infant for both weights.

  • If no substantial improvement in supply is seen within 1-2 weeks of ideal management (including a period of triple feeding, if appropriate), investigate further risk factors/underlying conditions such as those listed below.

  • A diagnosis of CLI/CLMS is appropriate if, after ruling out/managing any health issues described below, the parent is not making adequate milk for the infant to thrive

  • Secondary low milk supply is also possible. Some parents make sufficient milk initially but milk supply fails to increase or later reduces

It is typically necessary to run lab work in order to rule out conditions underlying conditions that may impact milk supply. See risk factors and underlying conditions below for recommended blood work.

 

Support

  • Avoid dismissal of the impact of low milk supply, such as statements like “some people just can’t breastfeed” or “some women/parents just don’t make enough.”

  • Counsel parents that with proper management, it is possible to breastfeed long-term alongside supplementation. Providing some breast milk is likely to be beneficial.

  • Some patients may also need emotional and practical support in transitioning to exclusive formula or donor milk feeding. Remind them that their worth as a parent is not measured in the amount of breast milk they provide.

  • When establishing and revising management for low milk supply, the parent’s emotional and physical wellbeing should be carefully considered alongside the infant’s wellbeing.

  • Parents experiencing CLMS may need longer-term support (i.e. beyond 6 weeks postpartum)

  • Parents with CLMS may be at increased risk for postpartum psychiatric disorders or subclinical symptoms of these.

  • Wherever possible, support the parent in identifying possible underlying causes of their low supply.

  • If chronic conditions are discovered, make sure any treatment plans are manageable and appropriate for the postpartum period.

Support resources

  • Finding Sufficiency: Breastfeeding With Insufficient Glandular Tissue by Diana Cassar-Uhl (3)

  • Healing Breastfeeding Grief: How mothers feel and heal when breastfeeding does not go as hoped (4)

These resources are appropriate for sharing with patients as well as for providers interested in better understanding CLMS.

Parents with chronic low milk supply often struggle to find supportive and knowledgeable medical providers. Your empathy, compassion and understanding can make all the difference in that parent’s emotional journey.

Risk factors and underlying conditions in the parent

Chronic low milk supply has been associated with a number of conditions, including thyroid disorders, polycystic ovarian syndrome (PCOS), insulin resistance, hormonal imbalances, micronutrient deficiencies, and insufficient glandular tissue (IGT). (5–7)

Some parents with hypoplastic breast appearance can produce a full supply, while parents with insufficient supply and capacity can have a typical breast appearance. (3)

The following conditions may cause or increase risk of CLI and should be tested for/ruled out in patients experiencing LMS that does not resolve with management best practices:

  • Polycystic ovary syndrome (PCOS)

  • Thyroid (more commonly hypo, but hyper can also cause issues)

  • Diabetes or Insulin Resistance (IR)

  • Insufficient Glandular Tissue (IGT) - distinct from, but frequently associated with, breast hypoplasia

  • Breast surgery

  • Micronutrient deficiencies

  • Cystic Fibrosis

  • Also consider if the parent has any other major illness that may impact supply

Additional risk factors for delayed lactogenesis and short-term LMS, which could lead to CLI if not adequately addressed:

  • Blood loss, long inductions, cesarean sections, gestational hypertension

Common blood work to diagnose conditions impacting milk supply:

- Insulin Resistance: fasting glucose, fasting insulin, A1C. Consider 3-hour GTT with hourly insulin.

- Thyroid: TSH, Free T3, Reverse T3, Free T4, Anti TPO, Anti TG (for full panel, additionally: T4 Total, T3 Total, T3 Uptake)

- Prolactin: two blood draws. Baseline 2-3 hours after breastfeeding/pumping and then 30 minutes after beginning breastfeeding/pumping. Prolactin should double after feeding. Baseline reference ranges vary by time postpartum (8)

Other testing to consider:

  • Metabolic panel including cholesterol/lipids

  • HCT/HGB/ferritin

  • RBC Mag, RBC Zinc, 25 OH Vitamin D and Calcitriol

  • Progesterone

  • Testosterone (free and total)

  • DHEA-S

  • Vitamin A, Selenium, Copper, Ceruloplasmin

Lactation reference ranges for some of these tests differ substantially from lab reference ranges, see Marasco 2019. (8) Also, lactogenesis can be more sensitive to deviation from ideal ranges, even if within reference ranges. This is especially the case for insulin and thyroid hormones.

Management

Feeding

For dyads experiencing low milk supply, and especially chronic lactation insufficiency, it is critical to provide the infant with sufficient supplemental breastmilk or formula to allow them to grow and thrive. However it is also important to provide supplementation in such a way that it does not sabotage the parent’s milk supply and ideally supports continued breastfeeding. (9)

Tools for long-term supplementation:

  • Bottle feeding:

    • Slow flow nipple (preemie or newborn)

    • Paced bottle feeding and preferred nipple shapes (10) 

    • Smaller bottles - especially if used by a pumping/expressing lactating person with CLMS

  • Supply line at the breast, which may be effective in preventing/resolving bottle preference and in maintaining milk supply through more time at the breast. Common types include:

Types of supplementary milk:

  • Formula: provide guidance on preferred types for example protein content (11) and additional ingredients such as FOS, GOS, DHA etc.

  • Donor milk

Increasing milk supply

Breast Pumping and Triple Feeding (2)

  • Breastfeeding followed by supplementation (bottle/supply line) followed by pumping. This is often a first line intervention for LMS and may be effective for short-term LMS and infant-side issues

  • Providers should be aware that triple feeding is often prescribed without a clear endpoint. Where triple feeding has not resulted in increased supply within 1-2 weeks, it is likely not going to be effective

  • Triple feeding is extremely time-consuming. In cases of CLI, triple feeding may reduce supply because of reduced time at the breast and loss of sleep

  • Flange sizes should be appropriately fitted by measurement and assessing comfort

Methods of supporting milk production and extraction

  • Breast massage while breast pumping can increase the amount of milk expressed (12,13)

  • Warming the breasts during pumping has been shown can improve the efficiency of milk removal (14) 

  • Stress may inhibit the milk ejection reflex leading to insufficient milk production (15) 

  • Relaxation techniques such as deep breathing, gentle massage, having something enjoyable to eat or drink, and/or listening to their favorite music can help foster the milk ejection reflex (16,17)

    • A study from 1989 by Feher, Berger, Johnson, & Wilde found an increase in breast milk production for lactating people with babies in the NICU who used this audio galactagogue

Galactagogues (18–21)

Parents are likely to try galactagogues. Encourage an open dialogue so that patients feel comfortable revealing the medications and/or supplements that they are taking. Rather than simply discouraging galactagogue use, consider discussing risks and benefits of each and offering monitoring of patients in case side effects emerge. 

The following is an incomplete list of some of the more commonly used galactagogues. There is some evidence for the effectiveness of pharmaceutical galactagogues. There is little evidence for herbal galactagogues, though many herbal galactagogues have minimal risk of side effects. However, providers should be aware that some herbs may actually reduce supply in certain patient sub-populations. See notes and citations.

  • Pharmaceutical galactagogues

    • Domperidone (Motilium): increases prolactin, commonly prescribed for lactation outside the USA (e.g. Canada, UK, Australia) (22–24)

    • Metoclopramide (Reglan): increases prolactin, high risk of side effects (24)

    • Synthetic oxytocin spray:  promotes let-down, typically for short-term use, can cause dependency (25, 26)

    • Metformin: insulin-sensitizing, study showed inconclusive improvement, GI side effects dose-dependent (27)

  • Herbal galactagogues (28)

    • Alfalfa leaf capsules

    • Black Seed Oil or Nigella Sativa

    • Brewer’s Yeast

    • Fenugreek: contraindicated in individuals with hypothyroidism (29)

    • Goat's Rue

    • Lecithin (Sunflower or Soy)

    • Malunggay or Moringa Oleifera (29)

    • Shatavari (aka Wild Asparagus) (30)

  • Food and other supplements - likely ineffective

    • Additional water, coconut water and electrolyte drinks are unlikely to be effective unless the individual is dehydrated

    • Foods such as beer, oats are unlikely to be effective unless the individual is consuming insufficient calories/carbohydrates

    • Lactation cookies and brownies frequently contain much smaller amounts of herbal galactagogues than the recommended dosages. Unlikely to be effective unless the individual is consuming insufficient calories/carbohydrates

    • Many of these foods/supplements may be harmful in individuals who are experiencing insulin dysregulation and/or are sensitive to a high carbohydrate diet.

    • Placenta Encapsulation - some have argued that this may reduce supply because placentas contain progesterone

A note on contraception: counsel patients of the potential risks to milk supply of using hormonal contraceptives. Consider non-hormonal options (copper IUD, diaphragm, condoms (internal or external), spermicide) or low dose options such as progesterone-only pill or low dose LNG IUD. If prescribing any hormonal contraceptives, counsel parents to monitor for supply changes.

References

1. Lee, S. & Kelleher, S. L. Biological underpinnings of breastfeeding challenges: the role of genetics, diet, and environment on lactation physiology. Am. J. Physiol. Endocrinol. Metab. 311, E405–22 (2016).

2. Riddle, S. W. & Nommsen-Rivers, L. A. Low milk supply and the pediatrician. Curr. Opin. Pediatr. 29, 249–256 (2017).

3. Cassar-Uhl, D. Finding sufficiency: breastfeeding with insufficient glandular tissue. Amarillo: Praeclarus Press, LLC (2014).

4. Jacobson, H. Healing Breastfeeding Grief: how mothers feel and heal when breastfeeding does not go as hoped. (Rosalind Press, 2016).

5. Neifert, M. et al. The influence of breast surgery, breast appearance, and pregnancy-induced breast changes on lactation sufficiency as measured by infant weight gain. Birth 17, 31–38 (1990).

6. Cromi, A. et al. Assisted reproductive technology and breastfeeding outcomes: a case-control study. Fertil. Steril. 103, 89–94 (2015).

7. Baker, J. L., Michaelsen, K. F., Sørensen, T. I. A. & Rasmussen, K. M. High prepregnant body mass index is associated with early termination of full and any breastfeeding in Danish women. Am. J. Clin. Nutr. 86, 404–411 (2007).

8. Marasco, L. Making More Milk: The Breastfeeding Guide to Increasing Your Milk Production, Second Edition. (McGraw Hill Professional, 2019).

9. Kellams, A. et al. ABM clinical protocol #3: Supplementary feedings in the healthy term breastfed neonate, revised 2017. Breastfeed. Med. 12, 188–198 (2017).

10. Kassing, D. Bottle-feeding as a tool to reinforce breastfeeding. J. Hum. Lact. 18, 56–60 (2002).

11. Lower protein in infant formula is associated with lower weight up to age 2 y: a randomized clinical trial. Am. J. Clin. Nutr. 89, 1836–1845 (2009).

12. Jones, E., Dimmock, P. W. & Spencer, S. A. A randomised controlled trial to compare methods of milk expression after preterm delivery. Arch. Dis. Child. Fetal Neonatal Ed. 85, F91–5 (2001).

13. Morton, J. et al. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. J. Perinatol. 29, 757–764 (2009).

14. Kent, J. C., Geddes, D. T., Hepworth, A. R. & Hartmann, P. E. Effect of Warm Breastshields on Breast Milk Pumping. Journal of Human Lactation vol. 27 331–338 (2011).

15. Geddes, D. T. Inside the lactating breast: the latest anatomy research. J. Midwifery Womens. Health 52, 556–563 (2007).

16. Mohd Shukri, N. H., Wells, J. C. K. & Fewtrell, M. The effectiveness of interventions using relaxation therapy to improve breastfeeding outcomes: A systematic review. Matern. Child Nutr. 14, e12563 (2018).

17. Gómez, L. et al. Perinatal psychological interventions to promote breastfeeding: a narrative review. Int. Breastfeed. J. 16, 8 (2021).

18. Brodribb, W. ABM clinical protocol #9: Use of galactogogues in initiating or augmenting maternal milk production, second revision 2018. Breastfeed. Med. 13, 307–314 (2018).

19. Foong, S. C. et al. Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non‐hospitalised term infants. Cochrane Database Syst. Rev. (2020) doi:10.1002/14651858.CD011505.pub2.

20. Donovan, T. J. & Buchanan, K. Medications for increasing milk supply in mothers expressing breastmilk for their preterm hospitalised infants. Cochrane Database Syst. Rev. CD005544 (2012).

21. Grzeskowiak, L. E., Wlodek, M. E. & Geddes, D. T. What Evidence Do We Have for Pharmaceutical Galactagogues in the Treatment of Lactation Insufficiency?—A Narrative Review. Nutrients 11, 974 (2019).

22. Paul, C. et al. Use of domperidone as a galactagogue drug: a systematic review of the benefit-risk ratio. J. Hum. Lact. 31, 57–63 (2015).

23. Haase, B., Taylor, S. N., Mauldin, J., Johnson, T. S. & Wagner, C. L. Domperidone for Treatment of Low Milk Supply in Breast Pump–Dependent Mothers of Hospitalized Premature Infants: A Clinical Protocol. J. Hum. Lact. 32, 373–381 (2016).

24. Ingram, J., Taylor, H., Churchill, C., Pike, A. & Greenwood, R. Metoclopramide or domperidone for increasing maternal breast milk output: a randomised controlled trial. Arch. Dis. Child. Fetal Neonatal Ed. 97, F241–5 (2012).

25. Fewtrell, M. S., Loh, K. L., Blake, A., Ridout, D. A. & Hawdon, J. Randomised, double blind trial of oxytocin nasal spray in mothers expressing breast milk for preterm infants. Arch. Dis. Child. Fetal Neonatal Ed. 91, F169–74 (2006).

26. Cowley, K. C. Psychogenic and pharmacologic induction of the let-down reflex can facilitate breastfeeding by tetraplegic women: a report of 3 cases. Arch. Phys. Med. Rehabil. 86, 1261–1264 (2005).

27. Nommsen-Rivers, L. et al. Feasibility and Acceptability of Metformin to Augment Low Milk Supply: A Pilot Randomized Controlled Trial. J. Hum. Lact. 35, 261–271 (2019).

28. Budzynska, K., Gardner, Z. E., Low Dog, T. & Gardiner, P. Complementary, holistic, and integrative medicine: advice for clinicians on herbs and breastfeeding. Pediatr. Rev. 34, 343–52; quiz 352–3 (2013).

29. Bazzano, A. N. et al. A Review of Herbal and Pharmaceutical Galactagogues for Breast-Feeding. Ochsner J. 16, 511–524 (2016).

30. Alok, S. et al. Plant profile, phytochemistry and pharmacology of Asparagus racemosus (Shatavari): A review. Asian Pacific Journal of Tropical Disease3, 242–251 (2013).

Last updated August 7, 2021.