Breastfeeding is a public health issue that has drawn the attention of organizations such as the American Academy of Pediatrics and the World Health Organization, both of which encourage exclusive breastfeeding (no foods or liquids other than mother’s milk) for the first 6 months of an infant’s life. In the United States, breastfeeding education, promotion, and support is available for an increasing number of mothers who give birth. Because of this, at last analysis, 76.9% of new mothers initiate breastfeeding—breastfeed their babies at least one time—in the hospital, but by the 6-month mark, 43.5% are breastfeeding at all and only 16.4% are exclusively breastfeeding (Centers for Disease Control and Prevention [CDC], 2012). In a study of over 1000 mothers, approximately 60% of them stopped breastfeeding earlier than they were planning to continue before their babies were born, and they cited concerns about difficulty with lactation, their babies’ nutrition or weight gain, their own illness or need to take medicine, and the effort required to pump breastmilk (Odom, Li, Scanlon, Perrine, & Grummer-Strawn, 2013).
Mothers’ concerns that lead them to stop breastfeeding earlier than the recommended time may be related to their expectations of how infants are supposed to behave. After generations of bottle-feeding, many families have lost the ability to pass along the wisdom and knowledge of how a normal, breastfed infant behaves. Without being taught about how long a normal, healthy baby can go between feedings, what typical sleep-wake patterns of a newborn are really like, and what babies do when they are first hungry (before they start to cry, which is a late-stage hunger cue) mothers may struggle to feel confident in their bodies’ ability to produce enough milk. Babies who are fed a breastmilk substitute typically space out feedings or sleep longer between feedings than those fed human milk because non-human milks are difficult for babies to digest. Mothers may perceive these normal needs to breastfeed more often, especially through the night, as a sign that their milk is not adequate, either in quality or quantity. This may lead to early, unnecessary supplementation, which may then be followed by a real decrease in milk production; the baby stays asleep longer while breaking down the less-digestible proteins in a breastmilk substitute, and the mother’s body does not receive the signal that more milk needs to be made (Walker, 2007). These misunderstandings, perhaps the result of incomplete or absent education about normal infant behavior or lack of availability of local breastfeeding support, often cause a mother to perceive a breastfeeding or lactation problem that may not actually be present.
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Perceived Insufficient Milk
Perceived low milk production, also called Perceived Insufficient Milk (Neifert & Bunik, 2013), is present when a mother is producing enough milk for her baby, but she believes she is not, often because she incorrectly assigns certain normal behaviors of her baby as hunger or dissatisfaction at the breast. There are several factors that can contribute to perceived lactation insufficiency. Socio-cultural influences, such as a worried, insistent grandmother who thinks the baby “just ate” and therefore can’t possibly need to feed again can undermine a mother’s confidence in whether she can satisfy her baby’s appetite. Mismanagement of breastfeeding through a scheduling regime, as is encouraged by popular “baby-training” programs such as On Becoming Babywise (Ezzo & Bucknam, 1995) and Growing Kids God’s Way (Ezzo & Ezzo, 1993) can also wreak havoc on how a mother is able to decipher her baby’s cues, since she is taught to watch the clock to determine when to feed the baby, not his signals that he is hungry. Normal lactation physiology, such as whether a woman believes her breasts are large enough, or whether she leaks milk, feels engorged, or experiences a sensation of “let down” when the milk begins to flow can also affect a mother’s perception of her ability to produce milk, even though these feelings are not predictive of milk output. The woman’s psychological state, especially if she is depressed or anxious about her ability to care for the infant she has given birth to, can contribute to perceived lactation insufficiency (Dykes & Williams, 1999). Without qualified, competent, consistent breastfeeding support in every community, it is difficult to truly assess how many mothers struggle with Perceived Insufficient Milk or a true inability to exclusively breastfeed their babies. Research does indicate a relationship between a perceived “difficult” infant temperament and less understanding of infant cues (McMeekin, Jansen, Mallan, Nicholson, Magarey, & Daniels, 2013)—a baby that is “fussy” or vocal about his needs may be perceived as hungry, even if he is not, and his mother may conclude that she is unable to produce enough milk for him. Even though we don’t always know whether a mother might have made enough milk with competent intervention and support, Perceived Insufficient Milk, including concerns about milk supply and whether the baby is growing enough, has consistently emerged among the most common reasons mothers introduce supplemental bottles of infant formula or stop breastfeeding altogether (Li, Fein, Chen, & Grummer-Strawn, 2008; Gatti, 2008; Ahluwalia, Morrow, & Hsia, 2005).
As we continue to identify risk factors for lactation insufficiency (variations in infant oral anatomy, hypoplastic breast appearance or insufficient glandular development, high pre-pregnant body mass index, insulin resistance, other hormonal irregularities), it is extremely important that mothers, whether they believe they are “at risk” or not, identify appropriate breastfeeding support before their babies are born. A prenatal breastfeeding class should teach all families how to recognize when breastfeeding is going well and what to do if it isn’t. Obtaining qualified, competent help early can make a huge difference in milk supply whether the problem is the result of inaccurate information about normal newborn behavior or an actual problem with lactation.
Podcast by Diana Cassar-Uhl: Low Milk Supply
Ahluwalia, I. B., Morrow, B., & Hsia, J. (2005). Why do women stop breastfeeding? Findings from the Pregnancy Risk Assessment and Monitoring System. Pediatrics, 116(6), 1408–1412.
Centers for Disease Control and Prevention. (2012). Breastfeeding report card 2012, United States: Outcome indicators. Retrieved from http://www.cdc.gov/breastfeeding/data/reportcard2.htm
Centers for Disease Control and Prevention. (2022). Breastfeeding report card 2022.
Dykes, F. & Williams, C. (1999). Falling by the wayside: a phenomenological exploration of perceived breast-milk inadequacy in lactating women. Midwifery, 15(4), 232-246.
Ezzo, G. & Bucknam, R. (1995). On becoming babywise. Parent Wise Solutions, Inc.
Ezzo, G. & Ezzo, A. M. (1993). Growing kids God’s way. Growing Families International Press.
Gatti, L. (2008). Maternal perceptions of insufficient milk supply in breastfeeding. Journal of Nursing Scholarship, 40(4), 355-363.
Li, R., Fein, S. B., Chen, J., & Grummer-Strawn, L. M. (2008). Why mothers stop breastfeeding: mothers’ self-reported reasons for stopping during the first year. Pediatrics, 122(Supp. 2), S69-S76.
McMeekin, S., Jansen, E., Mallan, K., Nicholson, J., Magarey, A., & Daniels, L. (2013). Associations between infant temperament and early feeding practices: A cross-sectional study of Australian mother-infant dyads from the NOURISH randomised controlled trial. Appetite, 60(1), 239-245. doi: 10.1016/j.appet.2012.10.005
Neifert, M. R. & Bunik, M. (2013). Overcoming clinical barriers to exclusive breastfeeding. Pediatric Clinics of North America, 60(1), 115-145. doi: 10.1016/j.pcl.2012.10.001
Odom, E. C., Li, R., Scanlon, K. S., Perrine, C. G., & Grummer-Strawn, L. (2013). Reasons for earlier than desired cessation of breastfeeding. Pediatrics,131, e726-e732. doi:10.1542/peds.2012-1295
Walker, M. (2007). Breast-feeding: Good starts, good outcomes. Journal of Perinatal and Neonatal Nursing, 21(3), 191-197.
About the Author:
Diana Cassar-Uhl, MPH, IBCLC, has supported breastfeeding families and healthcare professionals since 2005 as a La Leche League Leader, IBCLC, breastfeeding educator, and researcher. She is the author of “Finding Sufficiency: Breastfeeding with Insufficient Glandular Tissue,” which was published by Praeclarus Press in July of 2014. Though her academic and career pursuits keep her around Washington, DC, Diana’s home is in upstate New York, with her husband and three children.