Factors that may cause or contribute to inadequate milk intake in young infants

Condition	Comments/explanation/examples	Management
Maternal
Breast surgery	Likely to affect milk production – Breast reduction using a technique that has a high risk of insufficient milk production. As an example, if the "free nipple" technique was used for breast reduction, breastfeeding is typically not feasible. Possibly may affect milk production – Breast augmentation. Unlikely to affect milk production – Breast biopsy.	Optimize breastfeeding technique and any other contributing factors, while monitoring infant's weight gain. Use pumping after feeds to increase milk supply. If infant's weight gain is inadequate, consider supplementation.
Nipple conditions	Sore nipples may decrease milk supply because of infrequent feeds or inadequate breast emptying.	Assess cause, and optimize nipple care and breastfeeding technique. Continue breastfeeding to stimulate milk production. Refer to UpToDate content on nipple pain during breastfeeding.
Medications associated with decreased milk production*	Combination oral contraceptive pills with high estrogen content. Pseudoephedrine. Nicotine. Diuretics. Antihistamines in high doses. Aripiprazole. Steroids (in high doses). Ethanol – Excessive use may decrease milk supply. Conversely, a small amount of beer may raise prolactin levels.	Optimize breastfeeding technique; consider alternative medication if possible. Refer to UpToDate content on postpartum contraception and to the LactMed database*.
Hormonal	Maternal stress, obesity, preeclampsia, hypertension, diabetes, hypothyroidism, PCOS, and elevated androgen levels can delay full milk production (lactogenesis II). Pituitary insufficiency due to postpartum pituitary infarction (Sheehan syndrome). Retained placenta.	Optimize breastfeeding technique while monitoring infant's weight gain closely. Assess for the cause, and treat if possible. The degree to which these factors affect milk production and ability to breastfeed varies with the cause and severity.
Other	Insufficient breast tissue due to congenital decreased glandular development.
Infant	Prematurity. Ankyloglossia. Neuromotor delay. Sucking and swallowing disorders. Malformations of the lip and palate, including cleft lip and/or palate.	Optimize breastfeeding technique; refer to a lactation consultant or other expert in swallowing disorders. For ankyloglossia, consider frenulotomy.
Mother and infant dyad	Delayed breastfeeding initiation. Separation of mother and infant. Poor latch. Infrequent feeding. One-sided feeding.	Room-sharing (including in the postpartum period). Optimize breastfeeding technique; refer to a lactation consultant if needed.

PCOS: polycystic ovary syndrome.

* Refer to the LactMed database for information on specific medications. LactMed, produced by the National Library of Medicine, is a free, authoritative reference for lactation compatibility for prescription and over-the-counter drugs. It provides data on drug levels in human milk and infant serum, potential adverse effects on breastfeeding infants and lactation, and recommendations for alternative drugs.

References:

Reilly S, Reid J, Skeat J, Academy of Breastfeeding Medicine Clinical Protocol Committee. ABM clinical protocol #17: Guidelines for breastfeeding infants with cleft lip, cleft palate, or cleft lip and palate. Breastfeed Med 2007; 2:243.
Thomas J, Marinelli KA, Hennessy M, Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #16: Breastfeeding the hypotonic infant. Breastfeed Med 2007; 2:112.
Academy of Breastfeeding Medicine. ABM clinical protocol #10: Breastfeeding the late preterm infant (34(0/7) to 36(6/7) weeks gestation) (first revision June 2011). Breastfeed Med 2011; 6:151.

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Factors that may cause or contribute to inadequate milk intake in young infants