Blog 8: Is it something about your breasts?

Of all the causes of low milk production, those due to an inherent primary problem with your breasts or physiology can be the most mysterious and frustrating. It may be difficult to tell if the root issue is temporary or long-term Those that are short-term usually resolve on their own so long as breastfeeding continues to be managed well. Long-term primary problems result from either anatomical causes, such as breast structure problems, or physiological causes, which are often related to genetic or hormonal dysfunctions. This Blog delves into the known anatomical factors that can affect milk production, while Blog_9 discusses physiological factors. If nothing you’ve read so far seems to fit, these Blogs may shed more light on your situation.

The Milk Supply Equation

Suicient glandular tissue

+ Intact nerve pathways and ducts

+ Adequate hormones and hormone receptors

+ Adequately frequent, effective milk removal and stimulation

GOOD MILK PRODUCTION

Do you have any of the following risk factors for anatomical problems:

  • Breast or chest surgery or medical procedures, even as an infant Injury to your chest during childhood or adolescence
  • Damage to any nerves or a spinal cord injury Unusual breast or nipple features, such as one breast being much smaller than the other or a nipple that’s divided into two sections
  • Little or no breast tenderness or changes during pregnancy or after birth
  • A chronic illness or condition.

Anatomical Variations

 Nature doesn’t always form every part of our bodies perfectly. Anatomical variations also can result from accident, disease, illness, or surgery. Whatever the cause, structural problems with your milk factory can affect milk production.

Making a “breast sandwich” can help some ba- bies to latch, stay on, and get more milk

Flat and Inverted Nipples

Your baby is hardwired to seek the firm nipple on the “top of the hill” by rooting and feeling the landscape of the breast with his cheek. A “flat nipple that doesn’t protrude much congenitally or because of postpartum edema is confusing and harder to sens more easily by placing your fingers on one side of the breast and your thumb on the other about two inches back from the nipple and compressing lightly to form a “sandwich” that lines up with baby’s mouth. Pressing your index finger up into the breast and outward can push some inverted nipples out farther; this technique is in formally referred to as the nipple nudge. ThiS may need to be maintained while baby nurses.

Around 3 percent of women have congenitally inverted nipples that pull back into the breast. This is caused by either exceptionally short milk ducts or fibrous adhesions that constrict the nipple, drawing it inward. Women with inverted nipples tend to have more problems with milk production, usually because the baby has difficulty latching and drawing out milk. In some cases, there may be fewer ducts, or the ducts are obstructed. Occasionally, breasts with inverted nipples may have other structural problems as well.

Some nipples appear inverted, but when the areola directly behind them is gently compressed, they protrude fairly easily. After a few weeks of breastfeeding, they typically remain everted until weaning. True inverted nipples pull inward when the areola behind them is compressed. Of these, some can be manually pulled out, at least momentarily. Others are firmly tethered in the breast and can’t be pulled ut at all. Both types of true inversions are tricky for babies to learn to attach to, but tethered nipples cause the most problems. They may not drain well or at all, even for a good breast pump In such cases, little can be done, and the breast will eventually dry up.

Inverted nipples can be surgically released, but only when you are neither pregnant nor lactating. The ability to breastfeed afterward depends on the underlying cause of the inversion any nerve damage from the surgery and the healing process. An inversion caused by fibrous adhesions can be released without affecting milk production capability. However, surgery for an inversion caused by short ducts severs the ducts, making it difficult for milk to exit unless they reconnect over time. A nonsurgical option for treating inverted nipples is the Avent NipletteT, which creates sustained suction in a small cup worn inside the bra for several hours at a time. This has been reported to correct both types of inverted nipples but requires at least one to three months, ideally before the last trimester of pregnancy.

Once baby is here, your two goals are to help him latch and to keep the milk moving. First, try reverse pressure softening if there is any edema (SEE _BLOG_11). Then, see if you can gently pull your nipple out by pushing your fingers deep into your breast and finding the sides or “back” of the nipple shank. You can also use the Maternal Concepts Evert-It Nipple Enhancer to do this, or you can use a periodontal syringe with the tip end cut off and the plunger inserted so that the smooth side is against you. Pumping for a minute or two may also draw out the nipple, but this may cause the areola to swell, creating a bulb of tissue that may be too large for baby to latch to. Whichever you try, once you let go, the nipple will usually retract quickly, so you’ll have to work fast to get baby latched.

When all else fails, a properly sized silicone nipple shield can create an artificial nipple to help baby latch, so long as your actual nipple can be pulled out a little and isn’t tethered. Invert the dome of the nipple shield halfway, then press the flat part of the shield on the areola.

The dome should pop back into shape, drawing the nipple partially into it to increase baby’s effectiveness. Before baby latches, compress your breast behind the shield to express some milk into the dome to encourage him to suck. (You can also inject milk through a hole with a periodontal syringe.) Make sure the latches as deeply as possible! Finally, pump after feedings to thoroughly drain the breasts because it can be difficult for a baby to remove milk effectively with a nipple shield in this situation. A shield is usually temporary until the baby learns to trust the breast and latch easily.

Unusually Shaped Nipples

Nipples are generally round and cylindrical but can also come in unusual shapes such as bumpy elongated, or separated into two distinct parts Most nipples still work normally but if they are partially or completely nonfunctional, lack of milk removal usually leads to an unavoidable shutdown in production.

Large Nipples

If you naturally have large nipples or started with normal-sized nipples that enlarged after years of nursing, baby can have trouble latching When the mismatch is too great, baby can’t get his mouth around the nipple and deep enough onto the areola to adequately draw milk. Deanne Francis, B.S.N., IBCLC, wittily refers to this condition as “oro-boobular disproportion.” The solution is to feed the baby by an alternative method and pump-you’ll need extra large flanges-until his mouth grows bigger. Latch him periodically until he can do it comfortably and remove milk well. If he has trouble returning to the breast, see “Breast Refusal” in BLOG_4 or contact a lactation consultant.

Nipple Piercings

Although some babies don’t seem to like a breast that has piercing scars, nipple piercings aren t usually a problem for milk production; if anything, they may add additional outlets in the nipples. (Removal of any nipple rings or bars dur ing feedings is recommended, of course.) How- ever, unusual or extensive scarring due to infec tions or poor piercing technique could obstruct milk flow. If this happens, there isn’t anything you can do to fix it; the lobes that can’t drain will eventually dry up. Pumping and galactogogues can help you get the most from the usable areas Areolar piercings can also cause damage to the nerves that affect milk ejection (see BLOG_10 and BLOG_11 for methods to stimulate milk ejection)

Breast Structure

Two basic breast structure issues can affect milk production. Tissue density is the relative elasticity and compressibility of the breast, areola, and nipple, ranging from very firm to jello-soft. Glandular development refers to the overall amount of milk-making tissue. Soft Breast Tissue.

Soft Breast Tissue

Soft, flaccid breast tissue can be difficult for some babies to grasp. In some instances, the skin is so loosely attached to the underlying gland that baby has mostly skin in his mouth and can’t extract milk efficiently. Firmly shaping the breast and pulling back toward your chest wall to tighten the skin against the gland can help baby get his mouth around the milking area. Or try the “nipple nudge” described earlier in this blog to make the nipple and areola stick out farther, Holding baby against your side with his feet pointing behind you may align him to latch more easily. Breast compressions are usually;y necessary to remove all of the available milk to keep up your supply.

Insufficient Glandular Tissue

Women with small breasts often worry that they don’t have enough milk-making tissue, but smaller breasts don’t necessarily mean there’s less tissue any more than having large breasts means there’s more. It isn’t the outer size of the breasts that matters, but rather the amount of glandular tissue inside them. This starts with a healthy basic tree in place before pregnancy and then having that tree respond to the pregnancy with new growth. True insufficient glandular tissue, or mammary hypoplasia, usually refers to the state of the breasts before pregnancy and typically involves a lack of fullness in part or all of the breast. Small breasts may look peripubertal, as if they never completed puberty, and are often less than an A cup with little palpable tissue, Larger hypoplastic breasts may look “deflated” or have an unusually long tubular or bowed Shape, with the nipples pointing down or away from the body. One side may be much larger than the other, known as asymmetric. There may also be stretch marks that aren’t related to pregnancy or adolescent growth.

 Decreased development usually results in more flat space between the breasts; greater than 1.5 inches (4 centimeters) is considered higher risk for milk supply problems. The are- olas may also be disproportionately large and “bulbous,” almost as if they’re a separate struc- ture attached to the breast. Most telling, affected women usually experience few, if any, breast anges during pregnancy and have difficulty identifving when the breasts start making milk after birth.4 However, more mammary growth may occur after birth if there is frequent milk removal and stimulation. The permanence of hypoplasia is discussed in more detail in the next blog.

A fair question to ask is why some breasts would be hypoplastic at all; it certainly isn’t common in nature when survival depends on our ability to nourish our young, Is it congenital? Is it hormonal? Is there another cause? We simply don’t know yet. Some mothers say that their breast shape” runs in the family,” which suggests a hormonal-genetic component, while others have no close relatives with hypoplasia. As discussed in BLOG_9, women with polycystic ovary syndrome (PCOS) have hormonal problems that sometimes affect breast development. Breast hypoplasia seems to have been rarer in the past but may now be increasing. Why might this be?

Hvpoplasia variations: A-incomplete development before puberty; B-poorly developed upper portion, scant lower tissue; C-tubular with bulbous areola; D-long, bowed to outside, with extra-large areola; E-classic wide-spaced and uneven; F-wide-spaced with scant tissue.

Environmental research may shed light on at least part of this mystery. Common contaminants in our environment can bind in place of regular hormones to hormone receptors, potentially altering normal hormonal function. Exposure to organochlorines, such as TCDD and DDE, or to substances like BPA and PCBs has been found to stunt mammary gland development in rats, and there are reports of poor glandular development or early weaning, presumably due to poor milk production, in women living in heavily exposed areas. In some cases, the breasts looked normal, but the glan dular tissue inside was spotty or scant. The less glandular tissue there is, the less milk can be produced. With hard work, many women are able to improve their supplies significantly, while others seem to hit a ceiling quickly.7One of the biggest hurdles is getting enough stimulation since not all babies will continue to suck vigorously when milk flow is low. At-breast supplementation is an ideal strategy to encourage vigorous suckling while simultaneously feeding the baby. Breast compression also helps baby drairn the breast more thoroughly. Additional pump ing after a feeding coupled with more breast compression helps complete breast drainage and provides the extra stimulation that is ofter needed to continue stirnulating hormones and receptors.

Galactogogues can make a difference but are often disappointing, perhaps because expecta- tions tend to be high! The best herbal choices are those that have a dual reputation of also stimulating mammary growth, such as goat’s rue (BLOG_12). Prescription galactogogues superstimulate the existing tissue. Good results for either depends in part on how much functional breast tissue there is to work on.

With few exceptions, most mothers who have had breast surgery (either for cosmetic or medical reasons) are able to produce some amount of milk, so the question is not if you will produce milk, but rather how much milk you will be able to make. This is determined by the amount of damage to the ducts and nerves, the functionality of the milk glands prior to surgery, the healing process, the amount of time since the surgery, and any other lactation experiences between the surgery and current baby. Scarring or the complication of an infection may have an effect on lactation, depending on the extent.

 Ducts are able to regenerate over time in response to the stimulation of pregnancy and lactation. If you had a partial milk supply with your first baby, you may find that you get progressively more milk with each subsequent baby, sometimes even a full supply. The subtle stimulation from each menstrual cycle also plays a role in this regeneration process, so the more time between babies, the better.

The number of genetically determined ductal openings in the nipple makes a difference. The average number is nine but can be as few as four.3 A woman with nine openings can afford to lose a couple when ducts are severed during surgery, and the milk will still be able to get out, but a woman with only four can’t afford to lose any because some areas of her breast may no longer have an outlet. There isn’t an easy way to know how many openings you have because they’re very small and don’t drain at the same time.

When your milk comes in around the third or fourth day after birth, you may be warned about a risk of breast infection from the milk behind severed ducts that “has nowhere to go.” This is highly unlikely and is almost never seen in reality. Milk that builds up behind the severed ducts triggers production shutdown and involution of the milk-making cells in the immediate area. Meanwhile, the unaffected areas of the breast will continue to function and work even harder so long as the milk is removed from them.

 Like ducts, nerve fibers can also regenerate. The most critical nerve to lactation is the fourth intercostal nerve, which is generally located around the four o’clock position facing the left breast and the eight o’clock position facing the right. It is the primary carrier of messages to the brain for the release of prolactin and oxytocin and when injured, milk ejection doesn’t happen as easily.9 Unlike ducts, nerve regeneration is not influenced by lactation, past or current, but grows at a consistent rate of 0.04 inches (1 millimeter) per month after an initial period of repair. The normal response to touch and temperature indicates that the nerve network is improving, although the healing process can vary, and it’s possible that your nipples may never regain all of their previous sensitivity and functionality. The longer it’s been since the surgery, the greater the chances that the critical nerves have regenerated to their ultimate potential. BLOG_10 discusses ways to stimulate or enhance milk ejections.

Nerves that directly affect the breast and lactation

Biopsies that remove samples of breast tissue, aspirations to remove infectious or suspicious fluids from the breast, and removal of tissue such as lumps have the potential to interfere with lactation, although the impact is usually mild. Ducts or nerves may be severed, depending on where and what direction the surgeon cut. Incisions that are oriented toward the nipple like the spoke of a wheel reduce the likelihood of damaging nerves and ducts.

One of the most vulnerable periods for significant damage from any surgerv 1s prior tO puberty when the immature mammary gland is very small. Invasive cuts during that time car interfere with a greater number of ducts and nerves simply because they are closer together, eventually affecting the internal structure of the breast as it matures .

Breast Lift

Breast lift surgery repositions the breasts to reduce sagging without removing breast tissue, resulting in fuller, rounder, and higher breasts Breast implant surgery is often performed at the same time to further increase breast fullness Breast lift surgery alone doesn’t usually affect milk production because no glandular tissue is removed and the incisions are not usually deep  enough to sever critical nerves.

Breast Implants

Breast implants, or augmentation, is a common cosmetic procedure undertaken for many reasons: to enhance appearance, to correct abnormalities, or for reconstruction after other breast surgery. Augmentation surgery can affect your milk-making capability depending on the entry location and the placement of the implants. An incision around the areola, particularly in the lower, outer portion, is likely to reduce nerve response to the nipple and areola. A large implant can also reduce nipple and areolar sensitivity.11 An implant positioned directly under the glandular tissue is more likely to put pressure on the tissue and obstruct milk flow, resulting in reduced milk production over time compared with an implant positioned under the chest muscle away from the tissue.12 Another important factor to consider is the reason for your surgery. If your breasts were unusual in shape, perhaps lacking the normal amount of glandular tissue, the cause of low milk supply, later on, could have more to do with a smaller amount of milk making tissue than the surgery you had to even them out.

Breast Reduction

Breast reduction surgery reduces milk production capability in most cases because it removes mammary tissue and damages nerves. The techniques that harm production the least are those in which the areolae and nipples are not completely severed, even though they may have been moved, such as in the liposuction and pedicle” surgeries. With most reduction surg- eries, though, there is likely to be some damage to the ducts and nerves as a result of deep cuts in the breast tissue. The amount of milk made after reduction surgery varies tremendously, ranging from very little to full production.

Infections

Lactation is a robust process, but when your health is compromised, milk production can suffer as well. Serious infections or conditions, especially life-threatening ones, may cause your body to cut back on production in order to divert more energy into healing. As long as stimulation and milk removal continues, your supply usually comes back as your condition improves. The milk is almost always safe for baby during treatment. On rare occasions, breast tissue damage from an abscess, extremely prolonged engorgement, or severe mastitis may account for some otherwise inexplicable cases of low milk production.

Injuries

Various injuries have the potential to interfere with milk production by damaging glandular tissue or critical nerve connections, The types of injuries that are described next are the most likely to cause problems with milk production.

Spinal Cord Injuries

The nerves that supply the breast enter the spinal cord in the middle of the back at the T3, T4, T5 and T6 vertebrae, in the thoracic region. Spinal injuries below this should not affect milk production directly, but injuries above T6 carry the potential to cause problems A complete injury results in the loss of all motor and sensory function at the level of the injury and below, while an incomplete injury may allow for some sensory or motor function at the level of the injury or below.12 Spinal cord injuries are a concern for breastfeeding because they interfere with the normal messages sent by the suckling baby to the brain that stimulate the release of prolactin and oxytocin. It has generally been accepted that injuries above T6 usually result in a decrease in milk production between six weeks and three months. But a recent report may shed light on why the decreases occur and what compensations are possible. Three women had neck injuries resulting in paralysis of both lower and upper body. Two were first-time mothers, while the third had successfully breastfed a baby before her injury. In each case, their milk came in normally, but milk ejection wasn’t consistent. To compensate, some learned to bypass the physical and rely on the secondary emotional pathway of mental imaging and relaxation to elicit milk ejection, often multiple times during the feeding. Oxytocin nasal spray was also used for the same purpose. Both of these strategies helped the babies to get more milk and the mothers to sustain higher milk production for a longer time.

Blunt Force Trauma

Blunt force trauma occurs when the body is suddenly impacted by an object with great force. Breast tissue can be damaged, such as during a bad car accident when a seat belt across the chest crushes the breast and causes bruising. Dam age from blunt force trauma may be intensified in young girls and teens whose breasts haven’t started or completed development. Imagine dropping a rock on a flower, then dropping the same rock on a flower bud. The fully bloomed flower may be bruised, but not all of it will be harmed. The bud, however, is smaller and more completely crushed, and it may never bloom normally. The potential damage to breast tissue before and after puberty is similar, but each case is individual. If the side you were hurt on has lower milk production, your injury is a likely cause of the problem. This may be a permanent condition, but most mothers should be able to make enough milk with the undamaged breast to compensate. You may find that the higher producing breast becomes larger because it is doing most of the work. It’s a temporary inconvenience that will gradually diminish throughout lactation and weaning.

Burn Trauma

Damage to the breast tissue from burns on your chest varies depending on when it happened, how deep the burn went, and the extent of scarring. If the burn wounds were superficial, scarring is probably the biggest problem with possible blockage of the nipple pores and poor elasticity of the skin that can make latching more difficult. Deeper wounds may destroy milk-making tissue. Burn injuries to a young girl’s chest can damage the undeveloped gland and prevent normal growth later on. A lactation consultant can help you strategize and work around the damage as much as possible.

Muscular-Skeletal Problems

A variety of situations ranging from accidents to repetitive motions can result in subtle muscular- skeletal problems that can impinge nerves and obstruct lymphatic and blood flow, resulting in areas of numbness, tingling, or other unusual symptoms. This may reduce the sensations that trigger hormones, or a kink elsewhere in the nerve pathway might prevent messages from getting to the brain. If you’ve had such symptoms and your milk supply problem doesn’t seem to have another cause, it may be worth exploring the possibility of a mechanical interference with a chiropractor, doctor of Chinese medicine, or another holistic practitioner. See_blog 11