A New Day Dawns in Breastfeeding Practice and Research – Part II

“Just Keep Swimming”

By: Gloria Dudney, RN, IBCLC, RLC

“When life gets you down, just keep swimming”, Dory, in Finding Nemo teaches us.  In many ways, we nurses are the cheerful “Dorys” to our ocean full of frightened “Marlins” who are on their own perilous and frustrating journeys to rescue their precious children.  Often, life has them down.  Nothing is going as they pictured: their pregnancies, their deliveries, and now their breastfeeding journeys.

So, in our quest to swim alongside our patients, helping them navigate discouraging moments and significant challenges, how can we best serve them when it comes to feeding their precious little one?  As mentioned in Part I, we have been gifted with a cache of research that begins to illuminate the mysterious leagues of the Sea of Insufficient Milk Production and suggests some evidence-based strategies for mitigating the saboteurs of breastfeeding progress in the first 14 days post-delivery.

Examining the Evidence in the Special Issue 

In July, the Academy of Breastfeeding Medicine’s journal published a special issue entitled “Early, Unplanned Cessation of Lactation in Healthy and At-Risk Dyads: Priorities for Research and Practice.”

https://www.liebertpub.com/toc/bfm/20/7

Provided for you here is a miniature literature review with key concepts, statistics, and highlights from the special issue.  Also included is a glossary of terms for your reference, as needed.

Glossary of Terms from the Special Issue 

BMI = body mass index

CTV = coming to volume, pumping ≥ 500 ml/day of MOM

HDP = Hypertensive disorders of pregnancy

MOM = Mother’s own milk

Na concentration = one of the four biomarkers of SA achievement; can be measured with POC technology (pocket-size ion electrode sensors that retail around $400); should decrease as paracellular pathways close and milk begins to transition; studies in the current issue of Breastfeeding Medicine indicate that a Na concentration of < 12 mmol/L indicates SA achievement in healthy term infants1 and < 16mM indicates SA achievement in pump-dependent mothers of preterm (<33 weeks) infants.11

Opportunity Cost = maternal time invested in pumping rather than doing other paid and unpaid work12

SD = secretory differentiation in breast tissue is the process during pregnancy where mammary epithelial cells become specialized milk-producing cells, known as lactocytes.  This process prepares the breast for lactation and is the first stage in milk production, also known as stage I lactogenesis.

SA = secretory activation in breast tissue, also known as Stage II lactogenesis, is the process where the mammary glands transition from producing colostrum to mature milk after childbirth. It’s characterized by a significant increase in milk volume, often accompanied by breast fullness and swelling, and is driven by hormonal changes and the removal of the placenta. 

(Delayed) SA = DSA refers to a delay of >72 hours in the onset of copious milk production after giving birth.

Statistics and Highlights from the Special Issue and its Supporting Literature

  • 34% incidence of delayed secretory activation in the general breastfeeding population in the United States1,2
  • 60% incidence of early, unplanned lactation cessation in the general breastfeeding population 3,4
  • 20% decrease in exclusive breastfeeding rate during first 7 days (84% to 64%)3,5
  • The most frequently reported reason for early, unplanned cessation of lactation in both term and preterm population is insufficient mothers’ own milk (MOM), real or perceived, within the first 14 days postpartum.1,3,6,7,8,9
  • In a preterm cohort, mothers with HDP were less likely to achieve SA, mothers with higher BMI were less likely to achieve SA despite pumping as frequently as lower BMI mothers and only 44% achieved CTV with BMI value as a negative predictor.9
  • Dr Eglash in her commentary offers anecdotal evidence that mothers with elevated BMI in her practice achieve modest increases in milk production over time if provided with sustainable feeding plans and when an emphasis is placed on protecting their mental health.10 Just keep swimming.
  • Median time for achievement of SA in a preterm maternal cohort was 5.5 days with 14% of the study population delayed until days 11-12.11 Just keep swimming.
  • In a pilot study of exceptionally healthy dyads examining the feasibility of using point-of-care biomarkers in the term population, 91% of the sample was exclusively breastfeeding at 3 months, including dyads with delayed SA and formula use.1 Just keep swimming.
  • The achievement of secretory activation is not necessarily permanent in at-risk dyads.  Biomarkers, such as Na concentration, to measure SA achievement in the at-risk population have proven more accurate than maternal perception.9 Paracellular pathways close and open again in response to frequency of milk removal.  Just keep swimming.
  • In a preterm cohort, the frequency of pumping (1 additional pumping per 24h was significant), not the duration of pumping sessions (longer pumping times did not result in greater milk production) supported increased milk production.  The opportunity cost difference (see glossary) between CTV (coming to volume) and not establishing a sustainable milk production was $15512.  Compared to the cost of 12 months of formula and the downstream costs related to comorbidities that breastfeeding and breast milk help to prevent, this is a minimal investment.  But it’s an investment only the mother can make.  She “pays” for the breast milk with her own mental and physical energy, whereas the costs of donor milk and formula are shared burdens.  We must leverage all available assets on behalf of these mothers to help keep them swimming!
  • Performing test weights (weighing infant before and after nursing on an ultra-sensitive gram scale) is not overwhelming to mothers or sabotaging to breastfeeding, but rather informs the plan of care by providing objective data to both a concerned clinician and an anxious mother during a critical time in lactogenesis7.   Just keep swimming.

Figure 1.  Bookhart et al.3

An important nuance not depicted in the figure is the difference between a generally healthy, term newborn and a competent nurser.  A truly full term, competent nursing infant will naturally drive up milk production by effective, efficient milk removal.   But some infants who are considered “healthy term” are neither effective nor efficient in removing milk from the breast, so their mothers are forced into the pump dependent category.  The breasts may respond faster for the term-delivered mother, compared to the pre-term mother who may not have had sufficient time for complete secretory differentiation, but the work load is similar.

The figure is illuminating in its contrast between the expected time frames in the two journeys and their respective outcomes.  By day 7, the uncomplicated, low-risk breastfeeding dyad is “riding the EAC”.  You Nemo fans know that the East Australian Current is the swift water that carries Dory and Marlin to find Nemo at Wallaby Way.  For the low-risk breastfeeding journey, reaching the EAC means that the mother begins to benefit from the established flow of milk—the infant has sent the signal to mother’s body, mother’s body has responded, and the intense feeding rhythm required to build the milk production eases a bit.  The preterm mother, however, is only halfway to the EAC on day 7.  Ironically and cruelly, larger reserves of energy are required from a mother who likely began the journey depleted of all energy reserves due to antenatal complications, the stress of a preterm birth, NICU admission, and sequelae from co-morbidities that are common in this population.  It’s not easy to “just keep swimming”, but it is often the key to success.  All we nurses can do is to help her keep moving toward the goal—that, in and of itself, is a victory.  My grandfather called this state of mind “The Peace of Progress”; just knowing you’re moving in the right direction makes the burden more bearable.

A valuable tool absent from the special issue

Hand expression of breast milk was not studied by the workgroup for the special issue, but is a low-cost, low-tech option, particularly for mothers who cannot comply with pumping frequency guidelines.  Perhaps she can manage 4-5 pumping sessions per 24 hours, but her physical realities and various responsibilities will not allow for the 7-8 sessions needed to maintain SA permanence and achieve CTV.  She can be given the option to hand express her milk to avoid setting up and cleaning up all the pump apparatus.  Any milk removal is better than none, given the physiological mandate of milk removal to avoid down-regulation of milk production.

The valuable work of Jane Morton, MD and her team at Stanford University School of Medicine on this topic is graciously offered free of charge at their website firstdroplets.com13.  The video “A Mother’s Touch, Breastfeeding in the First Hour” is particularly powerful clinically and the QR code below can be added to mother’s hospital bracelets or posted in her room for on-demand reference and viewing.

Key Concepts from the Special Issue 

Modifiable vs Unmodifiable Risks Associated with Producing Sufficient Volume

  • Modifiable risks researched for decades include, but are not limited to, access to knowledgeable lactation support in each phase of the perinatal journey, frequency of milk removal from breasts (avoiding long intervals between nursing or pumping sessions), completeness of milk removal (assessing effectiveness of infant or breast pump’s ability to transfer milk), comfort of milk removal (assessing latch to breast and breast pumping flange fit to breast), and the myriad social and economic aspects driving a mother’s ability and freedom to connect with the right resources at the right time to realize/achieve the above.
  • Unmodifiable (at the time of delivery) risk factors for real insufficient milk production in both the term and preterm populations include overweight and obesity, diabetes, and pre-eclampsia/pregnancy-induced hypertension (HDP). For the preterm breastfeeding dyad specifically, the mother experiences a “shortened duration of pregnancy-induced breast development (e.g. secretory differentiation), as well as, specific comorbidities of pregnancy that are more likely to occur in this at-risk population”.9,14   Placental growth and inflammation can also impact mammary gland development.3
  • Dr Anne Eglash, in her commentary10 offers the following assessment of the challenges facing clinicians: “Low milk production is the chief complaint in my breastfeeding medicine practice.  By the time patients reach me, they’ve often endured lengthy breastfeeding sessions, power pumping, and have tried a variety of galactagogues, including baking lactation cookies, all with the belief that they must work beyond sustainable limits to produce more milk.  The dominant message in media and peer-reviewed literature often downplays low milk production as a self-reported issue rather than a legitimate one.  As a result, many lactating mothers experience stress, frustration, guilt, or even despair.  Low milk production is often not just perceived but is real, and it is crucial for physicians to recognize that low milk production is a medical problem that warrants evaluation and treatment like other health concerns.  In addition, low milk production, for many women, may be a marker of future health problems, including cardiovascular risk.”10

Research priorities revealed in the special issue identified by Bookhart, et al.7

  • Development and testing of evidence-based algorithms that distinguish between perceived and real insufficient MOM volume within the first postpartum week
  • Detection of modifiable maternal and infant risk factors that can lead to real insufficient MOM volume if left unaddressed including maternal metabolic disease and late preterm/early term birth
  • Address barriers to POC technologies like MOM transfer data via test weights and MOM Na measurement of SA achievement
  • Testing innovative models of lactation care that incorporate these POC technologies, such as breastfeeding peer counselors and doulas who visit mothers in the home

It is nearly impossible to distill 72 pages of emerging evidence into a digestible blog format—I would highly recommend you read the entire issue for both clarity and completeness of knowledge to inform your individual practices.  Thank you to the special issue work group for their commitment to the advancement of lactation science; your work, as Dr Eidelman predicted in his editorial, will no doubt be landmark.  The healthcare system as well as the societal structure around breastfeeding families can be improved by responding to the calls of the research shared by the Academy of Breastfeeding Medicine.

Exclusive breastfeeding remains the ideal and the emerging science provides tools and technologies that will aid the lactation care provider in their mission to help every mother maximize her individual potential.  But I believe we can also conclude from the evidence presented that exclusive breastfeeding is not the “biological norm” for women whose biology is not normal.  The authors identify three primary risk factors for impaired early lactation: overweight and obesity (currently 1 out of 2 mothers), diabetes (1 out of 10 mothers), and HDP (1 out of 8 mothers).  Prevalence of these co-morbidities has sharply risen over the last generation of US births, so we must rise to the occasion.

We can optimize the opportunities provided during months of regular access to patients during the antenatal season to better prepare at-risk mothers for the intensity of early breastfeeding, empower them with the knowledge and tools needed to maximize their individual potential during the first 14 days post-birth, and celebrate their victories as they provide as much breastmilk as they can for as long as they can (see blog “Redefining Breastfeeding Success by Defining Lactation Acuity”).  This recent evidence-based update in lactation science can be celebrated and built upon.  Hopefully, we Dorys can utilize it to fuel our fins and those of our precious Marlins and Nemos.  Happy swimming!

References

  1. Feasibility of Using Point-of-Care Biomarkers of Secretory Activation to Address Early, Unplanned Weaning Among Healthy, Term Dyads in Community Settings: A Pilot Study Katie T. Kivlighan, Jessica Long, Rebekah Martinez, Sandra Cardenas, and Esther Ryan Breastfeeding Medicine 2025 20:7, 484-492
  2. Peng Y, Zhuang K, Huang Y. Incidence and factors influ-encing delayed onset of lactation: A systematic review andmeta-analysis. Int Breastfeed J 2024;19(1):59
  3. Integrating Biological, Behavioral, and Economic Factors in the Practice and Study of Early, Unplanned Lactation Cessation Larelle H. Bookhart, Stephanie Devane-Johnson, Anita Esquerra-Zwiers, Yarden Golan Maor, Jessica Gomez, Katie T. Kivlighan, Clarisa Medina Poeliniz, Rachel Walker, Tricia J. Johnson, and Leslie A. Parker Breastfeeding Medicine 2025 20:7, 460-469
  4. Centers for Disease Control and Prevention. BreastfeedingReport Card United States, 2022. 2022. Available from:https://www.cdc.gov/breastfeeding-data/breastfeeding-report-card/index.html [Last accessed: March 6, 2025]
  5. Bookhart LH, Anstey EH, Kramer MR, Perrine CG, Ramakrishnan U, Young MF. A dose-response relationship found between the Ten Steps to Successful Breastfeeding indicators and in-hospital exclusive breastfeeding in US hospitals. Birth. 2023 Dec;50(4):916-922. doi: 10.1111/birt.12742. Epub 2023 Jul 12. PMID: 37435951; PMCID: PMC11022270.
  6. Odom EC, Li R, Scanlon KS, et al. Reasons for earlier than desired cessation of breastfeeding. Pediatrics2013;131(3):e726–e732;
  7. Point-of-Care Techniques to Identify Risks for Early, Unplanned Lactation Cessation Among Term Mother/Infant Dyads: An Integrative Review Larelle H. Bookhart, Stephanie Devane-Johnson, Katie T. Kivlighan, Clarisa Medina-Poeliniz, Leslie A. Parker, and Anita L. Esquerra-Zwiers Breastfeeding Medicine 2025 20:7, 470-483
  8. Pumping Behaviors of Breast Pump-Dependent Mothers of Preterm Infants in the Neonatal Intensive Care Unit (NICU): Importance of the First Five Postpartum Days Clarisa Medina Poeliniz, Rebecca Hoban, Judy Janes, and Paula P. Meier Breastfeeding Medicine 2025 20:7, 493-501
  9. Maternal Complications of Pregnancy and Achievement of Secretory Activation and Coming to Volume in Breast Pump-Dependent Mothers of Preterm Infants Rebecca Hoban, Qinglin Pei, Clarisa Medina Poeliniz, Yarden Golan Maor, Rachel E. Walker, Paula P. Meier, Angela Monk, and Leslie A. Parker Breastfeeding Medicine 2025 20:7, 512-520
  10. Early, Unplanned Lactation Cessation: Perspectives from a Breastfeeding Medicine Physician Anne R. Eglash Breastfeeding Medicine2025 20:7, 528-529
  11. Once- Versus Twice-Daily Measures of Mothers’ Own Milk Biomarkers: Does It Make a Difference in Research and Practice? Marion M. Bendixen, Qinglin Pei, Paula P. Meier, Clarisa Medina-Poeliniz, and Rebecca Hoban Breastfeeding Medicine2025 20:7, 521-527
  12. Pumping Behaviors, Pumped Milk Volume, and Maternal Opportunity Cost for Breast Pump-Dependent Mothers of Preterm Infants in the First 14 Postpartum Days Tricia J. Johnson, Clarisa Medina-Poeliniz, Paula P. Meier, Leslie A. Parker, and Rebecca Hoban Breastfeeding Medicine 2025 20:7, 502-511
  13. Firstdroplets.com [Last accessed August 24, 2025].
  14. Parker LA, Hoban R, Bendixen MM, et al. Milk biomarkers of secretory activation in breast pump-dependent mothers of preterm infants: An integrative review. Breastfeed Med2024;19(1):3–16;
Gloria_Dudney

ABOUT THE AUTHOR

Gloria Dudney, RN, IBCLC, RLC

Gloria Dudney, RN, IBCLC, RLC has been practicing maternal-child nursing for 31 years and has been board-certified as a Lactation Consultant for more than 20 years. She has inpatient experience in addition to 24 years in a large pediatric practice where she launched the first outpatient lactation clinic in the region. She now serves as the Director of Lactation Services for East Tennessee State University Health where she has pioneered an innovative antenatal lactation program that includes both patient care and OB resident training.

Gloria is an advocate for increased access to expert breastfeeding support and recently led a successful campaign to secure Medicaid coverage for lactation services in the state of Tennessee. She authored the book, “Mommy-Friendly Breastfeeding” and speaks nationally on various topics related to maternal-child health. Her vision statement is, “If mom’s ok, everyone’s ok.” Her mission statement is, “Make mom ok”. She is married to Bo and together they have 4 children and 7 grandchildren

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