In 1985, Neifert, Seacat and Jobe published an article (Lactation Failure Due to Insufficient Glandular Development of the Breast, Pediatrics, 76(5):823-28) in which they described three cases of inadequate milk production by women who appeared to present with insufficiently developed glandular tissue. They put forth several criteria that offered supportive history for the entity of insufficient glandular development: absence of typical breast changes with pregnancy and failure of postpartum breast engorgement to occur. Associated physical findings included a unilateral underdeveloped breast in each of the study women, and palpable patchy areas of glandular tissue. The 3 women (2 multips and 1 primip) had a history of lactation failure previously or currently, and had relatives with milk production problems. The case series concluded with a statement that has become controversial: "Preserving the "every woman can nurse" myth contributes to perpetuating a simplistic view of lactation and does a disservice to the small percentage of women with primary causes of unsuccessful lactation." A practitioner in private practice sees a self-selected group of clients who have been medically or self-referred because they are already having problems. This describes my clinical practice well. Over the years, it has been my clinical impression that there is a small sub-set of women whose lactation is initiated at very low levels of production in spite of early interventions. A mark of progress in my geographic area has been earlier postpartum follow-up of breastfeeding infants, and earlier referrals by physicians to community based LCs. Consequently, I am now seeing many mothers within 4-10 days postpartum. This allows me to begin interventions early when assessment seems to suggest they are needed. Over the years, since becomming aware of the Neifert article, I have more closely observed women with unusual breast configurations, and in many cases associated it with diminished early production. In some of these cases, aggressive interventions (breast compression during feeding, postfeed pumping with hospt. grade pumps, metoclopromide, supplementation for the infant) protected the infant's growth and gradually improved maternal production. In some cases, production seemed to have a ceiling, beyond which we could never rise. These mothers often made the choice to partially breastfeed. Neifert makes the point that these mothers often blamed themselves for inadequacy in meeting their breastfeeding goals. Understanding that a primary developmental issue was undermining their best efforts helped mitigate that guilt. Mothers in my practice have responded similiarly. I try to help them identify that regret (sadness, grief over a loss) is different from guilt (which implies responsibility). The important article by Huggins, Petok, and Mireles in Current Issues in Clinical Lactation (the current Journal Club discussion article) amplifies on the early work done by Neifert, et al. The prospective nature of their study design lends strength to the case series approach. Their findings, that women with certain configurations of breast type, along with lack of prenatal changes, etc. have early (and some persisitent) production problems, makes it important for care providers to observe for these issues during pre-and postnatal evaluations. It becomes a counseling issue as to how these observations are to be presented. Obviously bed-side manner in delivering news of health-related issues is one of the arts of practice. People have a right to understand the issues that impact their situations. I chose to describe these breast-configuration markers as red-flags; reasons for me to watch closely and assist if/when needed. I describe the body as a good system that works well, but occasionally organs have problems. I wear glasses. Some people have poorly performing bladders, or whatever. Then I ask: How can we maximize the potential for health and functionality in this situation? I am grateful for the work of researchers who include photographs, and whose work amplifies earlier, controversial findings. Hopefully the findings of the Huggins, et al study will lead researchers to design a randomized and controlled study that looks at variations in milk production in a blinded design that may uncover more information about the role played by glandular development of the breast. Barbara Wilson-Clay, BSEd, IBCLC Austin Lactation Associates, Austin, Texas http://www.lactnews.com *********************************************** The LACTNET mailing list is powered by L-Soft's renowned LISTSERV(R) list management software together with L-Soft's LSMTP(TM) mailer for lightning fast mail delivery. For more information, go to: http://www.lsoft.com/LISTSERV-powered.html