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

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