Jen,
What complicates the situation is that women with breast hypoplasia 
(undergrowth) can respond to stimulation by increasing supply. For some 
women, there is so little glandular tissue that the maximum supply is 
small, for others, a larger increase is possible. Petok and Huggins' 
study in Clinical Issues in Human Lactation 2000 is still very useful 
for determining whether or not any particular mom has hyperplasia, and 
for predicting outcomes.

I agree that the photo 162 in the 2nd edition of the Breastfeeding Atlas 
is a marginal case. Palpation is as important as observation when 
deciding whether glandular tissue is sparse or not. There is a 
difference in feel between understimulated breasts and underdeveloped 
breasts. This woman (162) has a somewhat wide intramammary spacing (a 
sign that increases suspicion of sparse glandular tissue), but the shape 
of her breast is normal. There is a nice round contour. Small breasts 
that are normal may be flat to the chest, but there will be that nice 
round shape, and the breast will cover the correct number of ribs. There 
is also generally asymmetry between the breasts in hypoplasia cases that 
helps us distinguish them from small normal breasts, but not always.

My rule of thumb is if I'm not sure, I keep my mouth closed and make 
sure the mom gets extra follow up. If it's clearly hypoplasia, I gently 
discuss the implications with the mom, and always hold out hope for 
increased milk. Then we get to supplementing at the breast, usually with 
a Lact-Aid, and stimulating supply as agressively as mom wants to and is 
able to.
Catherine Watson Genna, IBCLC  NYC

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