Hi Karleen,

You are correct in that we do not know definitively what proportion of
women with PCOS, adoptive mothers, or women with particular physical
markers are physiologically unable to produce sufficient milk, but we do
know that among women who struggle to produce milk after other known
factors have been accounted for and managed, there are some common threads
-- among them are the various endocrinopathies that Lisa Marasco and others
have educated our field about (not limited to PCOS), and breasts that are
consistent in appearance/presentation with those factors highlighted by
Huggins, Petok, & Mireles.

While I have seen many breasts of "suspect" appearance (based on Huggins,
Petok, & Mireles) go on to make plenty of milk (as did approximately 1/3 of
the 34 women in that study), as well as "normal-looking" breasts (absent of
physical markers of hypoplasia) on women with no known accompanying
endocrine comorbidities go on to make no milk at all, I have seen enough
cases of failure to produce milk that *are* correlated with the conditions
and appearance factors to consider them potential risk factors -- not
conclusive predictors, but risk factors.  For sure, more research is
needed, but until we have it, I will continue to encourage professionals to
recognize the markers and comorbidities we *suspect* might be predictive of
lactation difficulty (because so many with lactation difficulty have had
these markers and comorbidities) and to stress the importance of solid
counseling in sharing concerns with mothers whose history or appearance
gives cause for concern.  I don't think anyone is advocating telling a
pregnant mother "Oh, gee, your breasts sure do look strange, you probably
won't make much milk with them!"  However, to notice marked asymmetry, a
tubular appearance, and/or wide spacing in the breasts of an expectant or
new mother and *not* say "I notice your breasts are really different sizes,
and the left one looks a little tube-shaped ... some mothers with breasts
that look like yours have trouble making milk, but lots of others do just
fine ... we'll make sure you and your baby get lots of attention in the
hospital, these are xyz signs you know your baby is getting enough milk and
these are pqr reasons to be concerned after you go home ... etc., do you
have any questions?" is not ethically sound.  The fact that there is
currently no conclusive predictive or diagnostic tool (or even a
universally agreed-upon name) for hypoplasia that marks insufficient milk
production doesn't negate the fact that this happens to mothers.

We don't currently have evidence beyond clinical knowledge, case studies,
and the small prospective study of Huggins, Petok, and Mireles, but if
implementing a communicative, precautionary protocol based on the little
evidence we *do* have enables mothers to prepare practically and
emotionally for the possibility that they won't be able to exclusively
breastfeed, therefore setting them up to lactate, even if partially, and/or
foster the closeness of at-breast nurturing with a greater degree of
success than if they didn't receive anticipatory guidance, isn't that a
good thing?

Do you believe such anticipatory guidance in the presence of physical
markers and comorbidities that *may or may not* be predictive of lactation
insufficiency would cause more refusal to even attempt breastfeeding than
it would help those who do end up struggling?

Would you be more or less supportive of a global protocol, such as an
education campaign about lactation difficulty/failure to ALL expectant
mothers, not just those who present with the markers our field has come to
recognize as potentially predictive?

The ever-eloquent Alison Stuebe summarizes my thoughts in her piece for the
Academy of Breastfeeding Medicine blog entitled "Establishing the Fourth
Trimester:"

"In obstetrics, prenatal care is designed to detect relatively rare
disorders — preeclampsia, gestational diabetes, gestational hypertension —
and we counsel mothers to monitor fetal movement, loss of fluid,
contractions and bleeding to identify pregnancies at risk.  It’s debatable
how well we succeed in improving outcomes vs. medicalize a normal process.
But there is precedent for honoring normal physiology without turning a
blind eye to unexpected problems."

(Here is the link to Alison's piece for any who are interested:
http://bfmed.wordpress.com/2013/01/04/establishing-the-fourth-trimester/ )

My final thought before I get back to my thesis: a resounding "YES" to
yours and Gail's reminders that we don't know anything for sure until after
the baby is born -- this remains a central message of any education I do
and have received on this topic.

--Diana Cassar-Uhl, IBCLC (MPH May 2013)
New York

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