Cindy, thanks for the information on anemia. I lecture on milk synthesis
frequently and am passionate about including all the relevant factors, and I
hadn't seen your article on anemia.

I don't doubt what you see in practice, and certainly "not enough milk" is
the #1 documented cause of stopping BF. Milk retention in the breast is the
primary mechanism of reduced supply, and retention is usually caused by (1)
maternal behavior or (2) poor milk transfer. Does anemia affect the mother's
behavior, the baby's oralmotor response, or the secretory function of the
breast?  Did you look at the baby's suck and the mother's willingness/ability
to bring the baby to breast frequently and long enough?   In my experience,
that's usually the first thing to go wrong with milk supply. I could theorize
that anemia affects the mother's ability/willingness to interact as
frequently with the baby as needed, causing milk retention. Or whether an
anemic mom's baby has a slight sucking deficit because of the anemia, which
then causes milk retention in the breast.

If you addressed both those issues, then I'm really interested in why anemia
seems to affect milk secretion.  What is it about about being anemic that
affects milk secretion?  Is hemoglobin needed for lactose synthesis,
alpha-lactalbumin production, or some other metabolic pathway?  Does anemia
increase progesterone, which blocks prolactin?  Or something else?

I'd love to hear your thoughts on this. Thanks.

Linda Smith, private practice, Dayton OH