I have not seen many cases of hypoplasia considering how long I have been
working in this field, and I wonder what the epigenetic aspect of this is.
Most of my career has been spent in a society where pretty much everyone
initiated breastfeeding and most continued for some time, until recently.
We're now seeing a real decline in breastfeeding initiation, very troubling
as we know almost nothing about why more women are opting out before
they've even given birth. I wonder whether IGT is more common in
populations where there are more adults who were never breastfed
themselves, and if so, we will see an increase in the next generation.

I did work with one mother over several months, after meeting her when her
first breastfeeding experience had already come to a sad and premature end.
There were so many contributing causes that it didn't occur to any of us to
look at her breasts then and there. The baby never really came to breast so
their performance was untested. The mother had been breastfed and her own
mother had never had any trouble. We agreed to stay in touch and that I
would support her if she ever had another baby.

Happily, she did have a second child, and she did everything possible to
maximize production from the start. She lives in another part of the
country so I was not present. We kept in touch on Skype and by phone, and I
visited when I could. He was at her breast doing his best, all the time.
Signs of lactogenesis II were delayed and not overly convincing - whitish
milk started to appear but in scanty amounts around day 4. No engorgement
but baby was permanently fixed to one breast or the other so would not
expect them ever to get engorged. Baby looked hungry and never satisfied at
breast. Readmitted for treatment of significant jaundice and weight loss of
13% about day 7, with (too conservative) supplementation started on day 3.
She needed to supplement more and more over the ensuing weeks, and I was
thinking that this looked like primary lactation failure. This mother is
generously proportioned with small to medium size breasts, which should
perhaps have alerted me, because normally in women of her size, the breasts
match. I did not feel that their shape or the size of her areolae were
unusual, but the space between them was wide.

She asked me point blank about two weeks out: I've read that some women
have little or no glandular tissue. Do you think I might be one of those?
and I said the thought had started to occur to me, and we talked about it.
Her feelings were a mix of disappointment and anger that this breastfeeding
might end too soon, and relief that perhaps it wasn't her fault that she
was producing so much less milk than her baby needed. We talked a LOT about
the difference between being exclusively nourished on breastmilk and being
breastfed and I emphasized the relational part of breastfeeding. Her baby
loved breastfeeding as long as he got enough food otherwise. He didn't have
very gentle technique so breastfeeding for the closeness was not a trivial
act on her part. Every molecule of milk she produced went into his mouth
and she was proud to call herself a breastfeeding mother. Sometimes after
some night feeds he didn't need any supplementation but for the most part
she had to give him extra milk at every feed. She got hold of goat's rue
and other herbs, tried pharmaceutical galactogogues but didn't have much
effect from them, as they work on prolactin where in her case it seems to
be the end organ that is the limiting factor. After about 4 months the
physical discomfort started to outweigh the gratification of breastfeeding
and weaning from her breast was done before he was 6 months - with her
feeling she had been more in charge of the whole experience than the first
time around, and very proud to have persevered as long as she did. SNS
didn't appeal to her, nor to the baby really. I don't know how many times I
told her how much she impresses me, and not just for her efforts to
breastfeed (which I certainly acknowledged, specifically and in detail, as
being without parallel in my experience). She is one of the warmest, most
empathetic mothers I know.

Several months after she stopped breastfeeding, she phoned me, breathless
and excited, on her way home from a mammogram. She'd been referred because
she found a lump in her breast. The doctor who did it, told her immediately
that the lump was completely benign and he was entirely confident in saying
so. He said that dangerous lumps arise in glandular tissue, and she had
practically no glandular tissue at all. He showed her a mammogram of a
typical premenopausal breast, and then her own breast to show her the
difference, which she said was obvious.  She had asked 'So could that be
why I had some difficulties breastfeeding?' and the doctor's jaw dropped.
'If you managed to breastfeed at all with this little glandular tissue,
it's nothing less than a miracle!'  And then she went on to say to me 'So
now I know it wasn't because I just didn't try hard enough.'

It didn't matter how many times we had gone through this, how many times I
had listed all the things she did with minimal effect, how impressive it
was that she managed to maintain a breastfeeding relationship with her baby
over so many months in such circumstances, and on and on. Until she saw
that mammogram, she still felt she should have done better.

It is hard to bring up the topic, and I don't see any point in doing so
with a woman in her first pregnancy because it is not possible to predict
lactation performance by visual exam of the breasts and women are
undermined enough as it is. Every mother deserves safe follow-up during the
early postpartum period, until feeding is going smoothly at the very
least.  It's different if I meet someone with a breastfeeding history
consistent with possible IGT. If we are making a plan for her next baby's
birth, it comes up. I will mention that there are many reasons why milk
supply gets off to a bad start, and sometimes even when we make a plan to
prevent any of those things, there can be factors we have no control over,
like gland tissue. I try to get them to focus on the breastfeeding, not the
amount of milk, and I refer them to the great resources about making more
milk which have been mentioned here before. Women appreciate being taken
seriously. In my opinion refraining from commenting on the appearance of
breasts which might or might not be lacking in glandular tissue is not a
failure to take the primigravid woman seriously.  All women and babies need
follow-up care after birth. That care should be sufficient to catch
lactation problems before they are a threat to health, and the conversation
about what caused a failure to fully lactate is IMNSHO better held after
the fact. I guess I am not convinced that we have the means to influence
the outcome in a positive way, starting in pregnancy, and I am worried that
talking about IGT as if it may be more likely based on a visual exam of the
breasts could tip the balance for some women so they never even start
breastfeeding because what's the point if it might fail?

Rachel Myr
Kristiansand, Norway

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