this article is currently circulating on an e-mail l*st for women with
breastfeeding problems as "proof" that insufficient milk is quite common:


This is from the Colorado Breastfeeding Update, winter 1995 - Vol. 3 No.1 It
was given to me by my midwives after I was unable to produce milk for 14 days.

Insufficient Milk Syndrome: Fact or Fiction?
by Marianne Neifert, M.D.

In the wake of the recent national publicity given to cases of breastfeeding
related infant dehydration, the "insufficient milk syndrome" (IMS) has
repeatedly surfaced. The label has been widely used to explain the failure of
certain breastfed newborns to obtain adequate nutrition, occasionally whit
devastating health consequences. Some of the media reports of IMS cited a 5
percent incidence figure, which was used to derive an estimated number of
affected babies. With approximately 4 million U.S. births annually, the
implication was that 200,000 babies each year were at risk for dehydration,
brain damage or starvation. This gross misinterpretation of the incidence of
breastfeeding morbidity due to insufficient milk, coupled with the front-page
placement of the original report in The Wall Street Journal gave the false
impression that the problem was occurring in epidemic proportions.(1) Numerous
breastfeeding proponents countered these claims by vociferously denying the
existence of IMS altogether or insisting that it is extremely rare. The cases
exposed in The Wall Street Journal and on Prime Time Live were explained by
some breastfeeding enthusiasts as isolated horror stories deliberately
embellished by the reporters. They challenged the legitimacy of IMS by arguing
that the cases described could have been prevented by optimal breastfeeding
management, suggesting that potentially preventable cases don't count, even
when the baby is permanently damaged.
     In most media reports, IMS has been simplistically portrayed as a
mother's inability to produce sufficient milk. Although problems with
breastfeeding technique were also acknowledged by frequent use of the term
"breastfeeding management" the relationship between a baby's nursing
effectiveness and maternal milk production was not adequately clarified by the
media reports. Thus, readers were left confused about who was at risk for IMS,
whether the problem was of maternal or infant origin, and how to expediently
identify and help vulnerable mother-baby pairs. After all the coverage thus
far, many are left wondering what is the truth about insufficient milk
syndrome. How common is it? Does IMS refer to a mother's inability to produce
milk or is it the result of a baby nursing improperly and failing to obtain
sufficient milk?
     After years of working with breastfeeding mother-baby pairs, I am
convinced that insufficient milk is not uncommon. Thankfully, severe infant
complications of inadequate breastfeeding are relatively rare, but the problem
does appear to be on the rise and it must not be ignored. IMS can be due to
either maternal or infant factors, and often both contribute to the problem.
Although all cases of IMS are not preventable, all cases of infant dehydration
and malnutrition should be.
     Based on our experience evaluating thousands of breastfeeding mothers
with insufficient milk (all documented by infant growth parameters, infant
feeding test-weights, and pumped milk volumes) my colleagues and I at the
Lactation Program have formulated a construct of the problem that has proved
useful in our work. We classify IMS into two categories -- "primary" and
"secondary." These designations are extremely helpful in distinguishing
insufficient milk that results from or is "secondary" to problems in
breastfeeding management from "primary" insufficient milk that appears to be
unrelated to breastfeeding technique.
     To elaborate, primary insufficient milk refers to the failure to
establish a full milk supply from the outset, for reasons apparently beyond
the mother's control. While no conclusive studies document the incidence of
this problem, those who work extensively with lactating mothers consistently
estimate that from 1 percent to 5 percent of breastfeeding women fail to
produce sufficient milk to nourish their babies despite proper guidance and
optimal breastfeeding techniques and routines. However, this should never have
been misinterpreted to mean that 5 percent of all infants each year are
affected by life-threatening dehydration and starvation. In most cases of
primary insufficient lactation, women or their health care providers quickly
deduce that milk production is compromised, and they offer appropriate formula
or donor milk supplementation to permit adequate infant growth.
     Several historical and objective factors have been identified that place
a woman at increased risk for primary insufficient lactation (2). Often the
mother reports that her breasts did not enlarge appreciably during pregnancy
and that she experienced only minimal breast engorgement after deliver. She
may feel that her milk never really "came in" abundantly. Sometimes and
obvious breast abnormality is present to explain why inadequate milk is
produced. The breasts may be hypoplastic, tubular, markedly asymmetric (3), or
the mother may have had breast surgery that impairs her lactation potential.
    Other times primary lactation insufficiency accompanies serious maternal
illness, such as postpartum hemorrhage, infection, or hypertension. Since
lactation is the only elective body function, it is not an unreasonable
assumption that the process might be inhibited when the mother's well-being is
threatened.
    With "secondary" IMO, the breasts undergo normal prenatal changes and
postpartum lactogenesis occurs normally. The potential to breastfeed
successfully is present, and all the mother needs to continue abundant milk
production is a healthy infant who suckles vigorously and empties her milk at
appropriate intervals. Yet, all too often, problems in breastfeeding
scheduling or technique result in infrequent or incomplete breast emptying. At
the Lactation Program, we have concluded that failure to empty the breasts
regularly once lactogenesis occurs is the chief cause of secondary
insufficient milk. Millions of bottlefeeding mothers have provided a powerful
example of how quickly unrelieved pressure leads to diminished milk
production. When milk is not removed from the breasts, excessive pressure
results in atrophy and involution of the milk-producing alveoli. Common causes
of "secondary" insufficient milk include and infrequent breastfeeding schedule
or excessive brevity of nursings; overuse of pacifiers or supplemental fluids;
infant latch-on problems; reluctant nursers with difficulty sustaining
suckling; small, premature, ill or jaundiced infants who fail to stimulate and
empty the breasts effectively. No conclusive studies document the incidence of
secondary IMS, but the problem is far more widespread than primary lactation
insufficiency. In our prospective study conducted several years ago 15 percent
of healthy primiparous breastfeeding women nursing healthy infants were deemed
to have insufficient lactation at two to three weeks postpartum. (2) At least
two-thirds of these cases were judged to be "secondary" to breastfeeding
problems rather than "primary" in nature. Thus, secondary IM is not only more
common, it is potentially preventable and remediable, especially when it is
recognized early and when appropriate intervention occurs.
     To summarize, sometimes mothers don't make enough milk and even when they
do, sometimes babies don't take enough milk. Eventually failure to take leads
to failure to make, further compounding the problem. Yes, IMS does occur, and
is presently results in unacceptable infant morbidity. The fact that infant
complications should be preventable doesn't make reported cases any less
valid. Denying or minimizing the problem won't protect vulnerable infants. It
is my hope that the recent media attention given this controversial issue will
increase awareness of the problems and serve as the catalyst for implementing
long-overdue changes in professional training, maternity care, and follow-up
services that foster breastfeeding success and prevent infant morbidity.

Marianne Neifert, M.D., "Dr. Mom," is a consultant to the Lactation Program at
Presbyterian/St. Luke's Medical Center, Denver, Colorado. (#### NOTE: She is
now at Rose Medical Center in Denver.)

References:
1 Hellider, K. "Dying for Milk, Some Mothers, Trying in Vain to Breastfeed,
Starve their Infants." The Wall Street Journal, July 22, 1994, pp. A1 and A4.
2 Neifert, M., DeMarzo, S., Seacat, J., Leff, M., Young, D., Orleans, M:
"Breast Factors and Lacatation Performance: The influence of breast surgery,
breast appearance, and pregnancy induced breast chantes on lactation
sufficiency as measure by infant weight gain." Birth 17:31-38, 1990.
3 Neifert, M., Seacat, J., and Jobe, W. "Lactation failure due to insufficient
glandular development of the breasts." Pediatr. 76:823-828, 1985.

SIDEBAR: Clincal assessment of infants if IMS is a potential concern
* Detailed history including the feeding relationship since birth
* Evaluation of weight especially weight loss of failure to gain
* Physical exam including signs of dehydration
* Dehydration indicators:
-- scant or dark urine
-- dry mouth
-- lack of tears
-- poor skin turgor
-- lethargy
-- depressed fontanelle
-- tachycardia/brachycardia
-- hypothermia/hyperthermia