Delayed Lactogenesis

Delayed lactogenesis is failure of the milk to come in (copious milk production) by 72 hours after birth. Milk production normally rises on days 2 to 5 as progesterone falls after delivery of the placenta. It results from retained placental tissue, severe postpartum haemorrhage (Sheehan syndrome), diabetes, obesity, caesarean section with delayed feeding, stress, pain and infrequent milk removal. It matters because the infant loses weight and becomes dehydrated and jaundiced while waiting for the milk.

• Risk factors: first baby, caesarean section, diabetes, obesity, preterm birth, polycystic ovary syndrome, retained placenta, postpartum haemorrhage, separation of mother and infant, delay of more than 6 hours before the first feed, epidural with long labour.
• Milk usually comes in by 3 to 5 days; after 5 days it is delayed.
• Early frequent milk removal prevents most cases.

Mothers have soft breasts without fullness, warmth or leaking after day 3 to 5, and the infant is unsatisfied with frequent feeds, weight loss, scanty urine and yellow skin. Breasts remain soft after a feed with little milk on expressing.

• Infant weight loss above 7 to 10 percent of birth weight by day 3 to 4.
• Fewer than 4 wet nappies and stools still dark meconium on day 4.
• Differential diagnosis: normal timing of lactogenesis (up to day 5), low milk supply, retained placental tissue, Sheehan syndrome, hypothyroidism, infant tongue tie or poor suck, infant illness, maternal drugs (bromocriptine, cabergoline, oestrogen).
• Complications: infant dehydration, hypernatraemia, jaundice, hypoglycaemia, weight loss, early weaning, maternal anxiety.

The approach is to find the cause quickly and to monitor the infant closely.

• Infant weight daily and nappy count; hydration; jaundice level; sodium, urea and bilirubin if weight loss is above 10 percent.
• Observation of a feed for latch and swallowing; examination of the infant's mouth.
• Maternal examination for uterine size, lochia and signs of retained placental tissue; pelvic ultrasound if bleeding or foul lochia; haemoglobin, glucose, thyroid stimulating hormone.
• Prolactin, cortisol, thyroid stimulating hormone and free thyroxine if there was severe haemorrhage with fatigue or hypotension.

The principle is to stimulate and remove milk frequently, supplement the infant safely, and treat any cause.

• Supportive:
  • Skin to skin contact.
  • Feed or express 8 to 12 times in 24 hours including at night.
  • Hand express or pump both breasts for 10 to 15 minutes after each feed, and every 2 to 3 hours if the infant cannot feed.
  • Give all expressed colostrum to the infant.
  • Warm compresses and breast massage before feeds.
  • Rest and fluids.
  • Weigh the infant daily until weight is increasing.
• Pharmacological:
  • Infant supplementation by cup, spoon or syringe with expressed milk first, then formula:
    • Day 1 5 to 15 mL per feed.
    • Day 2 15 to 30 mL per feed.
    • Day 3 30 to 60 mL per feed.
    • Day 4 onward 60 to 90 mL per feed.
    • Give 8 feeds daily, reduced as milk comes in.
  • Domperidone 10 mg oral 8-hourly for 7 to 14 days (maximum 30 mg daily; avoid with prolonged QT interval).
  • Or metoclopramide 10 mg oral 8-hourly for 7 days then tapered over 1 week (avoid in depression or epilepsy).
  • Start if there is no response by day 5.
  • Amoxicillin-clavulanate 625 mg oral 8-hourly for 5 to 7 days with evacuation if retained tissue is infected.
  • Ferrous sulphate 200 mg oral 12-hourly for 3 months for anaemia.
  • Insulin dose adjustment to keep glucose 4 to 7 mmol/L in diabetes.
• Procedures: evacuation of retained placental tissue under ultrasound guidance; frenotomy for infant tongue tie.
• Special groups: women with Sheehan syndrome need hydrocortisone 20 mg oral in the morning and 10 mg at midday and levothyroxine under specialist care; women with diabetes keep glucose controlled and feed early; women with depression or epilepsy avoid metoclopramide.
• Red flags: infant weight loss above 10 percent, no urine for 8 hours, jaundice, lethargy, fever in the infant, maternal heavy bleeding or foul lochia, maternal hypotension and fatigue after haemorrhage.
• Follow-up: infant weight daily until gaining, then at 1 week and 2 weeks; reduce supplementation as milk comes in; review at 6 weeks; endocrine review if no lactation after 7 days and a history of haemorrhage.