Colostrum—the first breast milk, low in volume but rich in immune factors—begins to be made in the breasts a long time before your baby is born. After the birth, a sequence of events initiates milk production whether or not you plan to breastfeed your baby. Although you might not be able to express the colostrum yourself at first, or you might be worried that your milk hasn’t come in or is late; true lactation failure is very rare. There will almost certainly be some milk. However, how much milk depends on getting breastfeeding established early and often and, for a minority of women, whether you have any other potential Reasons for Low Milk Supply. This article discusses the causes for milk coming in late after delivery.
What triggers breast milk to come in?
During pregnancy the placenta has a vital role in generating hormones to develop the milk making factory in the breasts. After the birth of your baby the placenta separates from the uterus and is expelled. This causes a sharp drop in the hormone progesterone which triggers the breasts to start milk production about 32-40 hours after birth.1 Other important hormones that are needed for milk production are prolactin, insulin and cortisol (stress hormone). Oxytocin is another hormone that triggers the let down of milk at each feed.
When does breast milk come in?
Mothers usually notice their milk coming in two to three days after the birth. Around this time full or engorged breasts replace the small volumes of colostrum that are already present. Milk supply continues to increase as long as the baby—or hand expression or pump—empties the breasts. However if milk removal doesn’t happen, milk production will start to shut down. Anything that affects any of the hormones involved in lactation, the let down or the milk removal process has the potential to cause a delay in milk coming in, or a low milk supply.
Milk coming in late (delayed onset of lactation)
In a quarter of all mothers, milk can take longer than three days to come in, sometimes taking up to five days2. When milk is very slow to come in it is known as delayed onset of lactation. Just because your milk is late coming in doesn’t necessarily mean you will ultimately have no breast milk or low milk supply but it is a high risk factor. Women with milk that is late arriving are more likely to get stressed about it—which can itself interfere with let down—leading to a vicious negative cycle of events. If you find yourself in this situation, getting good help from an IBCLC lactation consultant is highly recommended because the sooner you can take action to boost your milk supply and reduce your stress levels, the better 3.if milk removal doesn’t happen, milk production will start to shut downClick To Tweet
No breast milk?
Certain birth practices and some medical conditions can delay milk arriving. It is unlikely that there would be no breast milk at all, as small volumes of colostrum (the first breast milk to appear) will usually have been present for some time before your baby is born. If milk is late arriving it can create a cycle of formula supplementation and a corresponding down regulation of your milk supply leading to more formula and lower milk supply. Possible reasons for no breast milk after delivery are set out below under the headings of birth, breastfeeding management and medical issues:
#1 Birth factors
- A very traumatic or stressful birth such as a long labour and/or long pushing stage, or the use of ventouse, forceps, or caesarean section will affect levels of stress hormones which can delay milk coming in 4.
- Large amounts of intravenous fluids (IV fluids) used during birth can engorge breasts and delay the availability of milk until the engorgement goes down.
- Losing a lot of blood (more than 500 mL/1 pint) e.g. maternal postpartum haemorrhage 5 or Sheehan’s Syndrome 6 may damage the pituitary gland in the brain which controls the hormones of lactation.
- Retained placental fragments can delay milk coming in as progesterone levels remain higher instead of dropping to trigger milk production.
- Pain relief medications given during childbirth have been linked with delayed onset of lactation 7.
- Nerve damage that affects key nerves involved in milk let down, or if spinal vertebrae are misaligned can affect milk production and let down. Body work or manual therapy has helped some mothers 8.
- A premature birth or a placenta not working properly. Pregnancy is an important time for mammary gland development. If a baby is born prematurely the breasts may or may not have had enough time to fully develop sufficient glandular tissue and similarly if the placenta wasn’t working optimally (placental insufficiency) the breasts may not have fully developed. Although this can affect the initial milk supply, with careful management, glandular tissue can continue to develop after the birth.
- Heavier babies? Riordan’s Breastfeeding and Human Lactation, 2015 page 369 and a 2012 paper9 cite heavier birth weight of babies born to first time mothers as a risk factor for delayed onset of lactation.
#2 Breastfeeding management
Separation from baby and a poor start to breastfeeding affects milk coming in because early milk removal in the first hours and days is associated with higher milk supply. Breastfeeding or hand expressing in the first hour after birth is especially important 1011. Without frequent feeds or good milk removal by hand expressing at this time, milk production begins to shut down. See the useful video Successful Breastfeeding Begins Right at Birth by Jane Morton of Stanford University for more information about hand expression in the first hour after birth to stimulate your milk supply. Unrelieved engorgement reduces milk production too.
#3 Medical issues
An imbalance of any of the hormones needed in lactation could affect milk coming in. Conditions that can influence lactation include:
Diabetes or gestational diabetes
Insulin is an important hormone involved in breast development and milk production. Diabetes is a condition where the body doesn’t produce enough insulin (Type 1) or can’t use it properly (Type 2). A temporary form of diabetes in pregnancy is called gestational diabetes. With Type 1 diabetes, insulin requirements are adjusted by the body after birth, and this may slow milk “coming in” by 24 hours. Any large fluctuations in insulin during the course of breastfeeding are said to lower milk production 12. A 2015 review of studies also found an increased risk of a delay in milk coming in when women have diabetes during pregnancy13. Not all mothers with diabetes will have problems with milk supply and careful control of blood sugar and insulin levels will help keep a milk supply stable.
The pituitary gland is a small gland in the brain that regulates many hormones including prolactin and oxytocin. If the pituitary gland is not functioning correctly (previous surgery, a pituitary adenoma or Sheehan’s Syndrome following severe blood loss) this could affect lactation.
Any medications given to the mother during labour that make baby sleepy can delay getting breastfeeding off to a good start. Some medications can have a side effect of decreasing milk production—for example hormonal birth control in the early months. Medications for certain disorders reduce milk supply too, so although milk might be coming in, the supply may be reduced.
Gestational ovarian theca lutein cysts
These cysts develop during pregnancy and produce high levels of testosterone which may temporarily suppress milk production after the birth. Studies have shown that these testosterone levels reduce after three to four weeks when the cysts resolve, allowing lactation to often proceed normally. It is recommended that mothers continue to pump during this time to give the best chance for their milk to come in. Diagnosis can be made by blood tests measuring testosterone levels 14 15.
Overweight or obese
A pre pregnancy BMI greater than 26 is a risk factor for delayed lactation and low milk supply associated with a lower prolactin response 16 17 18. If the underlying causes of obesity are due to metabolic disorders e.g. polycystic ovary syndrome (PCOS), or hyperthyroidism, these are also risk factors for affecting milk supply in their own right. Obese women often suffer from insulin resistance and diabetes (affecting milk supply) and excessive weight may be linked with poor breast growth 19.
Polycystic ovary syndrome, and thyroid disorders
PCOS (see Polycystic Ovary Syndrome and Breastfeeding) and untreated thyroid disorders can be associated with delayed onset of lactation.
Any surgery on the breast or nipples including a breast reduction procedure, a breast lift or breast implants could potentially affect the milk making or glandular tissue in the breast. It may also cause scarring or blocked ducts which might affect the ability of milk to leave the breast.
Older first time mothers
Older first time mothers may be at risk of delayed onset of lactation20
Until your milk comes in…
Small but regular amounts of colostrum in the first two to three days of life are normally enough for a newborn baby who is kept close to his mother, after all it is biologically normal for milk not to “come in” immediately. Until your milk comes in, latching your baby often (or hand expressing milk for your baby if they are not transferring milk) and holding your baby in skin-to-skin contact will promote the hormones involved in milk production (oxytocin and prolactin) and put your baby in the right place to feed frequently.
What do I do if my milk is late?
If your milk supply doesn’t come in by day three (or longer) your baby could begin to lose excess weight, or become dehydrated or jaundiced. You may also notice the meiconium in your baby’s nappy isn’t changing colour. In any of these situations it is important to get good breastfeeding help quickly, and ensure your baby is well fed. Hand expressing every couple of hours can help stimulate your milk supply and any expressed milk can be fed to your baby (pumping is not usually recommended before your milk has properly come in). Your health professionals will advise you about supplements as donor human milk or formula milk may be needed. It is very important to keep your baby well fed—see Baby Not Gaining Weight. Supplementing your baby doesn’t mean breastfeeding needs to be sacrificed as long as you have the right support.
After the birth, delivery of the placenta triggers milk production in an automatic process and true lactation failure is very rare. The rate of milk volume coming in will depend on getting breastfeeding established early and often, birth practices, and whether the mother has any medical conditions affecting lactation. For a minority of women, other Reasons for Low Milk Supply may be involved.
For ideas to maximise your milk production and ensure your baby is well fed, contact an IBCLC lactation consultant for a tailor made plan for you. In the mean time the ideas in How to Make More Breast Milk will help to both optimise and increase your milk supply.