Delayed lactogenesis II

Why is my milk coming in late?

In most mothers, the milk comes in by the end of the fourth day after delivery. In others, it may come in late and it may take up to two weeks. There are many causes, some related to labour and delivery. Milk may come in late after a difficult or long labour, or when the first breastfeed happens more than an hour after birth. It may happen when the baby does not breastfeed effectively for the first few days. Other causes are unrelated to labour and delivery, such as overweight or gestational diabetes. First-time and overweight mothers and mothers over the age of 30 may also find their milk coming in late. Mothers whose milk comes in late may benefit from expressing for the first few weeks to increase breast stimulation and optimize their milk supply. Their babies need to be supplemented with milk in the short term and possibly in the long term. They may consider supplementing with colostrum that was expressed before giving birth. 

A) Describing milk coming in late

Some mothers’ milk does not come in by the end of the fourth day after delivery and may come in as late as two weeks after delivery. This appears to affect as many as 20% of mothers (Brownell 2012; Dewey 2003).

B) Causes of milk coming in late

There are many possible causes for the milk to come in late.  

1) Ineffective breast stimulation

Not breastfeeding or expressing within one hour after birth and at least seven times each day thereafter or ineffective breastfeeding results in poor milk removal and breast stimulation and can cause the milk to come in late.

2) The nature of the baby

Having a premature delivery or a large baby (more than 3,600 grams [7 pounds 15 ounces]) is associated with milk coming in late (Dewey et al. 2003; Hoban 2021; Medina Poeliniz 2020; Nommsen-Rivers et al. 2010)  

3) Factors related to pregnancy, labour, or delivery

The nature of the pregnancy, labour, and delivery can delay the milk coming in. Factors include:

  • Being a first-time mother (Dewey 2003; Dimitraki 2016; Nommsen-Rivers 2010)
  • Being a mother over the age of 30 (Nommsen-Rivers 2010)
  • Severe pregnancy-related illness in the mother
  • Having high blood pressure brought on by pregnancy (Medina Poeliniz 2020)
  • Developing large cysts (fluid-filled sacs) on the ovaries during pregnancy (hyperreactio luteinalis
  • A difficult or long labour (Dewey 2003; Dimitraki 2016)
  • Losing a lot of blood (hemorrhage) or having a big drop in blood pressure  
  • The use of pain medication during labour (Lind 2014)
  • A Caesarean delivery (Dewey 2003)
  • Not passing all of the afterbirth with the delivery (retained placental fragment)

4) Factors not related to labour and delivery

Other conditions in the mother that can delay the milk coming in include: 

  • Being an overweight mother (Matias 2014; Preusting 2017; Tao 2017; Turcksin 2014)
  • Having diabetes (Achong 2017; De Bortoli 2016)
  • Having a severe illness not related to labour and delivery
  • Having a spinal cord injury that decreases feeling in the breasts
  • Alcohol use during pregnancy (Rocha 2019)
  • Depression during pregnancy (Rocha 2019)
  • Major stress (Caparros-Gonzalez 2019)

C) Breastfeeding when the milk comes in late

Mothers whose milk comes in late are less likely to breastfeed exclusively and are more likely to wean early (Brownell 2012; Huang 2020). These mothers may benefit from expressing after all feeds in addition to breastfeeding for the first few weeks after delivery to increase breast stimulation and optimize their milk supply.

When the milk comes in late, newborn babies will often show signs of not getting enough milk and need temporary, and possibly ongoing milk supplementation. As such, their growth should be closely monitored. 

Sometimes necessary supplements are started but not stopped once the milk comes in and they are no longer needed.  It is also possible that when milk comes in late, a mother may not develop a full milk supply and supplements will need to be on-going.

Mothers at risk of their milk coming in late may consider manually expressing colostrum (prenatal expression) before the baby’s birth. This may limit the need for infant formula. Please discuss this with your health-care providers as it may stimulate early labour.

References

Achong N, Duncan EL, McIntyre HD, et al. The physiological and glycaemic changes in breastfeeding women with type 1 diabetes mellitus. Diabetes Res Clin Pract. 2017 Nov 14;135:93-101
 
Brownell E, Howard CR, Lawrence RA, et al. Delayed onset lactogenesis II predicts the cessation of any or exclusive breastfeeding. J Pediatr. 2012 Oct;161(4):608-14

Caparros-Gonzalez RA, Romero-Gonzalez B, Gonzalez-Perez R, et al. Maternal and Neonatal Hair Cortisol Levels and Psychological Stress Are Associated With Onset of Secretory Activation of Human Milk Production. Adv Neonatal Care. 2019;19(6):E11‐E20

De Bortoli J, Amir LH. Is onset of lactation delayed in women with diabetes in pregnancy? A systematic review. Diabet Med. 2016 Jan;33(1):17-24
 
Dewey KG, Nommsen-Rivers LA, Heinig MJ, et al. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics. 2003 Sep;112(3 Pt 1):607-19
 
Dimitraki M, Tsikouras P, Manav B, et al. Evaluation of the effect of natural and emotional stress of labor on lactation and breast-feeding. Arch Gynecol Obstet. 2016 Feb;293(2):317-28

Hoban R, Medina Poeliniz C, Somerset E, et al. Mother's Own Milk Biomarkers Predict Coming to Volume in Pump-Dependent Mothers of Preterm Infants. J Pediatr. 2021 Jan;228:44-52.e3

Huang L, Xu S, Chen X, et al. Delayed Lactogenesis Is Associated with Suboptimal Breastfeeding Practices: A Prospective Cohort Study. J Nutr. 2020 Apr 1;150(4):894-900
 
Lind JN, Perrine CG, Li R. Relationship between use of labor pain medications and delayed onset of lactation. J Hum Lact. 2014 May;30(2):167-73
 
Matias SL, Dewey KG, Quesenberry CP Jr, et al. Maternal prepregnancy obesity and insulin treatment during pregnancy are independently associated with delayed lactogenesis in women with recent gestational diabetes mellitus. Am J Clin Nutr. 2014 Jan;99(1):115-21

Medina Poeliniz C, Engstrom JL, Hoban R, et al. Measures of Secretory Activation for Research and Practice: An Integrative Review. Breastfeed Med. 2020 Apr;15(4):191-212
 
Nommsen-Rivers LA, Chantry CJ, Peerson JM, et al. Delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding. Am J Clin Nutr. 2010 Sep;92(3):574-84
 
Preusting I, Brumley J, Odibo L, et al. Obesity as a Predictor of Delayed Lactogenesis II. J Hum Lact. 2017 Aug 1
 
Rocha BO, Machado MP, Bastos LL, et al. Risk Factors for Delayed Onset of Lactogenesis II Among Primiparous Mothers from a Brazilian Baby-Friendly Hospital. J Hum Lact. 2019 Mar 22:890334419835174
 
Tao XY, Huang K, Yan SQ, et al. Pre-pregnancy BMI, gestational weight gain and breast-feeding: a cohort study in China. Public Health Nutr. 2017 Apr;20(6):1001-1008
 
Turcksin R, Bel S, Galjaard S, et al. Maternal obesity and breastfeeding intention, initiation, intensity and duration: a systematic review. Matern Child Nutr. 2014 Apr;10(2):166-83