At-risk conditions and effective lactation support

The problem: potential delayed secretory activation

Secretory activation, i.e. milk ‘coming in’, normally occurs between 24 – 72 hours after delivery.¹ It initiates the increase of larger volumes of milk, and is closely connected to the natural interaction of the hormones progesterone, oxytocin and prolactin.² This interaction is highly dependent not only on the mother’s health but also on external factors like the birth process and the infant’s suckling at the mother’s breast directly after birth. In fact, early and frequent breast stimulation in these early hours and days is essential to support timely milk ‘coming in’ and long-term milk production.³

Over 40 % of mothers⁴ are at risk from delayed secretory activation or delayed onset of lactation (DOL) , which means little or no maternal perception of breast fullness or leaking in the first 72 hours post-birth.¹ The potential problems resulting from this are not to be underestimated: DOL can lead to excessive infant weight loss and the need for formula supplementation⁴, as well as a shortened duration of lactation overall.⁵ Women experiencing DOL have 60 % higher odds of stopping breastfeeding at 4 weeks.⁵

"Delayed secretory activation (≥72 hours after birth) is linked to risks of persistent low milk volumes and a shortened duration of lactation. ^4,5"

The risk factors: primiparity, induced labour & co

What are the risk factors for delayed secretory activation and how can healthcare professionals assess and address them effectively? Research names maternal primiparity among the most relevant factors with first time mothers at a 30 - 40 % increased risk of a delayed onset of lactation. ^4,6,7,8 It is the combination of this and other factors as well as the cascade of medical interventions they often trigger, that puts affected women at a much higher risk of inadequate milk volumes.¹

Many of the prenatal risk factors for lactation are closely linked with the mother having an increased chance of requiring an induction of labour (IOL)⁹. For instance, women with (gestational or pre-existing) diabetes and women with obesity are likely to be advised to have their labour induced.10 First time mothers tend not to give birth on their “due date“.

Rather than waiting for the pregnancy to continue until 42 weeks, as was done in the past, in many countries we now see obstetric care recommending inducing labour at 41 weeks. Compared to women who went into labour spontaneously, those who were induced are more likely to experience epidural use (71 % vs 41 % for spontaneous labour), episiotomy (41 % vs 30 % for spontaneous labour), vacuum or forceps use and/or, eventually, a caesarean section (29 % vs 14 % for spontaneous labour).¹¹ Overall, IOL means more stressful labours and the often resulting medicalised birth leads to increased risk of pain, postpartum haemorrhage, stress, sleepy and exhausted infants¹¹ or even the separation of mother and infant. All these conditions may result in the failure to breastfed well or at all within the crucial first hours and/or days and may have potential delayed secretory activation as a consequence.^1,4,15

"Prioritising initiation, building and maintaining mother’s milk volume is the most important lactationrelated responsibility for maternity and neonatal caregivers."

Effective lactation support: timely initiation through breast stimulation

It is the professional intervention and support of midwives, nurses, doctors and lactation specialists that can now ensure mother and infant get off to the right start. The mother‘s breast needs to be sufficiently stimulated to program the processes that regulate long-term milk synthesis. This will help infants who cannot effectively breastfeed in the early days after birth to be exclusively fed their own mother’s milk (OMM). The time between birth and secretory activation (milk ‘coming in’) is critical for safeguarding future milk supply.²⁶

The first hours after delivery are a crucial time window for priming the breast tissue and making use of the natural rise and fall in maternal hormones. Specifically, the rapid fall in progesterone and the elevated levels of oxytocin and prolactin shortly after birth switch on the lactocytes (milk-making cells).² Together with breast stimulation they are the physiological triggers for the onset of significant milk production (milk ‘coming in’) between 24 and 72 hours.

"NICU mothers who initiate pumping within 3 hours after birth significantly reduce the time to secretory activation and have higher daily and cumulative milk volumes over time.31-33 They are also more likely to be pumping at 6 weeks and when infants are discharged from NICU.^31-33"

Early breastfeeding and pumping

Early breastfeeding should commence within the first hour of the birth. If an infant cannot (effectively) breastfeed, pumping with a hospital-grade electric double pump should be started within the first three hours of birth. Only when milk is removed frequently (8-12 times in 24 hours)³² and the breasts are drained effectively, can an adequate milk supply be built and the mammary gland is programmed for long-term lactation.

Not all mothers with risk factors will need to use a breast pump. Mothers whose infants are breastfeeding well do not need to be pumping in addition to breastfeeding. They will need to focus on establishing good breastfeeding techniques. However, any mother, whose infant does not have a first breastfeed within the first hour after birth and/ or is sleepy and ineffectively/infrequently breastfeeding (less than 8x in 24 hours), should be given support and advice to stimulate the breasts with pumping until the infant can breastfeed effectively.