Lactogenesis, the production of breast milk, occurs in 3 stages. Lactogenesis one begins from the 16th week of pregnancy and lasts until a few days after a person gives birth. Lactogenesis two is the stage where milk production intensifies, or “comes in.” This begins around 3-5 days postpartum. Lactogenesis three is the final stage where breastmilk production has been established and continues to be produced as long as milk is being emptied from the breast.
Most problems with lactogenesis happen during lactogenesis two, according to Dr. Carly Dulabon, director of Akron Children’s Breastfeeding Medicine.
“The most common issues are a delay in milk coming in or difficulties with milk removal,” said Dr. Dulabon.
For a patient with delayed lactogenesis two, a cesarean section birth without labor, gestational diabetes, a baby who is not nursing well or if mom is struggling with pumping, are the most common causes.
“If a baby has a very painful latch or a sleepy latch, that can cause a delay in milk production,” she said.
Patients without a delay in lactogenesis two typically present with complaints of engorgement and pain, said Dr. Dulabon.
“Within the first week of the baby’s life, most postpartum women will either see their provider with complaints of either no or not enough milk coming in or pain and engorgement,” she said.
If a patient is engorged, it can make it difficult for baby to latch and effectively empty milk – or if baby lacks oral coordination or has an ineffective latch, these can lead to further engorgement.
Once lactogenesis two is complete, milk transitions to more mature milk, which is what baby receives for the rest of their breastfeeding journey.
Patients who present with complaints of painful nursing beyond the first few days of baby’s life or with babies who are struggling to gain weight should be referred to breastfeeding medicine as soon as possible, Dr. Dulabon noted.
“These are two concerns where it’s much more effective to address them early than it is to try and play catch up later,” said Dr. Dulabon.
Dr. Dulabon notes that if a patient presents with an exquisite pain during latching, it’s likely because the baby doesn’t have an effective latch.
“And if the baby doesn’t have a good latch, they’re probably not getting enough milk, which can lead to issues with weight gain. You can see how these issues go hand-in-hand,” she said.
If you’re seeing patients postpartum you should ask them how their baby’s latch feels, Dr. Dulabon said. If they report pain, consider referring to breastfeeding medicine. You can make a referral online or via Epic here.
“The earlier you refer, the better the outcomes are going be if we can get our hands on these families as soon as they have issues,” she said.
Immune response from lactogenegesis
In addition to common issues with lactogenesis two discussed above, patients can present with pain, redness, engorgement in both breasts and sometimes fever, which can be mistaken for mastitis. The pain, redness, engorgement in both breasts is typically a result of the immune response that happens with lactogenesis two.
“Many moms can get misdiagnosed because they will get a fever, and that’s because milk coming in is such an inflammatory response,” she said.
To treat a patient presenting with pain, redness, engorgement in both breasts and fever, Dr. Dulabon advises applying ice and encouraging the patient to take an anti-inflammatory to lessen swelling and pain. If a patient’s fever lasts more than 24 hours, they should be seen.
Whether your patient has pain, milk supply issues or baby has difficulty latching or feeding, referring to Akron Children’s Breastfeeding Medicine can help address common issues before they become larger problems.
