Question
I have a client who had breast augmentation in 2001 with incisions under her arms.  She said her breasts were a B-cup size and she was “not in proportion” as the reason for the cosmetic surgery.  During a medical history, she reported she had previous “mini strokes” at age 21 while on hormonal birth control.  Genetic testing revealed a clotting disorder and several mutant genes.  Lovenox was prescribed for the clotting disorder.

The mother stated the reason for the consultation as “low milk supply – cannot pump much milk.”  Her baby was 2 oz. below birth weight at 15 days of age.  A weight check after breastfeeding from both breasts indicated an intake of approximately 2 oz (58 cc).  Pumping after breastfeeding yielded another 1 oz (28 cc).  The mother has added pumping with the hospital-grade pump but still does not have a full milk supply.  The baby is gaining weight and is more content now with supplementation of expressed breast milk and formula.

Do you think the clotting disorder could be related to her low milk production?

Deborah Ehrhardt, BA, IBCLC

Answer
Dear Deborah,

As you know, unusually shaped breasts can be a marker for abnormal development and insufficient glandular tissue (Neifert 1985 Huggins 2000).  Therefore her underlying breast development issues (now disguised by the augmentation) may explain her low milk production.  I don’t know if a history of stroke, per se, has ever been implicated in subsequent low milk production.  I hope that any of our readers with experience in this regard will comment.  We know that injury to the pituitary can affect lactation, but without evidence of brain damage in the regions that impact breastfeeding, we would only be speculating as to the relevance of her stroke history in the present situation.

Enoxaparin (Lovenox) is a low molecular weight fraction of heparin with low bioavailability and a molecular size that precludes its entry to milk in any clinically relevant levels (Hale 2006).  Both heparin and Lovenox are anticoagulants.  Hale doesn’t list any side effects beside risk of bleeding.  I doubt the drug would have a direct affect on milk production, however, I wonder if the mom (owing to the clotting disorder) lost an unusual amount of blood during delivery?  If so, perhaps she is slightly anemic and/or still recovering enough metabolic energy to support full lactation.  This phenomenon (poor milk production following greater-than-normal blood loss and anemia) is noted in the literature (Henly 1995, Willis 1995).

In cases where postpartum blood loss is an issue, the best strategy is to encourage good maternal nutrition with increased protein intake and iron supplementation.  The mother should be encouraged to rest and to augment breast stimulation.  You have taken steps (supplementation with pumped milk and formula) to stabilize the baby.  It remains to be seen whether the mom’s supply will improve.  I would ask her about the blood loss issue, because recovery from blood loss takes time.

It is interesting that the baby removed 2 oz (~60 g) directly from the breasts during the feeding you observed.  The mom then pumped an additional 1 oz (~30g), This would constitute a normal volume of intake if the milk supply was consistent at this level over the course of 24 hours.  However, the infant’s failure to recover birth weight by Day 15 suggests that something is problematical.  I know you will be reviewing management issues (number of feeds per day, etc.) and I agree that watchful waiting will bring more information.  This mother may simply have gotten off to a slow start and will increase her milk supply to normal in response to your interventions.  Whether her health history limits her to a partial supply will only become obvious over time.  I support you in what you are doing to manage the case and invite you to report back in a month to let us know whether her supply increased.

Barbara

Hale, T.  Medications and Mothers Milk, 12^th ed.  Hale Publishing, Amarillo, 2006, pp 302-3.

Henly S, Anderson C, Avery M, et al.  Anemia and insufficient milk in first-time mothers. Birth 1995; 22(2):87-92.

Huggins K, Petok E, Mireles O.  Markers of lactation insufficiency: a study of 34 mothers, in K Auerbach, (ed) Current Issues in Clinical Lactation 2000. Sudbury, MA: Jones and Bartlett, 2000, pp 25-35.

Neifert M. Seacat J. Jobe W:  Lactation failure due to insufficient glandular development of the breast, Pediatrics 1985, 76:823-28.

Willis C. Livingston V:  Infant Insufficient Milk Syndrome Associated with Maternal Postpartum Hemorrhage, J Hum Lact 1995, 11(2):123-126.