Thorley, V. G.

University of Queensland eSpace


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BREASTFEEOING REVIEW 
INTRODUCTION 
Hypoplasia of the breast. although uncommon, results in reduced 
milk production and, if unrecognised, undesirable sequelae in the 
infant such as poor weight gain and failure to thrive. Antenatal 
examination of the breasts will facilitate identification of women 
exhibiting signs of possible hypoplasia. Matemal factors indicative of 
hypoplasia outlined by Huggins et al [2000] include: 
tubular breasts that have a narrow base on the chest wall and 
are pendant 
widely-spaced breasts [an intramammary gap of 3.75 em or 
more) 
an overdeveloped areola relative to actual breast tissue 
little or limited development of the inner lower quadrant and 
possibly other quadrants 
little or no breast growth during pregnancy. 
There may be a marked asymmetry between breasts. However. 
some women have breasts that appear normal on a cursory 
inspection, but are found to be hypoplastic when examined closely 
after the baby fails to thrive or is admitted to hospital following a 
crisis. Some women with glandular insufficiency may never feel 
fullness, while others do [Huggins et al 2000]. 
The four categories of breast hypoplasia are breasts that are 
rounded but wide-spaced [type 1 ]. have hypoplasia of the lower inner 
quadrant (type 2]. have hypoplasia of both lower quadrants [type 3], or 
have minimal breast base [type 4] [Huggins. Petak & Mireles 2000]. 
The following case history describes how a mother with breast 
hypoplasia partly breastfed several children for extended periods. 
CASE HISTORY 
Previous infant-feeding history 
A 35-year-<Jid multiparous mother presented during pregnancy, with a 
history of minimal milk production with previous babies. Nevertheless, 
two of her previous babies had been willing to be suckled at the breast 
for prolonged periods for about four years. despite being primarily 
artificially fed. This happened despite health professionals telling her 
that there was no milk present. She wanted more information before 
giving birth again as she had always wanted to breastfeed. 
After the birth of her first baby, the mother had attempted to 
breastfeed on demand and was well informed about breastfeeding. 
Unfortunately, her glandular insufficiency was unrecognized and she 
was discharged early. After a home visit by a midwife on day three, the 
baby was admitted to hospital to undergo phototherapy for jaundice. 
The staff fed the baby artificial baby milk [ABM] by bottJe while the 
mother pumped her breasts unsuccessfully. The baby was discharged 
from hospital after passing a sufficient volume of urine in a 24-hour 
period. Thereafter. the baby was artificially fed by bottle, but was willing 
to continue being suckled at the breast for four years. 
After the birth of her second baby, the mother was prescribed 
metoclopramide tablets to support her lactation, but this medication 
was ineffective. Metoclopramide promotes breastmilk production by 
VOL 13 NO 2 2005 
raising prolactin levels, but is ineffective in a very small number of 
women (Hale 2004 ]. At two weeks of age, this baby had not regained 
its birth weight. A midwife set up a feeding tube attached to a syringe, 
so that the intake could be supplemented while the baby was at the 
breast. The amount of ABM was increased so that it was sufficient 
to promote growth and a bottJe was used. At five weeks of age, the 
baby began projectile vomiting and was hospitalised for one week. 
Pyloric stenosis was diagnosed and the baby underwent surgery. 
After returning home. a supplemental feeding system was used 
to provide ABM by tube while breastfeeding. Health professionals 
expressed various opinions on the cause of the low supply, generally 
attributing it to baby;-elated factors. Despite the underlying lactation 
problem and the unrelated setbacks, this infant was also willing to 
comfort itself at the breast for about four years. 
Breastmilk supplementer system. Note: The model does not have breast 
hypoplasia. 
On the third day after the birth of her third baby, when her milk 
had not come in, the mother was told emphatically by health care 
staff who examined her breasts that she was unable to breastfeed. 
A long, straight teat was recommended in the belief that it would 
improve her baby's suckle, but this strategy was so ineffective that 
by three weeks she was unable to get her baby to accept the breast 
at all. The mother again tried a supplemental feeding system and 
every ruse she had tried previously, but could not persuade this baby 
to breastfeed again- the only one of her children to refuse to accept 
the breast despite the minimal supply. During these experiences she 
accepted the opinion she was given, that her babies received only 
comfort at her breast, but no milk. 
Course of breastfeeding 
When this mother consulted the author while pregnant with her 
fourth child, examination revealed breast hypoplasia with extremely 
wide spacing of her breasts. Her breasts were proportional and 
were not tubular or pendant but there was a large intramammary 
gap of about 12 em. There was very little visible glandular tissue 
outside of the areolae, though the upper outer quadrant of the right 
breast had slightly more tissue. The mother recognised the need 
to use ABM to prevent dehydration and hunger and to enable the 
infant's growth. She sought encouragement to set and meet realistic 
breastfeeding goals. These were to encourage her new baby to 
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accept the breast, even though it was likely that most of the baby's 
nutritional requirements would need to come from other sources. 
Graduating to exclusive breastfeeding would not be an option. 
I postulated that, if two previous babies had suckled at the breast 
until about four years of age, they must have been receiving some 
milk, however little. My clinical judgment was to support this mother's 
desire to breastfeed, with appropriate supplementation. She was well 
versed in how to latch a baby at breast. We discussed methods of 
giving the necessary ABM, which would provide most of her baby's 
nutritional requirements. She used a supplemental feeding system for 
nearly six-and-a-half months to deliver ABM to her baby by tube while 
at the breast, before its use became impossible Thereafter she gave 
her baby ABM by bottle. 
Even though this cannot be used as a reliable measure of breastmilk 
intake, I advocated that at nappy changes the mother observe her 
baby's stools for traces of breastmilk, something that had never been 
suggested to her before. The rationale for this suggestion was that I 
had found it encouraging for adoptive mothers, and that I believed it 
was an appropriate suggestion for this mother for whom even a slight 
change in the stools would be gratifying. As she focused on her baby's 
growth and needs, rather than on the appearance of the stools, lack 
of such stools would not be a source of discouragement. When her 
baby was between two and four months old, she reported up to one-
third of this baby's stools showed evidence of breastmilk ingestion. 
Some stools were, predictably, classic artificial-feeding stools, some 
were combination stools, and a few were mostly breastmilk stools in 
appearance. The mother derived emotional benefit from seeing visible 
evidence of breastmilk production in her baby's stools. 
The infant thrived as her mother provided sufficient ABM for her 
to grow satisfactorily. After use of the supplementer was discontinued 
ABM was given by bottle. The mother had stopped breastfeeding after 
approximately two years as she was pregnant and had tender breasts. 
Subsequent breastfeeding history 
The next child also breastfed with the aid of a supplementary feeding 
system. Feeding with the supplementer in place seemed to work best if 
mother and baby were lying down. Eventually, this baby too began to prefer 
to receive ABM by bottle, rather than by tube. At about four months, 
although ABM was provided by bottle during the day, breastfeeding was 
used almost exclusively at night. The right breast felt full at the end of the 
day and it seemed 'well emptied' by moming. The baby also accepted the 
breast at other times. The previous child has occasionally asked for the 
breast since the birth of the new baby and some nights the older child 
has breastfed to sleep. At the time of writing, the mother is still tandem 
breastfeeding her toddler along with her severHTlonth-old baby, a situation 
that gives her great emotional satisfaction. Most of the baby's nutritional 
requirements continue to be in the form of ABM 
DISCUSSION 
In addition to the maternal indicators of infant hypoplasia described 
earlier there are also several infant indicators of this condition. These 
include failure to regain birth weight in less than three weeks, poor 
BREASTFEEDING REVIEW 
weight gain or failure to thrive, continuous weight loss after ten days 
and signs of dehydration. Infant factors which may be indicative of 
breast hypoplasia can also be indicative of other causes of insufficient 
milk supply such as poor latch, infrequent breastfeeding, or infant 
defects such as oral abnormalities or unidentified cardiac problems. 
When several infant or maternal indicators are noticed, the mother's 
breasts should be examined in case hypoplasia has been previously 
missed. In extreme cases where hypoplasia goes unrecognised and an 
inexperienced mother is discharged from hospital without appropriate 
information about what is normal and abnormal in newborns, the 
infant is at risk from dehydration and emergency readmission. 
The clinical questions to be considered in individual cases are: 
Should this mother be encouraged to breastfeed at all? Would it 
be easier to 'teed artificially? Can the baby be fed at the breast, with 
appropriate supplementation? Should this mother be encouraged 
to aim eventually to breastfeed exclusively? 
A number of well-conducted studies show that babies who 
have never been breastfed are at risk of developing various health 
problems when compared to those who are exclusively breastfed for 
the first few months of life [Oddy et al 1999; Oddy 2001; Kramer et 
al 2001 ]. Babies who are partly breastfed receive some protection, 
putting them ahead of the exclusively artificially fed. While a mother 
with insufficient breast tissue will need to supplement with ABM, 
it should be feasible for her to continue also to provide breastmilk 
for her child. Measures to maximise the breastmilk supply should 
be discussed on an individual basis. Although there is merit in the 
initial use of a supplementary feeding system that allows the baby to 
receive the ABM at breast while stimulating the mother's lactation, 
the choice of how to supplement the baby will also be individual. The 
experience of providing all the baby's nutritional requirements while 
at the breast may be meaningful to the mother. 
The mother whose case is reported here derived emotional 
satisfaction from seeing her babies at the breast, from being 
able to breastfeed in public like other mothers in her community 
and from her babies' willingness to use the breast as comfort well 
beyond early infancy. Her babies received some breastmilk, a good 
deal more skin-to-skin contact than would have been possible with 
exclusive bottle-feeding and were able to be comforted at the breast. 
This mother was highly motivated, was reluctant to opt for exclusive 
artificial feeding and was willing to take the extra time to offer the 
breast along with preparing ABM and the related equipment. Both 
the degree of hypoplasia and her past history indicated that exclusive 
breastfeeding would never be possible and she was realistic about 
what could be achieved. 
IMPLICATIONS FOR PRACTICE 
Although the specifics of this single case may not be generalised 
to other women presenting with breast hypoplasia, this report 
demonstrates what has been possible for one motivated mother.lt is 
hoped that this report may assist health professionals in determining 
appropriate information and support to meet the differing and 
individual needs of clients who have inadequate lactation owing to 
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BREASTFEEOING REVIEW 
breast hypoplasia and who are motivated to continue breastfeeding. 
Babies of breastfeeding mothers with breast hypoplasia need 
monitoring because of the risk of underfeeding. They may always 
need ABM [but not necessarily at every feed] and this will depend 
on the amount of functioning breast tissue that is present. Where 
the hypoplasia is less extreme than in the case presented here, the 
maternal supply may be built up over about a month to 50-1 00% of 
needs [Huggins, Petak & Mireles 2000]. Realistic encouragement, 
based on a careful clinical appraisal and follow-up, can enable the 
mother to achieve a breastfeeding relationship and ensure that the 
infant's breastmilk intake is maximised without risking dehydration. 
REFERENCES 
Hale T 2004, Medications and Mother's Milk. Pharmasoft Publishing, 
Amarillo. Texas. pp548-551 . 
Huggins KE. Petak ES, Mireles 0 2000, Markers of lactation 
insufficiency: a study of 34 mothers. Curr Issues Clin Lactation 
2DDD Jones and Bartlett, Sudbury. MA. pp 25-35. 
Kramer MS. Chalmers B, Hodnett ED. Sevkovskaya Z, Dzikovich I, 
Shapiro S, Collet J.P. Vanilovich I, Mezen I. Ducruet T. Shishko G. 
Zubovich V, Mknuik D, Gluchanina E. Dombrovskiy V. Ustinovitch 
A. Kat T. Bogdanovich N. Ovchinikova L. and Helsing E for the 
PROBITStudy 2001, Promotion of the breastfeeding intervention 
trial [PROBIT}: A randomized trial in the Republic of Belarus. 
JAMA 285[4]: 413-420. 
VOL 13 NO 2 2005 
Oddy WH. Holt PG. Sly PD. Read AW. Landau Ll, Stanley FJ, Kendall 
GE. Burton PR 1999, Association between breastfeeding and 
asthma in 6 year old children: findings of a prospective birth 
cohort study. BMJ319: 815-819. 
Oddy WH 2002, The impact of breastmilk on infant and child health. 
Breastfeeding Review 1 0[3]: 5-1 B. 
Phillips V 1991, Successful Breastfeeding. Nursing Mothers' 
Association of Australia, Melbourne. pp205-209. 
Riordan J [ed] 2004, Breastfeeding and Human Lactation. 3rd ed, 
Jones & Bartlett, Sudbury Massachusetts. p240. 
ABOUT THE AUTHOR: 
Virginia Thorley has been involved in the breastfeeding field since 
1966 and has been continuously certified IBCLC since 1985. She 
has over 70 publications in peer;-eviewed journals. on breastfeeding. 
professional issues, self-help groups in health care, and infant 
feeding history. She is currently enrolled as a PhD candidate at the 
University of Queensland. 
Correspondence to: 
Virginia Thorley 
4/14 Moreton Street 
Norman Park, QLD 4170 
vgthorley@optusnet.com.au ©ABA2005 
Statement of Mutual Support from the Australian 
Breastfeeding Association for the International Board 
of Lactation Consultant Examiners 
The Australian Breastfeeding Association [ABA] (formerly the 
Nursing Mothers' Association of Australia] has been involved from 
the inception of the International Board of Lactation Consultant 
Examiners [IBLCE] because it recognised that some of the problems 
mothers experienced were beyond the scope of practice of the 
ABA counsellor. This credential was seen as providing a career 
option and professional recognition for those ABA counsellors who 
wanted to specialise in clinical lactation, ensuring their ongoing 
education as they built evidencecHJased practice. 
Similarly, the IBLCE recognises the value of the ABA counsellors in 
providing the mother-to-mother support essential to widespread 
breastfeeding success in a contemporary setting. The IBLCE 
recognises that mother-to-mother support is the foundation 
on which rests the community based public health programs in 
educating the public about the value of breastfeeding, advocating 
for breastfeeding babies. helping mothers and their families 
understand the normal course of breastfeeding and thereby 
empowering women to breastfeed. 
The IBLCE recognises that the role of ABA counsellors is different 
from that of the IBCLC. The ABA counsellor provides ongoing 
support and information that is necessary to improve lactation 
outcomes.IBCLCs provide another layer of support and information, 
working cooperatively as members of the health care team by 
offering skilled crisis intervention and non-medical problem solving 
which the ABA counsellor may not wish to provide. The roles of 
the two designations are not duplicative but rather integrative and 
complementary, and mutual referrals provide optimum benefit to 
the mother-baby dyad . 
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Breast hypoplasia and breastfeeding: A case history

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Breast hypoplasia and breastfeeding: A case history

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