PCOS and Milk Supply

Last year, I posted about Carbohydrates and PCOS (and fertility) and at the end of the post, I said there would be a follow up about PCOS and Breastfeeding.  I received a lot of positive feedback about that post and inquiries about where the follow-up post was....so here it is!

PCOS disrupts a delicate balance of hormones that affects milk supply.  Here is a diagram I created to show some of the theoretical pathways in which the breast or the milk supply itself may be affected by PCOS hormone.  It is estimated that one-third of women with PCOS actually have problems with milk overproduction, rather than insufficient milk supply.
 

The following 3 scenarios are example of what could happen in women with PCOS:

Scenario 1 (Most common)

Lisa’s baby seems to be dehydrated and Lisa does not want to supplement with formula. Lisa’s baby latches on effectively, sucking strongly for a few minutes with no evidence of effective milk transfer and then comes off still showing signs of hunger. The baby is "always sucking on his fingers," but Lisa read that frequent breastfeeding will help to make more milk. Therefore, she was resistant to giving any formula so as not to miss an opportunity to breastfeed. During a conversation with a Lactation Consultant, Lisa realizes that she has not been providing her baby with enough milk and reveals to the LC that she is very sad because she wanted to do the best for this baby since it took her many years to get pregnant due to PCOS.

Scenario 2 (Also common)

Michelle calls a lactation consultant because she is concerned that her baby is not getting enough milk since he only takes her right side at each feeding. He will latch on to the left side but quickly comes off. Michelle states that her baby seems satisfied from one side, but she grew concerned when she heard that her friend always nursed on both sides at each feeding. Upon examination, the lactation consultant notices that her left breast has evidence of hypoplasia (underdevelopment).

Scenario 3 (Less common but does happen)

At a breastfeeding support group, Maria seems worried about the way her baby eats. She doesn’t understand why he is having difficulty because she knows that she “has a ton of milk.” In fact, she reports that she has so much milk that she “switches sides after ten minutes because otherwise my breasts get too engorged.” Her baby gags, pulls off her breast, spits up after feedings, and seems hungry shortly afterwards.

What to do?

The usual practices that lactation consultants employ to improve milk supply in woman without PCOS, are indicated as the initial treatment for women with PCOS as well. Most importantly, these include frequent feedings with an effective latch. In fact, if you know that you have PCOS, ask your prenatal/postpartum health care providers to support you by encouraging an early latch - that means allowing the baby to stay with you immediately after birth for the first hour, resting on your body. Your baby will slowly find its way to your milk. Only send the baby to the nursery if medically necessary and afterwards, nurse frequently whenever the baby shows hunger cues or use a pump. All of this will improve your prolactin and oxytocin levels, helping you  make more milk.  It helps to bring the telephone number of a good lactation consultant with you to the hopsital just in case you don't have qualified nurses (not all postpartum nurses are actually good at breastfeeding education!). Ideally, postpartum health care providers should teach and show you what an effective latch looks and how to identify milk transfer. Skin-to-skin contact should be encouraged to increase milk supply. Medications, such as progesterone and metformin, and some food and herbs (galactologues) have been shown to improve milk supply in women with PCOS without breast under-development (hypoplasia).

More Specific advice for each scenario 

Scenario #1:

• An effective latch was still insufficient to provide enough milk.She can pump or hand express milk to provide milk for supplementing at the breast
• It is likely that she will not be able to express a significant amount of breast milk. A lactation conultant can show her how to supplement "at the breast" using a special feeding kit. Supplementing at the breast for all feedings may establish a full milk supply, but it may take many weeks.
• If her milk supply never increases, she has the option of continuing to supplement at the breast or using a bottle. Supplementing at the breast will enhance any milk that she is able to produce, enable her to breastfeed for a longer duration, and will increase the likelihood of her being able to breastfeed future children.  If it was not her intent to use formula, it should be pointed out that it is exactly for times like this that we are happy to have a nutritionally adequate supplement. 

Scenario #2:

• The mother receives education on her hypoplasia condition in her left breast and that she can produce enough milk in one breast to ensure proper nutrition and growth. Breast should drain fully at each feeding session.
• She should be taught how to ensure that the infant is latched well, is swallowing rhythmically, and is satisfied after feeds. Her breast should feel soft after feedings.
• The infant’s weight should be monitored closely (re-gain birth weight by 2 weeks; then gain 4-7 ounces/week or 1 pound/month) and output (5-6 wet diapers and 3-4 dirty diapers after the first week).

 Scenario #3:

• First, infant health issues should be investigated, such as suck/swallow/breathe coordination and/or gastric reflux.
• If it appears that she has a true oversupply issue, the mother should be taught that her baby may seem hungry because he comes off the breast too early due to an uncomfortably fast flow, or because he is drinking a lot of foremilk. Foremilk is rich in carbohydrates and protein, while hindmilk, which comes towards the end of feeding on each side, is rich in fat. Fat will help to keep the baby full and prevent spitting up.
• The usual guideline for oversupply should be employed:
  • Instead of timing her feedings, she should feed her baby on one side at each feeding.
  • She can hand-express or pump the other breast between feedings if she is uncomfortable. She should express only enough milk to feel comfortable. She should not fully drain the breast, as this will only reinforce an oversupply problem.
  • Milk supply usually adjusts to match the infant’s needs at about 6 weeks postpartum. At this point the infant may want to nurse at both sides again.

Low milk supply issues are often incorrectly perceived as being the cause rather than the result of unsuccessful breastfeeding. However, a true milk supply issue is a real concern in women with have low milk supply due to a hormone imbalance such as PCOS. The same recommendations that should be made to all breastfeeding women (breastfeed early, breastfeed often, with an effective latch and swallowing) is even more important for the woman with PCOS. Keep in mind that some women might not be aware that they have PCOS, and the lactation consultant might be the first health care professional to realize this condition.

If a pregnant mother is aware that she had PCOS, she should choose her obstetrician and pediatrician wisely, to ensure supportive providers in the event that she has a low milk supply or delayed milk production. First time moms who are experiencing milk supply issues may be encouraged to hear that is they continue to breastfeed this will increase their chance of making more milk with the next baby as she can develop more prolactin receptors.

Lactation consultants working with moms who intended to breastfeed exclusively will need to have an extra dose of compassion to help guide the mother through the first few weeks.