Milk supply mystery?  Could it be insufficient glandular tissue?

Milk supply mystery? Could it be insufficient glandular tissue?

We're very pleased to share an excerpt from the new book, Finding Sufficiency: Breastfeeding with Insufficient Glandular Tissue by Diana Cassar-Uhl. Insufficient Glandular Tissue (IGT) often creates serious breastfeeding challenges, yet it remains poorly recognized. We're thrilled that this book is available to help mothers, and hope you find the following excerpt useful.


In the absence of a consensus on how we might classify lactation insufficiency as caused by IGT, I use the following criteria to identify IGT cases:

  • Intent to exclusively breastfeed from birth through the middle of the baby’s first year (about 6 months)
  • Appropriate social and clinical support for the intent to breastfeed, resulting in proper breastfeeding management and early detection/resolution of any infant difficulties in breast stimulation or milk transfer
  • Lack of breast changes in pregnancy (breasts did not become at all sensitive, warm/hot, swollen, or larger in size during early pregnancy)
  • Lack of or “spotty” breast changes postpartum (some mothers feel “engorgement” where they do have glandular tissue, typically in all quadrants except the lower middle quadrant)
  • A medically indicated need to feed a supplement other than mother’s milk to the baby within the first 14 days after birth*
  • Widely spaced breasts or nipples that seem to “look away”from each other or “look down,” which indicate soft, fatty tissue in the lower center quadrant of the breasts
  • Asymmetrical breasts

In 2013, Penny Liberatos (New York Medical College) and I conducted a study of mothers with breastfeeding difficulties related to milk supply. As a result of that research, we determined that other red flags that might be present in mothers with IGT include:

  • A pre-pregnant body mass index (BMI) of greater than 30
  • BMI greater than 26 or 30 during puberty
  • Hormonal disorders, such as insulin resistance, diabetes,or hyperandrogenism
  • Use of hormonal birth control during puberty (for reasons other than to prevent pregnancy
  • Unexplained fertility issues
  • History of an eating disorder or extreme athleticism that delayed or stopped menstruation

However, even in Huggins et al.’s sample, there were women with the physical presentation of hypoplasia/IGT who made enough milk to exclusively breastfeed, and there are women with very full-appearing breasts who make barely any milk after their babies are born. How can you determine if IGT is really your problem?


In our study, Penny Liberatos and I noticed that, of the 6 breast characteristics suggested by the Huggins study, 4 were most prev­alent: lack of breast changes in pregnancy, lack of breast changes postpartum, wide spacing, and asymmetry. While stretch marks were a popular characteristic, in my clinical experience, the presence or absence of them on breasts that were otherwise developed does not seem to be related to milk output—but stretch marks on very underdeveloped breasts do raise my suspicions. Because the majority of our study respondents had a high BMI, it also seemed impractical to consider breast shape; it is possible for a woman to have large, full breasts but still have IGT. Indeed, because there is so much fat tissue in these breasts, IGT is very often missed in these women—appearance alone can’t tell the whole story of what is or isn’t there.

Another important aspect of a mother’s history is whether she had to offer a supplement to her baby within the first two days of his birth. In this time frame, a baby only needs a very small amount of colostrum—1/4 teaspoon in a 20-minute feeding session is normal transfer for a newborn. There are women who believe they didn’t make any colostrum, but this is highly unlikely, since the hormonal setting of pregnancy and the immediate postpartum (when colos­trum is made) is so drastically different from the hormonal setting of normal lactation. Also, the very small amount of colostrum that is needed can be made by the glandular tissue that is there, and storage capacity—how much milk a mother can accumulate and store between feedings—isn’t of consequence when we’re dealing with such small amounts.

There is a good reason why some babies don’t wet or soil diapers in those first 48 hours, though: they might be unable to transfer the colostrum that’s there. This can happen for a variety of reasons, but the most common are oral irregularities (such as tongue tie) in the baby or incorrect positioning/latching. If these issues are not immediately noticed and resolved, they could cause or further complicate very early breastfeeding problems. However, low milk output due to IGT does not typically reveal itself during a regular (short) postpartum hospital stay.


Low milk supply that starts later, say after the 4- or 5-week mark, is also not likely to be caused by IGT, but it could be if those 4 weeks were spent with the baby barely hanging on to his growth curve. A “vanishing milk supply” is more likely due to…you guessed it, a tongue-tied or otherwise unable to effectively transfer milk infant.

There may always be some uncertainty about exactly why you aren’t (or weren’t, if your breastfeeding days are behind you already) able to make a full milk supply. There are so many variables that can affect lactation, and definitive identification of which of those affected yours can be difficult to pin down.

You may not ever truly know whether your issue was IGT, sufficient glandular tissue that simply didn’t respond to the hormones of pregnancy and lactation, a complicated birth/postpartum period that compromised breastfeeding management during a critical window, or something to do with your baby’s ability to adequately transfer milk. You can know, though, that regardless of the reason(s) breastfeeding didn’t work as you hoped it would, you are still your baby’s mother, and your love for that child isn’t measured in drops, milliliters, or ounces of milk.

* This can be subjective. Normal newborn infant behavior is often poorly understood, and it is com­mon for health care providers and parents to misinterpret normal newborn needs for physical closeness and suckling as hunger. Every effort should be made by qualified practitioners and parents to distinguish between normal newborn behavior and insufficient nutrition in the first 2 weeks of life.
Excerpted from Finding Sufficiency, published by Praeclarus Press. Used with permission.
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