{{Short description|Breast milk production delay}} [[File:Barefoot Dutch Woman Breastfeeding.jpg|alt=Breastfeeding an infant|thumb|Breastfeeding an infant|218x218px]] '''Delayed onset of lactation (DOL)''' describes the absence of copious [[milk secretion]] (onset of lactation) within the first 72 hours following childbirth.<ref name=":26">{{Cite book|last=Wambach|first=Karen|title=Breastfeeding and human lactation|date=2021|others=Becky Spencer|isbn=978-1-284-15157-2|edition=Sixth|location=Burlington, MA|oclc=1120695924}}</ref><ref name=":21">{{Cite journal|last1=Haile|first1=Zelalem T.|last2=Chavan|first2=Bhakti Bhaoo|last3=Teweldeberhan|first3=Asli|last4=Chertok|first4=Ilana R.|date=2017-03-01|title=Association Between Gestational Weight Gain and Delayed Onset of Lactation: The Moderating Effects of Race/Ethnicity|journal=Breastfeeding Medicine|volume=12|issue=2|pages=79–85|doi=10.1089/bfm.2016.0134|pmid=28060524|issn=1556-8253}}</ref> It affects around 20–40% of lactating women, the prevalence differs among distinct populations.<ref>{{Cite journal|last1=Jiang|first1=S.|last2=Duan|first2=Y. F.|last3=Pang|first3=X. H.|last4=Bi|first4=Y.|last5=Wang|first5=J.|last6=Zhao|first6=L. Y.|last7=Yin|first7=S. A.|last8=Yang|first8=Z. Y.|date=2016-12-06|title=[Prevalence of and risk factors for delayed onset of lactation in Chinese lactating women in 2013]|journal=Zhonghua Yu Fang Yi Xue Za Zhi [Chinese Journal of Preventive Medicine]|volume=50|issue=12|pages=1061–1066|doi=10.3760/cma.j.issn.0253-9624.2016.12.008|issn=0253-9624|pmid=28057109}}</ref><ref name=":1">{{Cite journal|last1=De Bortoli|first1=J.|last2=Amir|first2=L. H.|date=2016|title=Is onset of lactation delayed in women with diabetes in pregnancy? A systematic review|journal=Diabetic Medicine|volume=33|issue=1|pages=17–24|doi=10.1111/dme.12846|issn=1464-5491|pmid=26113051|s2cid=205073241}}</ref>
The onset of lactation (OL), also referred to as stage II lactogenesis or secretory activation,<ref name=":26" /><ref name=":1" /> is one of the three stages of the milk production process.<ref name=":26" /> OL is the stage when plentiful production of milk is initiated following the delivery of a full-term infant.<ref name=":2">{{Cite journal|last1=Fu|first1=Manjie|last2=Zhang|first2=Lingsong|last3=Ahmed|first3=Azza|last4=Plaut|first4=Karen|last5=Haas|first5=David M.|last6=Szucs|first6=Kinga|last7=Casey|first7=Theresa M.|date=2015|title=Does Circadian Disruption Play a Role in the Metabolic–Hormonal Link to Delayed Lactogenesis II?|journal=Frontiers in Nutrition|language=English|volume=2|page=4|doi=10.3389/fnut.2015.00004|pmid=25988133|pmc=4428372|issn=2296-861X|doi-access=free}}</ref><ref name=":3">{{Citation|last1=Pillay|first1=Jaclyn|title=Physiology, Lactation|date=2021|url=https://www.ncbi.nlm.nih.gov/books/NBK499981/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=29763156|access-date=2021-04-01|last2=Davis|first2=Tammy J.}}</ref> It is stimulated by an abrupt withdrawal of [[progesterone]] and elevation of [[prolactin]] levels after the complete [[Placental expulsion|expulsion of placenta]].<ref name=":2" /><ref name=":3" /> The other two stages of milk production are stage I lactogenesis and stage III lactogenesis.<ref name=":26" /> Stage I lactogenesis refers to the initiation of the [[Mammary gland|mammary glands']] synthetic capacity, indicated by the onset of [[colostrum]] production that takes place during pregnancy.<ref name=":26" /><ref name=":2" /> Stage III lactogenesis refers to the continuous supply of mature milk from day nine postpartum, until [[weaning]].<ref name=":2" />
Late-onset of lactogenesis II can be provoked by a variety of pathophysiological, psychological, external and mixed causes.<ref name=":26" /><ref name=":2" /><ref name=":3" /> The delay of the process is associated with a range of complications such as excessive [[neonatal]] weight loss{{who|who lost too much weigh, the baby or the mother?|date=November 2022}} and early cessation of [[breastfeeding]], which can lead to undesirable outcomes for the infant and the mother.<ref name=":12" /> These problems can be addressed by different interventions targeting the underlying cause of the delay.
== Diagnosis == [[File:Progesterone.svg|alt=Chemical structure of progesterone, a key hormone in the onset of lactation.|thumb|Chemical structure of progesterone, a key hormone in the onset of lactation|198x198px]] Women who experienced delayed OL reports the absence of typical onset signs, including breast swelling, breast heaviness<ref name=":3" /> and sense of breast milk "coming in"<ref name=":0">{{Citation|last1=Lawrence|first1=Ruth A.|title=Physiology of Lactation|date=2011|url=https://www.sciencedirect.com/science/article/pii/B9781437707885100033%20/|work=Breastfeeding|pages=62–97|publisher=Elsevier|doi=10.1016/b978-1-4377-0788-5.10003-3|isbn=978-1-4377-0788-5|access-date=2021-04-01|last2=Lawrence|first2=Robert M.|url-access=subscription}}</ref> within the first 72 hours postpartum; nevertheless, some reports suggest that the sensation of "milk coming in (to the breasts)" is resultant of milk production overshoot instead.<ref name=":0" />
Clinically, [[obstetricians]] may look for biomarkers to determine the onset of lactation. Some common [[biomarker]]s for the determination of secretory activation include: * A drop in progesterone levels<ref name=":0" /> * Increase in blood flow, oxygen and [[glucose]] uptake<ref name=":0" /> * A sharp increase in [[Citric acid|citrate]] and [[lactose]] concentration<ref name=":0" /><ref name=":5">{{Cite journal|last1=Nommsen-Rivers|first1=Laurie A.|last2=Chantry|first2=Caroline J.|last3=Peerson|first3=Janet M.|last4=Cohen|first4=Roberta J.|last5=Dewey|first5=Kathryn G.|date=2010-09-01|title=Delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding|journal=The American Journal of Clinical Nutrition|volume=92|issue=3|pages=574–584|doi=10.3945/ajcn.2010.29192|issn=1938-3207|pmid=20573792|doi-access=free}}</ref> * Plasma [[Alpha-lactalbumin|α-lactalbumin]] levels peak<ref name=":0" /> and * Decreased breast milk [[sodium]] concentration<ref>{{Cite journal|last1=Hoban|first1=Rebecca|last2=Patel|first2=Aloka L.|last3=Medina Poeliniz|first3=Clarisa|last4=Lai|first4=Ching Tat|last5=Janes|first5=Judy|last6=Geddes|first6=Donna|last7=Meier|first7=Paula P.|date=June 2018|title=Human Milk Biomarkers of Secretory Activation in Breast Pump-Dependent Mothers of Premature Infants|journal=Breastfeeding Medicine|language=en|volume=13|issue=5|pages=352–360|doi=10.1089/bfm.2017.0183|pmid=29708764|s2cid=14061217 |issn=1556-8253|doi-access=free}}</ref><ref>{{Cite journal|last1=Boss|first1=Melinda|last2=Gardner|first2=Hazel|last3=Hartmann|first3=Peter|date=2018-06-20|title=Normal Human Lactation: closing the gap|journal=F1000Research|language=en|volume=7|page=801|doi=10.12688/f1000research.14452.1|issn=2046-1402|pmc=6013763|pmid=29983914 |doi-access=free }}</ref>
Note that delayed onset of lactogenesis II is distinct from [[low milk supply]], where there is a normal onset of lactation, but breast milk is produced in small and insufficient amounts.<ref>{{Cite journal|last1=Sultana|first1=Arshiya|last2=Rahman|first2=Khaleeq U. R.|last3=Manjula|first3=S.|date=2013-01-01|title=Clinical Update and Treatment of Lactation Insufficiency|journal=Medical Journal of Islamic World Academy of Sciences|volume=21|issue=1|pages=19–28|doi=10.12816/0000207|issn=1016-3360}}</ref>
== Causes and risk factors == Delayed onset of lactation can be a result of various factors including pathophysiological, psychological, external, and mixed factors.<ref name=":26" /><ref name=":2" /><ref name=":3" /> {| class="wikitable" |+Summary table: Factors associated with DOL !Factors !Causes |- |Pathophysiological | * Retainment of placental fragments<ref name=":16">{{Cite journal|last1=Perlman|first1=Nicola C|last2=Carusi|first2=Daniela A|date=2019-10-07|title=Retained placenta after vaginal delivery: risk factors and management|journal=International Journal of Women's Health|volume=11|pages=527–534|doi=10.2147/IJWH.S218933|issn=1179-1411|pmc=6789409|pmid=31632157 |doi-access=free }}</ref> * Maternal obesity<ref name=":21" /><ref name=":23">{{Cite journal|last1=Chang|first1=Yan-Shing|last2=Glaria|first2=Amaia Artazcoz|last3=Davie|first3=Philippa|last4=Beake|first4=Sarah|last5=Bick|first5=Debra|date=2020|title=Breastfeeding experiences and support for women who are overweight or obese: A mixed-methods systematic review|journal=Maternal & Child Nutrition|language=en|volume=16|issue=1|article-number=e12865|doi=10.1111/mcn.12865|issn=1740-8709|pmc=7038894|pmid=31240826}}</ref> |- |Psychological | * Stressful labor and delivery<ref name=":23" /> |- |External | * Ineffective breastfeeding practices<ref name=":24">{{Cite journal|last1=Yu|first1=Xiurong|last2=Li|first2=Jianhua|last3=Lin|first3=Xiangyun|last4=Luan|first4=Dandan|date=2019-05-01|title=Association between Delayed Lactogenesis II and Early Milk Volume among Mothers of Preterm Infants|url=https://www.asian-nursingresearch.com/article/S1976-1317(18)30667-4/abstract|journal=Asian Nursing Research|language=English|volume=13|issue=2|pages=93–98|doi=10.1016/j.anr.2019.02.001|issn=1976-1317|pmid=30776448|s2cid=73456588 |doi-access=free}}</ref> * Labor pain medications<ref name=":10" /> |- |Mixed | * Primiparity<ref name=":5" /> |}
=== Pathophysiological === [[File:Placenta held.jpg|alt=Photo of a placenta expelled after labor. Failure of complete expulsion of placenta can hinder the onset of lactation.|thumb|264x264px|Photograph of a placenta expelled after labor. Failure of complete expulsion of placenta can hinder the onset of lactation.]]
==== Retainment of placental fragments ==== [[Retained placenta|Retained placenta fragments]] is an outcome of failure in the complete [[Placental expulsion|expulsion of the placenta]], and contributes to DOL.<ref name=":16" /><ref name=":27">{{Cite book|last=Lauwers|first=Judith|title=Counseling the nursing mother: a lactation consultant's guide|date=2016|others=Anna Swisher|isbn=978-1-284-05263-3|edition=Sixth|location=Burlington, MA|oclc=910948499}}</ref> Residual portions of the placenta continue to secrete progesterone, which inhibits progesterone withdrawal and subsequently hinders the initiation of lactogenesis II.<ref name=":3" /><ref name=":18">{{Cite journal|last1=Dimitraki|first1=Marina|last2=Tsikouras|first2=Panagiotis|last3=Manav|first3=Bachar|last4=Gioka|first4=Theodora|last5=Koutlaki|first5=Nikoletta|last6=Zervoudis|first6=Stefanos|last7=Galazios|first7=Georgios|date=2016-06-25|title=Evaluation of the effect of natural and emotional stress of labor on lactation and breast-feeding|url=http://link.springer.com/10.1007/s00404-015-3783-1|journal=Archives of Gynecology and Obstetrics|language=en|volume=293|issue=2|pages=317–328|doi=10.1007/s00404-015-3783-1|pmid=26112355|s2cid=22282075|issn=0932-0067|url-access=subscription}}</ref>
The successful onset of lactation following clearance of placenta fragments has been reported in multiple case studies.<ref>{{Cite journal|last1=Berens|first1=Pamela D.|last2=Villanueva|first2=Mariana|last3=Nader|first3=Shahla|last4=Swaim|first4=Laurie S.|date=2018-11-01|title=Isolated Prolactin Deficiency: A Possible Culprit in Lactation Failure|url=https://www.aaceclinicalcasereports.com/article/S2376-0605(20)30138-3/abstract|journal=AACE Clinical Case Reports|language=English|volume=4|issue=6|pages=e509–e512|doi=10.4158/ACCR-2018-0132|s2cid=80737449 |issn=2376-0605|doi-access=free}}</ref> The [[dilation and curettage]] (D&C) procedure has been reported with dramatic therapeutic effects for mothers experiencing delayed OL due to placenta retainment.<ref name=":0" />
==== Maternal obesity ==== [[File:BMI weight obesity scale.jpg|alt=A chart showing BMI classification for obesity and overweight. Overweight or obese mothers have a higher risk of experiencing DOL.|thumb|365x365px|A chart showing BMI classification for obesity and overweight. Overweight or obese mothers have a higher risk of experiencing DOL.]] Obesity has been reported as a risk factor that has significant associations with DOL,<ref name=":21" /><ref name=":23" /> although different studies have shown varied conclusions on such connection.<ref name=":23" /><ref name=":7">{{Cite journal|last1=Garcia|first1=Audry H.|last2=Voortman|first2=Trudy|last3=Baena|first3=Cristina P.|last4=Chowdhurry|first4=Rajiv|last5=Muka|first5=Taulant|last6=Jaspers|first6=Loes|last7=Warnakula|first7=Samantha|last8=Tielemans|first8=Myrte J.|last9=Troup|first9=Jenna|last10=Bramer|first10=Wichor M.|last11=Franco|first11=Oscar H.|date=2016-06-20|title=Maternal weight status, diet, and supplement use as determinants of breastfeeding and complementary feeding: a systematic review and meta-analysis|journal=Nutrition Reviews|volume=74|issue=8|pages=490–516|doi=10.1093/nutrit/nuw016|pmid=27330143|issn=0029-6643}}</ref> Relevant reports reveal around one-third of overweight and obese women encountered late arrival of milk, in comparison to approximately one-sixth among women with normal [[body mass index]] (BMI).<ref name=":21" /><ref name=":23" />
One theory behind delayed copious milk production is that progesterone stored in [[adipose tissue]] has led to elevated progesterone levels among obese or overweight women.<ref name=":7" /> This interferes with progesterone withdrawal upon the delivery of the placenta and consequently disrupts the activation mechanism of lactogenesis II.<ref name=":21" />
Another theory affiliates delayed lactogenesis II with large breasts, which is typically observed in obese females. Women with large breasts may encounter physical difficulties with [[Latch (breastfeeding)|latching]] the infant onto the breast, while the positioning of heavy breasts on an infant's chest may also hamper successful attachment.<ref name=":23" /> Unsuccessful attachment may lead to poor infant suckling, which can impede neurohormonal responses and subsequently interrupt the secretion of lactogenic hormones, resulting in delayed secretory activation.<ref name=":23" />
=== Psychological ===
==== Stressful labor and delivery ==== Maternal stress experienced during labor and delivery can induce DOL.<ref name=":18" /> Stress levels can be influenced by factors including the way of labor, duration of labor and degree of post-surgical pain after a [[Caesarean section|cesarean surgery (c-section)]].<ref name=":23" /> Unscheduled cesarean delivery and [[Prolonged labor|long labor duration]] place excessive pressure on the mother and the fetus.<ref name=":23" /> In these cases, high perceived pressure raises [[cortisol]] levels inside the body.<ref name=":18" /><ref>{{Cite web|date=2018|title=Stress effects on the body|url=https://www.apa.org/topics/stress/body#:~:text=The%20consistent%20and%20ongoing%20increase,,%20heart%20attack,%20or%20stroke|url-status=live|access-date=2021-04-01|website=www.apa.org|archive-url=https://web.archive.org/web/20210201172123/https://www.apa.org/topics/stress/body |archive-date=2021-02-01 }}</ref> The elevated level of the [[stress hormone]] affects the secretion of lactogenic hormones in the mother, which delays the onset of lactation.<ref>{{Cite journal|last1=UvnäsMoberg|first1=Kerstin|last2=Ekström-Bergström|first2=Anette|last3=Buckley|first3=Sarah|last4=Massarotti|first4=Claudia|last5=Pajalic|first5=Zada|last6=Luegmair|first6=Karolina|last7=Kotlowska|first7=Alicia|last8=Lengler|first8=Luise|last9=Olza|first9=Ibone|last10=Grylka-Baeschlin|first10=Susanne|last11=Leahy-Warren|first11=Patricia|date=2020-08-05|title=Maternal plasma levels of oxytocin during breastfeeding-A systematic review|journal=PLOS ONE|volume=15|issue=8|article-number=e0235806|doi=10.1371/journal.pone.0235806|pmid=32756565|pmc=7406087|bibcode=2020PLoSO..1535806U|issn=1932-6203|doi-access=free}}</ref>
Women who underwent a c-section are more likely to experience DOL compared to women who delivered vaginally.<ref name=":23" /><ref name=":18" /> This affiliation could be the result of post-surgical pain and stress associated with emergency c-section or prolonged labor.<ref name=":23" /><ref name=":18" /> Similarly, a significantly larger proportion of mothers who gave birth by emergency c-section were reported to be unsuccessful on their first attempt at breastfeeding than women who delivered vaginally, or via scheduled c-section.<ref>{{Cite journal|last1=Hobbs|first1=Amy J.|last2=Mannion|first2=Cynthia A.|last3=McDonald|first3=Sheila W.|last4=Brockway|first4=Meredith|last5=Tough|first5=Suzanne C.|date=2016-04-26|title=The impact of caesarean section on breastfeeding initiation, duration and difficulties in the first four months postpartum|journal=BMC Pregnancy and Childbirth|volume=16|issue=1|page=90|doi=10.1186/s12884-016-0876-1|pmid=27118118|pmc=4847344|issn=1471-2393 |doi-access=free }}</ref>
Maternal stress can also be induced by a protracted separation between mother and infant upon cesarean birth under hospital policies,<ref name=":27" /> where the infant has to be transferred to transitional care nursery,<ref name=":13">{{Cite journal|last1=Konstantelos|first1=Dimitrios|last2=Ifflaender|first2=Sascha|last3=Dinger|first3=Jürgen|last4=Burkhardt|first4=Wolfram|last5=Rüdiger|first5=Mario|date=December 2014|title=Analyzing support of postnatal transition in term infants after c-section|journal=BMC Pregnancy and Childbirth|language=en|volume=14|issue=1|page=225|doi=10.1186/1471-2393-14-225|issn=1471-2393|pmc=4096413|pmid=25011378 |doi-access=free }}</ref> or admitted into the neonatal department due to minor illnesses.<ref name=":13" /> In both scenarios, the extended period of separation is a significant problem to the initiation of breastfeeding.<ref name=":27" />
=== External ===
==== Ineffective breastfeeding practices ==== Suboptimal breastfeeding practices of mothers and fetuses also influence the onset of lactation.<ref name=":24" /> In particular, exclusive [[Infant formula|formula-feeding]] and poor quality of breastfeeding can account for DOL.<ref name=":24" /> Mothers whose baby is completely formula-fed from birth may not receive adequate neurohormonal stimulus required for the timely onset of lactation,<ref name=":4">{{Citation|last=Crowley|first=William R.|title=Neuroendocrine Regulation of Lactation and Milk Production|date=2014-12-23|url=http://doi.wiley.com/10.1002/cphy.c140029|journal=Comprehensive Physiology|volume=5|issue=1|pages=255–291|editor-last=Terjung|editor-first=Ronald|place=Hoboken, NJ, USA|publisher=John Wiley & Sons, Inc.|language=en|doi=10.1002/cphy.c140029|pmid=25589271|isbn=978-0-470-65071-4|access-date=2021-04-15|url-access=subscription}}</ref> given that frequent infant suckling is shown to have a stimulatory effect on secretory activation.<ref name=":4" /> Meanwhile, breastfeeding quality within the first 48 hours of birth, indicated by signs of successful lactation such as nipple discomfort, is inversely correlated with DOL.<ref name=":5" /> This association can be attributed to insufficient nipple stimulation and breast emptying for stimulating lactogenesis II, as a result of low breastfeeding quality.<ref name=":5" />
==== Labor pain medications ==== [[File:Epidural Anesthesia.png|alt=Administration of epidural anesthesia, a procedure to alleviate pain during labor.|thumb|368x368px|Administration of epidural anesthesia, a common procedure to alleviate pain during labor]] Receiving pain-relieving medications during labor increases the chance of mothers experiencing DOL by around 2–3 times, compared to women without medications,<ref name=":10" /> with a higher incidence of delayed OL among the mothers who underwent unexpected cesarean section.<ref name=":10">{{Cite journal|last1=Lind|first1=Jennifer N.|last2=Perrine|first2=Cria G.|last3=Li|first3=Ruowei|date=2014-01-22|title=Relationship between Use of Labor Pain Medications and Delayed Onset of Lactation|journal=Journal of Human Lactation|language=en|volume=30|issue=2|pages=167–173|doi=10.1177/0890334413520189|issn=0890-3344|pmc=4684175|pmid=24451212}}</ref> Although the link between the medications and DOL is yet to be proven, there are two proposed mechanisms on how the administration of such medications can lead to late-onset. One is that most of the [[analgesic]] medications are [[lipid-soluble]], implying that drug molecules can potentially reach the fetus by passing through the [[placenta]] or via the [[umbilical cord]].<ref name=":11">{{Cite book|url=https://www.ncbi.nlm.nih.gov/books/NBK279567/|title=Pregnancy and birth: Epidurals and painkillers for labor pain relief|date=2018-03-22|publisher=Institute for Quality and Efficiency in Health Care (IQWiG)|language=en}}</ref> This might exert a [[sedative]] and depressive effect on the fetus, which can lead to suboptimal breastfeeding behaviors.<ref name=":11" /><ref name=":17" /> For instance, diminished [[suckling]] and reduced ability to latch onto the breast effectively, by which the initiation of breastfeeding could be impeded.<ref name=":11" /><ref name=":17">{{Cite journal|last=Reynolds|first=Felicity|date=2010-06-01|title=The effects of maternal labour analgesia on the fetus|url=https://linkinghub.elsevier.com/retrieve/pii/S1521693409001412|journal=Best Practice & Research Clinical Obstetrics & Gynaecology|language=en|volume=24|issue=3|pages=289–302|doi=10.1016/j.bpobgyn.2009.11.003|pmid=20005180|url-access=subscription}}</ref> An alternative explanation is that the administration of [[Epidural administration|epidural anesthesia]] is associated with lower plasma [[Oxotoxin|oxytocin]] levels in mothers, hence reducing [[Lactation|milk ejection reflex]].<ref name=":10" />
=== Mixed ===
==== Primiparity ==== Primiparity, or first-time bearing a child, is among the most evident risk factors for the delayed onset.<ref name=":5" /> It is observed that the prevalence of the condition among primiparae is significantly higher than that among [[multipara]]e.<ref name=":5" /><ref>{{Cite journal|last=Piesesha|first=Frieska|date=February 2018|title=Maternal Parity and Onset of Lactation on Postpartum Mothers|url=http://heanoti.com/index.php/hn/article/view/hn20219|journal=Health Notions|volume=2|issue=2|pages=249–251|via=Humanistic Network for Science and Technology (HNST)}}</ref> Although the full mechanism behind this association is not clear, it can be partly attributed to inadequate breastfeeding experience or physiological knowledge on normal lactation,<ref name=":15">{{Cite journal|last1=Rocha|first1=Beatriz de Oliveira|last2=Penido Machado|first2=Marcia|last3=Bastos|first3=Livia Lima|last4=Barbosa Silva|first4=Livia|last5=Santos|first5=Ana Paula|last6=Santos|first6=Luana Caroline|last7=Ferrarez Bouzada|first7=Maria Candida|date=2020-02-01|title=Risk Factors for Delayed Onset of Lactogenesis II Among Primiparous Mothers from a Brazilian Baby-Friendly Hospital|journal=Journal of Human Lactation|language=en|volume=36|issue=1|pages=146–156|doi=10.1177/0890334419835174|pmid=30901295|s2cid=85456531|issn=0890-3344}}</ref> as well as long duration of labor. Primiparity is a risk factor for prolonged labor,<ref name=":6">{{Cite journal|last1=Nystedt|first1=Astrid|last2=Hildingsson|first2=Ingegerd|date=2014-07-16|title=Diverse definitions of prolonged labour and its consequences with sometimes subsequent inappropriate treatment|journal=BMC Pregnancy and Childbirth|volume=14|issue=1|page=233|doi=10.1186/1471-2393-14-233|issn=1471-2393|pmc=4105110|pmid=25031035 |doi-access=free }}</ref> which is affiliated with worse labor pain<ref name=":6" /> and prolonged second stage of labor, both of which may lead to increased maternal stress resulting in a delayed onset.<ref name=":1" /><ref name=":6" />
== Associated consequences == The delayed onset of lactation may leave unfavorable outcomes for the mothers and infants like suboptimal infant breastfeeding, behavior excessive neonatal weight loss and shortened duration of breastfeeding.[[File:IBFAT.png|alt=nfant Breastfeeding Assessment Tool (IBFAT) is used for the assessment of breastfeeding quality.|thumb|494x494px|Infant Breastfeeding Assessment Tool (IBFAT) is used for the assessment of breastfeeding quality.<ref name=":8" />]]
=== Suboptimal Infant Breastfeeding Behavior (SIBB) === Studies observed that SIBB is prevalent among infants with mothers experiencing delayed copious milk production.<ref name=":5" /> In most of these studies, SIBB is indicated with a low [https://www.sciencedirect.com/science/article/abs/pii/S0266613888800718?via%3Dihub Infant Breastfeeding Assessment Tool (IBFAT)] score.<ref name=":8">{{Cite journal|last1=Ingram|first1=Jenny|last2=Johnson|first2=Debbie|last3=Copeland|first3=Marion|last4=Churchill|first4=Cathy|last5=Taylor|first5=Hazel|date=January 2015|title=The development of a new breast feeding assessment tool and the relationship with breast feeding self-efficacy|journal=Midwifery|language=en|volume=31|issue=1|pages=132–137|doi=10.1016/j.midw.2014.07.001|pmc=4275601|pmid=25061006}}</ref> This indicates a correlation between DOL with low milk consumption, which can be a cause for inadequate nutritional intake by the infant in the long term, and result in suboptimal growth and development.<ref name=":5" />
=== Excessive neonatal weight loss === Infant weight loss greater than 10% of initial [[birth weight]] during the first 72 hours of life is observed in infants with mothers experiencing DOL.<ref name=":5" /> Although neonatal weight loss is a normal physiological process where the infant excretes extra [[extracellular fluid]]s accumulated pre-birth, it typically should not exceed 10% of birth weight.<ref name=":12">{{Cite web|last=Mackay|first=Karen|date=2017|title=NHS Highland Guidelines for Prevention of Excessive Weight Loss in the Breastfed Neonate|url=https://nhshighland.publichealth.scot.nhs.uk/wp-content/uploads/2016/06/Prevention-of-Excessive-Weight-Loss-in-the-Breastfed-Neonate.pdf|access-date=2021-04-01|website=NHS Highland}}</ref> With delayed OL, excessive weight loss is likely to be an indication and result of ineffective milk transfer, which can subsequently lead to reduced breast milk production due to [[Feedback Inhibition of Lactation|Feedback Inhibition of Lactation (FIL)]].<ref>{{Cite journal|last=C. J. Wilde, C. V. Addey, J. M. Bryson, L. M. Finch, C. H. Knight, M. Peaker |date=2017|title=NAutocrine regulation of milk secretion|journal=Biochemical Society Symposium|volume=63|pages=81–90|pmid=9513713}}</ref><ref name=":12" />
=== Shortened period of breastfeeding === Delayed lactogenesis II is associated with earlier cessation of breastfeeding, and lowered mother confidence in breastmilk production.<ref name=":23" /><ref name=":22">{{Cite journal|last1=Brownell|first1=Elizabeth|last2=Howard|first2=Cynthia R.|last3=Lawrence|first3=Ruth A.|last4=Dozier|first4=Ann M.|date=2012-10-01|title=Delayed Onset Lactogenesis II Predicts the Cessation of Any or Exclusive Breastfeeding|url=https://www.jpeds.com/article/S0022-3476(12)00311-3/abstract|journal=The Journal of Pediatrics|language=English|volume=161|issue=4|pages=608–614|doi=10.1016/j.jpeds.2012.03.035|issn=0022-3476|pmc=3670592|pmid=22575242}}</ref> This eventually leads to earlier formula-transitioning.<ref name=":22" /> Even though nutrition obtained from [[Infant formula|formula milk]] is comparable and sufficient for the normal physical growth of an infant, maternal milk remains the best source of infant nutrition.<ref>{{Cite journal|last1=Martin|first1=Camilia R.|last2=Ling|first2=Pei-Ra|last3=Blackburn|first3=George L.|date=2016-05-11|title=Review of Infant Feeding: Key Features of Breast Milk and Infant Formula|journal=Nutrients|volume=8|issue=5|page=279|doi=10.3390/nu8050279|issn=2072-6643|pmc=4882692|pmid=27187450|doi-access=free}}</ref> It has been recommended by the [[World Health Organization]] to opt for exclusive breastfeeding until after six months post-delivery, in order to achieve optimal infant health.<ref>{{Cite web|title=Breastfeeding|url=https://www.who.int/westernpacific/health-topics/breastfeeding|access-date=2021-04-15|website=www.who.int|language=en}}</ref><ref>{{Cite web|title=Breastfeeding in NSW - Promotion, Protection and Support|url=https://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=PD2018_034|url-status=live|access-date=2021-04-11|website=www1.health.nsw.gov.au|archive-url=https://web.archive.org/web/20190318221957/https://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=PD2018_034 |archive-date=2019-03-18 }}</ref> One of the rationales of this suggestion is that formula-milk does not fully support the normal trajectory of fat tissue development, as reflected in the altered body-composition development in formula-fed infants compared to breastfed infants.<ref>{{Cite journal|last1=Gale|first1=Chris|last2=Logan|first2=Karen M|last3=Santhakumaran|first3=Shalini|last4=Parkinson|first4=James RC|last5=Hyde|first5=Matthew J|last6=Modi|first6=Neena|date=2012-03-01|title=Effect of breastfeeding compared with formula feeding on infant body composition: a systematic review and meta-analysis|journal=The American Journal of Clinical Nutrition|volume=95|issue=3|pages=656–669|doi=10.3945/ajcn.111.027284|pmid=22301930|issn=0002-9165|doi-access=free}}</ref> Formula-feeding is also linked to poor health outcomes in less developed countries, with higher mortality from [[diarrhea]] and [[pneumonia]] in formula-fed than breastfed babies due to the prevalence of unsanitary preparation, equipment and lack of clean water.<ref>{{Cite web|title=Improving breastfeeding, complementary foods and feeding practices|url=https://sites.unicef.org/nutrition/index_breastfeeding.html|access-date=2021-04-01|website=UNICEF|archive-date=2019-05-20|archive-url=https://web.archive.org/web/20190520035941/https://www.unicef.org/nutrition/index_breastfeeding.html}}</ref><ref>{{Cite journal|last1=Black|first1=Robert E|last2=Victora|first2=Cesar G|last3=Walker|first3=Susan P|last4=Bhutta|first4=Zulfiqar A|last5=Christian|first5=Parul|last6=de Onis|first6=Mercedes|last7=Ezzati|first7=Majid|last8=Grantham-McGregor|first8=Sally|last9=Katz|first9=Joanne|last10=Martorell|first10=Reynaldo|last11=Uauy|first11=Ricardo|date=2013-06-06|title=Maternal and child undernutrition and overweight in low-income and middle-income countries|journal=The Lancet|volume=382|issue=9890|pages=427–451|doi=10.1016/s0140-6736(13)60937-x|pmid=23746772|s2cid=12237910|issn=0140-6736}}</ref>
== Management == When DOL is suspected, intervention should be cause-driven, with a common purpose to improve lactation performance.<ref name=":0" /> The strategies include lactation consultation, regular removal of milk from breasts, nipple stimulation or surgical procedures to remove the retained placenta.{{citation needed|date=September 2023}}
=== Lactation consultation === Mothers experiencing [[breastfeeding difficulties]] are often being referred to the [[lactation consultant]]s attached to the [[maternity unit]] or a child-and-family health center.<ref name=":5" /> Lactation consultants provide breastfeeding assistance, training and advice for the mother-infant pairs facing challenges during breastfeeding.<ref name=":25">{{Cite journal|last1=Patel|first1=Sanjay|last2=Patel|first2=Shveta|date=August 2016|title=The Effectiveness of Lactation Consultants and Lactation Counselors on Breastfeeding Outcomes|url=http://journals.sagepub.com/doi/10.1177/0890334415618668|journal=Journal of Human Lactation|language=en|volume=32|issue=3|pages=530–541|doi=10.1177/0890334415618668|pmid=26644419|s2cid=26056972|issn=0890-3344|url-access=subscription}}</ref><ref name=":20">{{Cite book|last=Lawrence|first=Ruth A.|title=Breastfeeding: a guide for the medical profession|date=2016|others=Robert M. Lawrence|isbn=978-0-323-39420-8|edition=Eighth|location=Philadelphia, PA|oclc=921886130}}</ref>
For instance, the consultants provide suck training. It is a special technique aiming to help infants with difficulties in coordinating with the [[Digestion#Tongue|undulation of the tongue]] to learn proper muscle coordination in breastfeeding.<ref name=":20" /> In addition, these trained experts can intervene by supporting mothers in establishing long-term breastfeeding goals, as well as by giving practical assistance in breastfeeding.<ref name=":25" /> It is also observed that obese women and women undergoing emergency cesareans are likely not to breastfeed owing to the fear of DOL or breastfeeding failure.<ref name=":23" /><ref>{{Cite journal |last1=Stevens |first1=Jeni |last2=Schmied |first2=Virginia |last3=Burns |first3=Elaine |last4=Dahlen |first4=Hannah |author-link4=Hannah Dahlen |date=2014 |title=Immediate or early skin-to-skin contact after a Caesarean section: a review of the literature |journal=Maternal & Child Nutrition |language=en |volume=10 |issue=4 |pages=456–473 |doi=10.1111/mcn.12128 |issn=1740-8709 |pmc=6860199 |pmid=24720501}}</ref> In such cases, effective and sustained breastfeeding can be initiated under a supportive environment, which can be achieved through providing emotional sessions<ref name=":25" /> and informing them about the minimal amounts of colostrum secreted on day one postpartum,<ref name=":15" /> to increase their confidence in breastfeeding.<ref name=":25" />
=== Regular removal of milk and nipple stimulation === [[File:Breast Pump (50265746936).jpg|alt=Breast emptying using breast pumps can increase the chance of successful establishment of lactogenesis.|thumb|327x327px|Breast emptying using breast pumps can increase the chance of successful establishment of lactogenesis.]] [[File:Dilation & curettage.svg|alt=Dilation and curettage is performed to remove the firmly attached placental fragments, for the restoration of declined progesterone level to initiate lactation.|thumb|Dilation and curettage is performed to remove the firmly attached placental fragments, in order to restore a declination in progesterone level to initiate lactation.|234x234px]] Lactation is maintained by routine deposition of milk and [[nipple stimulation]], which triggers prolactin and oxytocin release from the [[pituitary gland]]s.<ref name=":3" /> Women are encouraged to remove the milk from their breasts every two to three hours to maintain a steady milk supply.<ref name=":0" />
Effective ways of emptying the breasts involve breast pumping with a hospital-grade [[breast pump]], for the pumping action promotes complete breast emptying and breast stimulation.<ref name=":9">{{Cite book|last=Dahl|first=Linda|title=Clinician's guide to breastfeeding: evidenced-based evaluation and management|date=2015|publisher=Cham: Springer|isbn=978-3-319-18194-3|location=|oclc=920473435}}</ref> This emptying process has to begin at around day three postpartum to increase the chance of successful establishment of lactogenesis.<ref name=":9" /><ref>{{Cite journal|last1=Steurer|first1=Lisa M.|last2=Smith|first2=Joan R.|date=April 2018|title=Manual Expression of Breast Milk: A Strategy to Aid in Breastfeeding Success|journal=Journal of Perinatal & Neonatal Nursing|language=en|volume=32|issue=2|pages=102–103|doi=10.1097/JPN.0000000000000328|pmid=29689009|s2cid=13812133|issn=0893-2190}}</ref>
Stimulation of the nipple can also be achieved by means of terminating [[Estrogen (medication)|estrogen treatment]] and supplementation.<ref name=":14" /> Estrogen treatment can diminish nipple sensitivity, which leads to decreased prolactin release.<ref name=":0" /> Therefore, pausing estrogen treatment can effectively restore nipple tactile-sensitivity to infant suckling, thereby activating the release of lactogenic hormones.<ref name=":0" /><ref name=":14">{{Cite journal|last=Anderson|first=Philip O.|date=2017-03-24|title=Drugs that Suppress Lactation, Part 2|url=https://www.liebertpub.com/doi/10.1089/bfm.2017.0029|journal=Breastfeeding Medicine|volume=12|issue=4|pages=199–201|doi=10.1089/bfm.2017.0029|pmid=28338339|issn=1556-8253|url-access=subscription}}</ref>
=== Placental fragment removal === Removal of placental fragments is needed when the placenta cannot be expelled by natural [[uterine contraction]],<ref name=":16" /> this can be illustrated with two scenarios that require different treatment methods.
In situations where fragments have been separated from the uterus but yet to be expelled, manual extraction will be performed by directly pulling the detached placenta by hand to bring it outside of the body.<ref name=":16" /> Whereas in cases where placental fragments are firmly attached to the wall of the uterus, [[dilation and curettage]] is the definitive and therapeutic method of choice.<ref name=":0" /> Once the remaining placenta is removed, the mother will be able to restore the expected decline in progesterone level and initiate the onset of lactation.<ref name=":3" /><ref name=":18" /> {{clear}}
== References == <references />
== External links == * [https://www.nhs.uk/conditions/baby/breastfeeding-and-bottle-feeding/breastfeeding/help-and-support/ "Breastfeeding help and support"] [[National Health Service]] * [https://www.cdc.gov/breastfeeding/ "Breastfeeding"] [[Centers for Disease Control and Prevention|US Centers for Disease Control and Prevention]] * [https://ilca.org/ International Lactation Consultant Association]
[[Category:Breast diseases]] [[Category:Breastfeeding]] [[Category:Breast milk]] [[Category:Pathology of pregnancy, childbirth and the puerperium]] [[Category:Infant feeding]] [[Category:Babycare]] [[Category:Human female endocrine system]]