In-Hospital Lactation Assistance: The Opportunity to Get It Right

Irene Murphy Zoppi, RN, MSN, IBCLC / February 2018


By now, every health care provider and parent in America has heard the news that breastfeeding is best for babies. Human milk is the best and safest nutrition for all babies, and new families want to do what is best for their infants. Yet many families encounter challenging situations that complicate their breastfeeding journeys.

Many mothers don’t know why they were not able to achieve their breastfeeding goals, and question if something could have been done to prevent the difficulties they encountered.  Helping mothers meet their personal breastfeeding goals means proactively identifying those who may need assistance, recognizing what assistance is needed, and implementing evidence-based strategies and technology to assist them.

We need to ask the obvious questions: Can some of the challenges mothers encounter be prevented or managed with strategic interventions? Might there be missed opportunities within the hospital stay to manage some of these challenges?

A critical window of opportunity

The first two weeks post-birth represent a critical period in lactation to initiate and build milk volumes for all breastfeeding mothers.1 Increases in milk volumes occur because of the dynamic hormonal shift that takes place after delivery of the placenta; progesterone levels decrease while prolactin levels increase.

The increase in milk volume is further enhanced with infant sucking. Infant sucking stimulates maternal prolactin receptor growth and pulsatile increases in prolactin release. The increase in prolactin induces the natural progression of milk production within the mammary gland, specifically the lactocytes. The sucking infant accomplishes both feeding of colostrum and the initiation stimulation beneficial for triggering Secretary Activation (Lactogenesis II).2

Mothers usually begin producing increasing amounts of milk between 36 and 96 hours after delivery. In the absence of pathology, the frequent and continued sucking of the healthy, term infant will drive milk synthesis, producing copious volumes of breast milk.2 It’s important to keep in mind the initiation of a milk supply is a one-time event. Failure to accomplish the right start makes it very difficult for the mother to ‘catch up’ making enough milk.

The reality – why mothers give up on breastfeeding

Yes, our families want to breastfeed their babies.

Data from the CDC reports that 81% of mothers initiate breastfeeding. But this encouraging statistic is met with the reality that by three months after giving birth, only 44% of mothers are exclusively breastfeeding. More than one-half of U.S. mothers don’t achieve their intended breastfeeding goals, supplementing their infants with formula very early after birth or stopping completely earlier than they planned. Mothers cite the perception of insufficient milk supply as the major reason they supplement with formula.3

Mothers stop breastfeeding thinking they do not have enough milk without realizing that they may be at risk for milk production issues. In the past, mothers at high risk for milk production issues were primarily identified as pump-dependent mothers with hospitalized infants. Recent research recognizes more than half of “low risk” U.S. mothers experience a delay in milk production that is related to unrecognized risk factors.4 These risks are documented world-wide and thought to be associated with slower infant weight gain and contribute to why mothers begin supplementing with formula.

Maternal health conditions such as polycystic ovarian syndrome, hypothyroidism, or a history of breast surgery, particularly breast reduction and long, difficult labors, especially if they result in emergency section, are often associated with a delay in secretory activation. Recent research has focused on additional risk factors that can also have an impact on the initiation of lactation. These include maternal health conditions, occurring either antenatally or in the postpartum period. Evidence now indicates women who are having their first babies over 30, are overweight or obese – those with an elevated BMI – and women with insulin resistance, including diabetes, are at significant risk for a delay in milk production and subsequent issues with adequate milk volumes for their infants.4,5,6,7

Every day, we encounter mothers attempting to initiate breastfeeding with these health issues. And many mothers present with multiple documented risk factors. How unfortunate these mothers are unaware they have significant risks for milk production issues.

Opportunities to get it right

Given the frequency of these lactation risk factors, it is clear interventions are needed during the critical period of the first few days to improve milk production and breastfeeding outcomes.  Here are some suggested proactive interventions that may work to better serve at-risk mothers with milk production.

Develop a lactation risk assessment tool

Construct a list of documented risk factors for suboptimal milk production.  Using a check list, assess for any/all risk factors prenatally, on admission to labor and delivery, and on admission to the postpartum units. Identifying several risk factors or even just one risk factor indicates additional strategies for successful initiation of lactation is warranted. Early identification of risk factors allows for individualized management protocols.

Develop a clinical pathway of evidence-based strategies

  1. Initiate breast stimulation and expression using a hospital-grade (multi-user) double electric breast pump outfitted with Initiation Technology. This technology mimics early newborn sucking behavior and has effectively demonstrated a greater daily milk production of milk between days 6-13 post-partum in mothers.8,9,10

Clinicians face challenges deciding when to intervene with management strategies. Often, interventions are not initiated until problems are reported. However, successful initiation is essential for building and maintaining a milk supply. By identifying mothers who are at risk for delayed or suppressed milk production and proactively employing research-based technology early in the post-delivery period, the breastfeeding relationship may be preserved.

  1. Begin early and frequent pumping within 1-3 hours after delivery. Multiple randomized control studies identify that early initiation of pumping yields better milk outcomes.11,12,13
  1. Practice continuous skin-to-skin care. The benefits of skin-to-skin care in improving breastfeeding outcomes is well documented.14 Strategies for the safe implementation of this practice should be encouraged throughout the post-partum hospital stay and not limited to the immediate post-birth period.
  1. Teach feeding cues. Recognition of infant feeding readiness should be taught to prevent missed feeding opportunities.
  1. Manage expectations. Instruction on normal colostrum quantities, newborn feeding behavior, and stomach capacity should be given to all families. Normal newborn breastfeeding behavior includes frequent, clustered feedings.15
  1. Identify family supports. Help empower family members to support breastfeeding. Engage family members in breastfeeding education.
  1. Ensure appropriate post-discharge care. Confirm follow-up care is planned. Provide for continuity of breast pump technology after discharge.16 Provide a list of post-discharge resources.


Although breastfeeding initiation is at an all-time high, rates of breastfeeding exclusivity and duration lag behind national goals. Women who stop breastfeeding before meeting their personal goals often report they did not have enough milk. There are multiple maternal risk factors for delayed milk production and suppressed lactation and many women have multiple risk factors and are at significant risk for lactation problems.

Regardless of the cause, earlier than expected cessation of breastfeeding should be a concern to health care personnel. The early cessation of breastfeeding can negatively impact both mothers and their infants; infants don’t receive the health benefits of exclusive breast milk feeding and mothers may encounter emotional distress by not meeting their lactation goals.

Mothers may sadly relate stories of not meeting their individual breastfeeding goals months and even years later. All mothers deserve the best opportunity to successfully breastfeed and the best chance to meet their personal lactation goals. Intervening early prenatally and in the initial post birth period assessing for risk factors and employing evidence-based lactation strategies and technologies may make a difference. Let’s not miss out on the opportunities we have to assist mothers in meeting their personal lactation goals.


1 Neville MC. Anatomy and physiology of lactation. (2001). Pediatr Clin North Am, 48: 13-34.

2 Czank C, Henderson JJ, Kent JC, Tat Lai C, Hartmann PE. ‘Hormonal control of the lactation cycle.’ Pp. 89-11, Ch. 7 in Textbook of Human Lactation, 2007. By Thomas Hale and Peter Hartmann, Hale Publishing, Amarillo, TX.

3 Breastfeeding Report Card: Progressing toward national breastfeeding goals. United States 2016. In: Division of Nutrition, Physical Activity and Obesity. Centers for Disease Control and Prevention, 2016.

4 Dewey KG,  Nommsen-Rivers LAHeinig MJ, Cohen R. (2003). Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics, 112(3 Pt 1): 607-619;

5 Nommsen-Rivers LA, Chantry CJ, Peerson JM, Cohen RJ, Dewey KG.(2010). Delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding. Am J Clin Nutr, 92(3):574-84.

6 Nommsen-Rivers LA Dolan LM, Huang B. (2012). Timing of stage II lactogenesis is predicted by antenatal metabolic health in a cohort of primiparas. Breastfeed Med, 7(1), 43-49.

7 Nommsen-Rivers, LA. (2016). Does Insulin Explain the Relation between Maternal Obesity and Poor Lactation Outcomes? An Overview of the Literature. Advances in Nutrition, 7(2):407-414.

8 Meier PP, Engstrom JL, Janes JE, Jegier BJ, Loera F. (2012). Breast pump Suction Patterns that mimic the human infant during breastfeeding: greater milk output in less time spent pumping for breast pump-dependent mothers with premature infants. J Perinatol. 32(2):103-110.

9 Torowicz DL, Seelhorst A, Froh EB, Spatz DL.(2015). Human milk and breastfeeding outcomes in infants with congenital heart disease. Breastfeed Med. 10(1):31-7.

10 Post EDStam GTromp E. (2016). Milk production after preterm, late preterm and term delivery; effects of different breast pump suction patterns.  J Perinatol. 36(1):47-51.

11 Parker LA, Sullivan S, Krueger C, Kelechi T, Mueller M. (2012). Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: a pilot study.  J Perinatol. 32(3):205-9.

12 Parker LA, Sullivan S, Krueger C, Mueller M. (2015). Association of timing of initiation of breastmilk expression on milk volume and timing of lactogenesis stage II among mothers of very low-birth-weight infants. Breastfeed Med, 10(2), 84-91.

13 Parker LA,  Mueller M, Sullivan S, Krueger C. (2017). Optimal time to initiate breast milk expression in mothers delivering extremely premature infants. Abstract; FASEB,  2017.

14 Moore ER, Bergman N, Anderson GC, Medley N. (2016). infants. Cochrane Database Syst Rev. Nov 25;11:CD003519.

15 Kent JC, Gardner H, Geddes DT. (2016). Breastmilk production in the first 4 weeks after birth of term infants. Nutrients. Nov 25;8(12). pii: E756.

16 Meier PP, Patel AL, Hoban R, Engstrom JL. (2016). Which breast pump for which mother: an evidence-based approach to individualizing breast pump technology. J Perinatol. 36(7):493-9.


About the Author

Irene joined Medela in 1999 as a clinician for the Breastfeeding Division. She currently serves as a Clinical Education Specialist focusing on Advocacy Outreach. In this role, she acts as a vital resource for groups assisting breastfeeding mothers and infants. She has been frequently interviewed on radio and online regarding breastfeeding issues for mothers and clinicians.

Irene spent many years caring for new families in antenatal, labor and delivery, postpartum and NICU settings and was involved in direct patient care and family-based education. Irene has extensive experience teaching in a variety of nursing education programs.  She produced a video presentation on nursing students’ involvement in Community Health Nursing for the National League of Nursing.