When you just can't make enough milk - the truth about hypoplasia/IGT.

by Alissa Pemberton Midwife, International Board Certified Lactation Consultant (IBCLC), Infant Massage Instructor and Gentle Sleep Coach

*Please note this article contains images of real human breasts in various stages of hypoplasia

For the majority of women, exclusive breastfeeding is completely possible. Some mums may feel they couldn't breastfeed because of a variety of issues, but the majority of these can - with access to the right support - be solved. There is however, a small percentage of the population (about 1%) have a condition called breast hypoplasia or IGT (insufficient glandular tissue) which limits their milk production and means they may not be able to exclusively breastfeed their baby. In general, breast size doesn't have a direct impact on how much milk we can make. Small breasts don't necessarily produce less milk than larger breasts - what determines our milk making capacity is the amount of functional tissue in our breasts. This is our milk making tissue. We all have a certain amount of it, but during pregnancy the lactocytes (milk making cells) are 'primed' over the course of the pregnancy from about 16-18 weeks. These cells begin producing colostrum, and eventually will produce mature milk. Mums with less functional tissue to begin with, have less potential for milk making as even in the best circumstances there are physically less lactocytes to be 'primed' or 'switched on'. Breast size variations between women are usually due to differences in the amount of fatty tissue, so a mum with A cup breasts may be able to produce a full milk supply with her baby, just as a mum with DD cup breasts will - it's not the size that matters but the amount of functional tissue within the breast. Low milk supply can be: Pre Glandular - this includes hormonal issues like retained placental tissue, poorly managed over/under active thyroid, polycystic ovarian syndrome (PCOS) etc. Post Glandular - this includes anything that happens after your baby is born, such as ineffective milk removal, infrequent feeding, scheduled feeds, mum and baby being separated, early formula substitution etc. Glandular - this encompasses issues caused by previous breast surgery as well as insufficient glandular tissue (IGT/Hypoplasia) Why does IGT occur? Women may have insufficient glandular tissue if either there has been a lack of development during puberty, or due to surgery such as breast reduction. How will you know if you've got IGT? There are a number of warning signs to look out for which may indicate IGT. Depending on the case there may be obvious visual signs or within a mums history which suggest to clinicians that IGT may be causing issues with milk supply, sometimes it can be a process of elimination to diagnose. Some signs to look out for:

- lack of breast development during puberty (A) - widely spaced breasts (more than 4cm in between breasts over the sternum (A,B,F) - asymmetrical breasts (one side being noticeably smaller/larger than the other) (E) - tubular breasts (breasts which are narrow and long, often with a large areola, but lacking roundness/fullness) (C/D) - very large or bulbous areolae (they may appear as if they're almost separate to the breast, or much larger/wider than the majority of the breast). (C) - absence or breast size changes during pregnancy or postnatally.



Note: having some of these signs doesn't mean you definitely have IGT or that you won't be able to produce a full milk supply, but it indicates there may be issues and it's worth seeking the assessment of a breastfeeding professional such as an IBCLC (click here to find your local IBCLC in the UK)












Some mums may have one or two of the signs above, or may have a very obvious appearance of hypoplasia, but for others there may be more fatty tissue present and it may not be so visually obvious. In these circumstances a full clinical history as well as expert breastfeeding management is essential to ensure all other causes of low milk supply are ruled out.


I think I might have IGT, but I really want to breastfeed my baby - what should I do? All breastfeeding issues are easiest dealt with if expert support is sought as early as possible after birth/after the issue has been identified, but IGT is one that is best dealt with before your baby arrives. Whilst none of us know our milk making capacity until our baby begins to find, identifying issues such as IGT prior to birth allows you to put management into place from your baby's very first feed to increase your milk supply as much as possible, when your body is most responsive. If you've had significant milk supply issues with a previous baby which were unresolved/unexplained, or if you feel that you fit the signs listed above it's well worth speaking to a lactation professional before the birth of your baby. You can optimise your milk production by:

- Ensuring your baby has skin to skin contact and breastfeeds soon after birth - Hand expressing colostrum when possible during the first few days - Trying to ensure baby receives nothing but breastmilk in the first few days after birth - Allowing baby to feed as frequently as they demand in the early days - Offering both breasts at each feed (see our blog on low supply for more on the importance of this or our video on how milk supply works here) - purchasing or hiring a good quality hospital grade breast pump and forming a plan with your lactation professional/IBCLC for implementing expressing as soon as your milk comes in. - ensuring your baby is evaluated for complications such as tongue tie early after birth by a qualified practitioner (not all midwives, health visitors, paediatricians etc. have any training in tongue tie assessment so it's worth getting this done by an IBCLC or Tongue Tie Practitioner if you have concerns) - keep a close eye on your baby's feeding patterns, nappy output, whether they are actively sucking and swallowing at the breast, and their weight gain/loss. - if your baby requires supplementation use expressed breast milk wherever possible, and consider using methods such as a supply line to provide supplementation whilst also stimulating your milk supply (see of our blog on supplementing here) Those little milk making cells are like a lightbulb. During pregnancy our breasts have fitted light bulbs in all the sockets, these sockets have been 'primed' and the electricity supply connected but we need to switch those light switches on, and this is done through frequent, effective early feeding. It's crucial for all mums, but particularly mums where there is suspicion of IGT to ensure your baby is latching deeply, feeding frequently and effectively from that very first feed after birth, so don't hesitate to ask for help if you need it.

Can I take anything to increase my milk supply? Some mums with IGT may use a galactagogue (a herbal supplement or pharmaceutical drug to help increase milk supply). Most galactagogues work by increasing the production of prolactin, our milk making hormone. Higher prolactin levels stimulate milk production, however we need to combine this with effective milk removal for our body to continue to sustain this production. Some common herbal galactagogues include blessed thistle, brewers yeast, Moringa & fenugreek. You can find out more about the most common pharmaceutical options here It's worth remembering that will all galactagogues they will only work to increase milk supply when combined with effective and frequent milk removal. It's always important to resolve any issues directly related to feeding first (like optimising latch, ensuring baby is obtaining milk effectively, dealing with tongue ties etc) and also ensuring baby is feeding frequently/mum is also expressing.

Will I ever be able to exclusively breastfeed my baby? Every case of mammary hypoplasia/IGT is different. Even amongst the general population our milk making capacity varies (averages are thought to be anywhere from 550ml-900ml of breast milk in 24 hours!). Assessing your potential to meet your babies breast milk needs depends on a number of factors including assessing the signs discussed above, and implementing a comprehensive breastfeeding plan to ensure breasts are being stimulated regularly, milk is being removed effectively, supplementation is being done in the most supportive and safe way and that galactagogues are use appropriately. Even as an IBCLC I'm never able to give mums a definite answer on how much milk they are able to make, but by dealing with the issues above which could be hindering milk production we're then able to see how each mum's breasts respond and get an idea of her total milk making capacity. Many mums with hypoplasia/IGT use some form of supplementation in the first six months. Some choose to use infant formula, other mums prefer the option of donor breastmilk. The World Health Organisation recommends safely obtained donor breast milk as a viable option for babies where mums milk is not available/not sufficient and suggests this be used before formula where available. It's each mums very individual choice as to what they wish to supplement their baby with, but donor milk is an option many mums choose to use. Some mums find beyond six months once their baby's diet includes solid food that they are able to reduce supplements more and more and solid food replaces some of this need, an that they can continue to breastfeed beyond this point.

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Alissa Pemberton
BSc (Midwifery), IBCLC, CIMI, 
Gentle Sleep Coach
suffolkbreastfeeding@gmail.com

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