Received: 24 April 2020 Revised: 28 July 2020 Accepted: 2 September 2020

DOI: 10.1111/mcn.13080

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ORIGINAL ARTICLE

Causes of perception of insufficient milk supply in Western

Australian mothers

Jacqueline Coral Kent1 | Elizabeth Ashton2 | Catherine Meria Hardwick2 |

Alethea Rea3 | Kevin Murray4 | Donna Tracy Geddes1

1
School of Molecular Sciences, The University
of Western Australia, Crawley, Western Abstract
Australia, Australia A perception of insufficient milk supply (PIMS) is associated with early discontinua-
2
Breastfeeding Centre of WA, King Edward
tion of breastfeeding. Ideally, an objective measure of milk supply would either dispel
Memorial Hospital for Women, Subiaco,
Western Australia, Australia or confirm this perception and provide reassurance or guide professional advice. Clin-
3
College of Science, Engineering and ical signs of sufficient milk intake (steady growth, sufficient elimination, infant alert-
Education, Murdoch University, Murdoch,
Western Australia, Australia ness and breasts feeling full before breastfeeds and soft after breastfeeds) should
4
Population and Public Health, The University provide confidence in milk supply. We surveyed 423 mothers in early lactation who
of Western Australia, Crawley, Western
had breastfeeding problems to determine the proportion that had PIMS and to deter-
Australia, Australia
mine if the mothers with PIMS relied on these clinical signs or other perceptions of
Correspondence
their infants' behaviour as indications of insufficient milk supply. By 3 weeks after
Jacqueline Coral Kent, The University of
Western Australia, School of Molecular birth, we found that the rate of PIMS among mothers with breastfeeding problems
Sciences, M310, 35 Stirling Highway, Crawley,
was 44%. Supplementary infant formula was being given to 66% of the infants, so
WA 6009, Australia.
Email: jacqueline.kent@uwa.edu.au the clinical indications were that milk intake was sufficient, but 74% of the mothers
with PIMS cited concerns that their infants did not appear satisfied after breastfeeds.
Funding information
Medela AG After targeted advice from lactation consultants, mothers with PIMS showed positive
changes in their perceptions of their milk supply, underlining the value of professional
guidance soon after birth. We conclude that an appearance of infant dissatisfaction is
the major cause of PIMS in Western Australia.

KEYWORDS

breast milk production, breastfeeding problems, perceived insufficient milk

1 | I N T RO D UC TI O N Breastfeeding problems in general contribute to early discontinu-

ation of exclusive breastfeeding (Amir, 2014). In Australia, 83% of
In Western Australia, 93% of mothers initiate breastfeeding, with 70% mothers experience breastfeeding problems before leaving hospital,
exclusively breastfeeding and 16% mostly breastfeeding. However, by and by 2 weeks after birth, 21% have weaned, and 29% of those still
9 weeks after birth, only 49% are still exclusively breastfeeding and breastfeeding are experiencing problems (Binns & Scott, 2002). The
16% are mostly breastfeeding, and the greatest risk for early cessation problems include a perception of insufficient milk supply (PIMS). PIMS
of breastfeeding is within the first 3 weeks after birth (Hauck, is defined as when a mother believes she is not producing enough
Fenwick, Dhaliwal, & Butt, 2011). breast milk for her infant's satisfaction or weight gain (Hill &

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© 2020 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.

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https://doi.org/10.1111/mcn.13080
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Humenick, 1989) and is a major reason given by breastfeeding

mothers who discontinue breastfeeding (for example Gatti, 2008;
Key messages
Hauck et al., 2011). In addition, PIMS is associated with low
breastfeeding self-efficacy and loss of confidence in breastfeeding,
• In this study in Western Australia, 44% of the mothers
and this lack of confidence contributes to early cessation of exclusive
had a perception of insufficient milk supply within
breastfeeding (Ertem, Votto, & Leventhal, 2001; Galipeau, Baillot,
3 weeks of birth.
Trottier, & Lemire, 2018; Hauck et al., 2011).
• The most common reason for this perception was that
For infants who are fully breastfed, signs of sufficient breast milk
their infant was not satisfied after breastfeeds.
intake include the infant showing steady growth (Neifert et al., 1990),
• Supplementary infant formula was used by 66% of the
normal elimination, periods of calm alertness and an appearance of
mothers before their first visit to a lactation consultant.
satisfaction after breastfeeds, and the mother's breasts feeling full
• Maternal perception of insufficient milk supply improved
before breastfeeds and softer after breastfeeds (Eglash, Montgomery,
after targeted advice from a lactation consultant.
& Wood, 2008; Neifert, 2001; WHO Multicentre Growth Reference
Study Group, 2009). However, mothers can lack confidence in their
breastfeeding even if these indications are being met (Kent, Hep-
worth, Langton, & Hartmann, 2015). than the caesarean delivery per se (Zhang, Cheng, Yan, Wu, &
Physiological factors that affect initiation of milk production or Bai, 2019). Previous studies on breastfeeding after caesarean
actual milk supply include retained placenta, insufficient glandular tis- section delivery have also shown an increased incidence of PIMS
sue, breast surgery, breast irradiation, severe maternal illness such as (Chapman & Perez-Escamilla, 1999) and a decreased rate of exclusive
postpartum haemorrhage with Sheehan's syndrome, infection, hyper- breastfeeding at 1 week and 3 months (Torvaldsen et al., 2006;
tension (Neifert, 2001), hypothyroidism (Miyake, Tahara, Koike, & Zanardo et al., 2010), but have not distinguished between nonelective
Tanizawa, 1989), smoking (Vio, Salazar, & Infante, 1991), insulin- lower uterine segment caesarean section (NELUSCS) and elective
dependent diabetes (Arthur, Smith, & Hartmann, 1989), mastitis, pre- lower uterine segment caesarean section (ELUSCS). The proportion of
mature delivery, breastfeeding to schedule, use of pacifiers mothers who were exclusively breastfeeding at 6 weeks after
(Righard, 1998), delay in milk removal soon after birth and few NELUSCS (41%) has been shown to be similar to the proportion of
breastfeeds or expressions soon after birth (Yamauchi & mothers exclusively breastfeeding after instrumental delivery (48%),
Yamanouchi, 1990). Obesity is also a contributing factor to early ces- but these groups were not compared with mothers who had a sponta-
sation of breastfeeding, because obese women report PIMS earlier neous vaginal delivery (SVD) (Patel, Liebling, & Murphy, 2003). In
and are more likely to stop breastfeeding than those with BMI in the China, the rates of exclusive breastfeeding at 1 month for vaginal and
healthy range (Beauchamp & Mennella, 2009; Binns & Scott, 2002; caesarean delivery were 65% and 40%, respectively, and 4 months
Mok et al., 2008). In addition, although nitrous oxide has been shown 47% and 32%, respectively (Zhang et al., 2019).
to have no effect on full breastfeeding (Torvaldsen, Roberts, Simpson, PIMS and the associated lack of confidence may be physiological
Thompson, & Ellwood, 2006), pethidine administration during labour or psychological. However, the relative contribution of the above
can affect the delay of the infant's first breastfeed after birth and their physiological factors and mothers' perceptions of their infants' behav-
sucking technique (Righard & Alada, 1990). Another study found no iour to PIMS are not known. One study found that PIMS (assessed
difference between pethidine and remifentanil anaesthesia in using the Breastfeeding Self-Efficacy Scale-Short Form) was not
breastfeeding within an hour of birth, but a significant decrease in the related to actual insufficient milk supply (Galipeau, Dumas, &
rate of any breastfeeding at 6 weeks after birth among the mothers Lepage, 2017). However, actual milk supply is not normally measured.
who received pethidine (Moran et al., 2019). Further investigation is required to determine the relative contribu-
There is no reported correlation between epidural anaesthesia tions of physiological and psychological factors, and if perceptions can
and delayed onset of lactation, but further studies are required on the change after targeted advice from lactation consultants. Lactation
effects of epidural anaesthesia and short and long-term breastfeeding education and support using lactation consultants has shown an
success (Mauri et al., 2015). It has been shown that epidural anaesthe- improvement in breastfeeding initiation, duration and exclusive
sia is associated with a lower rate of exclusive breastfeeding in the breastfeeding rates (Patel & Patel, 2016 and Thurman & Allen, 2008),
first week, and an increased likelihood of complete weaning by but there are no previous studies on mothers' change in perception of
24 weeks (Torvaldsen et al., 2006). However, all of these infants were their milk supply following advice from a lactation consultant.
delivered by caesarean section (Torvaldsen et al., 2006), and there is
no consensus on the effect of caesarean delivery on breastfeeding 1.1 | Aims
duration (Hobbs, Mannion, McDonald, Brockway, & Tough, 2016). It
has been suggested that the negative effect of caesarean section on We aimed to survey mothers in Perth, Western Australia, who
both exclusive breastfeeding and PIMS is a result of suboptimal early sought professional advice for PIMS or other breastfeeding
breastfeeding (longer time to first breastfeed, shorter duration of first problems to determine the proportion of mothers that had PIMS
breastfeed, early introduction of supplemental infant formula) rather and to determine if there are differences between the two groups
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in demographics, physiological factors that affect initiation of milk responses of unsure, disagree or strongly disagree were classified as
production (maternal health, delivery of the infant) and lactation negative. For statements 9–11 and 14, responses of disagree and
events postpartum. We also aimed to elucidate the reasons for the strongly disagree were classified as positive, and responses of unsure,
PIMS and if the mothers' perceptions changed after advice from a disagree or strongly disagree were classified as negative. All participants
lactation consultant. were requested to complete a background questionnaire covering
demographics, maternal and infant variables.
2 | METHODS During the first consultation, the lactation consultant used a stan-
dard assessment form to record the mothers' concerns about maternal
Women who deliver their infants at the major public hospital for and infant aspects of their breastfeeding.
women in Perth, Western Australia (King Edward Memorial Hospital For the last 5 months of the study period, mothers with PIMS
for Women, KEMH) are offered free consultations at the who returned to the Breastfeeding Centre for a second consultation
Breastfeeding Centre of WA for advice for any breastfeeding difficul- 2–4 weeks after the first consultation were invited to complete the
ties, and about 20% of the women take advantage of this service. This same questionnaire again, and responses were again recorded.
percentage is consistent with the findings that 29% of mothers are The participants provided written, informed consent for the
still experiencing problems after 2 weeks (Binns & Scott, 2002). All study, which was approved by the ethics committees of the Women
the participants were asked to complete a written perception ques- and Newborn Health Service (HREC 2016055EW) and The University
tionnaire and background questionnaire before their first consultation, of Western Australia (HREO RA/4/1/8352).
and a subset were asked to complete a second perception question-
naire after their second consultation 2–4 weeks later. For this cross- 2.1 | Statistics
sectional study, a convenience sample was used. For 7 months,
between August 2017 and April 2018, if time permitted before the All survey responses were grouped into positive and negative as
lactation consultant was available, the chief investigator approached defined above. Some demographic responses were also grouped when
mothers of singleton infants, born at term or >33 weeks gestational there were some categories of response that were uncommon.
age at delivery, who attended the Centre for their first appointment A comparison of the mothers with PIMS and those with other
to complete the questionnaires. Women were not approached if they breastfeeding problems was carried out for demographic, maternal
were known to be severely stressed or they or their support person and infant variables. Categorical variables were analysed using a Chi-
were not fluent in English. squared test or Fisher's exact test, whereas continuous variables were
The perception questionnaire asked participants to choose analysed with a t test.
between strongly agree, agree, unsure, disagree or strongly disagree in Logistic regression was carried out with PIMS as an outcome. Uni-
response to the statements: variate modelling considered only the one questionnaire response at a
time, whereas multivariate modelling also accounted for parity (primip-
1. I think I produce enough breast milk for my baby. arous or multiparous), ethnicity (Caucasian or other), BMI category
2. My baby is growing well. (normal, overweight or obese), mode of delivery (indicator variables
3. My baby has enough wet nappies (diapers). for induced onset of labour and instrumental), use of drugs during
4. My baby has enough soiled nappies (diapers). delivery (indicator variables for none, gas, morphine and epidural),
5. My baby is normally alert. expressing before discharge, the day the milk came in, current feeding
6. My baby is well attached during breastfeeding. category (exclusive breastfeeding, breastfeeding and expressed breast
7. My baby sucks well during breastfeeding. milk, breastfeeding and formula, breastfeeding with expressed breast
8. My baby appears satisfied after breastfeeds. milk and formula), presenting challenges (slow weight gain and formula
9. My baby feeds too often. use) and whether supplementary formula was being used. Raw data
10. My baby feeds too quickly. percentages and modelling output p values are reported.
11. My baby needs supplementary infant formula. Within the PIMS group Chi-squared or Fishers exact tests were
12. My breasts feel full before feeds. used to investigate associations between the response to all the percep-
13. My breasts feel soft after feeds. tions questions with respect to the use of supplementary infant formula.
14. My breasts feel empty in the afternoon or evening. Changes in the questionnaire responses from first to second con-
sultation were analysed with a paired t test. The significance level was
Participants who responded to the first statement ‘I think I pro- set at 0.05, and R was used for all analysis (R Development Core
duce enough breast milk for my baby’ with unsure, disagree or strongly Team, 2017).
disagree, indicating they were not confident in their milk supply, were
classified as having PIMS. All questionnaire responses were grouped 2.2 | Ethical statement
into positive (consistent with a perception of adequate milk supply) or
negative (consistent with PIMS). For statements 1–8, 12 and The participants provided written, informed consent for the study,
13 responses of agree or strongly agree were classified as positive, and which was approved by the ethics committees of the Women and
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Newborn Health Service (HREC 2016055EW) and The University of nappies (p = 0.35), but mothers who used supplementary formula
Western Australia (HREO RA/4/1/8352). were less likely to agree that their infants had enough soiled nappies
(p = 0.015), and those who did not use supplementary formula were
3 | RESULTS marginally more likely to agree that their infants were usually alert
(p = 0.045).
During the 7 months of recruitment, 438 clients of the Breastfeeding Overall, significantly more primiparous mothers (45%) were offer-
Centre were approached to participate, 10 declined, two had twins and ing their infants supplementary formula than multiparous mothers
were therefore ineligible, 426 completed the perception questionnaire, (31%) (p = 0.017).
but three of those did not complete the background questionnaire,
leaving 423 who completed both questionnaires. Of these, 36 ques-
tionnaires were incomplete; therefore, analysis of perceptions included 3.3 | Changes in perception after advice from
387 participants. There were 171 participants (44%) who were classi- lactation consultant
fied as having PIMS, and 216 participants who agreed or strongly
agreed that they produced enough breast milk for their baby and were All mothers were given targeted advice by the lactation consultant.
seeking a consultation for other breastfeeding problems, commonly Advice to mothers with PIMS included correction of positioning and
infant attachment during breastfeeding, infant sleepy at the breast, attachment, advice to feed from both breasts on demand eight to
nipple pain, use of a nipple shield and tongue tie. The first consultation 12 times a day, use of breast compression during breastfeeding and
for the mothers was early in lactation (IQR PIMS 1.2, 3.2 weeks after expressing the breasts after or between breastfeeds. If the mother
birth, IQR other breastfeeding problems 1.3, 3.0 weeks after birth). was anxious but otherwise breastfeeding well, the lactation consultant
provided reassurance. Fifty-two mothers with PIMS did not attend
3.1 | Demographics the Breastfeeding Centre for a follow-up appointment and received
subsequent care (if required) from their child health nurse or general
Demographic data for mothers with PIMS and mothers with other practitioner. Eighty-three of the mothers who reported PIMS and ret-
breastfeeding problems are shown in Table 1. Analysis of PIMS by urned to the Breastfeeding Centre for a second consultation were
demographic, maternal and infant variables showed some differences requested to complete a second written perception questionnaire
from mothers with other breastfeeding problems, namely, a higher 2–4 weeks after following the advice from the initial consultation.
proportion of PIMS among: mothers of firstborns; mothers who are Sixty-six of these mothers provided partial data, and 57 provided
not Caucasian (mostly Asian, 15% or Indian, 6%); mothers whose complete data for both questionnaires. The initial perceptions of these
infants were delivered via NELUSCS; those presenting with slow mothers were not significantly different from the mothers with PIMS
weight gain or with formula use. Differences were also seen with the who only completed one questionnaire. The results of the two ques-
day the milk came in (typically later for those reporting PIMS) and the tionnaires are shown in Table 3.
current feeding with those reporting PIMS also reporting higher rates The follow-up questionnaire showed that at the second consulta-
of supplementing breastfeeding with EBM and formula. For mothers tion 26 of the 57 mothers who completed both questionnaires
with PIMS and those with other problems, there were 50 and thought they produced enough breast milk for their baby. On average,
52, respectively, whose infants were delivered by caesarean section, these mothers were more likely to agree with the statements: my
all of whom received anaesthesia during birth. Among the mothers baby is growing well; my baby has enough wet nappies; my baby is
whose infants were not delivered by caesarean section there were normally alert, my baby is well attached during breastfeeding; my baby
fewer mothers with PIMS who had no drugs during delivery. sucks well during breastfeeding and my breasts feel soft after feeds.
There were no changes in the mothers' perceptions of the number of
soiled nappies, infant satisfaction after breastfeeding, frequency and
3.2 | Perceptions duration of breastfeeds or the need for supplementary infant formula.
Nor were there significant changes in the mothers' perceptions of the
The perceptions of mothers with PIMS and mothers with other fullness of their breasts before breastfeeding or the breasts feeling
breastfeeding problems are shown in Table 2. The most marked differ- empty in the afternoon or evening.
ences between mothers with PIMS and mothers with other
breastfeeding problems were in the perceptions of infant growth,
soiled nappies, satisfaction after breastfeeds and need for supplemen- 4 | DISCUSSION
tary infant formula and for feeling of breast fullness before feeds and
feeling empty in the afternoon or evening. This study confirms that PIMS is a significant problem among
It is shown in Table 1 that 66% of mothers with PIMS were mothers who seek consultation at the Breastfeeding Centre of WA,
already using formula supplements. Between mothers who were or with 44% of the study population classified as having PIMS. Most of
were not giving supplementary formula, there were no significant dif- these mothers attended the Breastfeeding Centre within 3 weeks
ferences in their perceptions of their infant's growth (p = 0.60) or wet of birth.
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TABLE 1 Demographics of participants with PIMS (n = 171) and those with other breastfeeding problems (n = 216)

PIMS Other problems p value

Maternal characteristics
Married or de-facto 94.6 96.6 0.45
Parity 1 75.0 58.0 <0.001
Ethnic group Caucasian 67.6 78.1 0.021
BMI 25.9 (5.0) 27.0 (6.4) 0.054
Breast growth during pregnancy 90.0 94.9 0.10
Breast surgery/piercing 8.6 5.6 0.30
Smoked during pregnancy 1.1 0.4 0.59
Smoking during lactation 0.5 0.9 1
Education
Completed year 12 91.2 90.9 1
Further education 92.3 94.8 0.32
Maternal problems during pregnancy or after birth
High blood pressure 9.7 10.5 0.92
Gestational diabetes 10.3 10.1 1
Type 1 diabetes 1.6 2.1 1
Postpartum haemorrhage 8.6 8.0 0.95
Depression 7.0 6.7 1
Infection 4.9 3.8 0.76
Hypothyroidism 3.8 5.9 0.45
Hyperthyroidism 1.1 2.5 0.48
Mastitis 3.8 5.5 0.57
Birth
Mode of delivery
IOL 27.6 24.4 0.53
SVD 50.3 57.6 0.16
Instrumental 15.1 10.5 0.20
ELUSCS 16.2 20.2 0.36
NELUSCS 13.5 6.3 0.02
Augmented 1 1 0.86
Drugs during delivery (excluding ELUSCS and NELUSCS)PIMS n = 120, other problems n = 165)
None 18.5 30.3 0.026
Gas (nitrous oxide) 53.8 47.6 0.17
Morphine 9.2 6.3 0.46
Pethidine 1.5 0.0 0.18
Epidural 46.2 36.0 0.09
Infant
Gestational age at delivery, weeks 38.9 (2.1) 38.9 (2.1) 0.99
Weight at birth, g 3,314 (577) 3,266 (567) 0.40
Length at birth, cm 50.3 (3.1) 50.1 (3.1) 0.47
Admitted to special care nursery 26.6 27.4 0.95
Lactation
Infant skin-to-skin within 1 h of birth 80.4 84.3 0.36
First breastfeed within 1 h of birth 60.7 64.8 0.45
≥3 feeds first day 63.2 71.8 0.10
≥3 expressions first day 31.1 28.1 0.60

(Continues)
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TABLE 1 (Continued)

PIMS Other problems p value

≥6 feeds + expressions first day 31 29 0.84
Express before discharge 63.0 58.8 0.46
Express after discharge 86.3 84.1 0.65
Day milk came in 4.1 (2.1) 3.4 (1.7) <0.001
At first consultation
Exclusively breastfeeding 10.3 32.6 <0.001
Breastfeeding intended duration >6 months 85.4 88.2 0.29
Nipple pain (sometimes or usually) 82.2 82.4 0.50
Dummy usage (sometimes or usually) 43.8 35.3 0.14
Mother age, y 32.5 (4.4) 32.6 (4.4) 0.84
Baby sex (% female) 53.5 47.1 0.31
Baby age, weeks 3.1 (3.1) 3.0 (2.9) 0.92
Presenting challenges
Maternal milk supply 50 5 <0.001
Infant slow weight gain 23.8 12.6 0.004
Formula use 42.2 7.6 <0.001
Actually used formula 66 8 <0.001
Infant attachment 71.4 76.5 0.28
Infant sleepy at breast 16.2 14.7 0.77
Infant weight loss >10% 9.2 6.3 0.35
Nipple shield use 9.2 6.3 0.35
Infant unsettled 7.6 6.7 0.89

Note: Values are percentage or mean (SD).

Abbreviations: BMI, body mass index; IOL, induction of labour; SVD, spontaneous vaginal delivery; ELUSCS, elective lower uterine segment caesarean sec-
tion; NELUSCS, non- elective lower uterine segment caesarean section.

4.1 | Perceptions mothers about wet and soiled nappies, infant alertness and infant
growth. Indeed, lactation consultants and mothers expressed con-
The most marked differences between mothers with PIMS and cerns about infant growth for only 24% to 27% of the infants
mothers with other breastfeeding problems were the perceptions of (Tables 1 and 2). The infants were probably adequately nourished
infants' satisfaction after breastfeeds and their need for supplemen- because 66% of the mothers with PIMS used supplementary for-
tary infant formula. This is consistent with the common indicator of mula. This is consistent with the overall exclusive breastfeeding rate
insufficient milk supply reported by mothers as their infant's unsettled in public hospitals in Western Australia of 73% (Hauck et al., 2011).
behaviour (crying) (Lou et al., 2014; McCann & Bender, 2006). KEMH is a Baby Friendly Health Initiative accredited hospital; there-
The mothers with PIMS were also less likely than the mothers fore, the use of formula prior to discharge was not promoted unless
with other breastfeeding problems to agree that their breasts were medically indicated, for example, infants of mothers with insulin-
full before breastfeeds and more likely to agree that the breasts felt dependent diabetes, who are more susceptible to hypoglycaemia.
empty during the afternoon or evening. These perceptions would One study found that 41% of infants had received supplementary
reinforce a lack of confidence in the mothers' milk supply. infant formula prior to discharge, and this was associated with
Considering the accepted clinical indications of sufficient breast decreased exclusive breastfeeding at 4 months (Alikasifoglu
milk intake, there were significant differences between the two et al., 2001), and another study found that 77% of infants had been
groups in their perception of their infant's growth and elimination. given formula prior to discharge (Chan, Nelson, Leung, & Li, 2000).
However, these were concerns recorded by less than 28% of the These reports indicated that the main reason given for the introduc-
mothers with PIMS. Indeed, there has been only one study that tion of formula was PIMS. Unfortunately, the verification of actual
reports that mothers used frequency of elimination and infant milk supply that would confirm or alleviate PIMS is extremely rare
weight gain as signs of sufficient milk (McCarter-Spaulding & (Alikasifoglu et al., 2001). We did not establish when supplementary
Kearney, 2001). There were relatively few concerns among PIMS infant formula was introduced, nor the reason for its early
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T A B L E 2 Number of participants with PIMS (n = 171) and those with other breastfeeding problems (n = 216) with positive or negative
responses to each statement

Univariate modelling Multivariate modelling

Other p p
Response PIMS problems Coefficient SE value Coefficient SE value
My baby:
Is growing well Positive 114 175 −0.429 0.120 <0.001 −1.871 2.097 0.37
Negative 42 29 0.799 0.270 0.003 1.075 0.398 0.007
Has enough wet nappies Positive 141 195 −0.324 0.111 0.003 −1.372 1.98 0.49
Negative 15 9 0.835 0.440 0.06 0.665 0.563 0.24
Has enough soiled nappies Positive 124 191 −0.432 0.115 <0.001 −1.288 1.958 0.51
Negative 32 13 1.333 0.349 <0.001 1.358 0.494 0.006
Is normally alert Positive 134 185 −0.323 0.113 0.004 −1.723 1.897 0.36
Negative 22 19 0.469 0.333 0.16 1.077 0.438 0.014
Is well attached during Positive 26 50 −0.654 0.242 0.007 −1.872 2.081 0.37
breastfeeding Negative 130 154 0.485 0.270 0.07 0.645 0.400 0.11
Sucks well during breastfeeding Positive 49 100 −0.713 0.174 <0.001 −1.949 2.177 0.37
Negative 107 104 0.742 0.222 0.001 0.939 0.327 0.004
Appears satisfied after breastfeeds Positive 40 125 −1.139 0.182 <0.001 −2.771 2.348 0.238
Negative 116 79 1.524 0.233 <0.001 1.336 0.349 <0.001
Feeds too often Positive 60 99 −0.501 0.164 0.002 −1.740 2.156 0.42
Negative 96 105 0.411 0.216 0.057 0.637 0.323 0.049
Feeds too quickly Positive 78 110 −0.344 0.148 0.020 −1.755 2.151 0.41
Negative 78 94 0.157 0.213 0.46 0.505 0.309 0.10
Needs supplementary infant Positive 33 173 −1.657 0.190 <0.001 −1.691 2.214 0.445
formula Negative 123 31 3.035 0.277 <0.001 2.228 0.434 <0.001
My breasts:
Feel full before feeds Positive 93 179 −0.655 0.128 <0.001 −1.098 2.09 0.60
Negative 63 25 1.579 0.269 <0.001 2.044 0.400 <0.001
Feel soft after feeds Positive 107 142 −0.283 0.128 0.027 −1.353 2.01 0.50
Negative 49 62 0.048 0.230 0.836 −0.020 0.329 0.95
Feel empty in the afternoon or Positive 38 104 −1.007 0.190 <0.001 −2.525 1.964 0.198
evening Negative 118 100 1.172 0.233 <0.001 1.793 0.366 <0.001

introduction. Considering the possible effects on milk production, comparison of the results with the wide range of normal, particularly
this should be investigated in future studies. It is possible that better for the number of breastfeeds per day (Kent et al., 2006) may reassure
communication of evidence-based information with obstetricians, mothers and their health professionals that frequent breastfeeds are
midwives and expectant mothers is required. not necessarily a problem. The objective measurement would inform
Common concerns among all the participants in both groups were the mothers and their health professionals if the infants were requir-
the attachment of the infant during breastfeeding and how well the ing frequent breastfeeds to obtain a satisfactory daily milk intake
infant was sucking during breastfeeding. An incorrect sucking tech- (Kent et al., 2006). If the milk intake was shown to be inadequate, this
nique has been associated with breastfeeding problems and discontin- would help to guide the advice provided by the lactation consultant.
uation of breastfeeding (Cernadas, Noceda, Barrera, Martinez, &
Garsd, 2003); therefore, it is understandable that this was a concern
for most of the mothers in the study population. 4.2 | Demographics
Mothers with PIMS were marginally more concerned than those
with other breastfeeding problems that their infants were feeding too There are many demographics of breastfeeding mothers that have
often. Measurement of a 24-h breastfeeding milk profile and been associated with breastfeeding problems, and we investigated
 17408709, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/mcn.13080 by Cochrane Colombia, Wiley Online Library on [24/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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KENT ET AL.

T A B L E 3 Percentage of participants with PIMS who completed 4.3 | Birth

questionnaires before the first consultation (first) and during the
second (second) consultation responding to each statement with
Infant characteristics at birth (gestational age, weight and length) were
strongly agree or agree(n = 57)
not significantly different between the two groups and were also not
p specifically associated with PIMS.
First Second value
Mothers with PIMS and whose infants were not delivered by cae-
I think I produce enough breast milk for 0% 46% <0.001 sarean section were less likely to have given birth without intrapartum
my baby
anaesthesia. Whilst gas (nitrous oxide) and instrumental delivery have
My baby
not been shown to have an effect on full breastfeeding (Torvaldsen
Is growing well 73% 94% <0.001
et al., 2006), pethidine administration during labour can affect the
Has enough wet nappies 90% 97% <0.001 delay of the infant's first breastfeed after birth and their sucking tech-
Has enough soiled nappies 77% 80% 0.13 nique (Righard & Alada, 1990); however, none of the participants
Is normally alert 79% 96% 0.011 whose infants were not delivered by caesarean section received pet-
Is well attached during breastfeeding 19% 60% <0.001 hidine. Although epidural anaesthesia is associated with an increased
Sucks well during breastfeeding 31% 67% <0.001 rate of nonexclusive breastfeeding in the first week, this applied only
Appears satisfied after breastfeeds 30% 50% 0.14 when there was a vaginal delivery (Torvaldsen et al., 2006). We found

Feeds too often 33% 29% 0.40 no significant difference in the use of epidural anaesthesia between
women who had an SVD compared with other modes of delivery, nor
Feeds too quickly 14% 23% 0.91
between the mothers with PIMS and the mothers with other
Needs supplementary infant formula 70% 49% 0.09
breastfeeding problems. However, further studies are required on the
My breasts:
effects of epidural anaesthesia and short and long-term breastfeeding
Feel full before feeds 53% 59% 0.28
success (Mauri et al., 2015).
Feel soft after feeds 64% 79% 0.006
NELUSCS was significantly more common in mothers with PIMS
Feel empty in the afternoon or 51% 49% 0.75
than in mothers with other breastfeeding problems, in contrast with
evening
ELUSCS. Previous studies on breastfeeding after caesarean
section delivery have not distinguished between NELUSCS and
which factors may predispose mothers to PIMS as opposed to other ELUSCS but have found that caesarean section delivery is associated
breastfeeding problems. with an increased incidence of PIMS (Chapman & Perez-Escamilla,-
It is not surprising that mothers with PIMS were more likely to be 1999) and a decreased rate of exclusive breastfeeding at 1 week and
primiparous than mothers with other breastfeeding problems and that 3 months (Torvaldsen et al., 2006; Zanardo et al., 2010). Therefore,
primiparous mothers were more likely to be offering their infants sup- the current data indicate that NELUSCS could be a contributing factor
plementary infant formula, because primiparity and PIMS are risk fac- to PIMS.
tors for early cessation of exclusive breastfeeding (Hauck et al., 2011;
Torvaldsen et al., 2006). Although Asian women in Perth, Western
Australia have been shown to be less likely to initiate breastfeeding 4.4 | Initiation of lactation
(Forde & Miller, 2010), the participants in this study had all initiated
breastfeeding, but the non-Caucasian women were more likely to be Most mothers in both groups held their infants skin-to-skin, breastfed
immigrants and less likely to have support from an extended family, their infants within an hour of birth and intended to breastfeed for
which is a contributing factor to continuation of breastfeeding more than 6 months, and there were no significant differences
(Lavender et al., 2005). In addition, there was a tendency for the BMI between mothers with PIMS and mothers with other breastfeeding
of the PIMS mothers to be higher than that of the mothers with other problems in early milk removal. Most mothers expressed milk after
breastfeeding problems and obesity is also associated with delayed discharge from hospital and that would contribute to milk removal to
secretory activation (Rasmussen, Hilson, & Kjolhede, 2001) and early support continued milk production. The fact that the majority of
cessation of breastfeeding (Binns & Scott, 2002). mothers in both groups expressed before and after discharge from
We assessed many of the physiological factors that affect initia- hospital could indicate that there was concern either that the infant
tion of milk production or actual milk supply. However, the following was not removing milk adequately during breastfeeds or the mothers
conditions occurred infrequently or there were no significant differ- were wanting to ensure an adequate milk supply. The delay in milk
ences between the mothers with PIMS and those with other coming in for PIMS mothers compared with mothers with other
breastfeeding problems: lack of breast development during pregnancy, breastfeeding problems may be associated with the higher prevalence
breast surgery, smoking, high blood pressure, gestational or type 1 dia- of primiparous mothers in the PIMS group (Dewey, Nommsen-Rivers,
betes, postpartum haemorrhage, depression, infection, hypothyroid- Heinig, & Cohen, 2003).
ism and hyperthyroidism and mastitis, and therefore PIMS could not The concern regarding infant attachment during breastfeeding
be attributed to these factors. was extremely prevalent, with more than 70% of all mothers being
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KENT ET AL. bs_bs_banner
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concerned before the consultation with the lactation consultant. The commonly cite concerns about other clinical signs of sufficient milk
importance of correct positioning and attachment to successful intake (growth, elimination, alertness and breast changes). This is
breastfeeding is largely experience-based, but one study has shown not surprising considering 66% of the infants were already receiving
that infants using a correct breastfeeding technique or an incorrect supplementary infant formula and were probably adequately
breastfeeding technique that had been corrected by instruction within nourished.
6 days or birth, reported significantly fewer breastfeeding problems The positive changes in perceptions after targeted advice from
and longer breastfeeding duration than infants using an incorrect lactation consultants underline the value of professional guidance
breastfeeding technique (Righard, 1998). soon after birth.

4.5 | Changes in perception after advice from the ACKNOWLEDG MENTS

lactation consultant The authors thank the lactation consultants who assisted with admin-
istration of the questionnaires and provision of targeted advice to the
Almost half of the mothers who initially thought they did not produce breastfeeding mothers, and the breastfeeding mothers who partici-
enough breast milk for their baby changed their perception when they pated in the surveys. An unrestricted research grant from Medela AG
completed the second questionnaire. The positive changes in their is gratefully acknowledged.
perceptions of their infants' growth, wet nappies, alertness, attach-
ment and sucking during breastfeeding, along with a greater sensation CONFLICTS OF INTEREST
of breast softness after breastfeeds, could be attributed to the bene- JK and DG are supported by an unrestricted research grant from
fits of the advice of the lactation consultant. Although some mothers Medela AG. The remaining authors declare no conflict of interest.
indicated an improved perception of infant satisfaction after
breastfeeds and reduction in need for supplementary infant formula,
these did not reach statistical significance. This may indicate that it CONT RIB UTI ON S
may take some time to restore the confidence of mothers who have JK, EA, CH and DG designed the research study, JK performed the
had difficulties early in their lactation. Reviews by Thurman and research, AR and KM analysed the data. The paper was written by JK
Allen (2008) and Patel and Patel (2016) found some positive correla- and edited and approved by all coauthors.
tions between lactation consultant use and breastfeeding initiation,
duration, and exclusive breastfeeding rates, but there are no previous
studies on mothers' change in perception of their milk following OR CID
Jacqueline Coral Kent https://orcid.org/0000-0002-6614-1813
advice from a lactation consultant.

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