Oral Motor Series
Living with Chronic Low Milk Supply
A Basic Guide
By Angie Cannon, D.M.A., Hilary Jacobson, Beverly Morgan, IBCLC
A note from the author
My name is Angie and I am the mother of three beautiful children. With my first two babies I experienced the heartbreak of chronic low milk supply and I had to supplement both babies. Since 2003 I have been an active member of MOBI and I have acquired many tools to overcome low milk supply.
I am writing this article with the founders of MOBI, Susan Chick, Beverly Morgan, and Hilary Jacobson to share with you what I have learned along the way. It has been a difficult but rewarding journey. Through the support of wonderful women at MOBI I have been able to exclusively breastfeed my third child. This is an amazing accomplishment to me, considering that I made only 2-4 ounces total for the day during those first few weeks when I was pumping for my second child.
Many mothers experience episodes of low milk supply. This is not uncommon and can usually be resolved by standard methods such as correcting the latch, nursing more frequently or for longer periods of time, and with additional pumping.
While these and other time-tested methods work for many women, some mothers do not see an increase in milk supply with these methods alone. Many of these mothers have found their way to MOBI where they are able to explore additional options.
For the mother who is experiencing low milk supply, the loss of the opportunity to exclusively breastfeed is heartbreaking, and achieving any kind of nursing relationship may seem like an unobtainable goal. This can be very difficult for the mother to handle emotionally. Feelings of failure and even self-loathing are common. At MOBI, mothers have found that redefining breastfeeding success and mothering goals helps mothers find closure for their loss.
Causes of Low Milk Supply
There are many different causes for low milk supply, both on the side of the mother and the baby. Sometimes the mother and the baby both have issues that need to be addressed. Professional guidance is often necessary to implement a strategy for their resolution.
Common issues are painful conditions of the breast such as engorgement, cracked nipples, thrush, plugged ducts, and mastitis. These conditions require prompt treatment to protect the new breastfeeding relationship. Engorgement, if not relieved and managed, can lead to a reduced supply. Iron deficiency can impair a mother’s immune system, making her more susceptible to plugged ducts, mastitis and thrush. Iron deficiency also contributes to exhaustion and is associated with low milk supply. Iron deficiency anemia requires thoughtful treatment.
Flat or inverted nipples, or a mismatch between the size of the nipple and the size of the baby’s mouth, can also create temporary problems that require guidance.
A mother may have a physical or hormonal condition that makes her vulnerable to supply issues:
Other causes of low supply:
Diagnosing Chronic Low Milk Supply
If you have persistent low milk supply, your healthcare provider may order blood tests to ascertain underlying issues. Laboratory tests to consider are a blood count for anemia, thyroid stimulating hormone (TSH) for hypothyroidism, testosterone levels for gestational ovarian theca lutein cysts (a very rare condition), human chorionic gonadotropin (hCG) for retained placenta and prolactin levels for pituitary diseases.
Some of these issues, such as retained placenta and gestational ovarian theca lutein cysts, often resolve on their own during the first several weeks after birth. Others, such as hypothyroidism, require treatment. Both treatment and spontaneous resolution can lead to a quick increase in a mother’s milk supply.
Testing for PCOS-related milk supply problems is less clear. Polycystic Ovary Syndrome (PCOS) has received special attention during recent years as a major and often overlooked factor in true low milk supply. However, symptoms and hormonal imbalances present differently with different women, making this condition difficult to diagnose.
Insufficient Glandular Tissue and Milk Supply
Breast shape is listed as one of the risk indicators for low milk supply due to insufficient glandular tissue (IGT). While there is no one breast shape or kind of tissue that always indicates a reduced ability to produce milk, certain physical characteristics may indicate a problem with milk supply. Having irregularly shaped breasts, one breast that is dramatically smaller than the other, breasts that are very widely spaced on the chest wall, breasts that lack fullness, and other characteristics may be diagnostic.
Diagnosis of IGT is often done by an IBCLC examining the breasts. Women with this diagnosis frequently do go on to develop a milk supply, though not always a full supply.
Severe IGT can lead to the production of very little or no milk. The most reliable sign of severe IGT is the complete lack of breast changes during pregnancy and after birth.
Even in severe IGT, milk production can sometimes be obtained in a later pregnancy. For instance, if underlying hormonal conditions are treated, the mother’s breasts may be more responsive next time. Also, it is speculated that continuing to feed at the breast, say, with a supplemental breastfeeding device, will optimize the development of nerves and tissues facilitating milk production for a later baby.
Living With Low Milk Supply
Going Through Breastfeeding Grief and Redefining Breastfeeding Success
Mothers experiencing supply issues are frequently grieving the loss of exclusive breastfeeding. Mothers who are unable to feed at the breast sometimes say that they feel as they are grieving a death. These mothers are often frustrated that their family and friends are not sensitive to their mourning process. Some mothers even stay at home because they feel ashamed to bottle feed in public. They feel upset or humiliated by the perceived stares and comments of strangers.
Many mothers find that redefining their breastfeeding success and their mothering goals can help with the resolution of breastfeeding grief. They find closure by understanding that they did or are doing the best possible in the circumstances. Some mothers come to see the challenge of going out into the world as an opportunity to inform others about the issues that can undermine breastfeeding.
Redefining breastfeeding success restores a mother’s self-confidence, and enables her to feel that while things are not perfect, they are as right as they can be. For example, for some mothers, nursing can mean breastfeeding at the breast with a supplemental nursing device for some or for all feedings. This allows even mothers who produce no milk at all to keep their babies at their breasts. When the baby is old enough to get her calories through solids, this same mother may continue to “comfort nurse” for as long as she and her baby likes. This is a nursing relationship.
Other mothers and babies may need supplementing (topping off with supplement) after nursing at the breast. This is a nursing relationship.
Some mothers exclusively pump milk for a baby who can’t nurse. The mother can take pride in providing her baby with a special gift. She is a lactating mother and her body benefits form the hormonal benefits of lactation. Her baby benefits by receiving her milk.
Still other mothers wean and do not pump or supplement at the breast. They may also grieve and feel concerned about what their babies may have missed. Redefining mothering goals can help mothers find resolution: life with a newborn and young child affords many opportunities to develop a bond and to work on health-enhancing behavior.
Building a Nursing Relationship with Low Milk Supply
It is possible to build and maintain a nursing relationship with low milk supply. However, as described above, it may require an adjustment to one’s definition of a “successful nursing relationship.”
The traditional mother and baby dyad, where the baby is exclusively breastfed mother’s milk straight from the tap, is not an option during the low supply period or when the baby’s or mother’s condition does not support full breastfeeding.
Alternative Feeding Methods
There are many alternative feeding methods for a mother to choose from while building her supply. Some will be more suitable for her situation than others.
Supplemental Feeding Devices
Using a supplemental feeding device at the breast is the most direct way to stimulate a mother’s milk supply and get milk to her baby, and it is the most commonly used feeding device while building milk supply. It has the added benefit of providing the comfort of breast bonding, regardless of a mother’s supply.
However, using such a device at the breast is not possible for all mothers or babies. Mothers of babies with sucking issues, such as clamping or chomping, may need to take time away from breastfeeding even as they continue to pump, in order to allow their painful nipples time to heal. Some fragile babies (low weight, prematurely born, lethargic, low tone) tire easily and burn too many calories while nursing. These babies may initially require another kind of feeding, such as finger feeding, to help them improve their suck reflex or build their strength. Occasionally a baby will refuse to feed with a device directly at the breast, though the earlier the mother begins, the greater the chance that a baby will accept this as “normal.”
Using a supplemental feeding device can be difficult and time-consuming, though mothers say that it gets easier with experience. Many get through the initial learning curve by adopting a two-week trial period. At the end of it, they often find that they can integrate the device into their nursing relationship, and can view it as a tool to help them achieve their long-term goal of breastfeeding. That said, some mothers find it too tedious and awkward to use and discontinue using it.
At MOBI, we suggest that mothers with a history of an incomplete milk supply have a supplemental feeding device on hand after birth, so that it is available to use if necessary. Unfortunately, it is not always easy to obtain the proper equipment in the immediate postpartum period, and some hospitals routinely offer bottle feeding to the baby who needs a supplement. Bottle feeding can be detrimental in the early days of a nursing relationship. By providing your own supplemental feeding device(s) you can control how your baby is supplemented after birth.
The two most commonly used commercial devices are the Medela SNS™ and the Lact-Aid®. The Lact-Aid® and SNS™ differ in that the first allows the mother to place the supplement in a flexible plastic bag, and the latter in a plastic bottle. Both can hang between the breasts or can be positioned otherwise if the mother is reclining. They deliver the supplement to the baby via a small, flexible tube that is taped or placed on the mother’s nipple. The baby takes both the tube and the mother’s nipple into their mouth and receives the supplement while nursing at the breast. Which kind works best depends on the reason the device is needed in a given situation. For instance, a mother who breastfeeds in public will probably find the Lact-Aid® more discreet.
Additional methods for supplementing include a Haberman feeder, finger-feeding, cup-feeding and bottle-feeding. Consultation with a Lactation Consultant can be very beneficial, as these methods require some education on the part of the mother.
The age, size, and overall condition of your baby are all factors in making the decision as to the type of supplemental feeding method that is most appropriate for your individual situation.
How Can I Increase My Milk Supply?
Once you have determined that you have low milk supply, there are several things that you can do to help boost your supply. Eating a balanced diet that is filled with lactogenic foods and beverages (those that support lactation), power pumping (a technique for building milk supply), routine pumping to maintain or build supply and taking medications or herbs to increase milk production are all tools that may be helpful for the partial-supply mother. However, while most mothers with chronic low supply are able to develop a full milk supply, there are many who cannot attain this goal.
Foods, Beverages, Herbs, and Medications that Help Build Milk Supply
It is important to consume a sufficient number of calories in a well-balanced diet so that your body has the reserves necessary to produce milk and to maintain a healthy and energetic state. As any new mother knows, those first few months of caring for a newborn can be exhausting and draining. Partial-supply mothers may find that inadequate caloric intake or an imbalance in their nutrition affects them more than the full-supply mom. So-called lactogenic foods and beverages are especially helpful in maintaining that balance and can also boost milk supply. These can be added to the mother’s diet according to her individual needs and preferences.
Some Ideas for Healthful Eating From the MOBI Moms
Bring your crock pot back into circulation and cook a bag of chicken breasts at once to eat all week long. Chicken, along with some spinach salad, cherry tomatoes and red wine/vinegar make a tasty and quick lunch. My favorite recipe is a salad, made with different types of lettuce, tomatoes, onions, cheese, cucumbers and topped with a chicken breast and canned pears; garnish with slices of apple and sweet vidalia onion creamy salad dressing. One can vary the contents to suit individual tastes, but it is a quick and healthful lunch. The chicken breast is a good source of protein and the greens support lactation and are a good source of vitamins.
Oatmeal is another healthful and lactogenic food, and oats in any form can boost milk supply. My favorite oats recipe is a quick snack of whole cut oats mixed with yogurt for a tasty, textured treat. Some MOBI Moms have creative oatmeal recipes that call for adding frozen blueberries or other fruit, brown sugar or honey and butter to oats, then microwaving the combo for a few minutes until creamy. They have also come up with creative solutions like oatmeal bars, oatmeal cookies and homemade granola.
Here are the basics of my personal lactogenic diet. Experience and experiment will help you figure out what works best for you as you customize your own lactogenic meal plans.
There are several resources that contain information about lactogenic foods and beverages. One excellent resource is the book, Mother Food: Food and Herbs That Promote Milk Production and a Mother’s Health by Hilary Jacobson, whose article on diet and lactogenic foods and herbs is also on this website. This book provides a fascinating history of lactogenic foods and beverages, and an herbal lists usages and warnings for the most universally used lactogenic herbs.
Fenugreek, blessed thistle, alfalfa, red clover and marshmallow root are the most common, easily available supplements that are taken alone or in combination to support lactation. Each mother should educate herself about the risks and benefits of these substances so that she may make the best choices for her individual situation.
Medications That Enhance Milk Production
Medications are sometimes used to help a mother increase her milk production. The most commonly used are Domperidone and Reglan®.
Domperidone, although not FDA approved, is available through compounding pharmacies in the United States with a prescription. Dr. Jack Newman, a breastfeeding expert from Canada, was among the first physicians to recognize the potential of using domperidone for milk production. He has generously provided medical information handouts about domperidone as a milk enhancing drug that mothers can take to their doctors. Dr. Jack Newman's information can be found at: http://www.kellymom.com/newman/19a-domperidone1.html and http://www.kellymom.com/newman/19b-domperidone2.html
Dr. Newman's thoughts on the FDA standing on domperidone can be found at: http://www.breastfeedingonline.com/OfficialDomStatements.shtml
Domperidone is readily available as an over-the-counter medication in many countries. It may legally be purchased without a prescription and shipped into the United States from an overseas pharmacy by an individual for their own use.
Reglan® is available in the United States by prescription. Because it does often have side effects, such as depression, it is not as popular with mothers as domperidone.
Pumping and Techniques of Milk Expression
Milk removal is a crucial part of building a milk supply. It is necessary to remove milk frequently and completely to stimulate the production of more milk. A mother can achieve this by pumping frequently with an electric pump, by hand expressing milk, and by nursing frequently if the baby is able to nurse.
In the case of fragile or special needs infants, the mother may need to limit the amount of nursing until the infant becomes stronger. Nursing can place too much demand on the fragile infant’s energy reserves and cause the infant to gain weight poorly or lose weight because of the increased caloric expenditure during feeding. Once the baby has gained some weight, and has a strong and effective suck combined with a good latch, the baby will be good at removing milk. Until that point, the mother needs to empty her breasts frequently by some other means to build supply.
Tips to Make Pumping Easier
One technique that some MOBI mothers use to get more time with the pump is to pump in the car. Although some mothers do this while driving, I recommend pumping only when the car is parked or when one is a passenger and can be safely seated in the back seat away from all airbags.
If you enjoy watching a television show at night, you can pump or power pump during the show. Even if you aren’t producing much milk during these pumping sessions you are stimulating your breasts to make more milk.
Another tip to make pumping easier is to own multiple sets of horns (flanges) and pump parts. This way, a mother can pump several times per day and then do all of the cleaning and washing once, at the end of the day, instead of having to wash the same set multiple times.
If you have one set of pump parts, here is a trick so that you do not need to wash them after every pumping. Refrigerate the pump parts between uses to slow the growth of bacteria. Just put the whole container in the refrigerator. Change out the bottle, and cap the milk before the next pumping. This way, you can wash the pump parts every other time you use them, making pumping a little less time consuming.
To prepare for the night, wash out the pump parts before you go to bed. Keep them and the pump by your bed. Drink a big glass of water before you go to sleep. This will wake you in a few hours--a gentler way to wake up than with an alarm clock.
Keep a night light handy so you will not need to turn on a big glaring light, and keep a cooler by your bed. Once you pump, put your milk and pump parts in the cooler. Roll over and go back to sleep.
Helping the Milk to Flow
Mothers should remember that learning to pump milk can take time. Pumping in the early days may only result in drops rather than sprays of milk! Generally, the more a mom pumps the more easily she “lets down” for the pump. So don’t despair if pumping seems awkward at first.
Power pumping is a technique that can be helpful in building a milk supply. For more information on basic pumping techniques, see the pumping section below. Here is a brief explanation of power pumping.
Power pumping involves using regular pumping techniques and setup, but in a unique way. The idea is to mimic a baby who is nursing frequently to increase a mother’s supply, as is common in the nursing relationship during a growth spurt. To power pump, hook-up as you would for a normal pumping session, pump for 10-20 minutes, rest 10 minutes, then pump another 10 minutes, then rest for 10 minutes, then pump again for 10 minutes. The mother does this for about an hour, once per day, to increase supply. At other pumping times during the day, routine pumping is used. It can take about a week to see an increase, so don’t get discouraged.
Some mothers prefer to concentrate their efforts and have a power pumping weekend, called “Power Pumping Boot Camp” by some lactation consultants. They power pump at each pumping for a couple of days before returning to routine pumping.
What is Hand Expression?
Milk can be expressed through the use of a pump or via hand-expression. Hand expression is a good skill to learn. The skin-on-skin of hand expression can help some mothers “let down” better than a pump, and some mothers hand express exclusively. However, some mothers find that hand expression can be taxing on the hands, wrists, and arm muscles if she needs to express frequently. Hand expression is not only useful for extracting milk; it is also a helpful technique to empty the breast more thoroughly with each nursing or pumping session.
During a nursing session, one method is to hand-express the milk into the baby’s mouth once the baby’s sucking slows, and while the baby is latched on. This can help the baby feel successful at the breast and build your supply. More thorough expression is achieved by gently massaging the milk from the upper portions of the breast and from the ducts under the arm. A good Lactation Consultant can be very helpful when one is learning this technique.
Which Pump Should I Choose?
There are several types of pumps, including a variety of hand pumps and electric pumps. In general, an electric pump is a necessity for pumping as frequently as is necessary to build milk supply.
Hand pumps are useful for occasional pumping but many mothers find it to be tiring and time-consuming if used more than once in a day.
There are two basic types of electric pumps, hospital grade (multi-user pumps) and single-user pumps. A hospital grade pump, such as the Medela Lactina® Select or Classic™ models, the Medela Symphony®, or the Ameda Lact-E or Elite are recommended for those who are building milk supply. Many IBCLCs such as our own Beverly Morgan recommend that their clients look for a Lact-E by Ameda/Holister or a Classic by Medela as they have had the best record of building a milk supply for many years.
While some mothers may be able to maintain a good milk supply by pumping with a single-user pump (a non-hospital grade pump) such as the Medela Pump N Style®, many find that these pumps are not as effective and efficient at milk-removal. It is important that the breasts are completely emptied at each pumping session. A mother may need to experiment with different pumps. Many mothers for example find the hand pump by Avent called Isis™ works well even when the electric pumps don’t work as well for them. Using the gentle, massaging Isis™ flange as an insert in electric pumps helps many to produce more at the pump.
Adding in hand massage and hand compression while pumping increases milk volume, drains the breast better and faster, and helps move through the hindmilk better than just pumping alone.
Frequency of Pumping
Frequency of pumping will depend upon the mother’s nursing schedule, the presence of work or additional children who need care, and other factors such as whether she is pumping to build supply or to maintain her supply.
Whereas standard advice is to pump every two hours around the clock for a few days to increase supply, for a few mothers, getting five hours of sleep during the night leads to a stronger increase in milk production. For most though it is useful and even necessary to get that 2 am pump.
Generally speaking, emptying the breasts every two hours is a good way to build milk supply, whether it is done by means of a pump, hand-expression, nursing or a combination of the above methods.
Most mothers find that it is helpful to pump for at least 20 minutes per session, but some find that including sessions as long as 45 minutes to an hour in length are helpful.
Since several letdowns of milk can occur per pump session, it is desirable to pump through at least two to three letdowns. While this may sound like a very long time to pump, there are accessories that can make pumping easier and more manageable.
Hands Free Pumping
Several products are available that allow a mother to pump “hands free,” i.e. without having to hold the collection horns in place.
How Much Milk Will I be Able to Pump?
The amount of milk pumped per session will vary according to each mother, but in general, any amount pumped is beneficial, even if only drops of milk are obtained.
Pumping provides stimulation to the breasts that signal the body to make more milk. The more stimulation provided, the more milk produced, or so says the law of cause and effect for full-supply mothers. And this brings us to a discussion of some of the anomalies of being a low-supply mother. Here, the rules are different. Many chronic low supply mothers do not see an increase in milk production through pumping alone. This is explained more in the next section.
Will I be Able to Increase the Amount of Milk That I Am Able to Pump?
Full-supply mothers often see substantial increases in the amount of milk that they are able to pump if they start with a rigorous pumping schedule that is designed to increase production.
Partial-supply mothers may find that although they follow the same schedule as a full-supply mother, or even one that is more intensive, they are not able to increase their supply by much. Some can’t increase their supply at all, and some find that while they are able to increase at a rate that is satisfactory for a while, they reach an amount that they are unable to surpass. For some that amount is 10 ounces a day, while others reach 25 ounces per day.
Many of these mothers find that the addition of lactation-enhancing medication and the addition of lactogenic foods and herbs can make their body more receptive to the stimulus of pumping and breastfeeding.
Building milk supply is an individual experience. Even mothers who are unable to generate an increase in supply benefit from the process, as they know that they have truly tried. This helps many to make peace with their situation.
Partial-supply mothers often find that they need to follow a program of nursing, supplementing, and pumping to feed their babies as they are simply unable to produce enough milk to exclusively nurse their babies. Sometimes this is a temporary situation that the mother is able to overcome; sometimes it is a more permanent situation. At the beginning of the journey a mother just doesn’t know what the outcome will be.
How Should I Combine Pumping and Nursing?
To stimulate milk production for a baby who is nursing at the breast, it can be helpful to pump after baby is done nursing. The schedule may look something like this: nurse, supplement with mother’s milk or formula via an appropriate feeding device, pump both breasts, and then repeat for the next feeding.
The more feedings per day that are done this way, the better chance a mother has of increasing her supply. If the baby goes more than 1 ½ hours between feedings, it may be useful to pump in between feedings as well. But many low-supply moms find that their breasts do not “refill” with milk at the normal rate and that if they pump in between feedings they do not have enough milk to make nursing satisfying for baby at the next feeding. In this situation, topping off a meal with donated mother’s milk or formula, using a supplemental nursing device like an SNS™ or a Lact-Aid®, can be helpful.
Milk Storage Guidelines
Fresh milk can be stored in the refrigerator or freezer, with varying lengths of time depending upon the equipment that you have at your disposal.
Summary of Successful Pumping Strategies for the Low-Supply Mom
The low-supply mother may find that for her, pumping is a very different experience than it is for full-supply mothers. The following tips are designed specifically to assist low-supply mothers in their pumping journey. My advice is to try this program for two weeks and stick to it faithfully. Re-evaluate your progress at the end of two weeks and make any necessary adjustments.
While some low supply mothers are able to build and sustain a full-supply, many are not able to achieve this goal. At MOBI, mothers find that moving beyond the “all or nothing” approach to defining breastfeeding success helps them to accept and embrace their breastfeeding experience however it develops.
For some, this may mean nursing at the breast with a supplemental feeding device for some or all feedings, or it may mean supplementing by other measures after nursing at the breast. For others, it may represent exclusively pumping milk for a baby who cannot nurse, or it may include nursing for a period of weeks or months and then weaning.
These less-than-total-at-breast outcomes can be very difficult emotionally for the mother. It is crucial that she has the opportunity to come to terms with her achievements in nursing or providing breast milk for her baby. The sister group to MOBI, Breastfeeding Grief, can be helpful in assisting a mother in the transition from her ideal of a nursing relationship to the reality of her situation. MOBI also provides support in many ways both during the challenges of the active relationship and after the relationship has ended.
Will I Ever Have Enough Milk?
Some mothers take heart in knowing that here at MOBI many low-supply mothers have more milk with each subsequent child. Even mothers who had severe low-supply problems with their first children have been able to exclusively nurse subsequent children. Some experts say that the time spent nursing or pumping develops mammary and nerve tissue, and that this is in the bank for next time. This hopeful prospect provides some mothers with extra motivation to pump and supplement at the breast this time around. In other situations, the issues that caused the low milk supply may be resolved; for example a mother’s health issues or her hormonal imbalances may be discovered and treated. The mother may also find that it was an undiscovered oral motor issue with her child that suppressed her milk supply. Some mothers just won’t achieve the same quantity of milk by pumping that they would if their baby were effectively feeding.
By the time the second or third child comes along, many mothers are able to exclusively nurse their babies. This was my experience. I have been able to exclusively nurse my third child, even though my supply issues were serious with my first two children
For those chronic low-supply mothers who do not see a significant increase in their milk supply, the solution lies not only in trying to build a milk supply, but in accepting the lot that has been cast. Being able to grieve the loss of exclusive breastfeeding, yet put a plan in place that safeguards the baby, the milk supply and the nursing relationship is a challenge. Mothers do feel empowered when they learn to nurture their babies in their own, uniquely special ways. As Lactation Consultants say, “The most important thing is to feed the baby.” So, mothers, feed your babies. Love them and nurture them in your own special ways! And count on MOBI to support you in your journey along the path of your nursing relationship.
To find an IBCLC look in your local yellow pages under "breastfeeding" or call 1/800-TELL-YOU.
Contact your local hospital (maternity and birth areas) to ask about their breastfeeding support groups.
Talk to your resources about your special situation. Your hospital or local LLL group or IBCLC may refer you to a local breastfeeding expert who specializes in low milk supply.
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Nissen E, Uvnas-Moberg K, Svensson K, Stock S, Widstrom AM, Winberg J.Different patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women delivered by cesarean section or by the vaginal route. Early Hum Dev 1996;45(1-2):103-18.
Marasco, L., Insufficient Milk Supply: Common Factors and Relationship to Polycystic Ovary Syndrome. Master Thesis, Pasadena, California, 2001