At-risk conditions that can impact breastfeeding initiation

new mother in bed in the hospital using the Symphony double breast pump-her midwife by her side talking to her

Secretory activation

Milk ‘coming in’ normally occurs between 24-72 hours after delivery. It initiates (starts) the increase of larger volumes of milk.

Delayed secretory activation 

Is defined as little or no maternal perception of breast fullness or leaking at ≥72 hours post-birth. 1

Women experiencing delayed secretory activation have 60% higher odds of stopping breastfeeding at 4 weeks. 2

There are some conditions or circumstances which put mothers at risk for delayed secretory activation.

These risk factors should be screened for, pre and postnatally as they can negatively impact breastfeeding and overall milk production.

Many of these risk factors can be assessed before birth:  

  • Maternal obesity 3-5
  • Diabetes 1,6
  • Breast reduction surgery 7
  • Primiparity- First time mothers 1,6,8
  • Induction of labour (IOL) 8,9
    Compared to women who have spontaneous labour, those who have an IOL are more likely to have: caesarean sections, epidurals, episiotomies and postpartum haemorrhage (PPH).
  • Planned caesarean section 10

And some risk factors may be noted during or after the birth:

  • Unplanned/emergency caesarean section 10

  • Stressful or prolonged labour and delivery. 11-14

  • Psychosocial stress / pain 1

  • Postpartum haemorrhage (PPH) 1,15

  • Preterm or late preterm infant 1,16

  • Mother – infant separation 17

  • Delayed first breastfeeding episode 18

  • Formula supplementation within the first 48 hours 1,8

  • Breastfeeding (or pumping) < 8 times in 24 hours 1, 18-21

  • Additional risk factors: infant feeding issues and overuse of pacifiers 1, 8

Taking timely steps to minimise the impact of these conditions on future lactation is essential. 

Standardised ‘at-risk mother’ lactation protocol which includes: 

  • Identification of at-risk women during pregnancy
  • Best practice of effective early lactation support for identified women with risk factors

Educate pregnant women and families about:8, 22, 23 

  • The different stages of lactation
  • The milk production process
  • Risk factors associated with delayed secretory activation
  • The best practice to ensure adequate milk volumes

Lactation assessment during pregnancy should be offered to all women:1, 23 

  • Any risk factors should be documented and communicated in the maternity record
  • Education should be given to the pregnant woman and discussions about her situation should be had with her.

Educate hospital staff about:19, 24

  • The different stages of lactation
  • The milk production process
  • Risk factors associated with delayed secretory activation
  • The best practice to ensure adequate milk volumes, as part of the ‘at-risk mother’ lactation protocol

Initiation of lactation:1, 7, 19, 23

  • Promote early, frequent and optimal breast stimulation
  • Avoid initiation delays
  • Hospital-grade pumps that mimic the infant have been shown to help at-risk mothers achieve adequate milk volumes when delayed secretory activation occurs 21-24

Find out more about protecting milk supply for mothers who have at-risk conditions.


The proper clinical intervention at the right time offers a mother the best chance to achieve her breastfeeding goals.

For some mothers, when at-risk conditions are present, maximising breast stimulation and complete breast emptying through the use of pumping and hand expression in addition to breastfeeding, may be necessary to enable them to achieve adequate breast milk volumes. 1

Taking a “wait and see” approach may result in earlier breastfeeding problems. 1

Women who experience a delay in the onset of secretory activation may be less able to sustain any and exclusive breastfeeding at four weeks. 2

At-risk conditions and delayed secretory activation should be used as a clinical marker to identify women who have a higher chance of breastfeeding difficulties and earlier breastfeeding cessation. 2