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Breastfeeding

Calling First Responders

Time to read: 5 min.

Clinical Pathways for Proactive Lactation Support

Breastfeeding rates continue to be suboptimal, with less than 50% of infants receiving an exclusive human milk diet for the first 6 months.1 While there are many contributing factors, a recent international roundtable of nurse midwives, led by a PhD lactation nurse, found that to improve short-term exclusive breastfeeding and long-term breastfeeding duration, early identification and management of specific maternal and infant risk factors is paramount. They identified the most significant risk factors that can disrupt normal physiological lactation2 and developed clinical pathways to guide healthcare professionals in providing lactation support and care to families.3

Content

1. A gap in guidance

2. A question of timing

3. Assessing correctly

4. The right intervention

A gap in guidance

Making sure mothers and infants can meet their personal breastfeeding goals is at the heart of postnatal care, yet adequate protocols to guide healthcare providers are not a given. Currently, clinical guidance is available to support healthy lactating mothers in establishing an optimal human milk supply.4-6 The World Health Organization has issued clinical guidelines for the care of small, sick and preterm newborns7 and the Spatz 10-Step Model8 for promoting and safeguarding human milk for vulnerable newborns has been implemented internationally, demonstrating strong clinical outcomes.

However, mothers with known lactation risk factors who give birth to newborns presumed to be healthy may still face a high risk of not achieving a full milk supply, because they are often overlooked in current hospital protocols. For instance, a recent cross-sectional study9 confirmed that own mother's milk feeding initiation and continuation rates at 12 weeks after birth for late preterm infants were substantially lower than rates for infants with other gestational ages.

To date, no published clinical practice guidelines exist that specifically addresses the care of mothers with recognized risk factors affecting the physiological lactation process, or those who encounter difficulties initiating lactation during their hospital stay. As a result, these mothers may fail to receive the necessary lactation support needed to help them come to volume within the critical window during secretory activation.

Personalized breastfeeding plans are needed to identify and support these mothers from the get-go. A reactive approach of only intervening when problems arise will fail, because once secretory activation is delayed, the repercussions affect the whole breastfeeding journey. In fact, delayed secretory activation, more than 72 h postpartum, is associated with excessive neonatal weight loss, sub-optimum breastfeeding behavior at day 7, increased formula supplementation and reduced breastfeeding duration.10-11

'Wait and see' is not an option! Women with delayed secretory activation have a 60% higher odds of stopping breastfeeding at 4 weeks post birth.15

A question of timing

The first two weeks after birth will decide if a good milk supply can be built and maintained long-term, but it is an even shorter window – the first 72 hours – that is available to successfully initiate lactation. The reason for this critical window is a shift in mammary gland development which is guided by hormonal (endocrine) control, with quite dramatical changes in the first days after birth. During pregnancy, milk secretion begins around 20 weeks, but high progesterone levels suppress full milk production until after birth, when hormonal shifts trigger secretory activation.16,17

Following birth, there is a rapid drop in progesterone levels, facilitated by the delivery of the placenta. Once progesterone levels fall, prolactin is free to promote secretory activation. It supports the closure of the lactocyte tight-junctions sealing the alveoli, so milk stays inside and doesn’t leak into surrounding tissue. Each suckling event, each regular stimulation of the nipple and areola through breastfeeding or pumping, sends the message to the mother’s brain to 'produce prolactin'.17

Oxytocin also comes into play here. After stimulating contractions during labour, it remains high for the first days after birth to prime the ensuing breastfeeding interaction. Oxytocin pulses occur during suckling and are required for the release of available milk throughout lactation (milk ejections). 

Consequently, during this time, regular stimulation and effective milk removal is essential to activate the mother's milk production. Risk factors – whether hormonal, glandular, or related to poor milk removal because the infant is experiencing sucking difficulties – can disrupt this process and must be proactively identified and managed. This is why supporting and preparing mothers-to-be during pregnancy – by identifying potential risk factors for lactation and developing breastfeeding plans to achieve timely secretory activation – is the prerequisite for long-term breastfeeding succes.

 

Breastfeeding support must begin during pregnancy

Prof. Viktoria Vivilaki, President of the European Midwives Association, is a strong supporter of the roundtable discussions issuing the latest call for proactive lactation support. Her expectations for the future are clear.

Why is proactive lactation support so important?

Proactive lactation management plays an essential role in ensuring breastfeeding success. Early initiation and strategic support in birth centres and maternity clinics significantly impact long-term milk production and maternal confidence. Given the declining breastfeeding rates in some European countries, an evidence-based framework for enhancing perinatal care practices is crucial.

When should support begin?

Breastfeeding support must begin during pregnancy and immediately at birth. It should be an integrated part of perinatal care, not an optional service. It is important to set realistic expectations and address concerns. The recommendations we laid out emphasize structured, proactive guidance to prevent early breastfeeding challenges, especially in mothers at risk of delayed lactogenesis. This approach reduces unnecessary supplementation and increases breastfeeding success.

How should midwives implement the recommendations in daily practice?

Midwives are key players in breastfeeding support. Implementation involves routine lactation education to ensure standardized, evidence-based practices, as well as hands-on support in the first hours postnatally to ensure optimal latch and positioning. We also need to ensure close follow-up beyond hospital discharge by community midwives. Collaboration between professionals is key here. We need to work together to identify mothers at risk early on, to ensure immediate and continuous support is guaranteed.

Don´t delay - lead the way!

Whatever the risk factor identified, moving from a reactive to a proactive approach to lactation support can only be beneficial.

Assessing correctly

When looking at risk factors, experts differentiate between pre-existing maternal risk factors and those that arise during birth or that concern the infant specifically. Some mothers face a slower start to lactation due to common, often non-modifiable risk factors like diabetes18-20, high BMI 21-24, Polycystic Ovary Syndrome (PCOS)25,26, prolonged labour27-28, caesarean birth29,30, or postpartum haemorrhage.31,32 These factors can delay secretory activation and make it harder to reach the critical 500 mL/day milk volume by day14.33,34 If risk factors stem from a prolonged birth or an unexpected caesarean birth, the risk is equally high. If the baby is born with a low birth weight35-37 or a facial abnormality like a cleft palate38 and cannot stimulate and/or feed effectively, the breastfeeding journey is also challenged.

Special focus should also be placed on women with glandular hypoplasia.39-41 In summary, the more risk factors present, the greater the challenge – making early identification and assessment during prenatal care essential. Based on these assessments, a personalized perinatal breastfeeding plan should be developed to prepare families and guide care. A strong plan makes all the difference. Documenting supplementation preferences and sharing them with the birthing team ensures continuity of care. After birth, early skin-to-skin contact, direct breastfeeding, and hand expression of colostrum are vital first steps and if breastfeeding is delayed or ineffective, hospital-grade pumping should begin promptly to stimulate the breast and protect milk supply.2,3

Maternal Risk factors

➜ Disease/Disorders

  • Diabetes18–20
  • Obesity21–24
  • Polycystic ovarian syndrome25–26
  • Thyroid disorders42

➜ Medication/Treatment

  • After chemotherapy43
  • After radiotherapy44
  • Drugs that suppress lactation45–47

➜ Breast concerns

  • Glandular hypoplasia39–41
  • Breast surgery48–49
  • Nipple piercings50
  • Nipple anomalies45,51

➜ Other factors

  • Assisted conception52
  • Induction of labour53–54
  • Primiparity42,53,55
Birth & infant Risk factors

➜ Birth

  • Prolonged/stressful labour27–28
  • Caesarean section29–30
  • Postpartum haemorrhage31–32

➜ Infant

  • Gestational age56–57
  • Low birth weight36–37
  • Facial abnormalities e.g. cleft lip/palate38

➜ Postpartum

  • Separation of mother and infant58–59
  • Delayed or interrupted skin-to-skin contact60–61
  • Delayed first breastfeed62–63

➜ Feeding & pumping practices

  • Infrequent breastfeeding <8 times in 24 hours64
  • Infrequent breast pumping <5 times in 24 hours65
  • Supplementing with anything other than OMM66

The right intervention

Ongoing, hands-on support is key and the right intervention also depends on the underlying risk factors identified. The international round table defined two clinical pathways (see page 12) to guide care, also with a specific approach for those women with insufficient glandular tissue2 who are unlikely to achieve a complete milk supply. Breast surgery – whether for enlargement or reduction – is one of the most commonly performed cosmetic procedures worldwide. Thanks to a better understanding of how the breast functions during breastfeeding and advances in surgical techniques, many women can still breastfeed successfully after surgery. Nonetheless breast surgery can affect milk production and the more milk-producing (glandular) tissue is removed during surgery, the more likely it is that a woman may not be able48,49 to produce a full milk supply. Breast cancer treatment also often involves surgery – such as a full or partial mastectomy – along with chemo - therapy and radiation therapy.43,44

These treatments can remove, scar or impede mammary tissue and function breast tissue, which may affect the breast’s ability to produce milk. And while breastfeeding after radiation or chemotherapy is possible, it often results in a lower milk supply due to the impact on the milk-producing tissue.

Some cases from clinical practice have already demonstrated that with a structured, proactive approach, even these high-risk mothers can be set up for breastfeeding success. A recent systematic review showed that 40 of 42 (95.2%) women with insufficient glandular tissue could only provide human milk for less than 1 month.39 Nevertheless, one case report showed that with significant intervention (i.e. a hospital-grade pump and domperidone), this mother was able to achieve a milk supply of about 400 ml per day for the infant’s first 6 months.41

 

Training healthcare providers is a top priority

Salomé Álvarez Rodríguez, Former President of the Spanish Federation of Midwives Associations and co-author of the scientific committee on how she intends to implement the recommendations given in Spain.

One of our key initiatives is organizing a series of workshops and seminars for midwives and other healthcare professionals. These events will focus on best practices in breastfeeding support, techniques, and how to manage common challenges. They will also provide valuable opportunities for experience sharing and practical case discussions, helping to build a strong, informed professional community.

Training healthcare providers is a top priority. We are launching training programs for midwives, nurses, and doctors that emphasize the importance of breastfeeding, how to support mothers before and from birth, and how to handle complex situa-tions. Our goal is to ensure that all staff are well-prepared and aligned with current best practices. One of the main impacts I hope to see is a significant increase in breastfeeding rates, By implementing the new recommendations, we can help mothers overcome barriers like lack of information, limited support, and practical difficulties, A structured, proactive approach starting already before birth can make a real difference.

Advocacy also plays a central role in our plan. We are pushing for policies that facilitate breastfeeding, such as adequate maternity leave, breastfeeding-friendly workplaces, and the inclusion of breastfeeding in public health programs. These measures are essential to creating an environment where mothers feel supported and empowered. Through these initiatives, we aim to build a strong and sustainable support system for breastfeeding in Spain. My vision is that all mothers, regardless of their background or location, have access to continuous and comprehensive support that enables them to breastfeed successfully and with satisfaction.

Clinical Pathways for Proactive Lactation Support

For mothers with risk factors for delayed secretory activation and decreased milk production and/or newborns with risk factors for feeding issues

Is the infant feeding effectively?*

i. In the first 3 hours

YES

  • Ensure skin-to-skin contact of mother and infant.
  • Encourage responsive breastfeeding.
  • Assess every breastfeeding session for effectiveness.*

NO

  • Ensure skin-to-skin contact of mother and baby.
  • Assist with positioning and attachment.
  • Assist with hand expression of colostrum to facilitate direct breastfeeding and feed any expressed colostrum to infant.
  • Monitor infant feeding effectiveness.*

↓

ii. After 3 hours post-birth

YES

  • Ensure continued skin-to-skin contact of mother and infant.
  • Continue assisting with positioning and attachment.
  • Continue assessing every breastfeeding session for effectiveness.*

NO

  • Ensure continued skin-to-skin contact of mother and infant.
  • Continue assisting with positioning and attachment.
  • If no effective feed after assistance, instruct mother to express with a double electric hospital-grade breast pump (using Initiation Technology until milk ‘comes in’).
  • Feed available colostrum to the infant.
  • Consider if supplementation is required and encourage use of pasteurized donor human milk if supplementation is warranted.
  • Continue assessing every breastfeeding session for effectiveness.*
For mothers likely to have a compromised milk supply

Is the infant feeding effectively?*

i. In the first 3 hours

YES

  • Ensure skin-to-skin contact of mother and baby.
  • Facilitate latching and positioning.
  • Assist with hand expression of colostrum to facilitate direct breastfeeding and feed any expressed colostrum to infant.
  • Assess infant’s behaviour before, during, and after breastfeeding sessions.*

NO

  • Ensure skin-to-skin contact of mother and baby.
  • Assist with positioning and attachment.
  • Assist with hand expression of colostrum to facilitate direct breastfeeding and feed any expressed colostrum to infant.
  • Observe for the effectiveness of direct breastfeeding sessions.*
  • Because the mother has a known history that could impact milk supply, start pumping after each breastfeeding attempt with a double electric breast pump using Initiation Technology.

↓

ii. After 3 hours post-birth

YES

  • Ensure skin-to-skin contact of mother and baby.
  • Facilitate latching and positioning.
  • Assist with hand expression of colostrum and feed any expressed colostrum to infant.
  • Assess infant’s behaviour before, during, and after breastfeeding sessions.*

NO

  • Continue to ensure skin-to-skin contact of mother and infant.
  • Continue to assist with positioning and attachment.
  • Observe every breastfeeding session if possible and document feeding effectiveness.*
  • Continue to assist with hand expression of colostrum to facilitate direct breastfeeding and feed any expressed colostrum to infant.
  • Pump after each feeding attempt (using Initiation Technology until milk ‘comes in’).
  • Consider need for sup

*Assessment of effective feeding includes frequency, duration, stool and urine output, the infant's weight, visual appearance and activity of the infant and the appearance of the mother’s nipples and breast tissue before and after feeds. Parents should be instructed on the physiology of milk production, the importance of timely secretory activation to build a robust milk supply long term and how maternal and/or infant risk factors could impact effectively coming to volume.

Examples for pathways adapted from: Spatz DL et al J Midwifery Womens Health. 2025 Mar-Apr;70(2):343-349 3 and Slater CN,et al. Am J Matern Child Nurs. 2025 Jul-Aug 01;50(4):192-203.

 

 

This article was originally published in Issue 01 2025 of Beginnings Magazine.

The full series of Beginnings Magazine are also available.

Related links

Read the full recommendations of the international round table in these two papers

Learn more abouthow to put proactice lactation support into practice in our free e-learning

For more recent insights into lactation research we recommend Breastfeeding Medicine's July 2025 Special Issue, now available in open access.

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