Journal of Midwifery & Women’s Health www.jmwh.

org
Clinical Rounds

Mammary Hypoplasia: Not Every Breast Can Produce

Sufficient Milk
Megan W. Arbour, CNM, PhD, Julia Lange Kessler, CM, MS, RN, IBCLC

Breast milk is considered the optimal form of nutrition for newborn infants. Current recommendations are to breastfeed for 6 months. Not all
women are able to breastfeed. Mammary hypoplasia is a primary cause of failed lactogenesis II, whereby the mother is unable to produce an
adequate milk volume. Women with mammary hypoplasia often have normal hormone levels and innervation but lack sufficient glandular tissue
to produce an adequate milk supply to sustain their infant. The etiology of this rare condition is unclear, although there are theories that refer to
genetic predisposition and estrogenic environmental exposures in select agricultural environments. Women with mammary hypoplasia may not
exhibit the typical breast changes associated with pregnancy and may fail to lactate postpartum. Breasts of women with mammary hypoplasia may
be widely spaced (1.5 inches or greater), asymmetric, or tuberous in nature. Awareness of the history and clinical signs of mammary hypoplasia
during the prenatal period and immediate postpartum increases the likelihood that women will receive the needed education and physical and
emotional support and encouragement. Several medications and herbs demonstrate some efficacy in increasing breast milk production in women
with mammary hypoplasia.
J Midwifery Womens Health 2013;58:457–461  c 2013 by the American College of Nurse-Midwives.

Keywords: abnormalities, breast, breastfeeding, lactation, galactagogue, milk, human, postpartum period, prenatal care

CASE REPORT W for 7 months with formula supplementation at every

MW, a 29-year-old gravida 1, para 1001, experienced fail-
ure of lactogenesis II following the birth of her first child.
Her obstetric, medical, surgical, family, and social histories
were unremarkable. She took no regular medications and
did not use tobacco, drugs, or alcohol. She did note that her
breasts were small and widely spaced, without much change
during the pregnancy. MW’s mother breastfed 4 children
without difficulty. Following an unmedicated and uncom-
plicated labor at term, she gave birth to a male infant who
latched on to the breast within one hour of birth and nursed
with a good latch on demand every 2 to 4 hours while in the
hospital. MW and her newborn W were discharged home
on postpartum day 2.
MW initially sought help when her milk failed to come
in by 5 days postpartum, with no engorgement, leaking, or
letdown. Her infant had too few wet diapers and was in-
creasingly fussy. The pediatrician noted significant weight
loss (13% less than birth weight). MW was given a can of
formula and counseled to nurse, bottle-feed, and pump ev-
ery 2 to 3 hours. At 4 weeks postpartum all laboratory
tests including a complete blood count, prolactin, testos-
terone, and thyroid-stimulating hormone were normal. At
the same time, a course of metoclopramide (Reglan; 10 mg
3 times a day for 5 days) was prescribed but yielded no in-
crease in milk production. At the recommendation of one
lactation consultant, fenugreek was taken regularly, and a
slight increase in production occurred. Although fatigued
and viewing herself as a failure, MW persevered and nursed
Address correspondence to Megan W. Arbour, CNM, PhD, Clinical
Assistant Professor and Coordinator, Women’s Health NP and Nurse-
Midwifery Program, University of Cincinnati College of Nursing, P.O.
Box 210038, Cincinnati, OH 45221. E-mail: arbourmn@ucmail.uc.edu
feed. During this time, she was unable to pump more than
several milliliters.
Two years later a second pregnancy was conceived.
Breast changes during pregnancy did not occur. At 38 weeks
3 days, MW spontaneously ruptured her membranes and
had an un-medicated normal spontaneous vaginal birth.
Evaluation of her breasts, colostrum, and the newborn’s
latch were normal. This time when MW failed to lactate
she started formula supplementation on discharge from the
hospital. At 3 weeks postpartum during a visit to the lacta-
tion consultant, when MW pumped 5 mL from each breast
in 15 minutes, mammary hypoplasia, a diagnosis of exclu-
sion, was determined.
INTRODUCTION
Several case reports document the impact of mammary hy-
poplasia on new mothers.1–5 However, the prevalent assump-
tion among women and clinicians alike is that any breast can
produce milk, regardless of breast size.6 In general, pregnant
women are counseled to plan alternate feeding measures only
if they have a history of breast surgery. This article reviews
current breastfeeding recommendations, breast anatomy and
physiology, and how to recognize a failure of lactogenesis II
with a focus on mammary hypoplasia and associated clinical
implications.
BREASTFEEDING
Recommendations
All professional organizations currently recommend that
women exclusively breastfeed for 6 months.7–11 The Amer-
ican College of Nurse-Midwives recognizes that breastfeed-
ing is a combination of learned and instinctive behaviors and

1526-9523/09/$36.00 doi:10.1111/jmwh.12070 
c 2013 by the American College of Nurse-Midwives 457
that breastfeeding is a choice that is affected by health care
providers.9 The American Academy of Pediatrics further rec-
ommends that women continue breastfeeding for 12 months
and notes that contraindications to breastfeeding are rare.7
The World Health Organization opposes routine use of for-
mula secondary to the lack of antibodies in formula that are
found in breast milk, the increased risk of malnutrition asso-
ciated with formula, the practice of overdiluting formula due
to a lack of education and cost, and the risks associated with
unsafe water.10 Concern has also been expressed regarding
fluorosis or staining of permanent teeth because of overexpo-
sure to fluoride in powdered formula reconstituted with fluo-
ridated water.12 Although it is important to encourage breast-
feeding and support mothers to breastfeed, it is also important
to correctly and in a timely manner identify those women who
are not able to breastfeed their newborns.
Breast Anatomy and Physiology
Lactation requires an adequate amount of glandular tissue
as well as intact hormonal and neuroendocrine pathways.13
This does not mean that a woman needs large breasts,
but she does need an adequate amount of glandular tis-
sue. Research shows that there is little correlation between
the size of a woman’s breasts and her ability to produce
milk.6, 14, 15 After increased development during puberty, the
mammary glands typically complete their growth and devel-
opment during pregnancy with extensive epithelial expan-
sion and differentiation.16, 17 The increased levels of estro-
gen associated with puberty stimulate the proliferation of the
ductal tissue of the breast, promoting ductal elongation and
dichotomous branching in the direction of the mammary fat
pad. Increased progesterone and prolactin levels that occur in
pregnancy stimulate further epithelial proliferation, more di-
chotomous side branching, and differentiation of milk-filled
alveolar lobules.16 The changes seen during pregnancy that
initiate the milk-producing capacity of the breasts are re-
ferred to as lactogenesis I.17 During the first 4 days postpar-
tum, plasma progesterone significantly diminishes, leading to
transformation of mammary epithelium and the onset of co-
pious milk secretion. This stage of mammary development is
referred to as lactogenesis II.17, 18 The hormones necessary for
lactation are prolactin and the sudden drop in progesterone
that occurs after the placenta is delivered.18
Women with mammary hypoplasia have a lack of or a di-
minished amount of glandular tissue.5 Ultrasound can be used
to examine the anatomy of lactating human breasts.5, 19 Ram-
say and colleagues noted that in 80% of fully lactating women
who had a difference of more than 200 g of milk production
between the left and right breasts, there was more glandular
tissue in the more productive breast,19 a finding that supports
the thesis that increased glandular tissue yields more milk pro-
duction when all other factors are normal.20 However, several
questions about glandular tissue in the breast remain unan-
swered. It is not known if there is a minimum threshold of
glandular tissue that must be present for a woman to lactate
sufficiently. Nor is it known if the position of glandular tissue
in the breast affects the ability to lactate sufficiently. The post-
partum or lactating breast anatomy of women with mammary
hypoplasia has not been documented.
458
Failed Lactogenesis II
There are numerous reasons why women have an insufficient
amount of breast milk to support their newborns. Lactational
insufficiency is a blanket term that describes low milk pro-
duction without recognizing a specific etiology. Failed lac-
togenesis II describes the situation wherein a woman is not
able to achieve full milk supply postpartum. Known etiologies
of failed lactogenesis II are breast surgery, retained placental
fragments, hypothyroidism, mammary hypoplasia, polycystic
ovary syndrome, and Sheehan’s syndrome, among others.17
When a woman experiences primary failed lactogenesis II,
one of these key components is absent, hormonal or neuroen-
docrine pathways are not intact, or there is a lack of adequate
glandular tissue. Mammary hypoplasia, insufficient glandular
tissue, is an example of primary failed lactogenesis II.21
Failed secondary lactogenesis II is usually related to
breastfeeding difficulties such as maternal pain, ineffective
suckling, poor latch, or a return to work.17, 22 These conditions
are much more prevalent and also may be treatable or pre-
ventable. Both primary and secondary causes of failed lacto-
genesis II are important differential diagnoses when a woman
has lactational insufficiency. In addition, it is reasonable to
rule out or manage secondary causes before investigating a
primary cause of failed lactogenesis II because of the relatively
rarer incidence of primary causes.
Mammary Hypoplasia
The body of literature on mammary hypoplasia is not com-
prehensive, and the exact incidence of mammary hypoplasia
is not well documented, but by all accounts, it is rare that a
woman has insufficient glandular development of the breasts.
Neifert et al report that 5% of women experience primary lac-
tation insufficiency because of anatomic breast variations or
illness.22
The majority of the known information regarding women
with mammary hypoplasia is in the plastic surgery literature,
where it is often called tuberous breast deformity.23 A his-
tory of breast augmentation surgery can confound the diag-
nosis of mammary hypoplasia because it is often assumed that
the breast surgery itself interfered with the anatomy essential
for lactation when a woman is unable to successfully breast-
feed. One way to determine whether mammary hypoplasia is
present is to ask for photos of the breasts before the surgery
was performed.24
The etiology of mammary hypoplasia also remains un-
known, although theories about contributory factors exist.
Guillette et al described altered mammary tissue development
in women who grew up in an agricultural area in Mexico
and who had exposure to relatively high levels of organochlo-
rines in utero.25 Other theories are based on rodent mod-
els of mammary hypoplasia and include embryologic insults
and exposure to estrogenic and other chemical environmental
influences.20, 25, 26
Hormones may also play a role. In women with some
infertility conditions such as luteal phase defects, it is pos-
sible that the lack of progesterone stimulation limits mam-
mary gland development during lactogenesis I.2, 16 If a woman
presents with a history of luteal phase defect and difficultly
Volume 58, No. 4, July/August 2013

Figure 1. Mammary Hypoplasia Variations.
A) Incomplete development before puberty; B) Poorly developed
upper portion, scant lower tissue; C) Tubular with bulbous areola;
D) Long, bowed to outside, with extra-large areola; E) Classic wide
spaced and uneven; and F) Wide spaced with scant tissue.
c Taina Litwak 2009, from West D, Marasco L. The Breastfeeding Mother’s
Guide to Making More Milk. New York: McGraw-Hill; 2009. Reproduced with
permission.
breastfeeding, after ruling out secondary causes of failed lac-
togenesis II, the provider may more closely examine the
breasts for mammary hypoplasia as a primary cause of failed
lactogenesis II.
Huggins et al determined that it is possible to identify
women with hypoplastic breasts and determine the likelihood
of insufficient lactation.27 Physically, breasts of women with
insufficient glandular tissue may be widely spaced, tubular-
shaped, and/or asymmetric in shape.55 By assessing the physi-
cal characteristics and self-reported changes in the breast dur-
ing pregnancy and early postpartum—breast shape, stretch
marks, wide intramammary distance, and breast asymme-
try, as well as the volume of infant milk intake and breast-
pumping volumes immediately after feeding—the study re-
ports success in identifying women with hypoplastic breasts.
The authors had success in identifying women at risk for
failed lactogenesis II related to hypoplasia, but the study had
a small sample size and lacked a control group.27 Further re-
search is needed in this area. Nevertheless, this remains the
only published study with an attempt to identify women at
risk for mammary hypoplasia and contains important infor-
mation. There are several identified variations of mammary
hypoplasia depending on which aspect of the glandular tis-
sue failed to develop.20, 23, 27 Figure 1 displays some of these
variations.
CLINICAL IMPLICATIONS
Ideally, breast assessment should occur prenatally and in the
immediate postpartum period. During the prenatal period,
one can review the woman’s previous breastfeeding history to
determine if lactational insufficiency occurred and then ex-
plore possible etiologies. All women who state they did not
Journal of Midwifery & Women’s Health r www.jmwh.org
produce enough milk should be evaluated to see if the etiol-
ogy was a primary or secondary failure of lactogenesis II.27
Women can also be asked about breast changes during preg-
nancy. Minimal reported changes to the breasts during the
pregnancy can be noted in the chart as an indication for in-
spection and evaluation in the postpartum period.20, 21 While
performing a breast examination, note whether the woman’s
breasts are symmetric and whether the intramammary space,
the space between the breasts, is greater than or equal to 1.5
inches, or the size of a quarter.20, 27 Slight asymmetry is usu-
ally normal, but marked asymmetry may indicate inadequate
glandular tissue.28 Assessment during the immediate postpar-
tum period usually includes inspection for postpartum en-
gorgement or lack thereof. In addition to the anatomic vari-
ations described above, women with mammary hypoplasia
may experience minimal engorgement even on day 3 or 4
postpartum.21 The midwife is also in a key position to ad-
dress the emotional component women with lactational insuf-
ficiency can experience, associated with a desire to breastfeed
even in the face of difficulty.
Once an insufficient milk supply is identified and a pre-
sumed diagnosis of mammary hypoplasia is made, therapies
that may help to increase milk supply can be initiated. Med-
ications and herbal preparations that are used to increase
breast milk supply are called galactagogues20, 29 (see Table 1).
Many of the medications such as metoclopramide (Reglan)
and domperidone (Motillium) work via antagonism at the
site of the dopamine receptor, which results in an increase in
prolactin release.29, 30 Domperidone is not readily available in
the United States but is available through some compound-
ing pharmacies.33 However, domperidone, as compared with
metoclopramide, is less able to cross the blood-brain bar-
rier and is less freely expressed in breast milk.29 In addi-
tion, although not approved by the Food and Drug Admin-
istration, domperidone is the only galactagogue that has been
evaluated scientifically in a randomized, double-blinded, con-
trolled study.31
Although unregulated and lacking rigorous scientific
research, some herbal preparations have anecdotally been
shown to be effective in increasing milk supply in women
with mammary hypoplasia.20, 29 Fenugreek is a spice used in
India and Middle Eastern countries and is believed to have
a galactagogue effect by stimulating sweat gland production.
The mammary glands are altered sweat glands, and thus their
milk production is increased.20, 29, 32 Increased milk produc-
tion is often seen with fenugreek use within 24 to 72 hours
after initiation of therapy.29 Dosage and frequency of use are
not standardized because the content of each capsule is not
regulated. Clinical supervision should be employed when rec-
ommending the use of fenugreek or any galactagogue. An-
other relatively unknown herb, goat’s rue has a reputation as a
galactagogue and as a mammary gland growth stimulant.20, 30
Blessed thistle is an herb that is commonly paired with fenu-
greek for galactagogue effect by increasing mammary blood
flow.20, 32 The clinician should work with the mother to de-
termine individually which therapy works best for increasing
milk production. The lack of evidence for the use of herbal
preparations such as galactagogues is significant and calls for
future research.
459
 Table 1. Common Galactagogue Dosages and Side Effects for Women with Mammary Hypoplasia
Galactagogue Mechanism of Action
Domperidone Dopamine antagonist.
(Motilium) Stimulates prolactin levels. As
prolactin levels increase, milk
production is simulated.
Metoclopramide Stimulates release of prolactin.
(Reglan)
Fenugreek Thought to promote milk flow by
stimulating sweat gland production.
The breast is a modified sweat
gland.29
Goat’s rue Same family as fenugreek. Contains
galegin, a precursor of compounds
found in metformin. Reported to
20
increase breast tissue.
Blessed thistle Mechanism of action for milk
production: unknown. Frequently
given with fenugreek. Antibacterial
and anti-inflammatory due to nicin
component.20
Dosage
10-20 mg orally 3-4 times per day
Total: 30-80 mg per day20, 31
10-15 mg orally 3 times per day
Total: 30-45 mg per day33
2 dropperfuls of tincture (under
the tongue), 2-3 times per day or
2-4 500-mg capsules 3 times
daily with meals. Tinctures may
29, 32
work better than capsules.
Tincture: 1-2 mL 4 times per day
or 1 capsule once a day. If ⬎175
lbs, 2 capsules 3 times per day.
Tincture: 1-3 mL 2-4 times per day Virtually nontoxic. Very high doses may
or 1-3 250-300 mg capsules 3
times per day. Use with
fenugreek if possible.20
Adverse Effects
Not approved by the Food
and Drug Administration but remains
preferred galactagogue internationally.
Under very rare conditions may cause
minor arrhythmias. Other rare side
effects are dry mouth, skin rash,
headache, abdominal cramps, and
drowsiness.20
Crosses blood-brain barrier and may
cause drug-induced depression if taken
more than 3 weeks. Dystonia
(involuntary body movements) can be
problematic with long-term use.33
Hypoglycemia may be produced at high
doses as well as diarrhea, dyspnea
(exaggeration of asthmatic symptoms).
Maple-like odor to urine and sweat. It is
generally regarded as safe.20
Hypoglycemia. May have blood-thinning
properties.20
cause gastrointestinal symptoms.

CONCLUSION and nurse-midwifery programs at the University of Cincin-

Although the incidence of mammary hypoplasia is unknown,
assessment for breastfeeding potential is critical to the health
and well-being of the infant as well as the mother. Mammary
hypoplasia is one cause of primary failure of lactogenesis II
that needs to be considered when evaluating a women who
is at risk for or who is experiencing lactational insufficiency.
If a woman presents with any findings or history that sug-
gests she has mammary hypoplasia, education, support, and
encouragement can be given, along with an appropriate re-
ferral to a lactation consultant if indicated. Furthermore, the
pediatric provider should be involved to help the woman de-
termine which formula supplementation would be best for her
infant and by which method. While educating a woman about
the potential diagnosis, it is important to encourage her to at-
tempt breastfeeding, but to recognize that her anatomy may
not be designed to produce milk, through no fault of her own.
nati College of Nursing in Cincinnati, Ohio.
Julia Lange Kessler, CM, MS, RN, IBCLC, is a lactation consul-
tant, clinical instructor, and program coordinator of the Nurse
Midwifery Program at New York University, College of Nurs-
ing, in New York, New York.
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose.
ACKNOWLEDGMENTS
This publication was supported by grant number
D09HP22600 from the US Department of Health and Human
Service (Health Resources and Services Administration).
REFERENCES

1.Betzold CM, Hoover KL, Snyder CL. Delayed lactogenesis II: a com-
parison of four cases. J Midwifery Womens Health. 2004;49:132-137.
AUTHORS
2.Bodley V, Powers D. Patient with insufficient glandular tissue expe-
Megan W. Arbour, CNM, PhD, is a clinical assistant profes- riences milk supply increase attributed to progesterone treatment for
sor of nursing and coordinator of the women’s health NP luteal phase defect. J Hum Lact. 1999;15:339.

460 Volume 58, No. 4, July/August 2013

 3.Duran MS, Spatz DL. A mother with glandular hypoplasia and a late
preterm infant. J Hum Lact. 2011;27:394-397.
4.Thorley V. Breast hypoplasia and breastfeeding: a case history. Breast-
feed Rev. 2005;13:13-16.
5.Neifert MR, Seacat JM, Jobe WE. Lactation failure due to insuf-
ficient glandular development of the breast. Pediatrics. 1985;76:
823.
6.Cregan MD, Hartmann PE. Computerized breast measurement from
conception to weaning: clinical implications. J Hum Lact. 1999;15:89-
96.
7.Eidelman AI, Schanler RJ, Johnston M, et al. Breastfeeding and the use
of human milk. Pediatrics. 2012;129:e827-e841.
8.Committee on Health Care for Underserved Women, American Col-
lege of Obstetricians and Gynecologists. ACOG Committee Opinion
No. 361: Breastfeeding: maternal and infant aspects. Obstet Gynecol.
2007;109:479-480.
9.American College of Nurse-Midwives Breastfeeding Task Force. Po-
sition Statement: Breastfeeding. http://www.midwife.org. Accessed
March 28, 2012.
10.World Health Organization (WHO). Health Topics: Breastfeeding.
http://www.who.int/topics/breastfeeding/en/.
11.Kramer M, Kakuma R. Optimal duration of exclusive breastfeeding.
Cochrane Database Syst Rev. 2012, Issue 8. Art. No.: CD003517. DOI:
10.1002/14651858.CD003517.pub2.
12.Levy SM, Broffitt B, Marshall TA, Eichenberger-Gilmore JM,
Warren JJ. Associations between fluorosis of permanent incisors
and fluoride intake from infant formula, other dietary sources and
dentifrice during early childhood. J Am Dent Assoc. 2010;141:1190-
1201.
13.Kent JC, Prime DK, Garbin CP. Principles for maintaining or in-
creasing breast milk production. J Obstet, Gynecol Neonatal Nurs.
2011;114-121.
14.Lawrence RA. Breast-feeding. Pediatr Rev. 1989;11:163.
15.Jevitt C, Hernandez I, Groėr M. Lactation complicated by overweight
and obesity: supporting the mother and newborn. J Midwifery Wom-
ens Health. 2007;52:606-613.
16.Conneely OM, Mulac-Jericevic B, Arnett-Mansfield R. Progesterone
signaling in mammary gland development. Ernst Schering Found
Symp Proc. 2007;1:45-54.
17.Hurst NM. Recognizing and treating delayed or failed lactogenesis II.
J Midwifery Womens Health. 2007;52:588-594.
Journal of Midwifery & Women’s Health r www.jmwh.org
18.Neville MC, Morton J, Umemura S. Lactogenesis: the transition from
pregnancy to lactation. Pediatr Clin North Am. 2001;48:35-52.
19.Ramsay D, Kent J, Hartmann R, Hartmann P. Anatomy of the lac-
tating human breast redefined with ultrasound imaging. J Anat.
2005;206:525-534.
20.West D, Marasco L. The Breastfeeding Mother’s Guide to Making
More Milk. New York: McGraw-Hill; 2009.
21.Neifert MR, Seacat JM. Lactation insufficiency: a rational approach.
Birth. 1987;14:182-188.
22.Neifert MR. Prevention of breastfeeding tragedies. Pediatr Clin North
Am. 2001;48:273.
23.Chan WY, Mathur B, Slade-Sharman D, Ramakrishnan V. Develop-
mental breast asymmetry. Breast J. 2011;17:391-398.
24.Cassar-Uhl D. Supporting mothers with mammary hypoplasia.
Leaven. 2009;45:4-14.
25.Guillette EA, Conard C, Lares F, Aguilar MG, McLachlan J,
Guillette Jr LJ. Altered breast development in young girls from
an agricultural environment. Environ Health Perspect. 2006;114:
471.
26.Rudel RA, Fenton SE, Ackerman JM, Euling SY, Makris SL. Environ-
mental exposures and mammary gland development: state of the sci-
ence, public health implications, and research recommendations. En-
viron Health Perspect. 2011;119:1053.
27.Huggins K, Petok ES, Mireles O. Markers of lactation insufficiency.
Curr Issues Clin Lact. 2000:25-35.
28.Riordan J, Wambach K. Breastfeeding and Human Lactation. Sud-
bury, MA: Jones and Bartlett Learning; 2010.
29.Gabay MP. Galactogogues: medications that induce lactation. J Hum
Lact. 2002;18:274-279.
30.Zuppa AA, Sindico P, Orchi C, et al. Safety and efficacy of galacto-
gogues: substances that induce, maintain and increase breast milk pro-
duction. J Pharm Pharm Sci. 2010;13:162-174.
31.da Silva OP, Knoppert DC, Angelini MM, Forret PA. Effect of dom-
peridone on milk production in mothers of premature newborns: a
randomized, double-blind, placebo-controlled trial. Can Med Assoc
J. 2001;164:17-21.
32.Zapantis A, Steinberg JG, Schilit L. Use of herbals as galactagogues. J
Pharm Pract. 2012;25:222-231.
33.Hale TW. Breastfeeding mothers. In King T, Brucker M, eds. Pharma-
cology for Women’s Health. Sudbury, MA: Jones and Bartlett Learn-
ing; 2010:1150.
461