What You Need to Know as a Breastfeeding Hashi’s Mama

When I first got diagnosed with Hashimoto’s, I was devastated. One particular reason was that I had learned that thyroid issues could lead to fertility issues, and I always wanted to have children.

Once I received the diagnosis, in addition to spending time and effort on figuring out how to resolve my symptoms and get Hashimoto’s into remission, I intensely studied fertility. I was super nervous that I would have trouble getting pregnant, but it seemed all I needed to do was say I wanted to get pregnant, and then it happened. 🙂

Funny enough, in July 2017, on my 35th birthday, I told my husband I was ready to start a family, and went to a naturopathic clinic a few weeks later to get my labs done to prepare for pregnancy, when I realized my period was late! The clinic ran a pregnancy test that revealed I was already pregnant, which was a very happy surprise!

Once I realized I was pregnant, I had additional worries and fears to overcome – the fear of childbirth, becoming a parent, and postpartum depression. I spent a lot of time preparing for all of those three while pregnant, however, I never prepared for breastfeeding! In fact, I skipped the breastfeeding class offered at my hospital to buy a second car with my hubby (we only had one car prior to starting a family).

I thought that as long as I had enough thyroid hormone on board, I would be fine. I never realized that I would have so much trouble with breastfeeding, and that a history of hormonal imbalances (especially during puberty) could contribute to breastfeeding issues.

I was also surprised to learn about the many challenges that can occur with breastfeeding, such as latching issues, milk production issues, mastitis, and many others (that we’ll cover in this article).

I ended up experiencing lactation failure, and my son required donated breast milk for the first few weeks while I bonded with a breast pump and learned everything I could about how to induce lactation.

The first few months were really tough, and I had to figure out a lot of challenges, but I nursed my son for almost four years (much longer than initially planned). I always intended to breastfeed, but not for that length of time… (haha). While the World Health Organization recommends breastfeeding until age two, I initially had set a goal of making it to six months – and honestly, the first six months were incredibly difficult.

Throughout my nursing relationship with my little one, I learned so much that I wanted to share with you, that I started to make a list of factors that can contribute to someone’s ability to breastfeed (which eventually turned into this article ;-)):

1. Primary lactation failure
2. Insufficient glandular tissue
3. Tanner Stage 4 Breast
4. Flat nipples
5. Bulbous areolas
6. Baby with anterior, posterior tongue tie and lip tie
7. Sleepy baby
8. Bottle preference
9. Bottle refusal
10. Mastitis
11. High lipase milk
12. Overactive let down/Oversupply
13. Poor weight gain
14. Food sensitivities
15. Mucousy stools
16. Feeding aversion
17. Frequent night nursing, reverse cycling
18. Low-fat breastmilk
19. Torticollis
20. Low muscle tone
21. Hormonal imbalances after weaning
22. Mom’s own health challenges

Over the years, I’ve gotten lots of questions from my Hashi’s mama community about breastfeeding. Women want to know whether their Hashimoto’s might be causing their difficulties with breastfeeding. They also want to know about the safety of different types of medications and supplements while lactating, including concerns relating to taking thyroid hormone medication itself.

So I decided to put some resources together focused on thyroid-safe breastfeeding, and that is the focus of this article.

Breastfeeding (if you are able) has been recognized for its numerous health benefits to the mom and baby, but many new moms may find they have challenges with the lactation experience – thyroid dysfunction can be just one of those challenges.

I personally realized the impact of Hashimoto’s several times after becoming a new mom, including issues with lactation failure from hormonal imbalances likely experienced during puberty, and then having a gut infection that resulted in elevated thyroid antibodies while I was four months postpartum.

I wrote more about nursing-friendly thyroid protocols in my Nursing Mother’s Formulary article, as many of the usual protocols used for Hashimoto’s are not compatible with breastfeeding.

To pull the information together, I consulted with many brilliant practitioners, mamas, and waded through a lot of research. I hope it helps all the mothers out there (with or without Hashimoto’s) who need a little extra support.

In this article, I’ll discuss:

• The benefits of breastfeeding
• Issues that can affect breastfeeding
• Thyroid-related considerations when pregnant and breastfeeding
• Possible causes of low milk supply
• Weaning/ending breastfeeding

Benefits of Breastfeeding

Given the significant and well-documented health benefits that breastfeeding can offer your little one, I encourage women — even those with thyroid conditions — to consider giving breastfeeding a try (starting as soon after delivery as possible) for at least six months if they are able.

Breastfeeding with mom’s milk optimizes the health benefits both for mom and baby, and offers significant bonding opportunities.

Benefits for the Baby

Human breast milk is nutrient-rich and contains a variety of anti-inflammatory, immune-protective, and antimicrobial properties that support your baby’s immune system and reduce the risk of lower respiratory tract infections, ear infections (otitis media), and gastroenteritis. Research suggests many other potential health benefits, such as a lower risk for sudden infant death syndrome and asthma, and a reduced risk for obesity and type 2 diabetes later in life (due in part to breastfed infants learning to self-regulate their food intake). ^[1]

Colostrum (the initial special milk from the breast secreted in the first two or three days after delivery) provides a variety of antibodies (IgA, IgM, and IgG) that protect a nursing baby against pathogens in the gastrointestinal tract and those from the environment. Colostrum contains a greater percentage of protein, minerals, and fat-soluble vitamins than the regular breast milk that will come in afterwards. ^[2]

Breast milk contains mom’s beneficial microbiota like Lactobacillus and Bifidobacterium, which means that, via breastfeeding, the baby’s gut is colonized with the right balance of “good” bacteria.

Benefits of Skin-to-Skin Feeding

Whether a baby is fed breast milk or formula (or a combination of both), body contact between baby and mom during feeding is important, as it stimulates oxytocin release in both mom and infant. Oxytocin is the bonding and love hormone also associated with calmness and stress reduction. Newborns who have skin-to-skin contact with their mom appear to have more stable physiological functioning than newborns who do not.

Skin-to-skin contact is the initial bonding opportunity for baby and mom, and the sooner it begins after birth, the better (when medically possible, of course). It is associated with better gastrointestinal adaptation, better infant sleep, less crying, and a reduced pain reaction (to routine hospital procedures). ^[3] The World Health Organization (WHO) recommends skin-to-skin contact for at least an hour (ideally longer), as soon as possible after delivery. ^[4]

Oxytocin is important to breastfeeding success, as it is responsible for the milk ejection reflex, which occurs when an infant sucks at the breast. This pushes milk through the ducts toward the nipple. Skin-to-skin contact immediately after birth has been shown to result in more effective nursing, increased milk production, and increased infant weight gain. ^[5]

Breastfeeding also appears to benefit mom’s physical and emotional health. It can lower the risk for a number of conditions, including diabetes, hypertension, cardiovascular diseases, osteoporosis, and breast and ovarian cancer. Breastfeeding has been shown to regulate cortisol (the body’s stress hormone), reducing stress and postpartum depression. ^[6]

Breastfeeding may protect mom’s thyroid health. One study found that women who breastfed for longer durations had higher levels of serum free T3 later in life, and even those who breastfed for just six months showed higher free T3 levels. Researchers have suggested that lactation helps to reverse the metabolic changes that occur during pregnancy by mobilizing the fat stores and resetting maternal metabolism (reducing a woman’s risk for metabolic diseases, including thyroid dysfunction). ^[7] These same metabolic changes help a new mom lose her pregnancy weight! In healthy lactation, this amounts to a weight loss of about one pound per week. ^[8]

Risks, Issues, and Challenges with Breastfeeding

Breastfeeding can come with many challenges – I know this firsthand! Sometimes, despite our best efforts, it just isn’t possible or advisable to breastfeed, and that’s completely okay. I’ll be sharing some helpful ideas, and a skilled lactation consultant can also be an incredible resource.

Alternative feeding options include expressed breast milk, donor milk, or high-quality infant formulas.

Please keep in mind that the benefits of breastfeeding aren’t all-or-nothing. Even small amounts of breast milk are incredibly valuable for your baby, even if supplementation is needed.

If you are struggling with lactation and/or breastfeeding, and feel pressure to do so, please take a look at the stats below, and you’ll find that many women who want to breastfeed end up not doing so. (This is NOT a failure on your part!)

The World Health Organization and American Academy of Pediatrics both recommend that infants are breastfed during the first six months of life; however, many do not, can not, or should not breastfeed (exclusively or at all) for various reasons, and maternal psychological stress (stress, anxiety, depression) is often a factor.

According to a 2022 review article on maternal psychological distress and lactation and breastfeeding outcomes (data is based on the US population in 2017): ^[9]

• 85 percent of new moms start their newborn on the breast
• 60 percent of moms don’t meet their breastfeeding “goals”
• 75 percent do not meet the guidelines for exclusive breastfeeding (in other words, they can’t and/or should not)
• Less than half are exclusively breastfeeding by the time infants are three months old
• Only 25 percent are breastfeeding exclusively by six months
• Almost 20 percent provide formula before babies are two days old

The story behind these stats is eye-opening: many women may have the best intentions of breastfeeding and try to do so, but even if they do start out breastfeeding, they may not continue.

That said, while breastfeeding has many health benefits for the baby and the mom, the truth is, there are many moms and children who are incredibly healthy AND formula fed (and perhaps even healthier than they would have been if they were breast-fed).

My Story and The Problem with “Breast is Best”

Even though it’s technically possible for most people to produce milk given enough time, effort, and intervention, I really feel that it’s important to know that there are many reasons why breast isn’t always best, especially in the early days after a baby is born.

Even in full-term, healthy pregnancies, maternal health conditions including hypothyroidism, hormonal imbalances and PCOS (especially if they occurred during puberty), and many others can prevent or delay the production of breast milk.

It’s extremely important for moms to know the risks, signs, and symptoms that may mean that breastfeeding is not possible, not advised (even temporarily), or not going to be effective.

I love how there are various awareness campaigns about breastfeeding and that most women can/should breastfeed. However, I will say that this is not 100 percent correct, as some of us may not be able to breastfeed, or may not want to breastfeed.

Thus, I believe that breast is not always “best” – fed is best.

While most women have frustrating stories of hospitals “interfering” with setting up a milk supply by giving babies a bottle of formula, my story was actually the opposite. I was at a “Baby-friendly” Hospital that was very supportive of breastfeeding, which I thought would be a good thing, but instead it was a traumatic experience that required me to fight for my son’s health, even in the early days.

I was unable to produce milk after my son’s birth, and I actually had to advocate for him to get donor breast milk in the hospital, as he was losing weight too quickly.

The hospital nurses and lactation consultants wanted to “wait” until my milk supply came in, and did not recognize that I had primary lactation failure. I felt pressured to continue attempting to breastfeed, and was told that my milk would come in at any time, despite my instincts that something was off. I asked for donor breast milk for my son, and they said that “he hadn’t lost enough weight” and that I would need a “prescription” in order to get him breast milk. I pulled out my cell phone and asked where they wanted the prescription to be called in, and they said, “Oh, it has to be from one of our doctors,” and so I insisted on getting a doctor to see my son ASAP.

At discharge, they cautioned me against using bottles for my son, and encouraged me to use a supplemental nursing system (SNS) device, which is a device that allows you to supplement with expressed breast milk, donor milk, or formula while your baby remains latched at the breast.

The system includes a small container that holds the supplemental milk, connected to a soft, thin tube that’s positioned alongside your nipple. As your baby nurses, they receive both the supplemental milk and the stimulation needed to support your own milk production. However, these are notoriously difficult to use (especially for a sleep-deprived, stressed-out, first-time mom).

The first night at home trying to attach the contraption to my breasts was hell; then I came to my senses and said, “I don’t care, he’s getting a bottle! I need to feed this baby!” And so we switched to bottles.

I also want to say that whether your baby gets a bottle at the hospital or bottles for the first month of life, that does not mean you won’t be able to breastfeed.

My son was exclusively bottle-fed for over a month, and then we switched to breastfeeding exclusively, and he nursed for almost four years!

I feel that sometimes we come across life-changing information at the right time, and I have to tell you, I read Jillian and Landon Johnson’s tragic story a few weeks before my son was born, and while I don’t know Jillian, I think she may have saved my son’s life because she was brave enough to share her and her son’s story in an article titled, “If I had just given him one bottle, he would still be alive.”

Jillian and Landon Johnson’s Story

Jillian Johnson had her baby, Landon, in what she calls a “baby-friendly” (breastfeeding-focused) hospital. She breastfed regularly right away. There appeared to be no problems on her side with breastfeeding or milk production, except that at one point, a lactation consultant mentioned that mom may have a milk production problem. That was not investigated.

Jillian was being monitored by multiple professionals, and had several risk factors for delayed milk production, which had been identified by a lactation consultant, yet she was still encouraged to breastfeed exclusively. These risks included: PCOS, issues with infertility, small, widely-spaced breasts with minimal growth during pregnancy, being a first-time mom, and an emergency C-section.

Twenty-seven hours after he was born, Landon had lost 4.76 percent of his weight, yet was continuing to nurse for even longer periods of time. By the second day, he was nursing continuously, yet continued to lose weight. Mother and baby were discharged in 2.5 days, even though he had clearly lost weight despite the constant breastfeeding. After less than 12 hours, he went into cardiac arrest and eventually passed away.

The cause was cardiac arrest caused by dehydration, because while the beautiful baby had a “great latch” and was constantly at the breast, he was not getting sufficient milk due to delayed lactogenesis II, where the full milk supply (colostrum) was not produced in time to meet the nutritional needs of the newborn.

This is not the only example of a hospital missing important signs and risk factors (constant crying from the newborn, mom’s risk factors like PCOS and C-section birth) related to delayed milk supply. As the Fed is Best Foundation reports, after they shared this story, they received “tens of thousands of infant starvation stories,” which led to serious health complications. ^[10]

This situation illustrates the importance of following a baby’s symptoms and signs (and your mama instincts) even if it appears that breastfeeding IS working. You should look for signs of dehydration and starvation, trust your instincts, and ask for other opinions if you suspect something is wrong.

Making sure your baby is FED properly, whether by bottle or breast, is the most important thing.

(Adapted from fedisbest.org)

Most People Have the Ability to Breastfeed (Even Men)

Did you know that you do not need ovaries or a uterus to breastfed?

When I was stuck to a breast pump, I spent a lot of time researching the various ways of stimulating breast milk production. I was shocked to read stories about cultures where everyone breastfeeds, including women who never had babies, adoptive moms who induce breastfeeding, grandmothers who re-lactate, and even that men can breastfeed!

I previously thought that only women could breastfeed, but it turns out that anyone with a healthy pituitary gland can induce lactation, including adoptive moms, trans women, men, and non-binary parents!

Both men and women have nipples and can produce the hormone prolactin in their pituitary glands, which helps stimulate milk production. They also produce oxytocin, a hormone that helps release milk from the breasts.

I excitedly shared this information with my husband and my mom, but neither was interested in breastfeeding. 😉 So I decided to figure out a way I could do so too, even if it didn’t happen for me spontaneously/naturally.

I happened to read this article about how trans women breastfeed with a full milk supply, and figured that if trans women could figure it out, surely a nerdy pharmacist with a passion for root cause solutions could, too! I learned a great deal of information on what is possible, though I want to make sure you are working with a knowledgeable lactation consultant to guide you.

In some cases, there are genuine conditions or situations that may mean that a woman is unable to breastfeed, or it may be recommended that breastfeeding is avoided either temporarily or altogether. A practitioner will help assess individual patients to determine if or when breastfeeding is advised. ^[11]

These situations may include:

• Breastfeeding should be avoided in the case of medications including antineoplastics, cancer chemotherapy agents, certain anticonvulsants, ergot alkaloids (often used to treat severe headaches), some sleep medicines, and radiopharmaceuticals
• Women who are actively using/abusing illicit drugs or alcohol, or have a history of this, may be advised not to breastfeed (“drugs of abuse”)
• Women who are undergoing radiation therapy should avoid breastfeeding
• Infection with HIV and not on antiretroviral therapy – advised not to breastfeed (in more economically advanced countries at least). If you have questions on this topic, consult with a Perinatal HIV/AIDS expert
• Infection with human T-cell lymphotropic virus type I or type II
• Untreated, active tuberculosis or chicken pox – not advised (temporary)
• Ebola (do not breastfeed)
• Brucellosis, HSV, and Mpox are examples of diseases where breastfeeding would be temporarily suspended
• Some other chronic illnesses may warrant an avoidance of breastfeeding or may need to take special steps to ensure that breastfeeding is effective and normal (e.g. having diabetes, being underweight, or having thyroid conditions)
• Past breast surgery may lead to a difficulty or inability to breastfeed
• Taking medications such as amiodarone, cyclosporine, and lithium (monitor this closely with your doctor)
• Galactosemia (a rare condition in infants where they can’t digest galactose)

Note that the above is a general overview and not a complete list. It may also vary per case. I discuss some common breastfeeding issues that can affect moms with Hashimoto’s later in the article.

Many moms with thyroid disease should be able to breastfeed, but might need a little more help! I will go over common reasons for trouble with breastfeeding as well as what to do about them. I will also share some ideas for what to do if you’re not able or choose not to breastfeed, or need extra supplementation.

Considerations if You Are Unable To or Choose Not to Breastfeed

While some say that breast is best, I like to say that FED is best. What I mean is that if you’re unable to breastfeed your baby, the next best option would be to pump and feed your baby with a bottle or a supplemental nursing system (SNS) device.

If you are not able to produce enough of your own milk, I recommend donor breast milk. Breast milk donors are screened for diseases. The milk is usually provided in a frozen state, and then it is thawed and warmed in a bottle warmer, and can be fed via an SNS or bottle. If you have celiac disease or a strong dairy protein reaction, ideally the milk for your baby would be from a dairy-free and gluten-free donor; however, it likely won’t matter.

If your own milk and/or donor milk is not available, the next best thing is formula. Again, I want to stress that fed is best. Sometimes we can be perfectionists and not want to feed our baby formula, but this is not always realistic.

When possible, the supplemental milk/formula should be given via one or more alternative techniques, including use of a syringe, cup, spoon, or an SNS at the breast (skin-to-skin!), rather than using a bottle and artificial nipple. ^[12]

There are various types of formula options that are available. Cow milk and soy milk-based formulas are the most common. However, it’s worth noting that infants born with congenital hypothyroidism, fed soy formula, are found to be more likely to require increased levothyroxine, as soy can interfere with its absorption. ^[13]

Another study found that infants fed soy-based formula were more likely to develop autoimmune thyroid disease later in life. ^[14] Researchers examined the feeding histories of 59 children with autoimmune disease, 76 of their healthy siblings, and 54 unrelated healthy kids. They found that the children with thyroid disease were more likely to have been fed soy formula as babies (31 percent) compared to their siblings (12 percent).

Goat milk formulas are also available – many of my mom friends swear by Holle Organic Goat Milk Formula.

Some moms have made their own formula, though I would be a bit nervous doing that; instead, I’d recommend checking with a nutritionist and following nutritionist-developed recipes, such as this recipe from the Weston A. Price Foundation website. If you are interested in trying camel milk, here’s a camel milk infant formula recipe from Judy Converse.

You can also choose hypoallergenic formulas like Neocate that provide amino acids. These formulas have corn syrup solids and oils. Hydrolyzed formulas are also an option.

Thyroid-Related Considerations When Pregnant and Breastfeeding

The thyroid plays a predominant role in fertility, pregnancy health, postpartum health, and breastfeeding success!

I can’t stress enough how important this one factor is:

For your best chances at a healthy pregnancy and breastfeeding, thyroid levels need to be carefully managed from preconception through breastfeeding.

Breastfeeding is a state of enhanced thyroid hormone requirement. Women with treated thyroid conditions will likely need to adjust their medication dosage, perhaps multiple times.

Any woman can develop hypothyroidism during pregnancy, as well as postpartum thyroiditis. As such, you may need to manage thyroid hormones during your pregnancy and while breastfeeding.

The good news is that thyroid medication is generally safe to use throughout pregnancy and breastfeeding, but breastfeeding can be affected if the thyroid is over- or underactive.

That’s why testing and monitoring the thyroid is very important through all of these periods of time (whether a woman is already being treated for a thyroid condition or not).

Preconception

Prior to attempting to conceive, all women should get a complete thyroid panel. This includes screening for thyroid antibodies, as women with thyroid antibodies are at greater risk for postpartum thyroid complications. Knowing your thyroid levels is an important preventative measure prior to a pregnancy, and can also help discover undiagnosed or untreated thyroid issues, which can impact fertility and the chance of pregnancy. Read more about lab tests for pregnancy in this post.

Pregnancy and Thyroid Hormones

During pregnancy, the body’s immune system becomes suppressed as it adjusts to tolerate the fetus; this results in gestation-related thyroid disorders in some 10 to 15 percent of women; 3 to 5 percent will develop subclinical hypothyroidism (when TSH is mildly elevated but T3 and T4 are considered normal); others will develop overt hypothyroidism. ^[15]

Untreated maternal hypothyroidism is known to have the potential for serious adverse effects on the fetus, and the fetus depends on mom’s thyroid hormone (delivered through the placenta) during a critical period of development in early gestation. ^[16] Both conditions should be treated with thyroid hormones, particularly if a woman has tested with the presence of thyroid antibodies. ^[17]

Up to 18 percent of pregnant women have thyroid antibodies, which increases the risk of developing hypothyroidism postpartum. ^[18]

Symptoms such as depression, poor mood, anxiety, and brain fog are common in hypothyroidism and are frequently diagnosed during pregnancy and postpartum. ^[19] Keeping on top of your thyroid hormone levels can help support your mental health and stress response.

Due to pregnancy-related metabolic changes and hormone fluctuations, women with treated hypothyroidism should be tested approximately every four weeks, at least during the first half of pregnancy, as dose adjustments are often required. TSH levels tend to be lower when pregnant (which may confuse your true thyroid status if you are taking T4 medication already).

Women tend to need additional T4 hormones while pregnant, as pregnancy (and subsequent breastfeeding) increases the demand for thyroid hormones. While this increase varies, I have found many women need about 30 percent more.

Adjusting Thyroid Meds Postpartum

Hypothyroidism has been found to suppress milk production, but adequate treatment with levothyroxine during lactation may help to normalize it. Women experiencing low milk supply should have their thyroid function checked and start on levothyroxine when hypothyroidism is found. ^[20]

Researchers believe that changing levels of thyroid hormones postpartum impact mammary gland function by negatively interacting with the hormones needed for lactation (prolactin and oxytocin), resulting in low milk supply. ^[21]

Suppressed milk production is also likely due in part to the loss of iodine and thyroid hormones in the breast milk.

Research on how hyperthyroidism may affect milk production is more limited, but the condition may cause difficulty in triggering the letdown of milk, yet also cause an over-supply of milk once letdown occurs. ^[22]

New moms already undergoing thyroid treatment may need to adjust their dose in the postpartum period and while breastfeeding. If a woman develops subclinical hypothyroidism during pregnancy, she will likely require continued medication while breastfeeding. Breastfed infants depend exclusively on their mom’s breast milk for needed iodine (which is important to their neurodevelopment).

Research has found that women who had subclinical hypothyroidism during pregnancy, who do not continue with their thyroid medication after delivery, will often need to restart it during lactation for up to one year postpartum. ^[23]

About 50 percent of new moms with Hashimoto’s may require an increased thyroid hormone dose in the postpartum period. ^[24]

Postpartum Thyroiditis

In the general population, about five percent of pregnant women develop postpartum thyroiditis (PPT). ^[25] PPT is an autoimmune condition in which excessive levels of stored thyroid hormone are released (after the immune-suppressive period of pregnancy).

PPT most frequently presents as an initial hyperthyroidism state (for two to eight weeks), followed by hypothyroidism lasting anywhere from a few weeks to six months. Postpartum thyroiditis generally occurs between one and four months postpartum, and usually resolves itself (mom reverting to normal thyroid hormone levels).

Some 50 percent of women with PPT, however, may experience a period of hypothyroidism for a year or more, and there is a higher risk for them to develop permanent thyroid disease over time. ^[26]

Clinically, I have found that PPT tends to resolve itself in about 80 percent of cases, but develops into Hashimoto’s in 20 percent of cases.

Women who recover fully from PPT still have a 70 percent chance of developing PPT in each subsequent pregnancy. Some severe cases of PPT may require treatment with beta blockers. More severe cases are often seen in women with high levels of thyroid antibodies (TPOAb). Women who are positive for thyroid antibodies in their first trimester have a higher risk of developing PPT, ranging from 33 to 50 percent. ^[27]

Women with autoimmune disorders also have an increased risk of PPT. Selenium supplements taken during pregnancy can lower the risk of PPT, and some women may require thyroid hormones, even temporarily, while having PPT. ^[28]

See my Nursing Mother’s Formulary article for safe interventions for thyroid support for breastfeeding moms.

Thyroid Medication Safety During Pregnancy and Breastfeeding

Thyroid medications are known to be safe during pregnancy and are rated by the FDA as a category A drug for pregnancy, which means there is no evidence of harm to the fetus. Untreated hypothyroidism can lead to adverse pregnancy outcomes, so I am a big proponent of using thyroid hormones in pregnancy to support both mom and baby. ^[29]

Maintaining healthy thyroid hormone levels is important postpartum and while breastfeeding as well. The American Thyroid Association recommends that women with overt and subclinical hypothyroidism be treated with levothyroxine (T4) medication if they are planning to breastfeed. Most conventional guidelines are hesitant to recommend T3-containing thyroid meds to pregnant/postpartum women, but many experienced practitioners do advocate for using them, especially if a woman has already been using them prior to pregnancy/breastfeeding and they were shown to be effective.

Additional monitoring of T4 levels may be required, and in many cases, I see women stay on the same dose of T3 during pregnancy, but require additional adjustments of T4. The dose adjustments can be quite tricky to manage, so I recommend working with an experienced clinician.

A very small amount of mom’s thyroid hormone is present in breast milk, but the amount is so low that research has found it doesn’t have a meaningful impact on the infant’s thyroid hormone status.

While maternal hypothyroidism can lead to poor milk supply in postpartum, an overactive thyroid can lead to excessive milk supply. This sounds like a good thing in theory, but it can also be problematic!

While viewed as safe during lactation when used in low to moderate doses, note that if taking anti-thyroid drugs (for Graves’ disease or hyperthyroidism) such as methimazole or propylthiouracil, there are recommendations in place to take them in smaller doses and to have your baby’s thyroid levels checked if taking them while breastfeeding. While propylthiouracil is less likely to be secreted in breastmilk, methimazole is generally preferred for lactation due to liver toxicity concerns with propylthiouracil. Doses of methimazole ≤20–30 mg/day and doses ≤300 mg/day of propylthiouracil are considered compatible with breastfeeding, but if you require higher doses of anti-thyroid drugs, you will want to discuss having your baby’s thyroid levels tested with your practitioner. ^[30]

Some practitioners have found that using Low Dose Naltrexone (LDN) can stabilize Graves’ disease and reduce the need for anti-thyroid meds. LDN is generally considered safe while breastfeeding, but formal studies are limited.

Autoimmune Antibodies in Breast Milk

One fear women with autoimmune issues may have is whether autoimmune antibodies are transferred in breast milk. We know that, in general, disease-fighting antibodies passing through breast milk is a positive thing, and it offers baby protection from various illnesses; but is it possible that a baby could contract an autoimmune disease from mom’s breast milk if there are autoimmune antibodies present in the milk?

What does the research say?

IgG antibodies crossing the placenta during pregnancy is a normal and healthy process. This provides the fetus with passive immunity from the mother, and helps protect it from infections. IgG antibodies may include thyroid antibodies.

In breast milk, however, the dominant antibodies are secretory IgA, not IgG. While some IgG does make its way into breast milk, it’s present in much smaller quantities.

IgG antibodies, including thyroid peroxidase antibodies and thyroglobulin antibodies, can cross the placenta during pregnancy, which may temporarily affect the baby’s thyroid at birth, but this is usually mild and resolves on its own.

Newborn thyroid screenings are standard and can help identify cases where an infant may have transient hypothyroidism or hyperthyroidism. Early T4 treatment typically resolves the condition. ^[31]

These antibodies in milk are generally digested by the infant’s gut and do not enter the baby’s bloodstream in significant amounts — especially in full-term, healthy infants.

Other antibodies that have been studied include myasthenia gravis and lupus antibodies. They can affect the baby, but again, this is usually via the placenta (during pregnancy) rather than through breast milk.

Here’s a brief overview of these other antibodies:

• Maternal myasthenia gravis antibodies cross the placenta and about 10 to 20 percent of babies will develop neonatal MG, a temporary form of MG. Breastfeeding is still recommended and considered safe (with the exception of if mom is taking certain medications for MG, including Cyclophosphamide, which can be toxic in breast milk). ^[32]
• Neonatal lupus erythematosus (NLE) can pass through the placenta to the fetus and can result in harm to the fetus; however, research has concluded that breastfeeding does not appear to negatively affect the infant. ^[33]
• Thyroid antibodies (TRAb). In thyrotoxicosis (too much thyroid hormone caused by Graves’ disease, nodules, certain medications, thyroid medication, or thyroiditis), thyroid antibodies (TRAb) have been shown to pass through to the baby in utero through the placenta, resulting in transient neonatal thyroid disease. In one study, this was found to be worsened as a result of breastfeeding. These findings, however, are a bit controversial given that only small amounts of antibodies are thought to be present in breast milk in the first place. ^[34]
• Immune thrombocytopenia is a condition where antibodies pass through the placenta and can cause the condition in infants (neonatal thrombocytopenia). This results from low levels of platelets (cells that help the blood clot) and is seen by excessive bruising and bleeding. Breast milk has been shown to contain the specific antiplatelet antibodies in small amounts, and an infant’s platelet count has been found to normalize only after discontinuation of breastfeeding. ^[35]

The bottom line for most women with Hashimoto’s is that the antibodies are relatively low in breast milk, and breastfeeding benefits outweigh the risks. That said, in very rare instances, maternal antibodies in breast milk (particularly if the baby has increased gut permeability or other vulnerabilities) could theoretically have an effect, though this is extremely uncommon.

Generally, the recommendation by experts is that babies should be breastfed, as they benefit more from the immune protection of breastfeeding than they risk exposure to antibodies in the milk.

Effects of Antibodies on Placenta, TTC, and Fertility Outcomes

The presence of antibodies in autoimmune thyroiditis can impair fertility, and may increase the risk of miscarriage and adverse pregnancy outcomes. It seems that one reason behind this is that the zona pellucida (the membrane that surrounds the egg and plays a role in fertilization) may be a target for thyroid antibodies. ^[36]

See my full article on the thyroid and fertility to learn more about how antibodies impact the reproductive system.

Lactation Failure and Poor Milk Supply

Lactation refers to the process of secreting milk, and when working properly, it should start and continue as milk is removed from the breast regularly (lack of milk removal can be an issue for breastfeeding). How well this works (if at all) depends on a number of factors, including environmental issues, the mother’s physical and mental health, socio-economic issues, and even body image.

Lactogenesis I happens during pregnancy, where the mammary glands start to produce milk. Lactogenesis II starts after delivery. The change is marked by a change in the amount of milk produced as well as the changes in the milk itself (e.g. colostrum becomes regular breast milk).

Lactogenesis II typically starts 30 to 40 hours after (a full-term) birth. ^[37] Delayed lactogenesis II is a condition where the mom does not produce the right volume of milk as early as she should, within 72 hours of giving birth. ^[38]

The earliest type of milk that is important to the newborn is colostrum, a nutrient-rich form of milk which is typically produced for about two to five days after the baby is born. After this initial period, the body will produce a mix of colostrum and regular breast milk. ^[39]

Failed lactogenesis II refers to a delay or failure in the onset of full milk production after birth. When this transition doesn’t happen properly, the mother may not produce enough milk, which can put the baby at risk for inadequate nutrition. Failed lactogenesis II is where the mother has full lactation, but something has gotten in the way of making enough milk at the early stage; if the colostrum/full milk supply is not there, the baby can become malnourished.

Several years ago, research suggested that delayed onset of lactogenesis II happened in about 5 to 15 percent of cases, but newer research estimates that it may actually happen to 12 to 55 percent of mothers.

So it is actually quite common for women to have problems breastfeeding. One 2022 study even suggests that a third of women who deliver via C-section may experience delayed lactogenesis II. ^[40]

Other risk factors that can lead to delayed or failed lactation include:

• Diabetes
• Hypothyroidism
• Obesity
• Preterm birth
• Cesarean birth

Primary lactation failure usually has to do with an internal issue, rather than an external issue (e.g. latching). Causes/risk factors can include:

• Breast abnormalities
• Hormonal issues
• Insufficient mammary glandular tissue
• PCOS
• Maternal thyroid illness
• Sheehan syndrome (postpartum hypopituitarism)
• Some breast surgeries

Secondary lactation failure typically has to do with the infant or an environmental issue, rather than an internal milk supply issue in the mother. Some causes can include:

• Tongue-tie (infant)
• Palatial anomalies (infant)
• Heart defects (infant)
• Issues with breast emptying
• Some medications ^[41]

We will cover these in greater detail in the rest of the article.

My Story With Primary Lactation Failure

I had primary lactation failure, which means that I did not produce breast milk after my son’s birth. Fortunately, I had done some reading (I’d come across Jillian Johnson’s story) and had an amazing pediatrician to help me during that time.

While most women do start getting a full milk supply a few days after birth, my full milk supply didn’t come until approximately one month after, and it only came because of stimulating breast milk production via a breast pump and taking targeted lactation supplements under the guidance of a brilliant lactation consultant! I’m so grateful I found a wonderful natural solution to help with my milk production.

Low milk supply and even the perception of having low milk supply (whether it is true or not) is one of the most common reasons women discontinue breastfeeding in the first month. ^[42]

Low milk production is usually the result of other problems causing poor milk removal, which then leads to lower production.

These are some of the most common reasons for low milk supply:

Labor Experience

A long labor or stressful birth (use of forceps, emergency, loss of blood, use of IV fluids, nerve damage, use of epidural and pain medications, or any type of shock to the body) can delay milk coming in as well as impact a baby getting off to a good breastfeeding routine. Pain or health issues for either mom or baby can mean disruptive medications, separation, and delayed breastfeeding.

Cesarean Birth

Cesarean birth (without labor) may disrupt lactation hormones, and hospitals may limit skin-to-skin contact, which can reduce the lactation hormone, oxytocin (responsible for milk letdown).

Premature Birth

A premature birth may mean mom’s mammary glands won’t be fully developed with adequate glandular (milk-making) tissue.

One study found that 82 percent of preterm moms experienced delayed lactation activation; this has been associated with an increased risk of early discontinuation of breastfeeding. ^[43]

Retained Placenta

Retained placenta tissue can cause a delay in milk production. The placenta is supposed to be expelled out of the body after childbirth, dropping the levels of estrogen and progesterone, which then triggers a rise in prolactin (the hormone that produces breast milk). If any placenta tissue remains, prolactin levels will remain low, and the body won’t produce enough breast milk.

While a woman can’t change a lot of these factors, she can work with her doctor, the hospital, and a lactation specialist to ensure everything that CAN be done to ensure mom and baby are together as soon as possible after birth, with skin-to-skin contact (if possible).

Check out The Baby-Friendly Hospital Initiative (BFHI), which is focused on “Ten steps to successful breastfeeding,” including immediate and uninterrupted skin-to-skin contact and supporting mom in initiating breastfeeding as soon as possible after birth. ^[44]

Mom’s Psychological Stress

Increased maternal stress has been associated with decreased milk letdown, which results in reduced milk removal and production. ^[45]

Long labors and urgent C-sections are linked with postpartum stress (for both baby and mom) and delayed lactation. ^[46]

Breastfeeding itself can be stressful, and the stress associated with breast problems (such as pain, cracked nipples, and mastitis) increases the risk that women will give up breastfeeding sooner. Women under stress also report significantly more frequently that their milk quantity is insufficient. ^[47]

Researchers believe that oxytocin levels are responsible for many of these negative lactation outcomes and that maternal stress may interfere with oxytocin release. ^[48]

It’s not all about current stress, by the way! Maternal anxiety and depressive symptoms during pregnancy have been found to be predictive of depressive symptoms in the postpartum period, which are associated with shorter duration of exclusive (or any) breastfeeding. ^[49]

Lack of Sleep

Think of things that cause stress, and you’ll soon come up with a list that includes lack of quality sleep! Fatigue and stress may encourage mom to use a bottle and supplementation (so that she can get more sleep). This again means less breast milk being used by the baby, so prolactin (the hormone that maintains milk supply) synthesis is reduced, and less milk will be made.

In a randomized clinical trial of 133 new mothers and fathers, the parents of infants who were breastfed in the evening and night slept 40 to 45 minutes longer than parents who were using formula. The formula-using group also reported more sleep disturbances. ^[50]

Prolactin production is also positively associated with improved sleep and may promote REM sleep; thus, the prolactin produced during breastfeeding likely helps new mothers cope with stress and sleep better. ^[51]

We know that sleep deprivation can cause adrenal dysfunction, and when I was breastfeeding, I was nervous about taking adaptogenic herbs. But when my son got a little older, I started to use Tulsi tea, an adaptogen I find works well for reducing stress. It is thought to be a galactagogue (which means it supports milk production) as well.

Another great solution is aromatherapy – as mentioned earlier, lavender and clary sage can increase oxytocin. Aromatherapy can have positive effects on stress, depression, anxiety, fatigue, sleep quality, physical pain, post-cesarean-delivery nausea and pain, nipple fissure pain, and post-episiotomy pain and recovery. ^[52]

Epsom salt baths (a favorite of mine) are great to gain the benefits of sleep-supportive magnesium, or you can take an oral supplement of magnesium citrate, at a dose of ½ to 1 teaspoon in 8 ounces of water (a maximum of 400 mg) before bed.

Oxytocin nasal spray may also be beneficial for some women. Find more sleep solutions for Hashimoto’s in the linked article!

Placenta Pills: Helpful or Harmful for Breastfeeding?

Many women now request that the hospital retain their placentas for consumption postpartum, a practice referred to as placentophagy. Some women choose to have the placenta dehydrated and encapsulated.

While there isn’t conclusive research on its effects, common reasons people believe that placentas have plenty of benefits include:

• Helping to relieve postpartum depression
• Increasing energy
• Improving the recovery time frame
• Reducing postpartum bleeding
• Improving mood
• Improving milk production (quality and quantity)

Most studies have found no quantifiable positive effects while identifying potential harms (including the risk of contamination/toxicity during processing or via bacteria found in the placenta), although the risk of that is low. ^[53]

One reason behind the popularity of placentophagy is that placenta tissue contains beneficial hormones and nutrients such as: ^[54]

• Progesterone (a prolactin inhibitor)
• Estrogen
• Iron
• Oxytocin
• Human placental lactogen (related to metabolism and insulin), along with essential amino acids and trace elements such as iron

The placenta also contains adrenocorticotropic hormone (ACTH) – a hormone the pituitary gland releases that plays a major role in stress response – and corticotropin-releasing hormone (CRH), another hormone related to stress response. ^[55]

However, there is little in the way of supportive research on how or how much any of these substances are absorbed by the mother via placentophagy.

The thought behind why placenta pills may help, is that during birth there is an acute withdrawal of circulating hormones once the placenta is expelled, which is suggested to be the cause of various emotional imbalances (leading to depression, impacting milk production, etc.). Since there are small quantities of progesterone still detectable in the dehydrated placenta, that might “smooth” this sudden hormone disruption and have a positive effect.

Keep in mind that progesterone is a prolactin inhibitor, so too much (like seen with retained placenta) would inhibit milk production. I did get my placenta encapsulated, but my lactation consultant actually recommended not to take the capsules due to delayed milk supply.

In a survey of 189 women who had ingested their placenta, the majority reported numerous perceived benefits, including on milk production, and stated that they would do it again in future pregnancies. ^[56]

Ultimately, I think this is a personal choice to be discussed with one’s care team.

Poor Milk Removal

The key to milk production is early, frequent, and effective milk removal starting with colostrum, the first milk produced right after birth. If milk removal isn’t adequate, milk production will start to shut down.

Things that can interfere with this include:

• Delayed lactation start (due to separation from baby or a sleepy baby due to meds)
• Alcohol/caffeine (can delay letdown)
• Not feeding often enough (not feeding on demand, letting baby sleep, using a pacifier, or supplementing with formula)
• Not emptying breasts (either through feeding, pumping, or hand expressing)

Lactation consultants suggest that “using a bottle” (even if with breast milk) may have a negative effect on nursing levels for two reasons: first, bottle-feeding has not been found to increase oxytocin and prolactin release in the mother. ^[57] Second, an infant may develop a preference for the nipple of the bottle. That said, there are ways to increase our oxytocin and prolactin even while pumping and bottle-feeding, ensuring that a baby gets enough milk and that lactation is properly stimulated.

Boosting Oxytocin

Biologically, oxytocin is important for stimulating milk letdown, but it also has plenty of other physiological benefits for both mom and baby. ^[58] Oxytocin can promote healing and offer anti-inflammatory and pain-relieving benefits, as well as promote feelings of safety and calm, which is important for mom during this high-stress time.

Generally, parents (both moms and dads) with higher oxytocin levels tend to be more in tune with their infants. Research suggests that mothers with high levels of oxytocin are more likely to be nurturing and affectionate with their children, and there is a correlation between high levels of oxytocin in parents and high levels in infants. Babies exposed to oxytocin may even have improved developmental outcomes like socialization, appetite control, and even gross motor skills. ^[59] So anything that you can do to boost oxytocin will benefit the whole family! 🙂

There are many ways to boost oxytocin levels, including skin-to-skin contact (with your baby or partner), cuddling with a pet, getting a massage, making love, exercising, and even laughing with friends.

You can also try using oxytocin nasal spray that you can get prescribed and compounded by your compounding pharmacist, taking Epsom salt baths, or using essential oils like lavender and clary sage. ^[60]

Some moms report that looking at photos of their babies helps with producing more breast milk while using a breast pump.

Another common misunderstanding is not having access to the most effective breast pumps. An ineffective pump can be a problem, which is why I recommend using a hospital-grade pump. Hospital-grade pumps are generally used to induce milk supply, while commercial ones maintain milk supply. I was surprised when my lactation consultant told me that my wearable breast pumps that I got for pumping while hiking (I was living in Boulder, CO at the time) were not going to be super helpful for inducing the milk supply.

There are a number of things women can do to improve milk removal (some will be covered in the next sections). Increasing oxytocin with skin-to-skin contact facilitates letdown, and feeding a baby “on demand,” are a few suggestions. Massaging from the outside of the breast toward the nipple or breast compressions may make more milk available when expressing.

So let’s talk about a few things that impact milk removal and production, the first being a baby’s own abilities and physiology.

Baby’s Breastfeeding Abilities and Physiology

Improper latching may cause a number of issues that result in lower milk removal and production, as well as nipple pain. A good latch requires a baby to get a mouthful of breast tissue along with the nipple (not just the nipple) as well as having the interest, stamina, and physiology to suck.

If a baby is lethargic due to pain meds, birth trauma, or formula supplements, has respiratory problems, or has any of the physical conditions listed below, they may not be able to latch effectively, or may frequently slip off of or clamp down on the breast, causing pain.

Nipple pain is one of the most common reasons new moms introduce formula or cease breastfeeding. It also tends to occur most often in the first week after birth, which is typically before a good breast milk production pattern is established. ^[61]

A few of the more common physiological issues include the following:

• Anything that causes low muscle tone may impact a baby’s ability to suck and get a good seal on the breast tissue.
• Babies with special needs may have challenges to do with both physical and physiological issues — for instance, they may have trouble latching, coordinating, swallowing, or they may be reluctant to take the breast. They may need supplementation as they are not able to breastfeed exclusively.
• Babies with Down syndrome have a protruding tongue and poor muscle tone, which may make latching difficult. They may also be more likely to fall asleep. (La Leche League has some tips for breastfeeding a baby with Down syndrome.)
• Premature babies may also have difficulty sucking, latching, and coordinating breathing with swallowing. Other issues may include not taking enough milk from the breast at one time, not waking up to feed, or falling asleep easily at the breast. ^[62]
• A condition called tongue-tie limits tongue movement due to a tight lingual frenulum under the tongue, which may cause traumatized nipples and pain.
• Torticollis is a condition where the neck muscles contract, causing a baby’s head to twist to one side, which often causes one nipple to be sore.
• Cleft lip and/or palate, large adenoids with mouth-breathing, and retrognathia (jaw position) may impact the baby’s ability to suck and get a good seal on the breast tissue.

Hormone Imbalances and Other Co-Occurring Conditions

Many hormones play a role in breast tissue development (estrogen, progesterone), effective milk production (prolactin, thyroid hormone, cortisol, insulin, and possibly serotonin), and milk letdown (oxytocin). ^[63] Imbalances in any of these hormones can also affect milk production.

There is a high incidence of women with PCOS and hypothyroidism (22.5 percent) and TPO antibodies (27 percent). Many women with PCOS also have insulin resistance, which negatively impacts milk production. In the initial month of lactation, moms with PCOS are less likely to be exclusively breastfeeding. Additionally, due to low levels of progesterone and higher levels of estrogen and androgens (such as testosterone), there can be unusual breast development, including insufficient glandular tissue, which impacts milk production. ^[64]

Metabolic conditions such as obesity (high body mass index), insulin resistance, and diabetes or gestational diabetes are also risk factors. Pre-pregnancy obesity (if the mother has a BMI of over 30) is associated with up to 13 percent lower rate of breastfeeding initiation, and delays in the onset of milk production. ^[65]

Here are some hormone-related conditions that can cause problems with milk production:

• Pregnancy-induced high blood pressure, preeclampsia. ^[66] The issue here is more about the medication a woman may be taking for the condition, which is known to transfer to her infant in breast milk.
• Conditions that can cause pituitary insufficiency, such as Sheehan syndrome. Though rare in developed countries, this condition can happen after delivery if there is significant blood loss. The result is that the pituitary gland cannot produce the hormones needed for milk production. ^[67]
• Decreased prolactin. Anything that causes prolactin levels to drop can have an effect on milk production. Examples of possible prolactin inhibitors include some hormonal contraceptives, high doses of B6, pseudoephedrine (Sudafed), SSRIs, taking insulin, high body mass index, childhood cancer, a family history of alcoholism, and insufficient calcium. Though rare, there have also been cases of isolated prolactin deficiency. ^[68]
• Oxytocin inhibitors. If mom had synthetic oxytocin (Pitocin) used to induce labor, she may find it more difficult to produce naturally in postpartum.
• Low progesterone levels during pregnancy have been linked to reductions in milk production.
• Pregnancy while breastfeeding. ^[69] Many women report a major drop in milk supply once they become pregnant.

It is ideal to balance known hormonal issues as much as possible before conception, and monitor them closely during pregnancy and after birth; this includes losing weight if obese and addressing insulin resistance.

Note: All medications taken for mom’s health conditions should always be assessed by a healthcare practitioner for their safety profile during pregnancy and lactation. Two other resources I suggest for this are: Hale’s Medications and Mothers’ Milk 2023: A Manual of Lactational Pharmacology and the U.S. National Library of Medicine’s LactMedDrugs and Lactation Database.

In these situations, the right medications and supplements can help support these conditions and healthy milk production:

• Metformin (medication for diabetes, PCOS) may help increase milk production and is generally viewed as safe to take during and after pregnancy. ^[70] Metformin is recommended for pregnant women with gestational diabetes and should be continued for women with type 2 diabetes and PCOS if already being taken pre-pregnancy. Though it has been well-researched and may even offer certain benefits for mother and baby, there is still a question of potential long-term impacts. ^[71]Metformin gets into the breast milk in small amounts, but research shows no adverse effects on breastfed babies. It may even be useful as a galactagogue; however, there is no evidence to support this. Consult your doctor for more information on metformin and breastfeeding, especially if your baby is premature or has renal impairment. ^[72]

• Myo-inositol is a type of natural sugar alcohol that’s present in mammalian cells and plays a positive role in insulin sensitivity. Supplementation has been shown to reduce thyroid antibodies, reduce TSH levels, and even help those with Hashimoto’s get into remission. ^[73] It has also been found to be effective in increasing insulin sensitivity, which results in improvements in reproductive health, including enhanced fertility. ^[74] There is some evidence that supplementing with myo-inositol during pregnancy may reduce hypertensive disorders and gestational diabetes. ^[75]

• Moringa is another natural treatment that is considered a galactagogue and may have blood glucose-lowering effects (available via Fullscript; if you don’t have a Fullscript account, you can sign up with my credentials here). It stimulates prolactin and, in low doses, has been shown to increase milk production. ^[76]

• Domperidone (a prescription anti-nausea medication used for gastrointestinal disorders) has also been found to stimulate prolactin. ^[77]

If you have known hormone or metabolic issues, you might find that expressing milk before your baby is born may help you (and baby), given that your condition may have an impact on your milk production at the start.

You can freeze colostrum before delivery and bring it to the hospital to use if lactation delays occur. The DAME (Diabetes and Antenatal Milk Expressing) study found safe outcomes at 36 weeks of gestation (for women with diabetes and low risk for complications), but discuss with your doctor as expressing generates oxytocin, which could cause uterine contractions in some women. Pre-birth expressing has also been shown to improve postnatal lactation. ^[78]

Mom’s Breast Physiology

Along with hormone imbalances, a woman’s breast physiology can impact her milk supply. One example is a condition called insufficient glandular tissue (IGT). This affects both the appearance of a woman’s breasts and her ability to produce adequate levels of milk due to the amount of breast tissue, as well as milk duct and gland development (nothing to do with cup size!).^[79]

Another condition is Tanner Stage IV Breasts, which is when mammary development doesn’t progress to what is viewed as “normal” and may not be fully supportive of lactation.

Mom’s nipples can also cause her baby difficulties — very large breasts, inverted or flat nipples, and nipple piercings are a few examples. But know that most nipple issues can be improved upon with a little work (consult a good lactation specialist).

Insufficient Glandular Tissue (Hypoplasia, Hypoplastic, and Tuberous Breasts)

Insufficient glandular tissue (IGT) is often found related to hormonal imbalances and tends to be more common in Hashimoto’s, PCOS, and insulin-related conditions. It’s believed that insulin resistance affects the growth of the breasts and reduces milk synthesis and production. This can happen as receptor cells in the breast must be sensitive to insulin to work in conjunction with other lactation hormones, and if they lose that sensitivity, the production of breast milk can be affected.

Some researchers believe IGT may be caused by lower levels of progesterone or a mother’s exposure to toxins when she was herself in the womb. ^[80]

Moms with IGT will often note that their breasts did not change in size during pregnancy, and while attempting to breastfeed, they may have milk letdown challenges as well as not feel like their breasts are full. (This was me!)

IGT is not about the breasts being small (or large) but is about their shape, asymmetry, placement, and the degree of glandular tissue available to support effective nursing. Breasts are usually asymmetrical (one larger than the other), widely spaced, may have a bulbous areola, and may have a tubular shape.

Some breasts may actually appear to be normal but may consist mainly of fatty tissue instead of the glandular tissue required for lactation. Women with IGT may be able to produce milk, but typically only at low levels. Galactagogues may help in some cases. ^[81]

While supplementation may be required, please know that any amount of breastfeeding with breast milk is still liquid gold to a baby.

Supplemental nursing systems can be used to retain skin-to-skin contact and oxytocin release. SNS devices offer the same experience and benefits of breastfeeding if the mother is unable to produce enough milk. Essentially, they consist of a bottle filled with the milk/formula, and a tube that is attached to the breast, so that the milk exits in the same place as the nipple. Using an SNS can help ensure that milk production continues, the baby learns to breastfeed, and the baby is properly nourished. They are also useful to create the experience of breastfeeding for caregivers who are not able to breastfeed.

The most popular nursing system is the Medela brand, and they have a few product options, including this starter kit. You may also want to consider the Lact-Aid Nursing Trainer or Haakaa Supplemental Nursing System.

Like I mentioned earlier, they are a bit of a nightmare to use and can have a steep learning curve – especially when you’re attempting a 3 am feed after being in labor, not having slept for a week straight!

Tanner Stage IV Breasts

When women undergo puberty, their breasts change. Tanner Staging is a five-stage classification system used to track breast maturation. ^[82]

I personally had very mildly underdeveloped breasts and was unable to produce an adequate supply of breast milk for the first month, despite pumping and taking lactation supplements from a very knowledgeable lactation consultant.

Being myself, I did a lot of research and realized that I had Tanner Stage IV Breasts, which are often considered a “normal variation” of breasts, as up to 25 percent of adult women have them. ^[83]

My lactation consultant recommended the herb goat’s rue, which did the trick and had me producing a full milk supply within a day or two. Goat’s rue is an herbal supplement that may help improve insulin sensitivity as well as stimulate mammary tissue development. ^[84]

Going down the rabbit hole, I learned about how tuberous breasts may also be improved by advanced hormone hacking, such as using “ovarian glandulars,” which stimulate puberty to allow for proper breast development. This is not a method I personally tried, but I thought it was super interesting, and it made sense from a physiological perspective.

Bovine ovarian glandulars are glandular substances taken from cow ovaries. Ovarian glandulars work by stimulating the pituitary gland, which in turn stimulates prolactin as well as hormone secretions of the uterus, ovaries, and adrenal glands. This method has been used anecdotally by some women with PCOS as well as trans women to support their transition.

It is estimated that some five percent of women may not be able to lactate because of breast variations or medical illnesses. ^[85]

Estrogen contributes to breast development, with most girls reaching Tanner Stage III around the time menstruation begins. After that, both estrogen and progesterone continue to promote increases in breast size and volume.

Progesterone is primarily responsible for the growth of the areola, nipple, and underlying alveolar and lobular structures (ductal branching) needed for milk production.

The average age for reaching Tanner Stage V breast development is 15, but sometimes breasts may not develop into “adult” breasts and may remain “teenager-like,” as in the case of persistent Tanner Stage IV breasts. ^[86]

Women who get “stuck” in stage IV may not be able to produce adequate milk, especially with their first pregnancies, yet this breast variation is often missed, because it is a common variation, present in up to 25 percent of women. ^[87]

Here’s a sketch of the five stages as well as a photograph that shows a woman in early pregnancy with a Tanner IV Stage breast on her right breast, and a mature Tanner V Stage on her left breast.

Source: https://www.sciencedirect.com/science/article/pii/S174067572030013X

I personally had Stage IV Tanner Breasts. I never realized that my breasts were suspended in teenage development, as I guess I just thought I was petite and heard that every woman’s breasts were different.

I didn’t realize that my breasts were underdeveloped until I started researching why I couldn’t make enough breast milk, despite following the advice of a lactation consultant with the usual pumping and herbs.

I shared my thoughts about my breasts being underdeveloped, and started goat’s rue under the guidance of a lactation consultant. When I took goat’s rue to help with “maturing” my breasts, this allowed me to create a full supply of milk within three days of starting it, after having a partial supply for almost a month!

Prior to goat’s rue, I was pumping only 30ml per pump session, after many weeks of pumping six to eight times per day. After goat’s rue, I had full milk production, making 120ml to 150ml per session.

My breasts also grew more with goat’s rue. They’ve remained bigger after weaning, and I am the proud owner of adult breasts now. 🙂

PCOS is a condition that is often implicated in breast alterations; however, I feel that hypothyroidism, especially if onset was during childhood/teenage years, can also be a cause of abnormal breast development and lactation difficulties in adult women.

I was personally diagnosed with Hashimoto’s in my twenties, and my pediatrician mom actually suspected it in my teens, but of course, the pediatric endocrinologist we visited told her that my thyroid function was “normal.” As a side note, these are the conventional reference ranges for TSH for children:

• 1-3 days (newborns): 0 – 39.0 mIU/L
• 1 week – 1 month: 7 – 9.1 mIU/L
• 2-12 months: 8 – 6.0 mIU/L
• 1-5 years: 7 – 5.9 mIU/L
• 6-10 years: 6 – 4.8 mIU/L
• 11-18 years: 5 – 4.3 mIU/L

However, please note that, just like for adults, there is a narrower range that is considered optimal in functional medicine. My functional pediatrician friends suggest 0.5 to 2.5 mIU/L for most children and teens.

Animal studies have shown that administering prolactin and T4 increases milk production in hypothyroid mice and that during lactation, the mammary gland increases its production of the enzyme that converts T4 to T3, as well as increasing the number of thyroid hormone receptors. We know that during lactation, the mammary gland activates and uses more thyroid hormone. ^[88]

Along with hypothyroidism, there are other suspected causes for delays in puberty/development of breasts, such as low progesterone, insulin resistance, endocrine-disrupting chemicals, and an obesogenic diet. ^[89]

So, how does a woman deal with IGT and Stage IV Tanner breasts, especially if she’s planning on breastfeeding? Ideally, you want to focus on supporting breast development before pregnancy, as well as during and after. Examining your breasts and talking to your doctor is a good initial start.

The book Making More Milk is a great resource and provides some guidance in stimulating mammary tissue development. Getting insulin resistance and obesity under control is ideal. Progesterone is one method of support, and estrogen and progesterone have been used in trans women to support mammary development as well as lactation. ^[90]

Because insulin resistance can interfere with the hormonal balance needed for breast development and lactation (especially in conditions like PCOS), Metformin and myo-inositol are sometimes used to support metabolic and hormonal function, which may indirectly benefit mammary gland development.

In women with a history of low milk supply, insufficient glandular tissue (IGT), or conditions like PCOS and insulin resistance, some clinicians may cautiously use Metformin or myo-inositol during pregnancy to support hormonal balance and metabolic health. While not a standard treatment for lactation issues, improving insulin sensitivity in these cases may help optimize conditions for lactogenesis.

After pregnancy, there are a variety of methods that can help with building glandular tissue. There are also a number of “mammary hypoplasia herbs” that women can try, such as goat’s rue, shatavari, blessed thistle, and red clover (for more information, see next section). Keep in mind, however, that even with herbs, mom needs to continue effective milk removal, or milk production will be impacted.

In contrast to herbs targeted to hypoplasia, general lactation herbs such as fenugreek can only do so much if you lack the necessary glandular tissue.

It’s also important to note that some women who did not have success breastfeeding due to insufficient glandular tissue the first time around may spontaneously experience additional growth of breast tissue during subsequent pregnancies and breastfeeding, allowing them to have a milk supply.

Mammary Hypoplasia Herbs

Please use herbs under the guidance of a doctor or lactation consultant, as there can be side effects. I’ve included the LactMed (the National Library of Medicine’s Drugs and Lactation database) links below where available, which include a lot of detailed information, including research, safety profile, and precautions. Many of these have been used safely historically as a galactagogue (a compound that increases lactation), although this usually comes from anecdotal evidence rather than scientific research.

The book Making More Milk contains a chapter focused on galactagogues that may help with mammary development. The ­IGT and Low Milk Supply Facebook Support Group maintains a listing of galactagogues, including dosages, precautions, and additional resources.

Here’s a summary of some herbs you might want to consider:

• Goat’s Rue (Galega officinalis): I tried a variety of herbs as recommended by my lactation consultant, but this was the herb that finally worked for me, allowing me to produce a full milk supply within days of starting, likely due to having insufficient glandular tissue. It’s thought to be good for PCOS-related low milk production challenges! Interestingly, the medication metformin is actually a derivative of guanidine, which is one of the metabolically active compounds in goat’s rue known to lower blood sugar.^[91] Check out the Goat’s Rue LactMed page.
• Shatavari (Wild asparagus): Shatavari is an ayurvedic herb known as a tonic for female reproductive health. It may help support estrogen balance and prolactin response, and may help prepare the breasts for lactation by enhancing lobuloalveolar development. It has been shown to increase the weight of mammary glands in animal studies. ^[92] A recent study found it helped establish early lactation and improve breast milk production.^[93] Check out the Shatavari LactMed page.
• Blessed Thistle (Cnicus benedictus): This herb is often paired with fenugreek to support milk production. It is thought to increase prolactin, stimulating milk production and aiding in lactogenesis II. ^[94] This one may be better for milk supply rather than actual tissue growth. Check out the Blessed Thistle LactMed page.
  
• Red clover: Contains phytoestrogens that may mildly stimulate estrogen receptors, and is sometimes used to support ductal growth and hormonal balance.^[95]

Again, please use herbs under the guidance of a doctor or lactation consultant.

Lactogenic Foods

There are a number of “lactogenic foods” that have mainly historical and anecdotal support (versus research), but I’m including them here, should you be interested in investigating. Oatmeal is one, as are pumpkin seeds, sunflower seeds, almonds, sesame seeds, and coconut. Each of these is a “healthy” food (oatmeal has iron, almonds and sesame seeds are high in calcium, etc.), but it is unclear if the effect women report is anything more than simply eating healthy.

Recipes

Lactation Pancakes

I came across these in a lactation cookbook years ago and modified them (sadly I don’t remember the name of the book. If they look familiar, please email me the name of the book so I can give credit where credit is due!).

• 1 cup steel-cut oats
• Pinch of sea salt
• 4 tbsp coconut oil
• ¼ cup full-fat coconut milk or another dairy-free milk
• 1 tsp vanilla extract
• 1 tbsp olive or avocado oil
• ½ cup coconut yogurt
• ¾ cup Bob’s Red Mill gluten-free flour
• ½ tsp baking powder
• 1 cup fresh or frozen blueberries
• 1 banana, quartered then sliced
• 1 tbsp chia seeds, chopped walnuts, or hemp seeds (optional)
• Maple syrup, honey, or cooked fruit for serving (optional)

1. In a small pot, combine the steel-cut oats with 2 cups of water and the salt. Bring to a gentle boil over medium-high heat, then reduce heat to low, give it a gentle stir, and cook for 20 minutes or until tender. Remove from heat and add 2 tablespoons of coconut oil. Set aside.

2. In a large bowl, whisk the coconut milk, vanilla, and olive oil with the yogurt, and then add the eggs and whisk until incorporated. Stir in the flour and baking powder, and then add the blueberries, bananas, and chia seeds, if using.

3. Add the oat mixture to the batter and stir to combine. The consistency should be thicker rather than runny. If you need to add more flour, you can do that now.

4. Melt the remaining 2 tablespoons of coconut oil in a nonstick pan over medium heat. When the pan is nice and hot, scoop or spoon the batter into the pan, making either one large pancake per batch, or two or three small pancakes at a time if the pan will hold them.

5. Cook over medium heat for 3 to 4 minutes on each side, flipping to the second side when the batter bubbles on top. Transfer the pancakes to a plate and top with a little maple syrup, honey, or cooked fruit if desired.

Tigernut Lactation Milk

My dear friend Magdalena Wszelaki, women’s health expert and herbalist, made this delicious milk for me when I was starting to breastfeed, and I feel like it really helped! Tigernuts are traditionally used for lactation support in many African countries, and shatavari is also a traditional lactation herb!

• 1 cup dried tigernuts (or 2 cups fresh tigernuts)
• 4 cups filtered water (plus more for soaking)
• 3 to 4 pitted Medjool dates
• 1 teaspoon shatavari powder
• 1 teaspoon cardamom
• Pinch of sea salt

1. Soak dried tigernuts in water for 24 to 48 hours, changing the water halfway through. Skip soaking if using fresh tigernuts (just rinse well).

2. Soak dates if they’re dry or tough.

3. Drain tigernuts, and add them, dates, cardamom, and 4 cups fresh water to a blender. Blend on high for 1 to 2 minutes until smooth.

4. Strain through a nut milk bag, cheesecloth, or fine mesh strainer. Squeeze thoroughly to extract all the milk.

5. Store in a jar or bottle in the fridge for up to 3 to 4 days. Shake well before serving. Enjoy chilled or slightly warmed.

Lactation Bites

There are many recipes out there for Lactation Bites, which in addition to oats and healthy fats, usually contain brewer’s yeast, which is said to support lactation. Plus, they’re super handy when your hands are full with a breastfeeding infant. 😉

Breast Surgeries

Even if you’ve had breast surgery, you may be able to breastfeed – it will just depend on whether you’ve had damage to ducts or nerve pathways, or if you have compromised glandular tissue in the breast. Ducts and nerves can regenerate over time. ^[96]

The most impactful time period is surgery prior to puberty. Breast lifts don’t usually affect breastfeeding. Breast augmentation can affect breastfeeding depending on many things, including the positioning of the implant. Breast reduction and mastectomy are probably going to result in the most impact, as they remove mammary tissue and can damage nerves. The Making More Milk book has a more detailed explanation of the aspects of different types of surgery. Suffice it to say that most women will likely still be able to produce milk – it would just be a question of how much.

Any type of breast trauma (including radiation) can impact things, including past breast infections. I’ll talk about the very common breast infection of mastitis later on in this article.

Medications

A wide variety of medications may reduce milk supply. In addition, some appetite suppressants and a variety of medications may impact your milk supply or could adversely affect your baby. Check all medications with your doctor and/or lactation specialist.

Pain medications or other drugs associated with labor and delivery can linger and make a baby sleepy. Any estrogen-containing hormonal birth control should also be evaluated. ^[97] Even progesterone-only contraceptives should not be taken for a few months postpartum, as this will diminish milk supply. Drugs used in the treatment for hypertension (high blood pressure meds or diuretics) and insulin control may result in low milk supply.

Antihistamines, pseudoephedrine, and very high doses of vitamin B6 (450 to 600mg – I generally recommend no more than 50mg per day) may also affect milk production. ^[98]

Excessive alcohol use can slow milk letdown, and smoking can be a prolactin inhibitor. ^[99]

Nutrients and Milk Production

Breastfeeding is a high-energy activity and requires a lot of nutrients to make sufficient amounts of milk. Low levels of these nutrients can impact milk production:

• Low iron levels and iron anemia are common in Hashimoto’s, as well as during pregnancy and lactation. It may be a risk factor for early cessation of breastfeeding (possibly due to mom’s fatigue), as well as lower milk production. ^[100] Eat iron-rich foods and pair them with foods high in vitamin C for best absorption. Avoid dairy as it interferes with iron absorption. You should specifically test for ferritin levels before supplementing. Ferritin is our iron storage protein, and I find it to be a more accurate reflection of iron status. Ferritin level tests can be ordered by your doctor, or you can self-order one via Ulta Lab Tests. The optimal ferritin level for thyroid function is between 90 and 110 ng/mL, so that’s usually what I have my clients aim for. The lactation herb moringa is sometimes recommended to boost iron levels postpartum (available via Fullscript – you can sign up with my credentials here). See my full article on iron levels for more in-depth information.

• Low zinc levels are common during lactation (and a common nutrient deficiency in Hashimoto’s as well as the general population) and may impact milk production. Lactation zinc demands are high.^[101] Zinc deficiency is often found in exclusively breastfed infants when they are older (4 to 6 months), as the stores they get from their mom during pregnancy become exhausted. If mom had a zinc deficiency during pregnancy, the infant is more likely to have a zinc deficiency due to reduced stores. (Note that the infant’s zinc level while breastfeeding is not thought to be impacted by mom taking supplements.) ^[102] I generally don’t suggest zinc testing, since most people with Hashimoto’s will benefit from supplementation, and testing isn’t always accurate (read more about testing in my zinc article). For supplements, I prefer the zinc picolinate version, such as the one made by Pure Encapsulations, because of its improved absorption profile compared to other forms. I usually recommend doses of no more than 30 mg per day, unless you’re working with a practitioner who advises higher doses. In some cases, you may wish to use a topical compounded zinc supplement, or supplement the zinc directly to the baby (see section below).

• Low iodine levels can occur as lactation significantly increases iodine requirements necessary for proper thyroid function. Inadequate iodine can impact thyroid function, which could impact milk production (although I couldn’t find any specific research on this topic). But it’s also important to note that too much iodine can actually be a trigger for Hashimoto’s, so you want to stay in a moderate range. I generally caution against using a dose above 300 mcg/day unless breastfeeding or pregnant (the general recommended daily allowance of iodine is 150 mcg for non-pregnant persons; 220 mcg and 290 mcg for pregnant and breastfeeding women, respectively). This includes your intake from supplements as well as high iodine-containing foods like seaweed, spirulina, kelp, or chlorella. I usually suggest women take prenatal vitamins (most contain between 150 mcg and 220 mcg) throughout pregnancy and in postpartum. See my full article on iodine for more information.
  
  The use of excessive amounts of iodine in the mother during breastfeeding can increase breast milk iodine levels and cause transient hypothyroidism in breastfed infants. When given an appropriate dose of potassium iodide, mothers with Graves’ disease can usually supplement without negatively affecting their breastfed infants, though a small number of babies may develop mild hypothyroidism. ^[103]

• Folate plays a vital role in DNA synthesis, red blood cell production, and overall cellular growth, functions that are critically important during both pregnancy and lactation. During breastfeeding, a mother’s folate needs are elevated to support the continued development of her baby, particularly the rapidly dividing cells in the nervous and immune systems. When folate is deficient, it can lead to megaloblastic anemia in the mother, leaving her feeling fatigued, foggy, and irritable. ^[104] In infants, inadequate folate can also impair red blood cell formation and neurological development. ^[105] While folate is found in leafy greens, legumes, liver, and fortified foods, some mothers may need a supplement, especially those with MTHFR gene variants, who may benefit more from methylfolate rather than folic acid.

• Thiamine (Vitamin B1) and Riboflavin (Vitamin B2) are water-soluble B vitamins that play a central role in energy metabolism, milk production, and neurodevelopment. Thiamine is essential for converting food into usable energy and supporting nerve function, while riboflavin helps activate other B vitamins and supports skin, eye, and nervous system health. During breastfeeding, these nutrients are rapidly depleted, and deficiencies, though often overlooked, can lead to fatigue, weakness, irritability, and in severe cases, neurological delays in infants. ^[106] Thiamine deficiency has been reported even in well-nourished women, particularly in those with high-carbohydrate diets or underlying gut imbalances that impair absorption. Whole grains, meats, and dairy are key sources, but some mothers, especially those with a history of poor diet, alcohol use, or SIBO, may need targeted supplementation to restore optimal levels. As these are common deficiencies I see in women with Hashimoto’s, it may be wise to consider supplementing with them if they’re not already present in your prenatal vitamin. Thiamine in particular, may require a megadose approach for many women with Hashimoto’s.

Other Breastfeeding Issues

Here are a few other issues that can come up while breastfeeding, with some solutions:

Too Much Milk and Overactive Letdown (Engorgement)

Some women may produce too much milk for various reasons. These women may have an overactive letdown, which can cause an infant to pull off the breast, cry, start to choke, and refuse to continue nursing. Sometimes you’ll start to see frothy, explosive, green poop and a lot of gas from your little one, which means they are getting mainly the low-fat/high lactose (sugar) part of the milk (which comes out first).

Moms may experience hard, swollen, painful breasts, along with cracked nipples. All of these things may lead to early cessation of breastfeeding, plugged ducts, and infection (mastitis).

Engorgement may also occur more often when women are separated from their babies or are on a feeding schedule (versus feeding on demand).

There are a number of things that can help with this. Any galactagogues should be stopped. There are ways to best position your baby while nursing, as well as ways to reduce the flow of milk by expressing a bit prior to feeding or by applying gentle pressure. Breast massage (gua-sha therapy or Oketani breast massage) has been shown to reduce pain and engorgement. ^[107] A feeding pattern can be developed that may also help this issue. (I highly recommend reviewing this information on oversupply at La Leche League International for more strategies.)

Cabbage leaf treatment has been reported to reduce the pain and swelling of engorgement and to extend breastfeeding duration. Be careful, as it can also swing milk production the other way and lead to unwanted decreases. Research has also found that cold gel packs, massage, and herbal compresses can help. ^[108]

Sunflower lecithin can help emulsify breast milk so it doesn’t clog nipples and result in mastitis. (This is available via Fullscript. If you don’t have a Fullscript account, you can sign up with my credentials here.) ^[109] The emulsification also helps with mixing the fat and high-lactose milk, allowing for a slower flow of milk, preventing the high-intensity flow into the baby’s mouth, and allowing the baby to get more fat.

Sage, parsley, and peppermint have been shown to help decrease milk supply. ^[110] See this list of herb recommendations for decreasing milk supply.

Medications to reduce milk supply:

• Low-dose estrogen-containing oral contraceptives
• Low doses of pseudoephedrine (30 to 60mg)
• If mom is discontinuing nursing, a dopamine agonist (carbergoline) can be used. ^[111]

High-Lipase Milk

I suspect that high lipase milk is due to digestive enzyme/gallbladder issues. Some moms report that going gluten-free resolves the issue. I was already gluten-free, but the digestive enzyme from Klaire Labs/SFI Health helped me resolve this. (This product is available via Fullscript. If you don’t have a Fullscript account, you can sign up with my credentials here.)

Some moms work really hard to make a stash of pumped milk and freeze it, only to find out that the milk has gone on to taste sour, metallic, or soapy and that their baby refuses it. This is known as “high lipase” milk.

Conventional thought is that some moms have an excess of the digestive enzyme lipase in their milk. Many researchers believe it isn’t the amount of lipase, but the high activity level of the lipase. ^[112] Additionally, Ruth Lawrence, a leading lactation researcher, presented a research paper with just the opposite of this, that soured milk isn’t necessarily high in lipase, rather that it may be too low.

So what DO we know…and how can we treat it?

We know that the issue occurs with some women and affects breast milk after it is pumped and stored. Milk directly consumed from the breast is fine.

For moms with lipase issues, the milk that has been pumped and sitting out for a few hours or recently stored in the fridge is probably fine (moms can test for their “timing window” before their milk sours, see below). Milk that is frozen for more than a week will likely taste sour, metallic, or soapy. The milk is still perfectly fine and contains much of its original nutrients (it does have reduced vitamin levels and digestive enzymes, but still has more benefits than formula); it just potentially tastes bad, although some newborns may not mind. Others may reject it.

We know there are ways to reduce the souring from occurring by scalding the milk (before storing) within an individual woman’s window prior to their milk being affected.

We also know that lipase is normal in breast milk (and in baby’s tummy!) and has many beneficial functions, including making it easy for baby to digest the triglycerides in breast milk (breaking it into free fatty acids and glycerol) and making fat-soluble nutrients more readily absorbed and available to baby. It has been found to be a major protective factor in breast milk, inactivating protozoan pathogens and bacteria (including G. lamblia, E. histolytica, and Trichomonas vaginalis).

When breast milk is consumed from the breast, lipase breakdown occurs after the milk is already in a baby’s digestive system. But if a mom has lipase issues, any milk that isn’t immediately consumed (and is expressed and stored) starts fat breakdown, resulting in a change in taste. This process slows during freezing, but doesn’t completely stop.

The mechanisms behind high-lipase breast milk and the resulting sour or soapy taste in stored milk are still not fully understood. Some emerging theories suggest a potential link between digestive enzyme activity and immune responses, including gluten sensitivity, though this connection has not been clearly established. ^[113] There have also been some associations reported between high lipase levels in breast milk and jaundice, but more research is needed. Ultimately, the root cause of why some women produce high-lipase milk remains unclear.

In my opinion, milk souring may be related to a gallbladder issue and not enough lipase. In fact, a small study by Dr. Ruth Lawrence actually found this was the case. ^[114] In this case, I believe that digestive enzymes, especially those with lipase and ox bile (if recommended by your pediatrician/lactation consultant), would be able to help.

Regardless of the cause, we know a viable approach to prevent the milk from souring is to scorch it prior to freezing. You can test for your “timing window” (the time you can wait after pumping/storing before milk starts to sour).

Breast milk without this issue will usually last in the refrigerator for a week or so. But milk with lipase issues will go sour before that. To test, simply express some milk and set it aside; smell and taste it, too. Put it in the refrigerator. After that, every few hours, take a sip and a whiff. Take note of when it changes. It could be five hours, 24 hours, or days. If it tastes the same after six to eight days in the refrigerator, you likely don’t have this issue. Temperature affects this window, so if milk is left out at room temperature (let’s say you are pumping at work), the souring process will be sped up. Freezing slows it. You can test how long you can freeze your milk by thawing out a sample every day and seeing if it is okay. So you may find you can freeze your milk for a week, or three weeks, without it souring. Note that you never want to thaw and refreeze milk for your baby (just do that for this test).

Once you know your window, you can decide if you need to scald your milk prior to storing it. There are lots of ways to do this, including microwaving, using the stove, or using a bottle warmer. If using the stove and you don’t want to boil the milk, just slowly heat it, and once a small bubble starts to appear on the outside edge of the pan, it is done. Then quickly cool it by putting it into a sealed container and moving that to an ice water bath (use lots of ice!). If using a thermometer, you want to see about 180°F (82°C). Milk boils around 212°F (100°C). (For more info on scalding and storing milk, read La Leche League’s page on milk issues.)

If you have frozen milk that tastes sour, consider mixing it half and half with non-soured milk. If your baby still won’t take it, consider donating it. Donated milk is often given to tube-fed babies who won’t taste it anyway. Again, your breast milk is liquid gold, even for another fortunate baby!

Mastitis

Mastitis is common, occurring in anywhere from three to 20 percent of lactating women. It usually occurs in the early days of breastfeeding. It’s the result of a buildup of milk and restricted milk flow (milk duct blockage), which develops into inflammation, which may then develop into a bacterial infection (mastitis). It can lead to early cessation of breastfeeding due to the pain and/or baby’s refusal to take expressed milk. If left untreated, mastitis may develop into an abscess that can become life-threatening. ^[115]

Mastitis does seem to be linked with autoimmune diseases, including thyroiditis (autoimmune mastitis), and so new moms with Hashimoto’s should pay close attention to symptoms. ^[116]

One of the earliest signs of mastitis can be too much milk production, as this can cause duct blockage. The most important preventative step is frequent and effective milk removal.

Symptoms include:

• Breast tenderness
• Hard, swollen, and red breast area
• Warmth to the touch
• Fever
• Lumps in the breasts or armpit
• Flu-like symptoms
• Pain with nursing

As mentioned earlier, some women simply have overly abundant milk production. Other factors that can influence blocked ducts include baby’s ineffective latch or physiology, skipped or scheduled feedings, nipple soreness resulting in fewer feedings, pressure on the breast due to a bra, or maternal/infant medical conditions.

Treatment of Mastitis

Note: No matter what you do (antibiotics, probiotics, herbs, etc.), if you do not see improvement within 24 hours, you should seek medical assistance, as you could have a cyst that needs drainage and care.

• Continue milk removal! Continue to empty the affected breast by expressing. Feed the infant from the non-affected breast (there is no risk to the infant). Cessation of breastfeeding may lead to abscess development. Milk taste may change (become saltier). As far as pumping, I would take it very slow. If you’re pumping eight times per day for 15 minutes, pump less for one of the pumping sessions for a day or two, then decrease slowly. (I.e., go down to 10 minutes for one pumping session, and keep the other seven the same on the first day.)

• Natural therapies: Some of the natural therapies that may or may not work for a given woman include breast massage, cold laser over the breast, hot bath, sitting in a sauna, herbal formulas such as the Happy Ducts tincture, and sunflower lecithin (available via Fullscript. If you don’t have a Fullscript account you can sign up with my credentials here). I tried them all and still ended up taking antibiotics the first time I had mastitis. The second time, I was better prepared.

• Medications
  • Ibuprofen is considered safe for breastfeeding, is anti-inflammatory, reduces mom’s pain, and can help with milk letdown.
  • Antibiotics: They do work and are absolutely necessary in some cases, but they may change the taste of your milk and cause breast refusal and some dysbiosis in mom and baby. Be aware of this and be sure to take high-quality probiotics (see below). Given that mastitis is usually a Staph bacterial infection, there are certain antibiotics that work best against it, including: ^[117]
    • Cephalexin (contraindicated if you are allergic to penicillin)
    • Amoxicillin-clavulanate (combo required)
    • Dicloxacillin
    • Clindamycin
    • Trimethoprim-sulfamethoxazole (contraindicated for preemies, infants less than 1 month, jaundiced and ill babies)

• Solutions I recommend:
  • Poke root is an herb that can be taken to clear mastitis, and it usually works within 24 hours. You can order this on Amazon or get it at local herbal shops. It temporarily suppresses the production of breast milk. ^[118] If I were to ever get mastitis again, I would go straight for a protocol of poke root, probiotics, and sunflower lecithin.
  • Probiotics have been clinically found to prevent AND heal mastitis. ^[119] Hereditum LC40, also known as Lactobacillus fermentum CECT5716 (and more recently, Limosilactobacillus fermentum CECT5716) is a probiotic that has some clinical trials behind it for the prevention and treatment of mastitis. This probiotic strain is found in the breast milk of healthy women and has antibacterial, anti-infectious, and immune-enhancing activities. Results of two studies showed a significant improvement of mastitis. ^[120] I recommend taking a daily dose of the probiotic and doubling the dose in the case of an infection.
    
    Here are some probiotics that you may want to consider:
    • In the US: Target b2 Breast and Baby contains Lactobacillus fermentum. (This is available via Fullscript. If you don’t have a Fullscript account, you can sign up with my credentials here.) Each capsule has 30mg (3 billion CFU). Take 1 capsule, 1 to 3 times daily or as instructed by your physician.
    • In Australia: Consider Qiara Pregnancy & Breastfeedin, which contains Lactobacillus Fermentum. The recommended dose is one sachet per day (unless you are experiencing breast pain, mastitis symptoms, or are taking prescribed antibiotics, in which case it is recommended you take two sachets per day). Each sachet contains 3 billion CFU. You can get it shipped to the US, but it may take some time.
  • Sunflower lecithin can thin out your milk and prevent clogs. You can take it preventatively, available via Fullscript. (If you don’t have a Fullscript account, you can sign up with my credentials here.)
  • Other recommendations: Taking colloidal silver, takng garlic cloves (2 to 3 raw per day, chopped), nursing on your hands and knees (also known as dangle feeding), trying a football hold, trying Phytolacca homeopathic medicine, placing a heating pad on the boob (you can sleep with it), and taking systemic enzymes have been suggested as potential options for mastitis. I personally have not tried any of them other than the football hold, and am not sure of the safety of Wobenzym in breastfeeding, as the article I found was in German. If any of my German-speaking readers want to comment/help, please do so!

Note that antibiotic therapy can result in Candida growth on the nipple. This can cause stabbing or burning pain and may result in scaly nipples. ^[121]

Nursing Aversion

Breastfeeding aversion is not often discussed, but is a very real experience where a mom feels strong negative emotions such as irritability, anxiety, or even anger, while nursing.

It can feel confusing, especially if a mom wants to continue breastfeeding, but finds the act emotionally draining or even repulsive in the moment. This aversion may show up during extended breastfeeding, tandem nursing, or times of hormonal shifts (like ovulation, menstruation, or weaning).

While the exact cause isn’t always clear, common contributors include sleep deprivation, nutritional deficiencies, hormonal shifts, and sensory overload from constantly having to hold and feed a newborn.

If you’re experiencing this, you’re not alone. Here are some things that may help:

• Prioritize rest. Even small improvements in sleep can make a noticeable difference in mood and patience.
• Consider magnesium supplementation. Magnesium supports the nervous system and can reduce irritability, stress, and physical tension. Many moms find it helpful to take off the emotional edge that can come with aversion. Rootcology Magnesium Citrate is easy to mix into some water.
• Ask your provider about oxytocin nasal spray. Oxytocin is the hormone that supports bonding and milk letdown, and a nasal spray may help promote more positive feelings during nursing.

Please know that breastfeeding aversion doesn’t make you a bad mom. It’s a physiological and emotional response, and support can go a long way during this time.

Baby’s Feeding Aversion

While you may have heard of mom’s breastfeeding aversion, babies can have an aversion to feeding as well. The feeding aversion can be to the breast or bottle, and can lead to the baby rejecting feedings and having poor weight gain.

Here’s a list of feeding aversion symptoms to look out for:

• Skipping feedings without signs of distress
• Appears hungry but not eating
• Fusses when the bib is put on its neck
• Fusses or back arches when a bottle or breast is offered
• Turns away from breast, bottle, spoon, and/or food
• Takes only a small portion of milk or food offered, then cries or arches the back (arching the back is an indication of distancing)
• Feeds best when sleepy or asleep
• Consumes less milk than expected
• Refuses milk but eats solid food
• May have poor weight gain, slow growth, and a diagnosis of failure to thrive

Watching your baby refuse feedings can be extremely stressful and can send us down the rabbit hole of figuring out causes, such as acid reflux. Rowena Bennett, an RN and certified midwife with over 20 years of experience, has figured out that this condition can be reversed with a behavioral intervention and offers solutions for this condition. For more information on this, I highly recommend checking her book, Your Baby’s Bottle-feeding Aversion: Reasons And Solutions, as well as her website.

Poor Appetite in Babies

Zinc is critical for appetite regulation, immune function, growth, cognition, and overall development. ^[122]

In infants and young children, zinc deficiency can lead to poor appetite (hyporexia), growth delay, increased rates of diarrhea, and infections. ^[123]

A meta-analysis of supplementation trials in young children, including infants and toddlers, found improvements in weight gain and linear growth, particularly in those who were already undernourished or zinc-deficient. ^[124]

Low zinc levels in a baby may result in a poor appetite. ^[125] Zinc is a common maternal deficiency during lactation (for mom and baby), and preterm infants in particular may have zinc deficiencies. Zinc supplements taken by mom or baby, may improve appetite and growth in babies with zinc deficiency and poor appetite.

Studies show that zinc supplementation (typically 3 to 10 mg/day in infants, but please check with your pediatrician) can measurably improve growth and activity levels in zinc-deficient infants, including appetite stimulation and faster weight gain. ^[126] Pure Encapsulations zinc liquid drops are a convenient option to use with young children.

When Mom’s Nutrients Run Low, Baby Feels It Too

Breast milk is often described as the perfect food, but what many people don’t realize is that its nutrient content depends on the mother’s nutrient reserves. When a breastfeeding mom is low in certain key vitamins and minerals, the baby may not get enough, either.

Vitamin B12, vitamin D, and protein are some of the most important nutrients to watch.

Vitamin B12
B12 is essential for neurological development, and a deficiency in the breastfeeding mother can lead to low levels in her milk. Babies who don’t get enough B12 may experience: ^[127]

• Developmental delays
• Weak muscle tone
• Feeding difficulties
• Irritability and failure to thrive

This is especially important for vegetarian and vegan moms, since B12 is found primarily in animal products, but women with pernicious anemia, which is more common in Hashimoto’s and autoimmune gastritis, may be at risk for deficiency too. If you’re breastfeeding and plant-based, a B12 supplement is non-negotiable for both your health and your baby’s, and if you have Hashimoto’s, I highly recommend testing B12 levels (optimal should be around 800). See my full article on B12 deficiency for testing and supplement options.

Vitamin D
Vitamin D doesn’t transfer well through breast milk unless mom’s levels are robust. While pediatricians often recommend 400 IU of supplemental vitamin D for infants, another approach is to optimize maternal vitamin D levels (often requiring 4,000 to 6,400 IU daily, under supervision) so your milk naturally provides enough.

Low vitamin D in babies is linked to:

• Rickets (soft, weak bones)
• Increased risk of infections
• Autoimmune tendencies later in life

Protein Deficiency
Getting enough protein is essential for breastfeeding mothers because it directly supports both their own health and their baby’s growth and development.

Protein is a key building block for every cell in the body, and a mother’s dietary intake helps ensure that her breastmilk contains the amino acids her baby needs for brain development, immune support, and steady weight gain. It also plays a crucial role in maintaining the mother’s energy levels, supporting tissue repair, and preserving muscle mass during the physically demanding postpartum period.

Meeting protein needs helps sustain a healthy milk supply while giving the baby a strong foundation for thriving.

Women generally need to increase their caloric intake to support breastfeeding, and will likely need to increase their protein consumption as well. Some studies suggest that women who are exclusively breastfeeding may need as much as 1.7 to 1.9 grams per kilogram of body weight per day. ^[128] For example, a woman who weighs 160 pounds would aim to eat between 124 and 139 grams of protein per day while breastfeeding.

Increasing your intake of protein-rich foods can help you hit this target, and a high-quality protein powder can be a valuable tool for a quick protein source.

Can babies have food sensitivities?

Yes, babies can have food sensitivities to foods their mom has eaten while breastfeeding.

Symptoms can include colic, diarrhea, abdominal pain, vomiting, spitting up, bloody stools, respiratory issues (congestion, asthma, recurring ear infections, runny nose), and skin issues (hives, rashes, eczema). ^[129]

Proteins from the foods mom eats are passed to her baby through her breast milk and may cause a sensitivity reaction. The foods that most commonly cause reactions include cow’s milk, gluten, eggs, soy, peanuts, tree nuts, corn, and shellfish. Other foods that are known to upset an infant’s tummy are spicy foods, alcohol, caffeine, sugar, onions, nightshades, citrus, and brassica vegetables. ^[130]

In addition to these foods, I find that people often develop sensitivities to foods that are frequently eaten at the time their gut becomes compromised. For example, I became sensitive to coconut milk, which is usually considered hypoallergenic, after the birth of my son, when I developed an H. pylori infection. Food sensitivities can be an indication of an underlying infection due to leaky gut (so not only do you need to remove the triggering food, coconut milk in my example, but you may also need to treat any underlying infections).

You can test for food sensitivities by taking the Alletess food sensitivity test or trying an elimination diet. An elimination diet (see linked article with more details) removes the most common reactive foods from your diet and then has you add them back one at a time. If that doesn’t help you identify your problem foods, you can also opt for a blood test.

The Alletess test comes in 96 Food Panel and 184 Food Panel collection kits. I do this test annually to stay on top of any changes to my food sensitivities, as they can change over time. These tests should help you find the foods you and/or your baby might be sensitive to.

If your baby has bloody stools or skin issues, this can indicate a true allergy. You should consult with your pediatrician to determine next steps.

Some emerging research has identified a potential approach to food allergies when the mother uses pancreatic enzymes. ^[131] The thinking is that pancreatic enzymes will break down the protein allergens in the mother’s digestive tract before they are absorbed into her bloodstream and secreted into her breast milk. The recommendation is to start with the lowest dose of pancreatic enzyme.

Pancreatic enzymes such as Creon may be prescribed, and there are also OTC options such as Pancreatic Enzymes by Pure Encapsulations. I also found Klaire Labs Digestive Enzymes, which are broad-spectrum, to be helpful.

Colicky Baby and Probiotics

About 25 percent of infants experience colic or excessive crying, irritability, and fussiness without an obvious cause. Colic usually occurs a few weeks after birth and spontaneously resolves itself by about three to five months. ^[132]

Food sensitivities are thought to be one cause. But not every colicky baby has food sensitivities; sometimes it can be that a baby’s gut microbiome becomes out of balance. Infants with colic have been found to have different gut microbiota compared to infants without colic. Their gut microbiome is shown to have less microbial diversity (a sign of imbalance), more pathogenic organisms, and fewer beneficial ones. ^[133]

Moms pass on their microbiota during pregnancy and delivery, as well as during breastfeeding. Breast milk is loaded with probiotic and beneficial bacteria such as Lactobacillus and Bifidobacterium spp., so breastfeeding is a great way for mom to strengthen her baby’s immune system. But sometimes a baby needs more.

Probiotics provided directly to a baby (using infant drops) have been found useful in addressing colic. A 2021 review found as much as 50 percent less crying time in breastfed babies who were given specific probiotics such as Lactobacillus reuteri. ^[134] Hospitals will often give premature babies probiotics to support their immature immune systems.

One product I’ve heard good things about was Visbiome’s infant drops (which sadly is not available at the time of writing). This is a multi-strain probiotic, and their research has found a 70 percent reduction in crying. ^[135] I will definitely consider this if I have another baby. 🙂

Intestinal gas can also cause colicky babies, and there are a few additional steps beyond probiotics you can try for this issue. Several herbs have been found to be anti-colic:

• Caraway: Can be used topically as an anti-colic and carminative (gas reduction) treatment for infants and children. ^[136]
• Dill: This herb is an ingredient in a treatment called Gripe Water®, which has been used for colic and, at least anecdotally, has shown positive effects. Gripe water contains dill seed oil, ginger, sodium bicarbonate, and alcohol. The dill seed oil is supposed to be the carminative. ^[137]
• Fennel: Fennel seed oil emulsion has been found to decrease the intensity of infantile colic. ^[138]
• Simethicone has also been shown to help with colic. ^[139]

Weaning/Ending Breastfeeding

All good things must come to an end, but know that if you’ve breastfed your baby – or tried to – you have done the best for them and have initiated a strong, life-long bond.

When you do feel ready to give up breastfeeding, it can be difficult emotionally as well as cause physical discomfort. It can also be difficult for your child!

I read the book Nursies When the Sun Shines to help transition my young son off of his night feedings. Then I read additional weaning books, including My Milk Will Go, Our Love Will Grow, and gave him dairy-free milk in a sippy cup. A little extra snuggling that doesn’t involve a feeding can be very helpful and helps you maintain that breastfeeding bond a little longer.

You may feel moody due to the hormonal fluctuations that occur during weaning. As breastfeeding decreases, levels of prolactin and oxytocin begin to decline. This can disrupt the balance of estrogen and progesterone, especially in those already prone to hormonal imbalances.

I found that Vitex can help with weaning. It may help ease the hormonal changes by supporting the pituitary gland. This can support a better balance between estrogen and progesterone. Many women use Vitex to support mood, rebalance hormones, and help their period return to a more regular rhythm after weaning. ^[140]

I recommend reviewing the La Leche League website for helpful tips on night and daytime weaning.

Takeaway

There are plenty of things that can make breastfeeding difficult when you have Hashimoto’s — if you have had some challenges, please know that this is perfectly normal.

Now is the time to review this information and take whatever preventative steps you can, including:

• Optimizing thyroid hormones before, during, and after pregnancy
• Seeking support to help with sleep and stress levels after birth
• Ensuring you’re getting enough of the key nutrients for milk production
• Checking the physical makeup of your breasts
• Educating yourself on breastfeeding and how to mitigate possible challenges
• Finding a good doctor who shares your breastfeeding philosophy
• Finding a highly qualified lactation consultant

I encourage all of you who want to become moms to not give up hope if you have thyroid disease. When thyroid issues are monitored and treated properly, you can absolutely become pregnant, have a healthy delivery, and breastfeed.

If you are struggling with breastfeeding, please don’t feel like this somehow makes you a “bad” mother!

Please also remember that, when it comes to breastfeeding, “Fed is Best,” always! This means that whatever you can do to ensure your baby is healthy and growing is better than trying to get by with an inadequate supply of nourishment from your own breast milk.

I hope this information has been helpful to you. I’d love to hear your thoughts on your own breastfeeding experience, challenges, and successes.

I encourage you to share this with your mom friends!

P.S. If you need more information about supporting your thyroid in safe ways while breastfeeding, please check out my Nursing Mother’s Formulary article.

I love interacting with my readers on social media, and I encourage you to join my Facebook, Instagram, TikTok, and Pinterest community pages to stay on top of thyroid health updates and meet others who are following similar health journeys. For recipes, a FREE Thyroid Diet start guide, and notifications about upcoming events, be sure to sign up for my email list!

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