After a newborn is discharged from the hospital, the midwife and family physician become the primary points of contact for parents. Clinicians need clear guidance to establish and maintain breastfeeding, manage complications, and promote breastfeeding in primary care settings.

The World Health Organization (WHO) and the United Nations Children’s Fund recommend exclusive breastfeeding for the first 6 months of an infant’s life, followed by continued breastfeeding alongside appropriate complementary foods up to at least 2 years of age.

Global data show that while breastfeeding initiation rates are high, the rates of exclusive breastfeeding decline sharply after the first few months, particularly in high-income countries. In Spain, for example, exclusive breastfeeding or mixed feeding rates decreased from 75% at 6 weeks to 47% at 6 months.

Perceived insufficient milk supply or hypogalactia is a major reason for discontinuing breastfeeding.

Definition and Diagnosis

Hypogalactia is a medical condition characterized by insufficient breast milk production to meet an infant’s nutritional needs. It is also referred to as low milk supply or lactation insufficiency. Diagnosis is clinical, and regular assessment of infant weight gain is essential. Successful breastfeeding is best monitored through infant urine and stool output, weight gain, and the potential development of jaundice. As mothers cannot directly measure milk intake, clinicians rely on these indicators.

However, studies have indicated that approximately 35% of mothers perceive insufficient milk supply as the primary reason for discontinuing exclusive breastfeeding.

Hypogalactia, or insufficient breast milk production, is usually multifactorial and involves both infant and maternal factors.

Infant factors:

• Premature birth
• Anatomical issues such as ankyloglossia (short frenulum)
• Restricted feeding: current guidance recommends on-demand breastfeeding

Maternal factors:

• Endocrine or physiological conditions: placental retention, prolactin deficiency, acute anemia, PCOS, obesity, hypothyroidism, diabetes
• Mammary gland anomalies: congenital hypoplasia or postsurgical changes
• Poor breastfeeding technique
• Mother-infant separation
• Psychological factors: stress, postpartum depression, anxiety
• Medications affecting lactation, including certain antidepressants and estrogen-based contraceptives
• Exposure to endocrine disruptors
• Iatrogenic causes: emergency caesarean section, instrumental delivery, epidural analgesia

Infants may experience “lactation crises,” with feeding changes and maternal perception of low supply.

The breast functions as a factory rather than a warehouse according to infant needs. Monitoring weight, urine, and stool are the best indicators of adequate intake, and supplementation is rarely needed if growth remains normal.

Exclusive breastfeeding in Spain has increased, supported by hospital and community initiatives that promote the initiation and continuation of breastfeeding. Key practices include immediate skin-to-skin contact, rooming-in, and active support from healthcare professionals.

Targeted training for midwives and primary care providers, along with postpartum and breastfeeding support groups, has been shown to improve exclusive breastfeeding rates.

Despite these efforts, several challenges remain. Exclusive breastfeeding rates typically decline after the fourth month, often coinciding with mothers returning to work and perceiving low milk supply during lactation crises.

Ongoing support is essential to help mothers maintain exclusive breastfeeding and meet WHO recommendations.

This article is a joint editorial effort by the Spanish Society of General and Family Physicians and Univadis.

This story was translated from Univadis Spain.