When Breastfeeding Fails: Is It Biology, or Is It the System?

A response to The Economist's recent coverage of low milk supply

The Economist recently published a piece exploring the growing science of true biological low milk supply - the role of lactocytes, mammary gland development, placental dysfunction, and metabolic disease in determining whether a woman can produce enough milk for her baby. It is worth reading. The research it describes is real, it is important, and it has been neglected for too long.

For too long, many mothers with genuine biological insufficiency have been told some version of: "Just latch more. Pump harder. Try harder." When a woman's mammary physiology is genuinely working against her, that advice is not just unhelpful, it is harmful. It delays appropriate management, adds to her distress, and can leave her infant inadequately fed while she is blamed for something outside her control.

So yes: the biology matters. The science matters. These women deserve to be believed.

But I want to add something that the article does not, because it matters just as much.

The system also fails women. Routinely.

In clinical practice, many cases of low milk supply are not primarily biological failures of the breast. They are failures of the postpartum system and by the time a mother presents weeks later, the two can be almost impossible to distinguish.

Consider what happens in the early days after birth. Delayed first feeds. Maternal-infant separation after surgical birth. Poor latch assessment before discharge. Conflicting advice from well-meaning but differently trained clinicians. Pain that is normalised rather than treated. Sleepy babies who are not transferring milk effectively and whose hunger cues are being missed. Early supplementation introduced without a plan to protect supply. Mothers discharged from hospital before lactation is even fully established.

Each of these, on its own, is manageable. Together, they create the conditions for supply to collapse not because the mammary gland was always insufficient, but because it was never given a fair opportunity to work.

By the time that mother appears in a consultation six weeks postpartum, distressed and exhausted and producing very little milk, it can be genuinely difficult to determine whether she has primary biological insufficiency or secondary supply collapse following inadequate early support. And sometimes (this is the part that troubles me most) the language of insufficient glandular tissue, or "not enough lactocytes," becomes attached to a breastfeeding journey that was never properly supported in the first place.

Many women exist somewhere in the middle

The reality that clinical practice reveals, day after day, is that most women experiencing low supply do not sit neatly in either category. A degree of biological vulnerability: subtle mammary hypoplasia, PCOS, thyroid dysfunction, a placental issue that resolved but left its mark, is often present alongside a postpartum system that did nothing to protect lactation and quite a lot to undermine it.

This is not a binary situation. And it cannot be managed with binary thinking.

That is why breastfeeding support cannot be ideological. It must be skilled, physiological, and genuinely individualised. Not reflexive reassurance ("your body can do this") when biology is genuinely the limiting factor. Not premature biological attribution when the real problem is a system that discharged a mother before her milk came in and sent her home with a tin of formula and no follow-up plan.

What good support looks like is careful, unhurried assessment: of milk transfer, of infant feeding behaviour, of maternal physiology and birth history and endocrine factors and breast anatomy, of supplementation strategy, and always, of maternal wellbeing. Because a mother who is exhausted, distressed, and unsupported is not in the physiological conditions that protect lactation.

What we owe women

The Economist piece will, I hope, prompt more investment in lactation science. That is genuinely needed. But I would not want it to prompt something else: a new narrative that quietly lets systems off the hook by locating the problem inside the breast.

Women deserve better than to be told their body failed them when what actually failed them was the care they received around it. And they deserve better than to be told to try harder when trying harder cannot fix what biology has determined.

What they deserve is assessment that is honest enough to tell the difference.

Dr Mythili Pandi is a Family Physician, IBCLC, and Director of Mother & Child Singapore, which has provided lactation and breastfeeding support to families since 1994.