Dr. Tenise Horge explains hormonal, metabolic and infant contributors to low milk supply in NLM Health Bites webinar

Dr. Tenise Horge, an international board-certified lactation consultant and founder of Mother's Magical Milk and More Milk, told viewers in the National Library of Medicine’s November Health Bites that low human milk supply is multifactorial and often misunderstood.

In her 30–40 minute presentation, Horge said clinicians and caregivers should look beyond the simple 'supply and demand' framing to hormonal, metabolic, structural and infant contributors. "Feed the baby. Then protect mom's supply and then get baby back to the breast," Horge said, laying out a stepwise clinical priority for families and providers.

Horge defined clinical low supply as a form of primary lactation failure and described a commonly used clinical guide: an average daily production near 25–35 ounces by two to six weeks postpartum as a working benchmark (she emphasized this is a guide, not an absolute requirement). She reviewed maternal drivers including stress-related cortisol changes, insulin resistance and metabolic syndrome, insufficient glandular tissue (IGT), prior breast surgery, and endocrine conditions such as polycystic ovary syndrome (PCOS).

On stress and hormones, Horge cited recent research and told attendees that postpartum psychosocial stressors can alter the relationship between cortisol and prolactin and may reduce oxytocin and prolactin, hormones central to milk ejection and synthesis. "When cortisol rises we can see decreases in oxytocin and prolactin," she said, linking stress, caregiver separation, and early formula introduction to potential cascades that reduce supply. She recommended validating the emotional experience of families and offering coping tools, flexible feeding plans and team-based support.

Horge also discussed metabolic contributors, saying insulin resistance can delay lactogenesis and blunt prolactin responses. She advised earlier preconception and prenatal counseling on metabolic health where possible and suggested adding a comprehensive pumping regimen alongside direct breastfeeding when insulin resistance or metabolic concerns are present.

On structural causes, Horge described insufficient glandular tissue (breast hypoplasia) as a cause of limited milk-producing capacity, noting presentations range from partial to minimal output. She cited older case series and ongoing research into hormonal therapies to support glandular development but said milk outcomes from such trials remain unclear.

Addressing PCOS, Horge summarized recent publications and international prevalence estimates, saying PCOS is associated with a higher risk of delayed lactogenesis and receptor-level disruptions that may affect prolactin action — though she emphasized "not every woman with PCOS will have breastfeeding difficulties."

She reviewed contraceptive guidance, noting historical evidence (including studies from the 1970s and 1980s) that estrogen-containing combination pills can reduce milk yields and reiterated clinical practice that favors progestin-only options and close monitoring of supply when postpartum contraception is initiated.

Horge detailed infant contributors to poor milk removal — ineffective suck, tongue tie (tethered oral tissues), cleft palate, prematurity and hypotonia — and urged oral assessments, specialist lactation support, and pumping plans when infants cannot extract milk effectively. "If baby is not emptying the breast, do we have a pumping regimen?" she asked, urging clinicians to prioritize feeding, protect supply, then return baby to the breast when possible.

The presentation included two brief case studies: "Leo," a 2-week-old with painful latching and long feeds, where Horge recommended oral assessment and a pumping plan; and "Amari," a 10-day-old with slow weight gain and maternal features suggesting IGT, where she recommended history-taking, early intervention and individualized plans.

In audience questions, Horge recommended comprehensive pumping and close clinical collaboration when scheduled feeds are medically necessary (for critically ill or preterm infants), stressed kangaroo care where feasible for NICU dyads, and endorsed screened donor human milk for critically ill infants while noting that North America operates roughly 25 milk banks prioritized for NICU use.

The session concluded with a resource list and a bibliography that the speaker said would be shared with attendees. The video was produced by the National Library of Medicine.

Horge repeatedly emphasized clinician humility and individualized care: gather a detailed history, look for root causes rather than treating symptoms alone, and assemble a collaborative care team with clear pumping and supplementation plans when necessary.