For the broader O&G Magazine readership, Q&A seeks balanced answers to those curly-yet-common questions in obstetrics and gynaecology.

How do you suppress lactation and when should it be considered?

Why suppress lactation?

There are various reasons for the need to suppress lactation, ranging from personal choice to urgent necessity. Regardless of the reason, this topic requires a gentle and considered approach, as this can be a very emotional decision for any breastfeeding parent.

Pregnancy or neonatal loss is the most common reason for pharmacological suppression of lactation in the immediate postpartum period, but medication shouldn’t be first line in managing this process.

Whenever possible, counselling of the parents prior to the delivery is ideal as some parents find the onset of milk production and gradual cessation to be a very important and powerful part of the grief process. There are families who choose to lactate and donate milk as part of an ongoing legacy for their deceased babies, so the decision to suppress lactation should not be assumed.¹

Serious maternal or infant illness may require urgent weaning and/or lactation suppression, as may adoption or a past or present history of breastfeeding complications. Personal choice is also a valid reason to suppress lactation for families who have weighed the risks and benefits of breastfeeding for both the breastfeeding parent and the infant and have decided that formula feeding or donor milk is a more suitable alternative.

When should lactation suppression take place?

Management of lactation suppression varies slightly depending on whether it occurs immediately postpartum or once milk supply has been established.¹

In some lactating caregivers, colostrum will be produced as early as 16 weeks’ gestation, so suppression should be discussed with anyone delivering from this gestation. Regardless of whether breastfeeding is initiated, milk production will usually commence around day 3–4 postpartum (possibly earlier if they have lactated before) as lactation at this stage is under hormonal control. For some women, this can result in engorgement, discomfort and leakage, which, depending on the circumstances surrounding the delivery, can be very distressing for some parents, yet comforting for others. If the breasts are not stimulated, the supply will gradually reduce and cease over a few weeks. If parents are not wanting to commence or establish lactation, suppression should take place as early as possible, ideally within 24 hours of delivery.

If lactation has already commenced and established, a more gradual approach over a week or two is usually preferable to prevent complications such as blocked ducts, mastitis and breast abscess. Onset of milk production after the baby has been delivered may happen earlier if the parent has lactated before; however, this usually doesn’t occur prior to 24 hours postpartum and won’t alter the efficacy of lactation suppression in the immediate postpartum period.

How to suppress lactation

Regardless of the timing of lactation suppression, some basic non-pharmacological interventions can significantly reduce both the onset of milk production and the associated discomfort.

These measures include wearing firm, well fitting breast support, avoiding heat (unless needing to manage engorgement), using cold packs to both reduce blood flow and treat the inflammatory changes associated with lactation and providing regular simple analgesia such as ibuprofen and/or paracetamol. Breastfeeding parents should be advised to avoid stimulating the breasts as much as possible, as the simple act of checking to see if milk is still being produced can be enough to promote milk production. If the parent finds themself to be painfully engorged, it may be necessary to remove a small amount of milk to relieve discomfort. In this instance, some gentle breast massage in a warm shower may be all that is needed to remove enough milk to be comfortable. It is important that the breasts aren’t drained completely, as this will stimulate further milk production.²

When reducing an already established supply, the recommendation is to gradually reduce the number of breastfeeds (or expressions) per day, starting with the least most productive feed. Every 3–4 days, if the breasts are feeling comfortable, a further feed would be ceased and replaced with a breastmilk substitute. If exclusively expressing, some will choose to just increase the time between pumping sessions every few days until down to 1–2 pumps per day, by which point the supply is likely to be low enough to be able to comfortably stop removing milk.²

If there is a need to expedite lactation suppression, medications such as cabergoline, oestrogen, and pseudoephedrine can be used with caution.

Cabergoline suppresses prolactin, the hormone responsible for milk production. If being used immediately postpartum prior to lactation being established, a single dose of 1mg will suffice. If lactation has been established, cabergoline 250mcg BD for two days is required. Common side effects associated with cabergoline include dizziness, headaches, nausea and hypotension.^{2 3}

The combined oral contraceptive pill is known to reduce breastmilk supply in established lactation; however, the risk of thromboembolism needs to be carefully considered in the immediate postpartum period.⁴

There is also evidence that pseudoephedrine significantly reduces supply in established lactation. The exact mechanism is unknown; however, it is thought to be related to the dopaminergic actions of the drug in the pituitary, causing alterations in prolactin levels. A single dose of 60mg has been shown to reduce milk production by up to 24%, but it appears to be safe to use the usual nasal decongestant dose of 60mg QID for 2–5 days in people with a more generous supply.⁵

While historical treatments for lactation suppression such as applying jasmine flowers to the breasts and drinking sage tea are still in use today, a Cochrane review in 2012 found that there is very limited data on the efficacy of these treatments.⁴

How long will lactation suppression take?

For most people, milk production will not be noticeable within a few weeks, but for some it can take many months to completely suppress lactation. Once lactation has been established, the process is likely to take much longer, and some will still be producing very small amounts of milk for up to a year, though this will only be noticeable if actively looked for.

It is important to remember that regardless of the reason for lactation suppression, the timing of the intervention or the method used, for the parent, there is likely to be a huge psychological burden associated with the decision, even if it’s a decision they are very confident in. As such, compassion, patience and support should be the underlying foundation on which to base any one of these managements.

1. State of Victoria (Department of Education and Early Childhood Development). Promoting Breastfeeding: Victorian Breastfeeding Guidelines. 2014. Available from: www.education.vic.gov.au/Documents/childhood/professionals/health/brestfeedguidelines14.pdf.
2. Australian Breastfeeding Association. Lactation suppression. 2020. Available from: www.breastfeeding.asn.au/bfinfo/lactation-suppression.
3. Government of WA. North Metropolitan Health Service. Women and Newborn Health Service. O&G Clinical Practice Guideline. Breastfeeding: Suppression of Lactation. 2021. Available from: www.kemh.health.wa.gov.au/~/media/Files/Hospitals/WNHS/For%20health%20professionals/Clinical%20guidelines/OG/WNHS.OG.BreastfeedingSuppressionLactation.pdf
4. Oladapo OT, Fawole B. Treatments for suppression of lactation. Cochrane Database Syst Rev. 2012;9:CD005937. DOI: 10.1002/14651858.CD005937.pub3.
5. Khalidah A, Thomas H, Illett K, et al. Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk. Br J Clin Pharmacol. 2003;56:18-24.