Lactation Physiology
and Management
Alison Stuebe, MD, MSc
[email protected]
Objectives
• Review public health impact of
breastfeeding
• Understand physiology of lactation
• Identify the differential diagnosis and
treatment for common breastfeeding
problems
» Low milk supply
» Mastitis
» Breast abscess
Health Impact of
Not Breastfeeding
Formula-feeding vs. breast-feeding: risk of adverse outcomes.
INFANT
MOTHER
Illness OR
Illness OR
Diarrhea 2.8
Premenopausal
1.4
breast cancer
Otitis media 2.0
Ovarian cancer 1.3
Pneumonia 3.6
Type 2 Diabetes 1.2
SIDS 1.6
Asthma 1.4
Leukemia 1.2
Breastfeeding and Maternal and Infant Health Outcomes in
Developed Countries. AHRQ Evidence Report Number 153. April 2007.
AAP Recommendations
• Exclusive
breastfeeding for
the first six months
of life
• Continued
breastfeeding for
at least one year,
‘As long as is
mutually desired
by mother and
child’
American Academy of Pediatrics (2005). "Breastfeeding and the Use of
Human Milk." Pediatrics 115(2): 496-506.
Contraindications
• HTLV-1 and HTLV-2
• HSV with lesion on
the breast
• Active tuberculosis
• Medications that
contraindicate
breastfeeding
• Newborn with
galactosemia
• Maternal HIV
» US: not recommended
» UNICEF: When
replacement feeding is
acceptable, feasible,
affordable, sustainable
and safe, avoidance of
all breastfeeding is
recommended;
otherwise, exclusive
breastfeeding is
recommended during
the first months of life.
How Does Lactation Happen?
Hypothalamus
PIF
Anterior
pituitary
Prolactin
Milk
production
Paraventricular
nucleus
Posterior
pituitary
Oxytocin
Milk
ejection
Where does milk come from?
Oxytocin
• Moves milk from
lobules to sinuses,
so baby can eat
• Inhibited by stress,
pain, anxiety
• Triggered by sound,
smell, sight of infant
Let Down: Ejection, not suction,
moves milk to the areola.
Stress and Milk Volume
Distraction and Milk Volume (g)
200
150
100
50
0
Control
Ice water
Math + shock
Toe Pull
saline
oxytocin
J. Pediatr 1948; 33:698-704.
Milk Transfer
•
•
Infant grasps most
of the areola in his
mouth
Tongue “milks”
milk to the back of
the mouth prior to
swallowing.
Latch: The baby’s tongue moves
milk from areola to nipple.
Negative feedback
• Milk in lobules contains
whey protein called
Feedback Inhibitor of
Lactation (FIL)
• If milk is not removed,
and lumen is full,
production will decrease
• Goal: 10-12 feeds in 24
hours, until baby is done.
Moving Milk:
Demand drives supply.
Evidence-based early care
Let
Down
Latch
Breastfeeding
Success
Moving
Milk
Start out right: establish
normal physiology
Low Milk Supply
• Primary lactation failure
» Anatomic abnormality
» Sheehan’s syndrome
• Disruption of normal physiology
» Infrequent or inadequate milk removal
» Postpartum depression
• First line therapy:
» Lactation consultation
» Mechanical expression after breastfeeding
• If needed:
» Supplement after breastfeeding as indicated
» Continue pumping during supplementation
» Consider metoclopramide
Mastitis
• Definition: tender, swollen, wedge-shaped
area of breast, usually unilateral, with fever,
malaise, chills, and systemic symptoms
• Incidence: 3 to 20%
• Treatment
» Rest, fluids
» Antibiotics – Dicloxicllin 500mg QID x 10-14d
» Empty the breast
•
•
•
•
Evaluate latch
Continue frequent breast feeding
Milk is not harmful to healthy, term infant
Abrupt weaning slows maternal recovery
• Poor response requires further evaluation
Academy of Breastfeeding Medicine. ABM Clinical Protocol #4: Mastitis.
Breastfeeding Medicine 3(3); 2008.
Breast abscess
• 3% of women with mastitis
• Diagnosis
» Hard, red, tender mass after appropriate
treatment
» Diagnostic ultrasound
• Treatment
» Needle aspiration for culture / treatment
» Surgical drainage for large or multiple
abscesses
• Follow-up care
» Antibiotics
» Continue breastfeeding
For more information
• American Academy of Pediatrics (2005).
Breastfeeding and the Use of Human Milk.
Pediatrics 115(2): 496-506.
• American Academy of Family Physicians.
(2001, 2/26/2007). Breastfeeding (Position
Paper).
• American College of Obstetrics and
Gynecology (2007). Breastfeeding: Maternal
and Infant Aspects. Special Report from
ACOG. ACOG Clinical Review 12(1
(supplement)): 1S-16S.
• Academy of Breastfeeding Medicine
www.bfmed.org