Lactation Physiology Lactation Physiology and Managementand Management

Alison Stuebe, MD, MSc

astuebe@med.unc.edu

ObjectivesObjectives

• 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 Health Impact of Not BreastfeedingNot Breastfeeding

INFANT INFANT MOTHERMOTHER

IllnessIllness OROR IllnessIllness OROR

DiarrheaDiarrhea 2.82.8Premenopausal Premenopausal

breast cancerbreast cancer1.41.4

Otitis mediaOtitis media 2.02.0 Ovarian cancerOvarian cancer 1.31.3

PneumoniaPneumonia 3.63.6 Type 2 DiabetesType 2 Diabetes 1.21.2

SIDSSIDS 1.61.6

AsthmaAsthma 1.41.4

LeukemiaLeukemia 1.21.2

Formula-feeding vs. breast-feeding: risk of adverse outcomes.

Breastfeeding and Maternal and Infant Health Outcomes inDeveloped Countries. AHRQ Evidence Report Number 153. April 2007.

AAP RecommendationsAAP 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.

ContraindicationsContraindications

• 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.

Milk production

Milk ejection

PIF

How Does Lactation Happen?How Does Lactation Happen?

Prolactin Oxytocin

Anterior pituitary

Posterior pituitary

Hypothalamus

Paraventricular nucleus

Where does milk come from?Where does milk come from?

OxytocinOxytocin

• 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 VolumeStress and Milk Volume

J. Pediatr 1948; 33:698-704.

Milk TransferMilk 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 feedbackNegative 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 careEvidence-based early care

Latch

Moving Milk

Let Down

Breastfeeding Success

Start out right: establish normal physiology

Low Milk SupplyLow 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

MastitisMastitis

• 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 evaluationAcademy of Breastfeeding Medicine. ABM Clinical Protocol #4: Mastitis.

Breastfeeding Medicine 3(3); 2008.

Breast abscessBreast 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 informationFor 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 Medicinewww.bfmed.org