Lactation Physiology and Management

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Lactation Physiology and Management

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1. Lactation Physiology and Management Alison Stuebe, MD, MSc astuebe@med.unc.edu

2. 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

3. Health Impact of Not Breastfeeding

4. 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?

5. 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.

6. How Does Lactation Happen? Breast tissue differentiates during gestation At delivery, loss of placental hormones allows milk production to begin Infant suckling at the breast causes contraction of myoepithelial cells and release of milk Breast tissue differentiates during gestation At delivery, loss of placental hormones allows milk production to begin Infant suckling at the breast causes contraction of myoepithelial cells and release of milk

7. Where does milk come from? Milk produced in mammary epithelium within lobules With nursing, oxytocin triggers contraction of myoepithelial cells and transfer to sinuses Milk produced in mammary epithelium within lobules With nursing, oxytocin triggers contraction of myoepithelial cells and transfer to sinuses

8. Oxytocin Moves milk from lobules to sinuses, so baby can eat Inhibited by stress, pain, anxiety Triggered by sound, smell, sight of infant

9. Stress and Milk Volume Study: 1 woman, monitored during morning feed at 7 months. 8 control days, 12 distraction days; given saline or pitocin injection prior to nursing. Pitocin returned milk supply to near-normal. Ice water - immersed feet for 10 of 30 sec; math - difficult verbal problems w/ shock if incorrect answer; toe pull - interemittent pulling of big toe, causing painStudy: 1 woman, monitored during morning feed at 7 months. 8 control days, 12 distraction days; given saline or pitocin injection prior to nursing. Pitocin returned milk supply to near-normal. Ice water - immersed feet for 10 of 30 sec; math - difficult verbal problems w/ shock if incorrect answer; toe pull - interemittent pulling of big toe, causing pain

10. Milk Transfer Infant grasps most of the areola in his mouth Tongue ?milks? milk to the back of the mouth prior to swallowing. A shallow latch, or sucking on the nipple, stimulates let down but doesn?t empty the breast. It also leads to sore, cracked nipples, engorged breasts, and hungry, frustrated babies. A shallow latch, or sucking on the nipple, stimulates let down but doesn?t empty the breast. It also leads to sore, cracked nipples, engorged breasts, and hungry, frustrated babies.

11. 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.

12. Evidence-based early care Don?t distribute formula company materials in your office or hospital Ensure pediatric follow-up in the first 3-5 days Skin-to-skin at birth, nurse in the first hour Room in Feed on demand No pacifiers or formula, unless medically necessary Don?t distribute formula company materials in your office or hospital Ensure pediatric follow-up in the first 3-5 days Skin-to-skin at birth, nurse in the first hour Room in Feed on demand No pacifiers or formula, unless medically necessary

13. 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

14. 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

15. 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

16. 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


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