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Lactation Physiology and Management. Alison Stuebe, MD, MSc 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

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lactation physiology and management

Lactation Physiology and Management

Alison Stuebe, MD, MSc

  • 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
Health Impact of Not Breastfeeding

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 recommendations
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.

  • 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
How Does Lactation Happen?



Paraventricular nucleus

Anterior pituitary

Posterior pituitary



Milk production

Milk ejection


Let Down: Ejection, not suction, moves milk to the areola.

  • Moves milk from lobules to sinuses, so baby can eat
  • Inhibited by stress, pain, anxiety
  • Triggered by sound, smell, sight of infant
stress and milk volume
Stress and Milk Volume

J. Pediatr 1948; 33:698-704.

milk transfer

Latch: The baby’s tongue moves milk from areola to nipple.

Milk Transfer
  • Infant grasps most of the areola in his mouth
  • Tongue “milks” milk to the back of the mouth prior to swallowing.
negative feedback

Moving Milk:Demand drives supply.

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.
evidence based early care


Let Down

Moving Milk

Start out right: establish normal physiology

Evidence-based early care

Breastfeeding Success

low milk supply
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
  • 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
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
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