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LACTOGENESIS
The Transition from Pregnancy to Lactation
Margaret C. Neville, PhD, Jane Morton, MD,
and Shinobu Umemura, MD,

Lactogenesis is the onset of milk secretion and includes all of the

changes in the mammary epithelium necessary to go from the undiffer-
entiated mammary gland in early pregnancy to full lactation sometime
after parturition. Based on work in ruminants, HartmamP and Fleet
and colleag~es'~ divided lactogenesis into two stages.
Stage I occurs during pregnancy, when the gland becomes suffi-
ciently differentiated to secrete small quantities of specific milk compo-
nents, such as casein and lactose. In humans, stage I occurs at approxi-
mately midpregnancy and can be detected by the measurement of
increased plasma concentrations of lactose and a-lactalb~min.~ After
lactogenesis stage I has been achieved the gland is sufficiently differenti-
ated to secrete milk, but secretion is held in check by high circulating
plasma concentrations of progesteronez7and, possibly, in some species
such as humans, estrogen. The secretion product, often called colostrum,
which can be extracted from the breasts of pregnant women? 3o contains
relatively high concentrations of sodium; chloride; and protective sub-
stances, such as immunoglobulins and lactoferrin. Casein is not pres-
ent'O," and the lactose concentration is low2at this time.
Stage I1 is the onset of copious milk secretion associated with
parturition. In many species, such as cows, goats, and rats, this stage
Preparation of this article was supported in part by NIH grant no. HD19547 (MCN).

From the Department of Physiology, University of Colorado Health Sciences Center,

Denver, Colorado (MCN); the Stanford University School of Medicine, Palo Alto
Medical Foundation, Palo Alto, California (JM); and the Department of Pathology,
Tokai University, Isehara, Japan (SU)

PEDIATRIC CLINICS OF NORTH AMERICA

-
VOLUME 48 NUMBER 1 FEBRUARY 2001 35
36 NEVILLEetal

begins before birth of the young, brought about by the sharp decrease
in plasma progesterone that also initiates parturition. In humans, the
progesterone level does not decrease prepartum but decreases approxi-
mately 10-fold during the first 4 days after birth, accompanied by a
programmed transformation of the mammary epithelium, which leads
to transfer to the infant of 500 to 750 mL/d of milk by day 5 postpar-
46 This transformation requires a concerted change in several
processes, including changes in the permeability of the paracellular
pathway between epithelial cells; changes in the secretion of protective
substances, such as immunoglobulins,lactoferrin, and complex carbohy-
drates; and an increased rate of secretion of all milk components. Lacto-
genesis stage I1 can be monitored by changes in milk composition and
volume in women and other species in which large milk samples can
easily be 0btained.4~The terms colostrum and transitional milk, tradition-
ally used to describe the mammary secretion product during the first 4
days postpartum and from days 4 to 10 postpartum, respectively, do not
define clear-cut temporal changes in milk composition and are not
useful distinctions. Rather, the changes in milk composition that occur
postpartum should be viewed as part of a continuum wherein rapid
changes in composition occur during the first 4 days postpartum fol-
lowed by slow changes in various components of milk throughout the
course of lactation?

CHANGES IN MILK VOLUME AND COMPOSITION

DURING LACTOGENESIS STAGE II

Figure 1 shows the average rate of milk transfer to infants during

the first 8 days postpartum in 11 multiparous, middle-class, white
women who weighed their infants before and after every feed during
this Milk transfer, originally less than lOOmL/d, began to
increase at approximately 36 hours postpartum, continued to increase
dramatically for approximately 48 hours, and then leveled off after
approximately 4 days. A similar pattern has been observed in other
careful studies of disease-free women delivering term infants by the
vaginal route.5* A detailed study of human milk composition over this
period reveals a carefully programmed cascade of events that leads,
after 4 days, to a mammary secretion product with a composition similar
to that of mature human milk.&
The first change in composition to occur after delivery in these
women was a decrease in the sodium and chloride concentrations in
the milk and an increase in the lactose concentration (Fig. 2A). These
modifications commenced immediately after delivery and largely were
completed by 72 hours p0stpartum.4~Similar changes were seen by
0thers.J 31 These changes preceded the onset of the increase in milk
volume by at least 24 hours and can be explained by closure of the tight
junctions that block the paracellular pathway. With closure of the tight
junctions, lactose, made by the epithelial cells, no longer can pass be-
 LACTOGENESIS 37

0 2 4 6 8
Days Postpartum

Figure 1. Milk volumes during the onset of lactation in American women. Eleven multipa-
rous women weighed their infants before and after every feed for 7 to 8 days postpartum.
Milk output was averaged by 0.5 day intervals for the first 3 days and then daily for the
remainder of the experiment. All women had successfully breastfed at least one previous
infant. Note the extensive variation in the volumes of milk produced. All these women
breastfed successfully for at least 6 months. Each symbol represents data from a different
woman. (Data from Neville MC, Keller RP, Seacat J, et al: Studies in human lactation: Milk
volumes in lactating women during the onset of lattation and full-lactation. Am J Clin Nutr
48: 1375-1386, 1988.)

tween the epithelial cells into the plasma, and sodium and chloride no
longer can pass from the interstitial space into the lumen of the mam-
mary alveolus and must be secreted by the cellular route (Fig. 3). These
changes result in a decrease in the concentrations of sodium and chloride
in the mammary secretion and an increase in lactose concentration,
which reflects not so much an increase in the rate of lactose secretion
but rather a decrease in its dilution by water entering the alveolar
lumina with the ions.
The next changes to occur are increases in the concentrations of
secretory IgA and la~toferrin.~~ The concentrations of these two im-
portant protective proteins remain high for the first 48 hours after birth,
the two together comprising as much as 10% by weight of the milk (see
Fig. 2B). Using the mean milk volumes from Figure 2A and these
concentrations, it is possible to calculate the rates of secretion of these
two proteins (see Fig. 2B, inset).48These concentrations decrease rapidly
after day 2 postpartum as a consequence of dilution as milk-volume
secretion increases and of a decrease in the rate of secretion, particularly
of immunoglobulins. By 8 days postpartum, these protective proteins
together make up less than 1%of the total weight of the milk; however,
the secretion rate still is substantial, amounting to 2 to 3 g / d for each
protein. Although both of these proteins are found at high concentrations
in colostrum, their secretion is likely under separate control because
lactoferrin is synthesized and secreted by the alveolar whereas
38 NEVnLEetal

A
180 600
Lactose
8 150
0
120
8

n 0

80

n 2 4 6 8
Days Postpartum

Figure 2. Changes in the concentration of certain milk components during the first week
postpartum. A, lime course of changes in the lactose, chloride, and sodium concentrations
contrasted with the mean milk volume transfer to the infant. Changes in these milk compo-
nents begin immediately postpartum and are complete at least 24 hours before the achieve-
ment of a steady state in milk volume. As described in the text, the decrease in sodium
and chloride and increase in lactose concentration reflect closure of the tight junctions
between the mammary epithelial cells (see Fig. 3). 6, Changes in the concentration of
secretoty IgA (solid squares) and lactoferrin (open squares) during the onset of lactation in
women. As shown in the inset, the secretion rate of both substances calculated from the
concentrations here and the mean milk volume in A, increases during the first 2 days
postpartum. (Data from references 34, 48, and 49; Adapted from Neville MC, Lactogenesis
in women: A cascade of events revealed by milk composition. In Jensen RD (ed): The
Composition of Milks. San Diego, Academic Press, 1995, pp 87-98; with permission.)

secretory IgA is secreted by a transcytotic pathway? Also, the secretion

rate of lactoferrin peaks approximately 1 day after the peak of secre-
tory IgA secretion. Concentrations of oligosaccharides in milk are also
high in the early secretion product of the mammary gland: approxi-
mately 20 g/L, or 2% of milk weight, on day 4,'l. ** decreasing signifi-
cantly to approximately 14g/L on day 30. These complex sugars also
 LACTOGENESIS 39

PREGNANCY
*
. . Sodium
7menyx Chloride

LACTATION Lactose
Sodium
Chloride

/nIersfit7a/Space

Figure 3. Change in paracellular permeability between pregnancy and lactation. (Modified

from Neville MC: Lactogenesis in women: A cascade of events revealed by milk composi-
tion. In Jensen RD (ed): The Composition of Milks. San Diego, Academic Press, 1995, pp
87-98; with permission.)

are considered to have substantial protective effect against various infec-

tion~.~~
Finally, approximately 36 hours postpartum, milk secretion began
in earnest in these multiparous women who initiated breastfeeding on
the first day after birth, and a 10-fold increase in volume, approximately
from 50mL/d to 500 to 600mL/d, occurred over the subsequent 36
hours (Fig. 40). This volume increase is perceived by parturient women
as the "coming in" of the milk and reflects a massive increase in the
rates of synthesis and secretion of almost all of the components of
mature including, but not limited to, lactose, protein (mainly
casein1",%), lipid, calcium, sodium, magnesium, and potassium, as shown
in Figure 4. Three milk components, citrate, glucose, and free phosphate,
are interesting because their concentrations increase in proportion to the
increase in milk v0lume.4~The change in concentration of glucose is
caused by increased glucose transport from the interstitial space into the
mammary alveolar cell?" whereas the increase in phosphate concentra-
tion probably results from dephosphorylation of the uridine diphos-
phate (UDP) generated during lactose synthesis. The increase in citrate
may be related to fat synthesis; however, it does not occur in all species
(rodent milk does not contain citrate). Although the pattern of increase
in these three substances was similar in all women studied? 47 unfortu-
nately, the variation among individuals is too great to use the concentra-
tion of any one substance as an index of milk secretion in individual
women5
The timing of lactogenesis has been determined carefully from milk
40 NEVILLEetal

( M d or g/d)
15 4 3
I
*

0
0 2 4 6 8 0 2 4 6 8

Milk Volume (mL/d)

800

400

'O0i;S:,
n
"
0 2 4
, , ,

6
, 1
8
Days Postpartum

Figure 4. A-C, The rate of secretion of various milk components by the women described
in Fig. 1. All values are in millimoles/day except for protein and-lipid, which are expressed
in g/day. The appropriate ordinate is indicated by right (R) or left (L) after the name of the
milk component. D, Mean total milk produced by these women; includes milk transferred
to the infant and milk removed by manual expression or breast pump (less than 100 m U
day on average).

volume or composition in only a few studies, all on middle-class, white

women.l0,30, 46, In the first three studies, milk volumes were meas-
ured during lactogenesis using changes in infant weight; the data from
these studies agree with the change in milk transfer shown in Figure
2A. Earlier studies published in the 1940s by Macy and colleagues58were
carried out on multiparous women from whom all milk was manually
expressed every 4 hours. During days 1and 2 postpartum, milk volumes
were low and similar to the values in other studies; however, by day 3,
volumes were significantly higher than in the other studies, achieving
1100 g/d on day 6 postpartum. Possible reasons for this difference are
discussed later. In the study by Chen et al?O milk volumes were deter-
mined only on day 5 postpartum, but the onset of casein secretion was
determined by daily measurements, and the time at which fullness of
the breast was perceived also was noted. The data from these studies
are plotted in Figure 5 and show some differences between multiparous
and primiparous women. Thus, milk volumes on day 5 postpartum
were significantly larger in multiparous women, and the time at which
breast filling was reported was significantly earlier. The casein band
 LACTOGENESIS 41

800
I I
' *T
h

600 d>.
0)
Y

c
400 5
0

D
2
[L
200 g
H

0
Primip Primip Multip
Vaginal Caesarian Vaginal

Figure 5. Effect of parity on measures of lactogenesis. Data show the mean time at which
fullness of the breast was observed (solid bar), the day on which the casein band first
appeared (cross-hatched bar) in an electrophoretic analysis of daily milk samples, and the
volume of milk produced on day 5 (bafcbed bar) by primiparous women delivered vaginally
(n = 19), primiparous (primip) women delivered by caesarian section (n = 5), and
multiparous (multip) women delivered vaginally (n = 16). 'Significant difference (P<0.05)
between multiparous and primiparous women delivered vaginally. The distance between
the error bars represents two SEM. (Dafa from Chen DC, Nommsen-RiversL, Dewey KG,
et al: Stress during labor and delivery and early lactation performance. Am J Clin Nutr
681335-344, 1998.)

appeared slightly earlier in multiparous women, but the data did not
achieve statistical significance. These data suggest that parity or previous
lactation experience may influence the timing of lactogenesis; however,
other explanations for the differences also are possible. No data are
available in the literature for milk volumes in women generally at risk
for lactation failure or for premature or twin births. No data allow for
assessment of ethnic or socioeconomic status on the course of lactogenesis.
Data on engorgement and changes in milk composition in non-
breastfeeding women are available. In the study by Kulski et al,295 mL/d
of milk were manually extracted from each breast from birth to 7 days
postpartum from 13 nonbreastfeeding women. The timing of changes in
sodium, lactose, and lactoferrin concentrations in the mammary secre-
tion product was similar to the timing of changes shown in Figure 2;
engorgement and leakage became perceptable on day 2 postpartum and
maximal on day 4 postpartum/ consistent with the timing of milk-
volume change in the breastfeeding women illustrated in Figures 1 and
2A. Some data also are available from changes in blood levels of milk
constituents. Martin et a13*measured the blood levels of a-lactalbumin
in breastfeeding and nonbreastfeeding women. The protein level showed
a sharp peak of approximately 1.5 pg/mL at 3 days postpartum in
breastfeeding women and 4 days postpartum in nonbreastfeeding
42 NEVnLEetal

women. Whether the difference in timing is statistically sigruficant is

unclear. These data indicate that suckling or milk removal during the
first 2 or 3 days postpartum is unriecessary for lactogenesis stage 11.
Whether they influence the timing of lactogenesis, the volume of milk
produced, or its composition is considered later.

HORMONAL REQUIREMENTSFOR LACTOGENESIS

During pregnancy, fetuses are nourished by the blood supply to the

uterus; this source of nutrition is replaced by milk from the mammary
gland after parturition. Clearly, the hormones of pregnancy have two
jobs: (1) to maintain and promote the pregnancy and (2) to produce a
developed mammary epithelium that is poised to secrete milk but does
not do so. Figure 6 shows the changing levels of relevant hormones
during pregnancy, derived from several sources in the literature from
the 1970s, when these measurements were made. Until recently, which

500 t /2ortisol ~

a,
K
0

I
E I //-Proaesterone
m

h
E 20

4- i /
/P-//

'0
u
20 30 10 40
Weeks Gestation

Figure 6. Plasma hormone levels during pregnancy. (Data from references 8, 16, 56, and
66.) (From Neville MC: Regulation of mammary development and lactation. In Neville MC,
Neifert MR (eds): Lactation: Physiology, Nutrition, Breast-Feeding. New 'fork, Plenum
Press, 1983, p 107; with permission.)
 LACTOGENESIS 43

of these hormones were important in mammary development during

pregnancy was difficult to determine; however, studies of mice in which
receptors for various hormones have been ablated show that progester-
oneE*36 and prolactin53 (or possibly its congener, placental lactogen) are
involved in alveolar development. Also, the major inhibitor of milk
production during pregnancy is
The stimuli to parturition in humans are complex and the subject
of considerable contr~versy.~~ Although some progesterone is required
to maintain pregnancy, no evidence shows a prepartum decrease in
progesterone level before parturition in women; however, the inhibitory
actions of progesterone on myometrial contractility seem to be abrogated
near parturition, possibly by coordinate actions of oxytocin and prosta-
glandins on a sensitized myometrium. Although the exact mechanisms
that regulate the timing of parturition are unclear, a developed mam-
mary epithelium, the continuing presence of levels of prolactin near
200 ng/mL, and a decrease in progesterone level are necessary for lacto-
genesis stage I1 after parturition.28The levels of these hormones and
estrogen are shown in Figure 7. That the decrease in progesterone level
is the lactogenic trigger is supported by evidence from many species.
For example, in one study,37the timing of the increase in milk lactose
in sows correlated closely with the timing of the decrease in plasma
progesterone at parturition. In other studies, progesterone prevented
lactose and lipid synthesis in the-mammary gland after removal of the
source of progesterone, namely, the ovary, in pregnant ratsz6,39 and
ewes.z1In early work, Rosen et a159showed that progesterone inhibits
the onset of casein synthesis in mammary tissues taken from pregnant
animals. In humans, removal of the placenta, the source of progesterone
during pregnancy in this species, is necessary for the initiation of milk
secretion.2o, * On the other hand, retained placental fragments with the
potential to secrete progesterone delay lactogenesis in humans.42The
conundrum that progesterone does not inhibit established lactation was
solved by Haslam and Shyamala,= who found that progesterone recep-
tors are lost in lactating mammary tissues.
In most species, the presence of high levels of plasma prolactin
also seems to be essential for lactogenesis. In women, for example,
bromocriptine and other analogs of dopamine, drugs that effectively
prevent prolactin secretion, inhibit lactogenesis when given in appro-
priate doses (reviewed in reference 51). Rodent tissues require prolactin
for synthesis of milk proteins in vitro." On the other hand, high levels
of prolactin may not be necessary for lactogenesis in all species because
milk formation occurs in cows, albeit with a delayed time course, when
prolactin secretion is suppressed with bromocriptine.' An older hypothe-
sis that a prolactin surge triggers lactogenesis is probably incorrect. A
biphasic increase in prolactin accompanies parturition in but
this increase, probably associated with the stress of parturition, precedes
the onset of copious milk secretion by 2 days.
In all in vitro mammary systems, insulin and corticoids, in addition
to prolactin, are necessary to maintain synthesis of milk components.64
44 NEVILLEetal

100000~

............. 3

................. P

- - ::z.:::
:: ......$:::::::
I r l I 1 1 1 1 ' 1 1 ' ' 1 1 1
I 2 4 6 8 10 12

...........' . . . S
........p.

1000 -
Upper limit of normal
..... ..I... - - - - -
-- - - --- ----
..._
menstruating range '""'..-.I
100 -

Lab Days Postpartum

Delivery

Figure 7. Maternal hormone levels after parturition in breastfeeding and nonbreastfeeding

women. Breastfeeding subjects (n = 10, open circles), nonbreastfeeding subjects (n = 9,
solid circles). 'P ~0.01.
(From Martin RH, Glass MR, Chapman C, et al: Human alpha-
lactalbumin and hormonal factors in pregnancy and lactation. Clin Endocrinol 13:223-230,
1980, with permission.)
 LACTOGENESIS 45

Also, cortisol replacement is required for maintenance of milk produc-

tion in adrenalectomized animal^.'^,'^ An early notion that a surge of
glucocorticoids triggers lactogenesis also is likely incorrect because the
increase in cortisol levels in unanesthetized women associated with the
stress of labor is complete by the time that milk volume begins to
increase to any extent. Further increased cortisol level, particularly in
cord blood, is associated with a delay in lactogenic markers.l0 Because
lactogenesis proceeds at parturition in severely diabetic a role for
insulin in lactogenesis as opposed to metabolic adjustments during
lactation seems improbable.
The most reasonable interpretation of the data available from animal
and human studies is that the hormonal trigger for lactogenesis is a
decrease in progesterone in the presence of maintained prolactin levels.
Postpartum prolactin levels are similar in breastfeeding and non-
breastfeeding women (Fig. 7), so that the basic process occurs regardless
of whether breastfeeding is initiated.%The caveat is that the mammary
epithelium must be sufficiently prepared by the hormones of pregnancy
to respond with milk synthesis.

DELAYED LACTOGENESIS

Several pathologic conditions are reported to delay lactogenesis in

women, including placental retention,&caesarean section,@diabetes: 46

and stress during parturition.'O The delay reported with placental reten-
tion likely was caused by continued secretion of progesterone from the
retained placental fragments. This condition is rare in part because
delivery of the placenta is controlled carefully in modern obstetric prac-
tice. In the case of caesarian section, in a much larger, earlier study by
Kulski et a1,3I milk composition was carefully measured, and no effect
on the timing of changes in the concentrations of lactose, sodium, IgA,
or other milk constituents was found. Also, no significant difference in
the self-reported time at which the milk came in was found between
vaginal and caesarian delivery. In another study,IDbreast fullness and
the appearance of casein in the milk occurred slightly earlier in a few
women who underwent caesarean sections, although these data did not
achieve statistical significance (Fig. 7).
Some understanding of the cause of delayed lactogenesis in patients
with diabetes may be provided by the careful study by Chen et a1O ,'
which showed that stress during parturition may delay lactogenesis
stage 11. The data from the women delivering vaginally (see Fig. 5) were
analyzed for effects of stress during parturition. The time of perception
of breast fullness and the appearance of casein in the mammary secretion
product were sigzuficantly increased with longer labors and increases in
other measures of stress, particularly cord blood glucose and cortisol
concentrations. Milk production on day 5 postpartum was significantly
decreased after stressful deliveries. In diabetic women studied by Neu-
bauer et alMand Arthur et a1,5 women with poorly controlled diabetes
46 NEVnLEetal

seemed to have delayed lactogenesis. Whether these women have more

stressful or prolonged deliveries is unclear and should be investigated.

BREAST MILK SODIUM CONCENTRATION AS A

PREDICTOR OF SUCCESSFUL LACTOGENESIS

The sodium concentration in breast milk during the early postpar-

tum period is an easily measured parameter that is predictive of lactation
success,41 particularly in some, but not all, mothers at high risk for
insufficient milk supplyz4;however, the reasons for high sodium content
in breast milk during the early postpartum period and the relationship
of this variable to milk-volume production in women at risk for lactation
failure have not been assessed properly. The data from many labora-
tories: z9, 33, 46 exemplified by the graphs in Figures 2A and 8A, confirm
the decrease in milk sodium concentration from approximately 60 mmol
directly postpartum to approximately 20 mmol on day 3 postpartum in
mothers of full-term infants who breastfeed regularly from the first day
postpartum. Also, this decrease has been found in women who do not
breastfeed but who remove small milk samples from day 1 (Fig. 8A). On
the other hand, a high breast-milk sodium concentration on or before
day 3 postpartum is seen in clinical situations such as those illustrated
in Figure 8B3r41and are statistically related to impending lactation failure.
Two questions regarding these high sodium concentrations must be

u
-2 0 2 4 6 8 0 4 8 12 16
A Days Postpartum B Days Postpartum

Figure 8. Effect of milk removal on the sodium composition of breast milk. A, The sodium
content of breast milk in nonbreastfeeding (NBF; n = 11) and breastfeeding (BF; n = 13)
Australian women. For the nonbreastfeeding women, 5 mL samples were expressed manu-
ally from each breast at the times indicated. For the breastfeeding women, samples of 0.5
to 3 mL were expressed after putting the infant to the breast. 6,The sodium content of the
milk in three patients who consulted a physician because of poor suckling by their infants.
The mean sodium content for the milk of the two breasts is plotted for each patient. After
the initial diagnosis on day 3 postpartum, each woman initiated a rigorous regimen of
breast-pumping. (A, data from references 29 and 31.)
 LACTOGENESIS 47

addressed in prospective studies: (1) What is the physiologic basis for

these findings: and, (2) How do these findings relate to milk production?
A high sodium concentration in the mammary secretion is associ-
ated with five conditions: (1) pregnancy, (2) mastitis, (3) involution, (4)
inhibition of prolactin secreti0n,2~ and (5) premature birth.6,18,19In early
clinical reports in which high breast milk sodium concentration was
associated with hypernatremia, dehydration, and failure to thrive in
breastfed infants, involution probably had begun by the time these
infants were seen in the clinic; however, involution was probably not
the problem with the patients depicted in Figure 8B because the high
sodium concentrations on day 3 were decreased soon thereafter as pa-
tients began a pumping regimen to obtain effective removal of milk
from the breast. These patients were able to pump significant volumes
of milk by the time that the measurements were terminated on days 10
to 16 postpartum, ruling out prolactin insufficiency. In all of these
patients, on day 3 postpartum, the milk of both breasts had a high
sodium concentration, effectively ruling out mastitis, which usually is
confined to a single breast. Prematurity was not involved because all
three infants were born at term. The infants of the three patients depicted
in the Figure 8 B all had failed to “latch on” and, therefore, to remove
milk from the breast effectively. These observations suggest that milk
removal or effective suckling are necessary to obtain junctional closure
at least in some women.
If removal of secretion product is involved in the decrease of milk
sodium at lactogenesis, the amounts removed must be small. Thus in
the study of nonbreastfeeding women depicted in Figure 8A, only 10 mL
of secretion product were removed from each breast on days 1 and 2
postpartum and only 5mL on day 3, all for analytic purposes. Milk
sodium concentration decreased effectively and reproducibly in these
women as it did in the women studied in the study by Neville et al,
some of whom produced small milk volumes during the first 2 days
postpartum.45, 47 The questions are whether removal of small amounts of

secretion product stimulates tight junction closure and whether increased

prolactin secretion is involved. If not, some underlying abnormality may
interact with a lack of breast stimulation in some women to produce
elevated breast milk sodium concentration. The answers to these ques-
tions require well-designed, prospective, clinical studies.
Studies in mothers of preterm infants who are too young to suckle
might be advantageous. These mothers often start pumping their breasts
at varying times postpartum, milk volume can be easily measured from
the pumped milk, and many of these mothers seem to have high breast
milk sodium concentrations on day 3 postpartum. In two studies in
which individual values for sodium concentration were published, so-
dium concentrations of more than 30mmol were observed in 25% of
mothers of preterm infants on day 3 postpartum.6,l9 No values above
this limit were observed in mothers of term infants in these two studies.
It should be possible to obtain longtudinal quantitative measurement of
milk volume and sodium concentration in this population related to the
48 NEVnLEetal

time at which milk removal from the breast is initiated. Such studies
will not only enhance the understanding of the physiology of lactogen-
esis but also provide a firm basis for diagnosing impending lactation fail-
ure.

ROLE OF MILK REMOVAL IN LACTOGENESIS

STAGE II

The perception that early breastfeeding contact between mother and

newborn is important in the establishment of lactation has given rise to
the current recommendations that infants be encouraged to suckle even
on the delivery table. Benefits of this practice may include better mother-
infant bonding, early attention to potential breastfeeding problems that
can be remedied by better breastfeeding techniques, and the delivery of
protective factors important to infant health. From the standpoint of the
regulation of physiologic lactogenesis, the careful evaluation of milk
composition and breast-filling by Kulski et alZ9showed that milk removal
is not needed for the programmed physiologic changes in the mammary
epithelium that trigger lactogenesis stage II. Also, in an exemplary study
from Thailand, Woolridge et aP7did not find any effect of breastfeeding
during the first 24 hours on later milk transfer to infants.
Milk removal must begin at approximately day 3 postpartum or
else the changes in milk composition associated with lactogenesis are
reversedz9and the likelihood of the successful establishment of lactation
decreased. Local factors dependent on milk removal have been associ-
ated with the regulation of milk secretion during lactati0n.5~The ques-
tion is, When do the effects of these local factors become apparent? That
milk removal may be necessary for the closure of tight junctions in the
human mammary gland was discussed earlier. Chapman and Perez-
Escamillayfound that formula-feeding before lactogenesis was associated
with a delay in perception of lactogenesis. Also, the time of first
breastfeeding and the breastfeeding frequency on day 2 postpartum
were positively correlated with milk volume on day 5 postpartum,10
suggesting that milk removal soon after birth increases the efficiency
of milk secretion. In animal studies, suckling was necessary for full
development of the enzymes of lipid synthesis in rats39and for expres-
sion of mammary metabolites in the milk of SOWS.~
Experiments that allow investigators to state with certainty at what
point removal of milk from the breast is necessary to complete lactogen-
esis in humans have not yet been published. In future studies, caution
must be exercised to distinguish between factors that stimulate physio-
logic lactogenesis and external factors, such as maternal-infant contact
and proper breastfeeding procedure, that are important in the establish-
ment of successful breastfeeding. Such studies should, at a minimum,
involve careful measurement of milk composition during the first few
days after parturition; observations of breastfeeding frequency; infant
weight; and a measure of outcome, such as a 24-hour determination of
 LACTOGENESIS 49

milk transfer by testweighing. This research is important. From a scien-

tific standpoint, investigators must understand the factors that affect the
physiologic changes in the breast during lactogenesis. From a practical
standpoint, physicians must be able to offer proper advice to women
with problem deliveries or diseases that affect lactogenesis.

SUMMARY

The most important factors in initiation of the cascade of changes

in the mammary epithelium that constitute lactogenesis stage I1 seem to
be a prepared mammary epithelium, progesterone withdrawal, main-
tained plasma prolactin (in most species), and removal of milk from the
breast within an undefined interval after birth. Although the molecular
mechanisms by which prolactin regulates milk protein synthesis are the
subject of intense and productive studies,% the specific mechanisms
by which progesterone and milk removal interact with the mammary
epithelial cell at parturition have not been studied, perhaps because no
in vitro model system exists that mimics lactogenesis stage 11, or because
of the complexity of the changes that must be coordinated during this
process, or because of a lack of general understanding of the complex
progression of changes in the function of the breast as it goes from the
quiescent state of pregnancy to the active secretory state of lactation.
With new technologies designed to investigate the biology of complex
systems arising from the growing knowledge of the genome of human
and animal species and the growing availability of animal and tissue
culture models for these processes, physicians can expect a rapid increase
in the molecular understanding of lactogenesis in the near future. These
fundamental studies must be coupled with good prospective clinical
studies if physicians are to obtain a useful, comprehensive understand-
ing of lactogenesis in women.

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Address reprint requests to

Margaret C. Neville, PhD
Department of Physiology
Box C240, Room 3802
University of Colorado Health Sciences Center
Denver, CO 80262

e-mail: peggy.neville@uchsc.edu