Topic -

LACTATION
AND
BREASTFEEDIN
G
 Lactation….
1. Lactation refers to the physiological process by
which a woman's body produces and secretes milk
from the mammary glands in the breasts, typically
following childbirth.
2. It is a normal and natural part of the reproductive
process in mammals.
3. It is initiated by hormonal changes, primarily
involving the hormones prolactin and oxytocin.
 Colostrum….
1.Colostrum is the first form of milk produced by the
mammary glands in the breasts for the first 2 days
following delivery.
2. It is a thick, yellowish fluid that is rich in nutrients
and antibodies, providing essential components for the
newborn's health and immune system.
3. It is deep yellow serous fluid and is alkaline in
reaction.
 Composition of colostrum….
• Protein
• Carbohydrate
• Fat
• Vitamin A Composition of colostrum
• Sodium and chloride
• Immunoglobin A
• Complement factors
• Macrophages
• Lymphocytes
• Lactoferrin
• Lactoperoxidase
Breast milk vs colostrum
Breast milk Colostrum

8.6

7.5
4.2

3.2
2.3
1.2

P r ot ei n F at Car bo hydr at es
 Physiology of lactation…
1. Preparation of breasts
(Mammogenesis)
2. Synthesis and secretion from breast alveoli
(lactogenesis)
3. Ejection of
milk
(galactokinesis)
4. Maintenance of
lactation
1. Mammogenesis: Pregnancy is associated
with remarkable growth of both ductal
and lobuloalveolar systems. An intact
nerve supply is not essential for the
growth of mammary glands during
pregnancy.
2. Lactogenesis: The alveolar cells are the
principal sites for production of milk.
Milk secretion starts on 3rd or 4th
postpartum day.
• Around this time, the breasts become
engorged, tense, tender and feel warm.
• In spite of a high prolactin level during
pregnancy, milk secretion is kept in abeyance.
• Progesterone and estrogen make breast tissue

unresponsive to prolactin.
• After delivery , when progesterone and
estrogen are withdrawn, prolactin begins its
milk secretion.
• Prolactin , insulin , growth hormone, and
glucocorticoids are important hormones in this
3. Galactokinesis: Oxytocin is the major
galactokinetic hormone.
• Discharge of milk from the mammary glands
depends not only on the suction exerted by the
baby during suckling but also on the contractile
mechanism which expresses the milk from the
alveoli into the ducts.
• Prolactin and oxytocin: Prolactin stimulates
alveolar epithelium to secrete milk and oxytocin
stimulates the myoepithelial cells that
surrounds the alveolar epithelium to contract
and to eject the milk from the acini to the duct.
• 4. Galactopoiesis: Prolactin is an
important galactopoietic hormone.
• For maintenance of effective and
continuous lactation, frequency of
suckling (>8/24 hours) is essential.
• Distension of the alveoli by retained milk
is due to failure of suckling. This causes
decrease in milk secretion by the alveolar
epithelium.
• Ductal and alveolar distension due to
failure of milk transfer (suckling) is a cause
of lactation failure.
Lactational
reflex arc and
role of prolactin
and oxytocin
MILK PRODUCTION: A healthy mother will produce about 500-
800 mL of milk a day to feed her infant. This requires about 750
Kcal/day for the mother, which must be made up from diet or from
her body store. For this purpose a store of about 5 kg of fat during
pregnancy is essential to make up any nutritional deficit during
lactation.

INADEQUATE MILK PRODUCTION (Lactation failure): It may be

due to infrequent suckling or due to endogenous suppression of
prolactin (ergot preparation, pyridoxine, diuretics or retained
placental bits). Pain, anxiety and insecurity may be the hidden
reasons. Unrestricted (frequent) feeding at short interval (2-3
hours) is helpful.
DRUGS TO IMPROVE MILK PRODUCTION (Galactogogues):
1. Metoclopramide (10 mg thrice daily) increases milk volume
(60-100%) by increasing prolactin levels.
2. Sulpiride (dopamine antagonist), domperidone has also
been found effective by increasing prolactin levels.
3. Intranasal oxytocin contracts myoepithelial cells and
causes milk let down.

Lactation suppression: It may be needed for women

who cannot breastfeed for personal or medical reasons.
Lactation is suppressed when the baby is born dead or dies in
the neonatal period or if breastfeeding is contraindicated.
Methods commonly used are:
(i) To stop breastfeeding
(ii) to avoid pumping or milk expression
(iii) to wear breast support
(iv) ice packs to prevent engorgement
(v) analgesics (aspirin) to relieve pain
(vi) a tight compression bandage is applied for 2-3 days. The natural
inhibition of prolactin secretion will result in breast involution.

Medical methods of suppression with estrogen, or androgen is not

advised. Bromocriptine inhibits prolactin secretion. It is given orally
2.5 mg daily for 2-3 days. Contraindications: Hypertension in
puerperium, seizures, cardiac valvulopathy.
Breastfee
ding
Breastfeeding is the act of a mother
providing nourishment to her infant by
allowing the baby to suckle at her
breast, obtaining milk produced by the
mammary glands.

It is a natural and essential process for

the health and well-being of both the
mother and the newborn.
• The two vital considerations for the infants in tropical
countries are breastfeeding and avoidance of infection.
• Artificial feeding may be required in a very rare
situation.
• All the babies, regardless of the type of delivery,
should be given early and exclusive breastfeeding up
to 6 months of age.
• Exclusive breastfeeding means giving nothing orally
other than colostrum and breast milk.
• Medicines and vitamins are allowed.
ADVANTAGES OF BREASTFEEDING
A. Composition: Breast milk is an ideal food with easy
digestion and low osmotic load.
• Carbohydrate: Mainly lactose, stimulates growth of
Intestinal flora, produces organic acids needed for synthesis of
vitamin B.
• Fat: Smaller fat globules, better emulsified and digested.
• Protein: Rich in lactalbumin and lactoglobulin, less in
casein.
• Minerals: Low osmotic load (K+, Ca2+, Na+, Cl-), less
burden on the kidney.
B. Protection against infection and deficiency states:
1. Vitamin D promotes bone growth, protects the baby
against rickets
2. Leukocytes, lactoperoxidase prevent growth of
infective agents
3. Lysozyme, lactoferrin, interferon protect against
infection
4. Long-chain omega-3 fatty acids essential for
neurological development
5. Immunoglobulins IgA (secretory), IgM, IgG protect
against infection
6. Supply of nutrients and vitamins.
C. Breast milk is a readily available food to the newborn at body
temperature and without any cost.

D. Breastfeeding acts as a natural contraception to the mother. Criteria for

LAM inculde: Continuous amenorrhea; Exclusive breastfeeding; Night
nursing
E. Additional advantages are: (i) It has laxative action
(ii) No risk of allergy
(iii) Psychological benefit of mother-child bonding
(iv) Helps involution of the uterus
(v) Lessens the incidence of sore buttocks, gastrointestinal infection
and atopic eczema. The incidence of scurvy and rickets is
significantly reduced.
Long-term risks of exclusive artificial (bottle) feeding:
(a) Type I diabetes
(b) Sudden infant death
(c) Adult type 2 diabetes
(d) Childhood obesity
(e) Adult obesity
(f) Crohn's disease
(g) Ulcerative colitis
(h) Atopic dermatitis
(i) Reduced Intelligence Quotient (IQ).
PREPARATIONS FOR BREASTFEEDING:
• Counseling for the need of early feeding (<1 hour of
birth), Frequent feeds (>10/day), No supplemental
feeding, unless medically indicated.
• To educate appropriate way to get the baby good latch on
to the breast with comfortable position.
• Massaging the breasts, expression of the colostrum and
maintenance of cleanliness should be carried out during
the last four weeks of pregnancy.
MANAGEMENT OF BREASTFEEDING:
• The modern practice is to reduce nipple cleansing to a
minimum and to wash the breasts once daily.
• A clean, soft, supporting brassiere should be worn.
• The mother should wash her hands prior to feeding. Mother
and the baby should be in a comfortable position during
feeding .
• Frequent feedings, 8-12 feeds/24 hours are encouraged.
First feed:
In the absence of anatomical or medical complications,a healthy baby
is put to the breast immediately or at most <1 hour following normal
delivery.
Following cesarean delivery, a period of 4-6 hours may be sufficient for
the mother to feed her baby.
Milk transfer: Milk transfer to infant is a physiological process. It
starts with good latch on.
The nipple is tilted slightly downward using a "C-hold".
The milk is extracted by the infant not by negative pressure but by a
peristaltic action from the tip of the tongue to the base.
The latent period between latch on to milk ejection is about 2 minutes.
Nearly 90% of the milk is obtained in the first 5 minutes. The calorie-
rich hind milk is obtained at the end part of suckling.
Frequency of feeding:◆ Time schedule: During the first 24 hours, the
mother should feed the baby at an interval of 2-3 hours. Gradually, the
regularity becomes established at 3-4 hours pattern by the end of first week.
Baby should be fed more on demand.•

Demand feeding: The baby is put to the breast as soon as the baby becomes
hungry. There is no restriction of the number of feeds and duration of
suckling time.

Duration of feed: The initial feeding should last for 5-10 minutes at each
breast. This helps to condition the letdown reflex. Thereafter, the time spent
is gradually increased. Baby is fed from one breast completely so that baby
gets both the foremilk and the hind milk. Then the baby is put to the other
breast if required. Hind milk is richer in fat and supplies more calories and
satiety to the infant. The next feed should start with the other breast
Night feed: In the initial period, a night feed is required to avoid long
interval between feeds of over 5 hours. It not only eliminates excessive
filling and hardening of the breasts but also quietest and ensures sound
sleep for the baby. However, as the days progress, the baby becomes
satisfied with the rhythmic 3-4 hourly feeding.

Amount of food: The average requirement of milk is about 60 mL/kg/24

hours on the first day, 100 mL/kg/24 hours on the third day and is
increased to 150 mL/kg/24 hours on the 10th day. However, the baby can
take as much as required.
Technique:
• The mother and the baby should be in a comfortable position.
• Feeding in the sitting position, the mother holds the baby in an inclined
upright position on her lap; the baby's head on her forearm on the same
side close to her breasts, the neck is slightly extended.
• Good closchment means the infant's mouth is wide open and chin
touches the breast .
• The mother should guide the nipple and areola into the baby's mouth for
effective milk transfer.
• The milk transfer to the infant begins with good latch on and by a
peristaltic action of the tip of the tongue to the base.
• The proper position for milk transfer is chest-to-chest contact of the
infant and mother.
• The infant's ear, shoulder and hip are in one line . Baby sucks the
areola (lactiferous sinuses) and the nipple holding between the
tongue and the palate.
• Feeding in lateral position following cesarean delivery or with
painful perineum is carried out by placing the baby along her side
between the trunk and the arm.
• When latching on, the neonate should take as much of the areola as
possible into its mouth.
• "C-hold" showed four fingers are placed below for cupping and
supporting the weight of the breast.
• The thumb is placed above and 1-2 cm away from the areolar
edge.
• This position points the nipple downward. Thumb should not
retract the areola away from the mouth.
FACTORS FOR SUCCESSFUL LACTATION:
• (i) Positioning
• (ii) Attachment to breast
• (iii) Nursing technique (to avoid breast pain, nipple trauma,
incomplete emptying)
• (iv) A rotation of positions is helpful to reduce focal
pressure on the nipple and to ensure complete emptying. To
break the suction, a finger is inserted between the baby's
lips and the breast. Other- wise it can injure nipple by
forceful disengagement.
DIFFICULTIES IN BREASTFEEDING AND
THE MANAGEMENT: At times, breastfeeding
poses some problems and if it is not promptly
detected and rectified, it may lead to adverse
consequences.

The causes may be classified as those:

1. Due to mother
2. Due to infant
Due to mother:
• Reluctance or dislike to breastfeeding-careful listening to
mother and intelligent counseling can solve the problem.
• Infant's attachment to breast -when poor, it a leads to
quick shallow sucks instead of slow and deep. Areola
remains outside the lips.
• This causes nipple pain. Skilled a support from
healthcare provider can improve the technique of
breastfeeding.
• Prelacteal feeds (e.g., honey, milk) inhibit lactation
process and should be avoided.
• Anxiety and stress, previous history of failed lactation or
elderly primipara-the mother fails to relax during feeding and
as such, the baby refuses to suck.
• Reassurance and practical support is helpful.
• Following operative delivery such as cesarean section or
following prolonged and exhaustive labor often there is a
delay.
• So mother should be helped to feed the baby in a comfortable
position as early as possible.
• Milk secretion is inadequate unrestricted feeding well-
positioned infant, practical and emotional support to mother-all
are important.
• Dopamine antagonist (metoclopramide) may be useful.
Due to infant:
• Low birth weight baby: The baby is too small or feeble to
suck.
• Temporary illness such as respiratory tract infection, nasal
obstruction due to congestion, lethargy due to jaundice and
oral thrush.
• All these conditions lead to imperfect suckling and are
managed appropriately.
• Overdistension of the stomach with swallowed air: The
problem can be overcome by breaking the wind of the baby
several times during feeding.
• Congenital malformation such as cleft palate needs surgical
correction.
 Contraindications of breast feeding
Temporary
Maternal • Acute puerperal illness
• Acute breast complications
such as cracked nipple ,
mastitis and breast abscess
• Herpes simplex lesion of the
breast
• Breast surgery/
Augmentation surgery
Infants • Very low birth weight baby
• Asphyxia and Intracranial
stress
• Acute illness
Permanent
• Chronic medical illness
such as decompensated
organic heart lesion,
Active untreated pulmonary TB
• Puerperal psychosis
• Mother having high doses of
antiepileptic , antithyroid
and antipsychotic drugs
• Severe degree of cleft palate
• Galactosemia
Acute mastiti
 Definition
Mastitis is a medical term that refers to the
inflammation of the breast tissue.

Cracked or Sore Nipples

Risk factors
Infrequent or Skipped Feedings
Stress and Fatigue
Nipple Piercings
Maternal Health Conditions - Conditions such as diabetes or immune system disorders
may compromise the body's ability to fight infections, potentially increasing the risk of
mastitis.
Obstructed Milk Ducts
Nipple Trauma or Injury - Any injury to the breast, including nipple trauma, can create
an entry point for bacteria, leading to mastitis.
Mode of infection: There are two different types of
mastitis depending upon the site of infection.
(1) Infection that involves the breast parenchymal
tissues leading to cellulitis. The lacteal system remains
unaffected.
(2) Infection gains access through the lactiferous duct
leading to development of primary mammary adenitis.
The source of organisms is the infant's nose and throat.
Onset: In superficial cellulitis, the onset is acute during first
2-4 weeks postpartum. However, acute mastitis may occur
even several weeks after the delivery.
Clinical features
Symptoms include:
(a)Generalized malaise and headache, nausea, vomiting
(b) Fever (>38.5°C or more) with chills
(c) Severe pain and tender swelling in one quadrant of the
breast
(d) Indurated.

Signs include:
(b)Presence of toxic features
(b) Presence of a swelling on the breast.
(c) The overlying skin is red, hot and flushed and feels tense
and tender.
Diagnosis: Microscopic examination of breast
milk, showing leukocytes more than 10/mL and
bacterial count more than 10³/ml., supports the
diagnosis of mastitis.
Complications: It may lead to the formation of a
breast abscess.
Prophylaxis: Thorough handwashing before each
feed, cleaning the nipples before and after each
feed, and keeping them dry, reduce the nosocomial
infection .
Management: (a) Breast support
(b) Plenty of oral fluids
(c) Breastfeeding is continued with good attachment. Nursing is
initiated on the uninfected side first to establish let down
(d) The infected side is emptied manually with each feed
(e) Dicloxacillin is the drug of choice. A dose of 500 mg every 6
hours orally is started till the sensitivity report available.
Erythromycin or clindamycin is an alternative to patients who are
allergic to penicillin. Antibiotic therapy is continued for 10-14
days
(f) Analgesics (ibuprofen) are given for pain
(g) Milk flow is maintained by breastfeeding the infant. This
prevents proliferation of Staphylococcus in the stagnant milk. The
BREAST ENGORGEMENT: Bilateral generalized
tenderness of breasts is seen on 2 to 4 days postpartum.
Low grade fever is often associated. It is due to interstitial
oedema or accumulation of excess of milk. It is treated with
worm compress followed by expression (by hand or pump)
of milk. Continued breast feeding is helpful .
BREAST ABSCESS: Features are
(1) Flushed breasts not responding to antibiotics promptly.
(2) Brawny oedema of skin
(3) Marked tenderness with fluctuation
(4) Swinging temperature.
Management of abscess….
1.Breast abscess is to be drained under general anesthesia
by a deep radial incision extending from near the areolar
margin to prevent injury of the lactiferous ducts.
2.Incision perpendicular to the lactiferous ducts increases
the risk of fistula formation and ductal occlusion.
3.Finger exploration is done to break up the walls of the
loculi. The cavity is loosely packed with gauze which
should be replaced after 24 hours by a smaller pack.
4.The procedure is continued till it heals up. The abscess
can also be drained by serial percutaneous needle
aspiration under ultrasound guidance.
• Breastfeeding is continued in the uninvolved
side.
• The infected breast is mechanically pumped
every 2 hours and with every let down.
• Once cellulitis has resolved, breastfeeding from
the involved side may be resumed.
• Antibiotics to be continued depending upon the
culture report of pus .
• Breast pain may be due to engorgement,
infection (C. albicans), nipple trauma, clogged
milk, mastitis or occasionally with latching on or
Treatment: For maintenance of effective lactation in an otherwise healthy
individual, the following guidelines are helpful.
• Antenatal:
(1) To counsel the mother about the advantages of breast milk
(2) To take care of any breast abnormality, especially a retracted nipple and to
maintain adequate breast hygiene, since 36 weeks of pregnancy.
• Puerperium:
(3) To encourage adequate fluid intake
(4) To nurse the baby regularly
(5) Painful local lesion is to be treated
(6) Metoclopramide, intranasal oxytocin and sulpiride (selective dopamine
antagonist) have been found to increase milk production. They act by
stimulating prolactin secretion. Metoclopramide given in a dose of 10 mg
thrice daily is found helpful.
INADEQUATE MILK PRODUCTION: The normal volume of milk
produced at the end of first postpartum week is 550 mL/day. By 2-3 weeks it
is increased from 80 about 800 mL/day. Production peaks at 1.5-2.0 L/day.
The causes of inadequate milk production are:
(1) Infrequent suckling
(2) Depression or anxiety state in the puerperium
(3) Reluctance or apprehension to nursing
(4) III- development of the nipples
(5) Painful breast lesion
(6) Endogenous suppression of prolactin (retained placental bits)
(7) Prolactin inhibition (ergot preparations diuretics, pyridoxine)
(8) Previous breast surgery
(9) Insulin resistance
(10)High androgen levels.