Changes in Lactation

Lactation

the process by which milk is synthesized and secreted from the mammary glands of the postpartum female breast in response to an infant sucking at the nipple

Breast Milk

• provides ideal nutrition and passive immunity for the infant

• encourages involution

• induces a substantial metabolic increase

• helps to protect the infant against infection during infancy, but also provide long-lasting active immunity

• has laxative properties that help expel meconium from the intestines and clear bilirubin through the excretion of bile

Prolactin

is instrumental in the establishment and maintenance of breast milk supply

5th week of Pregnancy

levels in the circulation increase by 10 to 20 times pre-pregnancy concentration

Late Pregnancy

levels begin to plateau, high enough to initiate milk production

After Childbirth

the baseline prolactin level drops sharply, but it is restored for a 1-hour spike during each feeding to stimulate the production of milk for the next feeding

Inhibitors

Estrogen, progesterone and other placental hormones

Other contributing hormone

growth hormone, cortisol, parathyroid hormone, and insulin

Frequent milk removal by breastfeeding (or pumping)

will maintain high circulating prolactin levels for several months

Protein in human milk per gram

4 kcal/g (17 kJ/g)

Carbohydrates of human milk per gram

3.8 kcal/g (16 kJ/g)

Fat in human milk per gram

8.8 kcal/g (37 kJ/g)

mature human milk yields

approximately 753 kcal/liter (3150 kJ/L)

An intake of 500 g/day of breast milk in the second year of life

can cover about 30% of energy, 45% of Vitamin A, and 95% of Vitamin C daily requirements of children

Iron in Breast Milk

Limit the growth of microbes and so protect the infant from gastrointestinal infections and prevents IDA in exclusively breastfed infants

Enzymes, growth factors and hormones

Growth and development, maturation of the gut and nervous systems (Breastfed infants have optimal visual development and higher IQ scores or academic outcomes)

Cell numbers

highest in colostrum and gradually decline during the first three months to a steady level

macrophages, lymphocytes, neutrophils, complement, lysozyme, lactoferrin and prostaglandins, immunoglobulins, oligosaccharides, nucleotides, and others

contribute to the host-resistant and immunological significance of human milk

Colostrum

• thick, yellowish substance

• high in protein but contains less fat and glucose than mature breast milk, rich with immunoglobulins

• secreted during the first 48–72 hours postpartum (3 oz in a 24-hour period)

Postpartum day 3

the mother secretes transitional milk.

Intermediate between mature milk and colostrum

Postpartum day 10

mature milk

Foremilk

watery, translucent, and rich in lactose and protein (quench the infant’s thirst)

Hindmilk

opaque, creamy, and rich in fat (satisfy the infant’s appetite)

Cow’s Milk

• not a substitute for breast milk

• contains less lactose, less fat, and more protein and minerals

• difficult for an infant’s immature digestive system to metabolize and absorb

First few weeks of Breastfeeding

may involve leakage, soreness, and periods of milk engorgement

approximately 1.5 liters of milk per day

Once this period is complete, the mother will produce _______ for a single infant

any remaining milk will be reabsorbed

once breastfeeding is stopped for approximately 1 week

Bilirubin

• a product of erythrocyte breakdown, is processed by the liver and secreted in bile.

• It enters the gastrointestinal tract and exits the body in the stool.

Jaundice

High concentration off bilirubin in the blood causes

Hyperbilirubinemia

most common condition requiring medical attention in newborns

Stage 1: Mammaogenesis

• occurs when the breasts are formed, right from birth, through to puberty and, then, the process is completed during pregnancy

• between mid pregnancy and two days postpartum

Stage 2: Lactogenesis

• when a mother starts to adequately produce milk

• between day three and day eight postpartum

Stage 3: Galactopoiesis

• the creation and sustaining stage of mature milk from day nine post partum until the baby besides to wean

• milk production relies on the supply and demand system

Stage 4: Involution

when the breasts cease to produce milk after weaning

Breast Engorgement

• congestion/increased vascularization, accumulation of milk and edema

• May occur 3rd to 5th day after delivery due to: late initiation of breastfeeding, infrequent breastfeeding, restriction on the duration and frequency of breastfeeding, use of complementary foods, and babies with poor suck.

• The breast is bigger, painful, with diffuse shiny reddish areas, and edema

• If no relief is obtained, milk production is interrupted, with later reabsorption of the residual milk.

Physiological Engorgement

discrete and is a positive sign that milk is "coming in"

Pathological Engorgement

excessive tissue distension, causing great discomfort, sometimes accompanied by fever and malaise

Breast Engorgement Prevention

• start nursing as soon as possible

• breastfeed on demand

• use a proper breastfeeding technique

• avoid the use of supplements

Breast Engorgement Treatment

• Manual expression before breastfeeding

• Breastfeed on demand on a regular basis

• Massage the breasts gently

• Systemic analgesics/anti-inflammatory drugs

• Wear a well-fitting, supportive bra with large flaps

• Apply warm compresses to help the ejection of the milk

• Apply cold compresses after or between breastfeeding to reduce edema, vascularization and pain.

Sore Nipples/Trauma

• improper positioning and inappropriate latch-on

• short/flat or inverted nipples

• oral dysfunctions in the infant

• excessively short frenulum

• prolonged nonnutritive sucking

• improper use of milk pumps

• not breaking suction before taking the infant off of the breast

• use of creams and oils that cause allergic reactions

• use of nipple shields and prolonged exposure to wet nursing pads

• includes erythema, edema, fissures, blisters, white "spots," yellow or dark spots and ecchymosis.

Sore Nipple/Trauma Prevention

• use a proper breastfeeding technique

• keep the nipples dry by exposing them to air or sunlight and change the nursing pads used to prevent milk flow, on a regular basis

• avoid products that remove the natural protection of nipples, such as soaps, alcohol or any drying agent

• breastfeed on demand

• manually express milk from the areola before breastfeeding if it is engorged, since this increases flexibility and allows for a proper latch on

• if a feeding has to be discontinued, slip the index or little finger into the infant's mouth between his/her gums to break suction before the infant is taken off of the breast

• avoid the use of nipple shields

Sore Nipple/Trauma Treatment

• Measures aimed at minimizing the stimulation of pain receptors:

  • offer the least affected breast first

  • express enough milk before breastfeeding

  • alternate between different positions

  • use "breast shells"

  • use oral systemic analgesics, if necessary

• Two methods to fasten healing of nipple trauma: Dry wound healing and Moist wound healing

Dry wound healing

exposure to light, sunbathing, blow drying

Moist wound healing

use of breastmilk, and appropriate creams and oils - recommended

S. aureus Infection

Secondary nipple infection is quite common

S. aureus Infection Treatment

• Topical use of mupirocin at 2% or systemic antibiotic therapy

• Study showed that systemic antibiotic therapy (dicloxacillin) was highly efficient in the treatment of nipple infection

Candidiasis

• Secondary to C. albicans in the puerperium

  • Infection can be superficial or affect the lactiferous ducts, and often occurs in the presence of moist nipples

• Characterized by itching, burning sensation and "twinges" in the nipples, which persist after breastfeeding

• Reddish and shiny appearance of the nipples

• Infant - oral white patches, which should not be mistaken for milk patches (the latter of which are removed without leaving a bloody area)

Candidiasis Prevention

• As the fungus grows in a moist, warm and dark environment, maintaining the nipples dry and exposing them to air, and also exposing them to light for some minutes every day.

• Pacifiers and bottle nipples should be boiled for 20 minutes, at least once a day

Candidiasis Treatment

• Mother and infant must be treated simultaneously

• Initially topical and includes nystatin, clotrimazole, miconazole or ketoconazole for two weeks - applied after breastfeeding

• If topical treatment is not efficacious, the use of systemic oral fluconazole is recommended for 14 to 18 day

Raynaud’s Phenomenon

• an intermittent ischemia caused by a vasospasm that often

  • occurs in the fingers and toes, can also affect the nipples occurs in response to cold temperature exposure, abnormal compression of the nipple in the infant's mouth or severe nipple trauma

  • vasospasms may cause nipples to become pale (due to the lack of blood irrigation)

  • often painful (twinging pain or burning sensation when the nipple is pale)

  • can appear before, during or after breastfeeding

Raynaud’s Phenomenon Treatment

• Warm compresses

• Some medications can be used: nifedipine, vitamin B6, calcium supplementation, magnesium supplementation and ibuprofen

Plugged Ducts

• often occurs when the breast is not properly emptied or when there is local pressure on some area (e.g., very tight bra) or as a consequence of the use of creams on the nipples

• typically characterized by the presence of sensitive and painful breast lumps in a mother without any other breast disease

Plugged Ducts Prevention

Any measure that facilitates the complete emptying of the breast

Plugged Ducts Treatment

• breastfeed on a regular basis

• alternate between breastfeeding positions

• apply local heat, and gently massage the affected region

• express milk from the breast

• If there is a whitish spot at the tip of the nipple, rub it off with a towel or use a sterilized needle.

Mastitis

• an inflammatory process of one or more breast segments

• usually occurs in the second and third weeks after delivery, and very rarely, after the twelfth week

• Initially, the intraductal pressure rises due to milk stasis with consequent flattening of alveolar cells and development of spaces between the cells.

• Some components cross from plasma into milk and from milk into the interstitial tissue (especially cytokines) through this space, inducing an inflammatory response, most times involving the interlobular connective tissue.

• The accumulated milk, the inflammatory response, and the resulting tissue damage facilitate the establishment of the infection, usually by Staphylococcus.

• Any factor that favors the stagnation of breastmilk predisposes

• affected portion of the breast is painful, hyperemic, edematous and warm

• malaise, high-grade fever (above 38 ºC), chills - if infection is present

• sodium and chloride levels are elevated in the milk, lactose levels are low

Mastitis Prevention

Same ones recommended for breast engorgement, plugged ducts and cracked nipple, and so is the early management of these intercurrent diseases

Mastitis Treatment

• Proper emptying of the breast is the most important part of the treatment

• Antibiotic therapy

Breast Abscess

Caused by untreated mastitis or results from late or inefficient treatment

Breast Abscess Prevention

Any measure that prevents the development of mastitis will consequently prevent breast abscess, and so will the early treatment of mastitis, if it cannot be prevented

Breast Abscess Treatment

• Emptying the abscess by way of surgical drainage or aspiration

• Despite the presence of bacteria in the milk, in case of breast abscess, breastfeeding should be maintained as it does not pose any risks to healthy full-term infants.

• If it is necessary to discontinue feeding on the affected breast, this breast should be regularly emptied and feeding should be maintained on the healthy breast

Galactocele

• Cystic formation observed in lactiferous ducts containing milky fluid

  • believed to be caused by a plugged duct

• Treatment consists of aspiration

  • the cysts should be surgically removed because they fill with milk again after aspiration

Poor Milk Production

Most women can produce enough milk to meet their infants' demand. However, "weak milk" or "insufficient milk" is the most frequent argument.

• complaint of "insufficient milk" is more often than not a wrong perception of the mother

• often leads to the introduction of complementary feeding, which negatively affects milk production, as the infant tends to suckle less

If milk production seems to be insufficient for the infant, due to low weight gain, in the absence of diseases, the first thing to do is to check whether the infant is properly positioned during breastfeeding and whether the latch-on is appropriate

When milk is not sufficient, the infant:

• does not feel satisfied, cries a lot

• does not properly gain weight

• number of wet diapers a day (less than six to eight) and infrequent bowel movements, with a small amount of stools

To increase milk production, the following measures are useful

• improve latch-on

• increase the frequency of feeding

• offer both breasts in each breastfeeding

• allow the infant to empty the breasts completely

• alternate between breasts during the same feeding if the infant feels drowsy or if he/she is not sucking vigorously

• avoid the use of bottles, pacifiers and nipple shields

• eat a balanced diet

• drink enough fluids (recall that excessive intake of fluids does not increase milk production, and can even reduce it.)

• take a rest

Medication to Poor Milk Production

domperidone and metoclopramide, dopamine antagonists, which increase prolactin levels

Diet for Lactating Women Characteristics

• Designed to encourage and support milk production of the mother

• RENI: 500 kcal increase per day in the diet to normalize body composition progressively and to provide for adequate lactation

  • Protein increase by 23 g/day (first 6 months) and 18 g/day (second 6 months)

• An additional intake of 750 to 1000 ml/day of fluids is recommended to avoid dehydration.

• Vitamin and mineral needs ordinarily will be supplied from these additional foods