Lactation, Bonding, and Attachment

immunity, diarrhea, low, bonding, uterine, loss, cancer

Benefits of Breastfeeding

-Infant __________

• Transfer of immunoglobulins, macrophages, and leukocytes

• Prevention of illnesses including gastroenteritis, _______, respiratory disease, COVID-19, otitis media, and SIDS

• Most impactful in ___ to middle resource countries

-Improves infant GI function

-Mother-infant _________ → skin-to-skin contact and early breastfeeding recommended

-Economic savings

-May decrease risk of type 1 diabetes, IBD, and wheezing

-Maternal benefits → accelerated ______ recovery and reduced risk of postpartum blood ____. Reduced risk of breast ________, ovarian cancer, endometrial cancer, cardiovascular disease, and type 2 diabetes

extra, calories, prenatal, alcohol, engorged, two, caffeine, mercury

Maternal Nutrition During Lactation

-Nursing mothers should have a fluid intake of > 3 L/day 

-25 grams of ______ protein 

-330 extra _______/day in the first 6 months of nursing

-Continuation of a _________ vitamin and mineral supplement 

-Alcohol and caffeine → a small percentage of ________ is transferred into breastmilk

• “Pump and dump” not necessary unless the breasts become uncomfortable ___________

• Wait at least ___ hours per serving of alcohol before breastfeeding 

• Most breastfeeding women can drink a moderate amount of _______ without significant effects on their infants

-Breastfeeding women should avoid fish with high concentrations of ________

growth, secretory, ducts, development

Breasts During Pregnancy and Lactation

-The mammary glands undergo _______ during pregnancy

• Cell proliferation in __________ alveoli at the ends of intralobular ______

-Degree of glandular _____________ varies among lobules, even within a single lobule

estrogen, alveoli, inhibits, production, contracts, growth

Hormones Involved in Lactation

-_________ → milk duct growth

-Progesterone → _______ and lobe growth. _______ milk production during pregnancy. Drops at birth, starts milk production.

-Prolactin → alveoli growth. Maintains milk ___________ after pregnancy by continued stimulation of alveoli. Induces a-lactalbumin that increases galactosyl transferase affinity for glucose. Negative feedback on GnRH suppresses FSH and LH secretion and, thereby, menstruation and ovulation

-Oxytocin → _______ smooth muscle around milk duct alveoli to squeeze milk into ducts and out of areolae. Maintains milk production after pregnancy

-Human placental lactogen → augments ______ of breasts, nipples, and areolae

dilated, colostrum, proteins, prolactin, IgA, passive

Colostrum

-Late in pregnancy, the glandular alveoli and ducts are _______ by an accumulation of _________

• Fluid rich in ________ and containing leukocytes

• Produced under the influence of __________

-___ antibodies pass into colostrum

• ________ acquired immunity is conferred on the breastfed newborn

alveoli, prolactin, enlarge, bilaterally, milk 

Lactation

-After childbirth…

• _______ of mammary glands start active milk production

• Stimulated primarily by ________ from the anterior pituitary 

• Epithelial cells of the alveoli _______

• May take 2-3 days for the milk to “come in”

• Breasts enlarge ___________

• In non-breastfeeding women, _____ will accumulate in the glands until the body stops making it 

suckling, oxytocin, production, contraction, ejection

Milk Ejection

-_________ stimulates the release of prolactin and _________

-Prolactin stimulates milk ___________ in readiness for the next feed

-Oxytocin causes ____________ of the myoepithelial cells lining the duct walls, causing _________ of the milk

first, hunger, weighed, caloric, lose

Normal Milk Intake

-During the _____ week of life, mothers with term infants should nurse when the infant exhibits ________ cues

• Usually 8-12 times in 24 hours

• By the 5th day of life, infants with adequate intake urinate at least 6-8 times daily and have 3 or more pale yellow and seedy stools daily

-Infants must be _________ naked at each office visit and at any time a parent is concerned about having enough milk

• To determine if _______ intake is adequate

• Term infants generally _____ weight in the first 3-5 days of life. Typically regain their birth weight b 1-2 weeks

removal, volume, demand, decrease, emptying, stress, illness, smoking

Milk Removal

-Milk _______ by the infant and/or the timing and frequency of milk expression si the major factor in determining milk ________

-More _______→ more volume

-Factors that may _________ milk production

• Incomplete breast ___________

• Infrequent milk expression

• Maternal ______ and anxiety

• Maternal fatigue 

• Maternal __________

• Maternal insulin resistance 

• Use of combined hormonal oral contraceptives 

• Maternal __________ 

• Separation from the infant 

production, pain, bloody, jaundice, medications

Common Breastfeeding Problems

-Inadequate milk ____________

-Inadequate milk intake

-Nipple and breast ____

-Breast infections

-________ nipple discharge

-Milk oversupply

-Neonatal __________

-Maternal use of ______________

surgery, PCOS, swallowing, latch, technique, gain, stress

Inadequate Milk Intake: Potential Causes and Management

-Potential causes → breast ________, nipple conditions, medications, hormonal (____, hypertension, hypothyroidism), prematurity, ankyloglossia, sucking and __________ disorders, separation of mother and infant, and poor _____

-Management → optimize breastfeeding __________, monitor infant’s weight ____ closely and supplement if weight gain is inadequate, relaxation techniques for maternal ______, and frenulotomy if absolutely indicated

injury, latch, blocked, infections, positioning, moisture, mupirocin, compresses

Nipple and Breast Pain

-Potential Causes 

• Nipple _______ from breastfeeding or pumping, due to improper _____ or poorly fitted breast shield 

• Nipple vasoconstriction

• Engorgement

• Narrowed (_______) ducts 

• Nipple and breast __________

• Excessive milk supply

• Nipple dermatitis/psoriasis 

-Management

• Ensure proper __________ and latch of the infant 

• Avoid excess _________ on the nipples and irritating cleansers. The nipples should be allowed to air dry after breastfeeding. 

• Bacitracin or ________ ointment for cracked or abraded nipples 

• Cool or warm ____________

• Acetaminophen or ibuprofen 

lingual, pain

Ankyloglossia

-_______ frenulotomy has been shown to decrease nipple ____ and may facilitate breastfeeding

-Colloquially known as being tongue tied

itchy, burning, rash, psoriasis, steroids

Areolar Dermatitis

-Typically presents as _____ and painful __________ of the areola and nipples with a red scaly ____

-More common in women with a history of eczema or __________

-Management → avoid potential irritants and allergens, medium potency topical ________ applied after feeding

vasospasm, vasoconstriction, Raynaud, pain, cold, trauma, warm, nicotine

Nipple Vasoconstriction

-Cutaneous __________ of the nipple due to arteriolar ______________

-Can occur in mothers who have ________, unusual cold sensitivity, or nipple trauma

-Presents with nipple _____, burning, and paresthesia with ____ exposure, nursing, or nipple _______

-Management → breastfeed in ____ conditions, heating source applied over the bra, avoid vasoconstricting substances such as ________ and caffeine, and nifedipine 

edema, firmness, small, areola, warm, decrease, Ibuprofen, cabbage

Engorgement

-Interstitial ______ with accumulation of excess milk, presenting as breast fullness and ____________ accompanied by pain and tenderness

-Management

• Manual expression of _____ amounts of milk before feeding to soften the _______ and facilitate latching

• Warm compresses or a _____ showed to enhance let-down, which is the reflex where nerves in the breast send signals to release the milk in the ducts

• Cold compresses between feedings to __________ swelling and discomfort

• ___________ or acetaminophen

• Application of cool green _________ leaves

blocked, painful, white, feeding, massage, triamcinolone

Ductal Narrowing

-Localized duct narrowing → commonly called __________ milk ducts

• A tender and often __________ palpable lump due to obstruction of a mammary duct

• Obstruction of the nipple pore ducts may also occur and present as a _____ bleb at the end of the nipple, “milk blister”

-Management → optimize ________ technique, cool compresses, manual _________, Ibuprofen and acetaminophen, and topical 0.1% ____________ cream for nipple blebs to reduce inflammation

cysts, inflammation, blocking, large, infected, thicker, ultrasound, aspiration

Galactocele

-Milk retention _______

-More common where there is a breast ___________ or edema, causing external pressure on milk ducts, thus __________ the ducts

-Sometimes very _____ masses

-Usually painless unless ___________

-Initially contain milky fluid but over time contents become _______, creamy, or oily 

-Diagnosed on ___________

-Management → needle __________ or surgical excision only if the galactocele is bothersome to the mother. Breastfeeding can generally continue 

inflammation, fever, pain, tender, dicloxacillin, bactrim, continue

Lactational Mastitis

-Localized _____________ of the breast that is associated with _____, myalgia, breast ____, and redness

-Most common during the three months postpartum

-Presents as a firm, red, and ______ area of one breast and systemic illness including fever

-Treatment with ___________ or cephalexin 

-If MRSA suspected, _________ or clindamycin 

-Breastfeeding can _________ during infection, or may pump for comfort while supplementing if too painful

pus, mastitis, fluctuant, mass, aspiration, drainage

Breast Abscess

-Localized collection of ___ within the breast tissue that is often preceded by _______

-________, tender, and palpable ____

-Treat with needle _________ and surgical ________

-May continue breastfeeding

pain, infant, flaky, scraping, fluconazole, nystatin

Candida

-Diagnosis

• Breast ____ out of proportion to physical findings

• History of _____ oral candidiasis, diaper candida infection, or maternal candida vulvovaginitis

• Physical finding of shiny or _____ skin of the affected nipple

• If available, a positive skin __________ of nipple or areolar region demonstrating candida or positive breastmilk culture for Candida

-Management

• Topical miconazole or clotrimazole

• Oral ___________

• Treat the infant for oral candidiasis, typically with _______

bloody, increased, alveoli, cracked, culture, stool, Apt

Bloody Nipple Discharge

-_______ nipple discharge during the first days of lactation → “rusty pipe syndrome”

-Thought to be due to _________ vascularization of the ________ and ducts with the onset of milk production

-Generally resolves within a few days 

-Other causes include ________ nipples or subacute mastitis, should be evaluated with a thorough breast exam and breastmilk _______

-If the infant is spitting up blood-tinged milk or has blood in the _____, an ___ test is used to confirm whether the source of bleeding is from the mother or the infant

hyperlactation, supply, forceful, choke, drugs, dopamine, position, compresses

Milk Oversupply

-Also known as hypergalactia or ___________, which is when the ______ exceeds the demand

-In some cases, the rush of milk with the mother’s ejection reflex may be too ________ and the infant may have trouble feeding

• Infants may _____, cough, become irritable with feeding, and may bite to clamp the nipple

-Evaluate for _____ that increase milk production

• Psychiatric meds that may be ________ antagonists

• Herbs like fenugreek

-Also evaluate the mother for hypo or hyperthyroidism

-Management → change nursing _______, manual reduction of flow, interrupt feeding as needed, pumping, cold ____________ for discomfort, low-dose oral contraceptives may be helpful, and milk collection shells to fit inside the bra to collect any leaked milk

persistence, weeks, declines, mild, calories, loss, breastfeeding

Neonatal Jaundice

-Breast milk jaundice → the __________ of benign neonatal hyperbilirubinemia beyond the first 2-3 ______ of age

• Typically presents after the first 3-5 days of like, peaks within 2 weeks after birth, and progressively ________ to normal levels over 3-12 weeks

• Generally ____ and does not require intervention, but it should be monitored to ensure that it remains in the unconjugated form and does not increase

-Inadequate milk intake

• Breastfeeding difficulties → inadequate intake of fluids and _________ → hypovolemia and significant weight ____ → hyperbilirubinemia and, in some cases, hypernatremia

• Establishment of successful __________ is challenging due to shortened postpartum length of stay for newborn infants and their mothers

compatible, safe, dopamine, statins, chemotherapy, codeine, aspirin

Maternal Use of Medications

-Most, but not all, therapeutic drugs are _________ with breastfeeding 

-If the medication could otherwise be prescribed to the infant for a medical condition, it is generally considered ____ for the mother to take while breastfeeding

-Doses of medications transferred via breastmilk are generally much lower 

-Medications that can decrease breastmilk volume → ________ agonists, decongestants, estrogens 

-Drugs that are not compatible with breastfeeding → ______, amphetamines, ergotamines, and _________ agents 

-Most analgesics are safe, but ______ and tramadol should be avoided. Use oxycodone and _______ with caution

HIV, suppression, HTLV, ilicit, ebola, HSV, tuberculosis, varicella

Contraindications to Breastfeeding

-Do not breastfeed or feed expressed milk

• If the infant has classic galactosemia

• If the mother has ___ and is not on ART or is on ART but does not have sustained viral ____________ with confirmed undetectable viral load

• If the mother has human T-lymphotropic virus (____)

• If the mother uses _____ drugs

• If the mother has suspected or confirmed _____ virus disease

-Temporarily do not breastfeed or feed expressed milk

• If the mother has untreated brucellosis

• If the mother is taking certain medications

• If the mother has an active ___ infection with lesions present on the breast

• If the mother has monkeypox

-Temporarily do not breastfeed but may feed expressed breastmilk

• If the mother has active ______________ (TB)

• If the mother has active _______ that developed between 5 days prior to delivery and 2 days following delivery

prolactin, GnRh, amenorrhea

Lactation Amenorrhea

-Regular suckling maintains ________ levels

-Prolactin inhibits ____ → thus no FSH/LH

-Results in anovulation and ____________

after, feelings, trust, gradually, mood, sleep

Bonding and Attachment

-Bonding occurs shortly _____ births and reflects the ________ of the parents toward the newborn

-Attachment involves reciprocal feelings between the parent and the infant

• “Emotional exchange” 

• Infant cues the parent that she/he is unhappy and the parent responds, leading to _____ development

• Develops _________ over the first year

• Crucial for optimal development

-Bonding and attachment can be affected by postpartum mood disorders, maternal/paternal stress, and _____ deprivation