Breast tissue differentiates during gestation At delivery, loss of placental hormones allows milk production to begin Infant suckling at the breast causes contraction of myoepithelial cells and release of milk
Milk produced in mammary epithelium within lobules With nursing, oxytocin triggers contraction of myoepithelial cells and transfer to sinuses
Study: 1 woman, monitored during morning feed at 7 months. 8 control days, 12 distraction days; given saline or pitocin injection prior to nursing. Pitocin returned milk supply to near-normal. Ice water - immersed feet for 10 of 30 sec; math - difficult verbal problems w/ shock if incorrect answer; toe pull - interemittent pulling of big toe, causing pain
A shallow latch, or sucking on the nipple, stimulates let down but doesn’t empty the breast. It also leads to sore, cracked nipples, engorged breasts, and hungry, frustrated babies.
Don’t distribute formula company materials in your office or hospital Ensure pediatric follow-up in the first 3-5 days Skin-to-skin at birth, nurse in the first hour Room in Feed on demand No pacifiers or formula, unless medically necessary
• Review public health impact of
• Understand physiology of lactation
• Identify the differential diagnosis and
treatment for common breastfeeding
» Low milk supply
» Breast abscess
Health Impact ofHealth Impact of
Not BreastfeedingNot Breastfeeding
IllnessIllness OROR IllnessIllness OROR
breast cancerbreast cancer
Otitis mediaOtitis media 2.02.0 Ovarian cancerOvarian cancer 1.31.3
PneumoniaPneumonia 3.63.6 Type 2 DiabetesType 2 Diabetes 1.21.2
Formula-feeding vs. breast-feeding: risk of adverse outcomes.
Breastfeeding and Maternal and Infant Health Outcomes in
Developed Countries. AHRQ Evidence Report Number 153. April 2007.
AAP RecommendationsAAP Recommendations
the first six months
at least one year,
‘As long as is
by mother and
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
• Active tuberculosis
• Medications that
• Newborn with
• Maternal HIV
» US: not recommended
» UNICEF: When
replacement feeding is
and safe, avoidance of
all breastfeeding is
the first months of life.
How Does Lactation Happen?How Does Lactation Happen?
Where does milk come from?Where does milk come from?
• Moves milk from
lobules to sinuses,
so baby can eat
• Inhibited by stress,
• Triggered by sound,
smell, sight of infant
Let Down: Ejection, not suction,
moves milk to the areola.
Stress and Milk VolumeStress and Milk Volume
J. Pediatr 1948; 33:698-704.
Milk TransferMilk Transfer
• Infant grasps most
of the areola in his
• Tongue “milks”
milk to the back of
the mouth prior to
Latch: The baby’s tongue moves
milk from areola to nipple.
Negative feedbackNegative feedback
• Milk in lobules contains
whey protein called
Feedback Inhibitor of
• If milk is not removed,
and lumen is full,
production will decrease
• Goal: 10-12 feeds in 24
hours, until baby is done.
Demand drives supply.
Evidence-based early careEvidence-based early care
Start out right: establish
Low Milk SupplyLow 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%
» 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 abscessBreast abscess
• 3% of women with mastitis
» Hard, red, tender mass after appropriate
» Diagnostic ultrasound
» Needle aspiration for culture / treatment
» Surgical drainage for large or multiple
• Follow-up care
» Continue breastfeeding
For more informationFor 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
• American College of Obstetrics and
Gynecology (2007). Breastfeeding: Maternal
and Infant Aspects. Special Report from
ACOG. ACOG Clinical Review 12(1
• Academy of Breastfeeding Medicine