breast feeding and initation of lactation pptx

By: Abdullah W (Lecturer)
Breast feeding and
initiation of lactation
Midwifery Department

Objectives
At the end of this session the students will able to
Discuss the Physiology of lactation
Explain the benefits of the breast feeding to the baby
and the mother
Explain problems of breast and their management
Recognize the contraindication of breastfeeding
4/24/2024 Abdullah W (Lecturer) 2

Anatomy of the Female Breasts
The breast undergoes dramatic changes in size, shape,
and function in association with puberty, pregnancy, and
lactation.
These changes are critical to successful breastfeeding.
Breast-feeding is associated with a decreased incidence
of childhood attention deficit Disorder.

ANATOMIC CHANGES
Composed of a stroma consisting of fat and
connective tissue that supports a tubuloalveolar
parenchyma.
The normal adult breast contains three types of
lobules, known as types 1, 2, and 3.
Formation of type 1 lobules (Lob 1) begins with
puberty.

ANATOMIC CHANGES
Development of mammary gland
 Development of mammary gland

Primar
y
Areol
a
Seconda
ry
Areola
Montgeomery
’s
tubercles
Areola and montgeomery’s tubercles

Physiology of lactation
I. Mammogenesis:-
Is the alveolar development and maturation of
the epithelium that occurs in response to the
hormonal changes of pregnancy.
The maximum branching capability of the breast
is expressed during this period

Physiology of lactation…
Mammogenesis:-
The development of the breast during
pregnancy occurs in two distinct phases.
Early pregnancy
Under the influence of hcG, many secretory glands
develop from each bud
the lobules further enlarge and increase in
number

Later pregnancy
Fully differentiated secretory units or acini
becomes increasingly evident.
Proliferation of new acini is reduced, the lumen
of already formed units becomes distended by the
accumulation of secretory material or colostrum.

II. Lactogenesis
development of the ability to secrete milk and
entails activation of the mature alveolar cells.
takes place in two stages,
1. secretory initiation and
2. secretory activation

1. Secretory initiation
 occurs during the second half of pregnancy.
 Small amounts of milk containing lactose and
casein may be secreted after about 16 weeks'
gestation, and lactose derived from the breast
begins to appear in maternal urine.
During late pregnancy, many women are able to
express colostrum

2.Secretory activation
marked by the onset of copious milk production after
delivery.
This stage is triggered by both the rapid decline in
progesterone and the elevated levels of prolactin,
cortisol and insulin.
 this occurs two to three days postpartum but may be
earlier or as late as seven days or longer after delivery
(primi, c/s, instrumental delivery, retained placenta)

III. Galactokinesis
IV. Galactopoiesis
maintenance of lactation the process of continued
secretion of copious milk.
It requires regular removal of milk and stimulation
of the nipple, which triggers prolactin and oxytocin
release

REGULATION OF MILK PRODUCTION
1. Breast emptying
2. Prolactin
3. Feedback inhibition
4. Lactose synthesis
5. Oxytocin reflex
6. Fetal reflex

1. Breast emptying
 maintenance of milk production depends upon the
removal of milk on a regular basis
 excessive and prolonged accumulation → elevating
intramammary pressure → impede blood flow
through the mammary capillaries →, reducing the
supply of nutrients and stimulatory hormones →
disrupt the synthesis and secretion BM milk.

2. Prolactin is necessary for milk secretion
plasma [prolactin] ↑ rapidly during suckling
secretion is mediated through stimulation of nerve
endings in the nipple-areolar complex.
concentrations do not correlate with the volume of
milk produced

But level in the lactocyte play a role
In a full breast, there is reduced uptake of plasma
prolactin into the lactocyte that may result in
reduced milk production

3. Feedback inhibition
 is another mechanism that limits milk production
by a milk protein “FIL”
 Mechanism = reversible blockade of the secretory
pathway by down regulation of cell-surface
prolactin receptors.

4. Lactose synthesis —
is the primary determinant of volume as it is the
major osmotic component of milk
 formed by lactose synthetase within the Golgi
complex from glucose and -galactose

5. Milk ejection
 Occur through tactile stimulation→ afferent
signals to the hypothalamus → oxytocin →
myoepithelial cells → milk ejection.
 If the breasts are sufficiently engorged to restrict
blood flow to the alveoli, normal milk ejection is
blocked

Early initiation of
breastfeeding
(within 1 hour of
birth)
Exclusive
breastfeeding
(0-<6m)
Continued breastfeeding
(2 years or beyond)
Complementary foods
Safe and
appropriate
infant and
young child
feeding
Complementary
feeding (>6 month
Optimal infant and young child
feeding recommendations

TYPES OF BREAST MILK
 The composition of breast milk varies at different
stages after birth to suit the needs of the baby.
Milk production appears to be highly responsive to
specific needs of the neonate.
Variations in the Composition
1.Colostrums and mature milk

1. Colostrums
Is the breast milk that produce in the first few days
after delivery (up to 5 days)
Characteristics of colostrums
It is thick and yellowish in color
It contains more protein than mature milk
Contains Antibodies immunoglobulin A (IgA)
which protects the newborn against infection
Rich in Vaitamin A and Has Purgative effects

2. mature milk
Is the breast milk that is produced after a
few days
The quantity becomes larger, and the breasts
feel full, hard and heavy
Has two composition
Foremilk and
Hind milk

Foremilk
Is the milk that is produced early in a feed
Provides plenty of protein, lactose, and other
nutrients
Foremilk looks thinner than hind milk
It is produced in larger amounts and contain much
more water that satisfy the babies thirst
Babies do not need other drinks of water before
they are six months old, even in a hot climate

Hind milk
Is the milk that is produced later in a feed
Hind milk looks thicker than Foremilk
It is produced in less amounts than foremilk
It looks whiter than foremilk, because it contains more
fat
This is an important reason not to take a baby off a
breast too quickly
The baby should be allowed to continue until he has
had all that he wants

Benefits of BF to the mother and
baby

Limitations of BF
Transmission of infections like HIV
Contains low vitamin D (intake should be 200 IU/day, starting at
2 mo of age for all breast-fed infants)
The iron content of human milk is low(supplement at 4-6
months)
Low content of vitamin K (Parenteral administration of 1 mg of
vitamin K1 at birth is recommended for all infants).
Vegans (vitamin B12), Fluoride, Iodine (low areas)
Preterm baby (Iron, calcium, phosphorus, protein)

Contents of BM
Contents of breast feeding (100 ml)
Energy: 67 Kcal per 100ml
Carbohydrates…7.2gm/dl : lactose, oligosaccharide
Proteins… 1.2gm/dl ( Whey -70% Vs Casein-30%)
Fats (Lipids) …3.5 gm/dl (50% of total energy)
Vitamins (Vitamin A, B, C, E etc)
Minerals (zinc, iron, calcium, phosphorus etc)
White blood cells, Secretary IgA, Lysozyme etc

Frequency, Duration of Breastfeeding
First few weeks: 8-12 feedings per day on
demand
Every two to three hours
10-15 minutes on each breast

 Depends upon factors including:-
1. the maternal milk supply,
2. efficiency of milk transfer, and
3. the ability of the infant to modulate behavioral
state
 the first one to two weeks = 8 to 12/day
 ↓ to 7 - 9 times per day by four weeks

 The duration is depends in part upon efficiency.
 The time required to transfer the same volume of
milk can range from 5 to 20 minutes for different
mother-infant dyads.
 The duration of feeding on each breast decreases
with maturation:-
 10 to 15 minutes soon after birth
 8 to 10 minutes at one month of age.

DEMAND FEEDING
 Feedings are initiated in response to infant cues of
hunger and satiety. Feeding cues:-
 movement of the hands toward the mouth,
 sucking on fists and fingers,
 agitation,
 swinging of the extremities, &finally,
 loud, persistent crying

Positioning
Mother should be in comfortable position
Mother’s back is supported sitting or laying down
 She may sit on a chair, bed or ground with back properly supported
She can feed the baby in lying or semi reclining posture

Positioning...
Proper position of baby while breastfeeding includes
 Straight body, whole body supported, facing and
touching the mother
Correct positioning will ensure effective sucking and
prevent sore nipples and breast engorgement.
At feeding time, the infant should be dry, and neither
too cold nor too warm.

POSITIONING

Good Attachment
Four signs of good attachment are:
a. Baby’s mouth wide open.
b. Lower lip turned outwards.
c. Baby’s chin touches mother’s breast.
d. Majority of areola inside baby’s mouth

Breast feeding-Techniques
Cross cradle
breast feeding
technique helpful
to support the
head, neck and
trunk of the baby
and keeping the
body near to the
mother.

Observe for signs of milk transfer
 Sustained suck/swallow pattern with occasional pauses
 Audible swallowing
 Relaxed arms and hands
 Moist mouth
 Satisfied after feeding
Jeanette
Panchula
-
BSW,
RN,
PHN,
IBCLC
-
Solano
County
Health
and
Social
Services

Signs of poor latch-on include:
 Contact between the upper and lower lip at the corners of the
mouth
 Sunken cheeks
 Clicking sounds that correspond to breaking suction
 Tongue not visible below the nipple when the lower lip is pulled
down
 Creased nipple following nursing

Causes of poor attachment
a. Use of feeding bottles.
b. Inexperienced mother
c. Lack of skilled support
d. Inverted nipples

Consequence of Poor attachment
a. Pain or damage to nipple or sore nipple
b. Breast milk not removed effectively thus
causing breast engorgement
c. Poor milk supply hence baby is not satisfied
after feeding
d. Breast produces less milk resulting in a
frustrated baby and refusal to suck. This leads
to poor weight gain.

Milk Expression
Refers to the process by which a woman expels
milk from her breast manually or using breast
pump.
when the mother and baby are
separated for work, illness, or
hospitalization of mother or infant,
born premature,
Mastitis, engorged,

Milk Expression
When & how frequent?
When?
Frequency of milk expression
premature 2-3 hr or 8-10 /day Every 1.5 hours.
lactation is established, every 3-4 hours or 6-8

Milk Expression
How much milk?
The correct amount of breast milk to express
varies.
The amount increases daily to be 50-70ml from
each breast at 4-5 days to 80-120ml at the
end of 1st week.
Once regular breast milk production is
established women express 440-1,200ml of
breast milk each day (90-120ml/session/breast

Milk Expression
Transporting the Expressed Breast Milk (EBM)
Fresh, refrigerated (frozen) milk can be packed in an
insulated cooler in ice or blue ice (for up to 24 hrs).
If the frozen milk is thawed during transportation it
should be used or discarded but not refrozen
Storage of EBM
Glass container is the best choice for freezing milk
 Hard, clear plastic container is the 2nd choice

Breast feeding---Twins

ASSESSMENT OF INTAKE
 Parents should be instructed to monitor their
infant for adequacy of intake by:-
1. Frequency and duration of feeding
 usually result in 8 to 12 feedings in 24 hours.
2. Urine output
 six wet diapers/day with clear or pale yellow
urine.

ASSESSMENT OF INTAKE
3. Stools
 should clear meconium and have transitional
stools within approximately three days of birth
4. Weight Loss
 The expected weight loss is 5 to 7 percent.
 Once it is established, infants gain 15 to 40 g per
day.

SUPPLEMENTATION
is recommended when:-
lost more than 7 % of birth weight,
exhibits signs of dehydration
stool output < 3 small stools a day, and/or
mother's milk supply remains limited
Glucose water or sterile water feedings should not
be used as they do not provide adequate nutrition.

Disadvantages of Artificial Feeding
 interfere with bonding
 An artificially fed baby is more likely to become ill
with diarrhoea, respiratory and other infections
 malnourished
 more likely to suffer from vitamin A deficiency
 more likely to develop allergic conditions such as
eczema and possibly asthma

Disadvantages of Artificial Feeding...
 The risk of some chronic diseases in the child,
such as diabetes, is increased
 He may not develop so well mentally, and may
score lower on intelligence tests
 She is more likely to become anaemic after
childbirth, and later to develop cancer of the
ovary and the breast

MOTHERS TO LEARN
 Proper position and latch on
 Nutritive sucking and swallowing
 Milk production and release
 Frequency and feeding cues
Expression of milk if needed
Assessment of the infant's nutritional status
When to contact the clinician

PROBLEMS IN BREAST FEEDING
Inverted nipples
Sore nipples
Not enough milk
Breast engorgement
Breast abscess
Mastitis

Inverted / flat nipples
 Flat or short nipples which protract well (become
prominent or pull out easily) do not cause difficulty in
breast feeding
 Inverted or retracted nipples make attachment to the
breast difficult
 They should be diagnosed in the antenatal period.
 These mothers need additional support to feed their
babies.
PROBLEMS IN BREASTFEEDING

Inverted / flat nipples
 Treatment is started after birth of the baby
 Nipple is manually stretched and rolled out several
times a day
 A plastic syringe is used to draw out the nipple and
the baby is then put to the breast

Sore nipples
Causes
Incorrect attachment: Nipple sucking.
Frequent use of soap and water.
Fungal infection of nipple.

Treatment
Continue breastfeeding and change position.
Attach baby to the areola while feeding.
Apply hind milk to the nipple after breastfeed.
Expose the nipple to air between feeds
Do not wash each time before and after feed.

Breast engorgement
The milk production increases during the second and
third day after delivery 3-5
If feeding is delayed or infrequent, or the baby is not
well positioned at the breast, the milk accumulates in
the alveoli
As milk production increases, the amount of milk in the
breast exceeds the capacity of the alveoli to store it
comfortably.

Breast engorgement….
Such a breast becomes swollen, hard, warm
and painful and is termed as an engorged
breast.
Breast engorgement is an exaggeration of the
lymphatic and venous engorgement that occurs prior
to lactation.
 Usually both breasts are affected

Treatment of Engorged Breast
Treatment for breastfeeding mother
If woman is breastfeeding and the baby is able to
suckle
– Encourage to BF more frequently, using both
breasts at each feeding.
Apply warm compresses to the breasts just before
breastfeeding, or encourage the woman to take a
warm shower.

•Support breasts with a binder or brassiere
• Apply cold compress between feedings
• Give anti pain by mouth as needed
If woman is breastfeeding and baby is not able to
suckle
– Encourage the woman to express milk by hand or
with a pump.

Treatment for not breastfeeding mother
• Support breasts with a binder or brassiere
• Apply cold compresses to the breasts to reduce
swelling and pain
• Avoid massaging or applying heat to the breasts
• Avoid stimulating the nipples
• Give anti pain by mouth as needed
• Follow up 3 days after initiating management to
ensure response

Mastitis
Mastitis occurs in 2-3% of lactating women
usually unilateral
 manifesting with localized warmth, tenderness, edema,
and erythema after the 2nd post delivery week.
Sudden onset of breast pain, myalgia, and fever with
fatigue, nausea, vomiting, and headache can also occur

Mastitis
It is usually caused by either cracked nipples or
engorged breasts.
Organisms implicated in mastitis
Staphylococcus aureus, Escherichia coli,
group A streptococcus, Haemophilus influenzae,
Klebsiella pneumoniae

Mastitis
Treatment of mastitis
Treat with antibiotics:
Cloxacillin 500 mg by mouth four times per day for
10 days; OR
erythromycin 250 mg by mouth three times per day
for 10 days

Mastitis
Encourage the woman to:
 Take baby off from affected breasts
Continue breastfeeding of unaffected breast
 Support breasts with a binder or brassiere
Apply cold compresses to the breasts &anti pain as
needed
Prevention of mastitis
 Treat cracked nipples and engorged breasts

Breast abscess
The affected breast is likely to remain erythematous
and painful ,palpable mass or area of fullness,
usually in the periphery of the breast; fever and
other symptoms persists.
the axillary’s glands became tender and enlarged
 fluctuant swelling develops in a previously
inflamed area.
 Pus may discharged from nipple

Breast abscess
If conditions like engorged breast, cracked nipple,
blocked duct or mastitis are not treated early, then breast
abscess may form
The mother may have high grade fever and pain in
breast.
Treatment:
Mother must be treated with analgesics and antibiotics
The abscess must be incised and drained
Breast feeding must be continued from the other breast

Not enough milk
Mothers may complain that they do not have enough
milk
Reassurance is needed if baby is gaining weight and
passing adequate amount of urine
 Common causes of not enough milk include
not breastfeeding frequently, too short or hurried breastfeeds,
poor position, breast engorgement or mastitis

Milk Leakage
Milk leakage is a common event in which milk is
involuntarily lost from the breast either in response to
breast-feeding on the opposite side or as a reflex in
response to other stimuli, such as an infant's cry
Milk leakage usually resolves spontaneously as
lactation proceeds

Contraindication of breast feeding
Maternal
HIV, Breast cancer, breast abscess
Postpartum psychosis, active TB, breast HSV
Drugs like psychotropic, chemotherapy, radioisotopes
Substance abuse like cocaine, heroin, amphetamine
Neonatal
Lactose intolerance, critical illness
Galactosemia (failure to convert galactose to glucose)

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