lactation failure in short from mechanism and causes to management

1. Sonali singh
Resident
Paediatrics
Grant medical college, mumbai

2. LACTATION
 It is the process of secreting milk from breast. It is a
physiological process under neuroendocrine control.
LACTATION FAILURE
 Condition where mother is not able to produce milk.

3. Physiology of lactation

4. PROLACTIN REFLEX
Prolactin
goes in
blood to the
breast
Makes milk
secreting
cells produce
milk
Baby suckles
at the breast
Sensory
impulse
from nipple
to brain
Prolactin
secreted
from ant part
of pituitary

5. OXYTOCIN REFLEX
Oxytocin
secreted from
posterior part
of pituitary
Oxytocin
makes muscle
cell around
alveoli
contract
Milk collected
in alveoli flows
along duct
towards nipple
Baby suckles
at the breast
Sensory
impulse from
nipple to brain

6. IMPORTANT
 Oxytocin reflex is positively affected by mother’s
sensation and feelings like thinking lovingly about the
baby,touching, smelling or seeing the baby or hearing
the baby cry.
 If mother is emotionally disturbed or experiencing
pain or discomfort oxytocin reflex doesn’t work well
and baby has problem getting milk.

8. Maternal: Psychological and
social causes(81%)
 Insufficient milk(80%/75%)
 Unsuitable milk(38%/50%)
 Refusal by baby(4%/2%)
 Illness of the mother(4%/-)
 Maternal employment(8%/2%)
 Advice by relative or friend(12%/-)
 Ill infant (43%/25%)
 Advice by doctor/nurse(7%/-)
 Dislike for breast feeding
 Fixed schedule feeding
 Previous unsuccessful breast feeding experience
 Lack of confidence,shyness
 Worry,stress
 Tired
 Religious customs

9. MATERNAL:BREASTFEEDING
RELATED
 Delayed start
 Fixed schedule feeding
 Infrequent feeds
 No night feeds
 Short feeds
 Poor attachment
 Bottle/pacifier
 Other food
 Other fluid

10. Maternal: Biological causes(local)
 Sore and cracked nipple (38%)
 Inverted nipple(27%)
 Engorged breast(18%)
 Mastitis and abscess(14%)
 Others(3%)
Burn/scarring
Breast surgery
Anatomically abnormal breast( insufficient glandular
tissue) very rare
Retained placentarare

11. Maternal: biological
causes(systemic)
 Endocrinopathies- thyroid, pituitary, ovarian
dysfunction.
 Chronic maternal illness- DM, SLE,HTN (do not affect
lactation .
 Physical disability.
 Complications of pregnancy- GDM, PIH early maternal
infant separationinterferes with initiation of lactation.
 Contraindications of breast feeding.
 Psychiatric disorder

12. DRUGS CAUSING SUPPRESSION OF
LACTATION
1. Calcitonin
2. Diuretics- loop, thiazide
3. Dopamine receptor agonist- bromocriptine,
cabergoline.
4. Ergotamine
5. Levodopa
6. Contraceptives
7. Pseudoephedrine
8. Pyridoxine
9. Tamoxifen

13. Neonatal causes
 Neonatal illness early maternal/infant
separationinterferes with initiation of lactation.
 Neonatal disorders associated with poor suck(cleft lip
and/or palate, short frenulum, micrognathia, choanal
atresia)
 maternal or infant medication that causes drowsiness
 neonatal asphyxia, preterm birth, Down’s syndrome etc
 Breast rejection

14.  The complaint of “insufficient milk” is more often
than not a wrong perception of the mother, fostered by
the mother’s uncertainty about her capacity to feed
her baby properly, no knowledge about the normal
behavior of a baby (who usually nurses frequently) and
negative opinions of significant persons.
 The wrong perception by the mother  leads to the
introduction of complementary feeding negatively
affects milk production.

15. When to suspect lactation failure?
SYMPTOMS
 Infant is not satisfied after feeds, cries a lot.
 Wants to nurse frequently.
 Takes very long feeds.
 Improper weight gain
 Infrequent bowel movement- small in amount, dry
and hard.
 Less need to change diaper(6-8)

16. SIGNS INDICATING LACTATION FAILURE IN 1ST
WEEK
 Weight loss greater than 10% of the birthweight,
 not regaining birth weight up to two weeks of life,
 no urinary output for 24 hours.
 absence of yellow stools in the first week
 Clinical signs of dehydration.

17. MANAGEMENT OF
LACTATION FAILURE
PRIMARY PREVENTION
SECONDARY PREVENTION
TERTIARY PREVENTION

18.  The concept of breast feeding kinetics as developed by
Livingstone conveys the idea that there is dynamic
interaction between a breast feeding mother and her
infant over time.
 Most disorders of lactation are iatrogenic because of
impeded establishment of lactation/ inadequate
ongoing stimulation and drainage of breast.
 Most breast feeding difficulties are due to lack of
knowledge, poor technical skills/ lack of support.
 Almost all problems are reversible.
 Prevention, early detection and management should
become a routine part of maternal and child health
care.

19. ANTENATAL SCREENING FOR RISK
FACTORS
 BREAST EXAMINATION
 EVALUATION OF SYSTEMIC ILLNESS
 MATERNAL GENERAL CONDITION AND DIETRAY HABITS
 LACTATION ASSESSMENT IN 3RD TRIMESTER
 BREAST FEEDING EDUCATION
 EDUCATION REGARDING ADVANTAGES OF BREAST
FEEDING TO BABY, MOTHER AND TO SOCIETY
 EDUCATION REGARDING DISADVANTAGES OF TOP FEEDS
 COUNSELLING TO MOTHER WITH PREVIOUS
UNSUCCESSFUL BREAST FEEDING EXPERIENCE
 IMPORTANT- mother should be accompanied by other
influential members of the family as attitude and knowledge of
mother as well as her near ones should be changed in order to
have successful breast feeding.

20. NATAL AND IMMEDIATE POST NATAL-
what to do?
 Medicated and interventional labor should be avoided as far as
possible interferes with instinctive rooting behaviour to locate and
latch onto the breast.
 Initiate breastfeeding as soon as possible after complete delivery of
placenta early breast stimulation  initiates early lactation.
 Breast feeding on demand regular breast drainage and stimulation
promotes lactogenesis( initially hormonal based, later autocrine)
 Proper positioning, attachment, latching on supervised.
 Rooming in (24 hrs)- same bed. Separation impedes drainage and
stimulation.
 Combined mother infant nursing  institution of patient centred
teaching.
 Address local problems(biological causes immediately)
 Counselling regarding diet of mother.

21. Instructions to be given to mother for successful
establishment of lactation.
 Positioning, attachment, latch-on.
 Frequency- on demand usually2-3 hourly(≥8 feeds),
including night feeds.
 Duration- varies between mother-infant pair.
 Pattern of breast use- 1st breast comfortably drained
followed by switching to 2nd
 Feeds not to be terminated prematurely in sleeping
infants.
 Mothers should be explained that it takes time for
proper milk formation

22. Baby friendly hospital initiative(1992)
1. Written breast feeding policy.
2. Training of health care staffs.
3. Information to all pregnant ladies regarding breast feeding.
4. Breast feeding within half an hour of birth.
5. No food or drink other than breast milk to the baby, unless
medically indicated.
6. Show mothers how to breast feed and to maintain lactation
even if they should be separated.
7. Rooming in.
8. Breast feeding on demand.
9. No artificial teats or pacifiers or prelacteal feeds to the baby.
10. Mother support group.

23. • Infant wt loss<7%+good breast feeding skills
• Plan discharge+ lactation assessment on f/u
• Infant weight loss<7%+poor breast feeding
skills
• Extended hospital stay
• Infant weight loss>7%
• Breast feeding assesssment+extended
hospital stay
Planning hospital discharge

24. Establishing relactation
(for mother with lactation failure on post natal
follow up)

25. Physiological basis of lactation on
which relactation depends.
 Breast feeding requires:-
 Growth of secretory alveoli in glandular tissue of breast.
 Secretion of milk.
 Removal of milk
 Depends on hormone
 Prolactin- Imp for:- development of secretory alveoli;
. secretion of milk
Stimulus- nipple stimulation
Most effective stimulus-suckling of an infant
(daytime<night time suckling)

26. Oxytocin- Imp for milk removal.
BEST WAY OF STIMULATION+REMOVAL OF MILK:-
SUCKLING INFANT.

27. APPROACH TO A MOTHER WITH
LACTATION FAILURE
 HISTORY +CLINICAL EXAMINATION
NO DISEASE
 TRUE LACTATIONAL FAILURE OR NOT
YES NO COUNSEL
 CHECK FOR:-POSITION,ATTACHMENT,SUCKLING
 NIGHT FEEDS?
 FREQUENCY?
NO PROBLEM
PLAN FOR ESTABLISHMENT OF RELACTATION

28. FACTORS WHICH AFFECT SUCCESSFUL
RELACTATION
Willingness to suck
Age
Breast feeding gap
Gestational age
Feeding experience
during the gap
Intake of
complementary food
INFANT
RELATED Woman’s motivation
Lactation gap
Condition of breasts
Previous experience of
lactation
Ability to interact
responsively with her
child
Support from family,
community,health
workers
MOTHER
RELATED

29. If infant is willing to suck
 Encourage the woman:-
Put infant to breast frequently(1-2 hrly/8-10 times in
24 hrs)
Sleep with infant and breast feed at night
Ensure good attachment
Let infant suckle at both breasts, for as long as possible
Feed infant supplements separately using a cup.

30. Infant is unwilling/unable to suck
 Ensure child is not sick
 Skin to skin contact
 Offer breast any time child is interested to suck
 Breast feeding supplementer method
 Drop and drip method

31. Breast feeding supplementer method

33. Drop and drip method

34. Supplementing the infant
 While mother’s breastmilk supply is becoming
established, it is essential to ensure that the child receives
adequate nutrition( through wati and
spoon/breastfeeding supplementer)
 Supplement- cow’s milk diluted till 2 m of
age(150ml+50mlwater+5g sugar)
 To begin with supplement should be full (150cc/kg/day
divided in atleast 8 feeds)
 As breast milk increases supplement should be reduced.
child’s weight should be regularly monitored.

35. How to reduce supplement
 In some cases child shows less interest by refusing
supplement/ refusal to suck on 2nd breast.
 Reduce total amount of supplement in 24hrs by 50ml.
 Continue reduced feed for next few days
 If by behaviour and weight gain(125g/week) feed appears
to be sufficient reduce it further else continue the same for
1 more week.

36. GALACTOGOGUES
 Galactogogues (or lactogogues) are medications or other
substances believed to assist initiation, maintenance, or
augmentation of maternal milk production.
 MEDICATIONS
 Metoclopramide- antagonizes dopamine in cns, hence increases
prolactin level.
Dose- 30-45mg/day in 3-4 divided doses. Given for 7-14 days then
taper off in next 5-7 days.
 Domperidone- dopamine antagonist increases prolactin level.
Dose-10-20mg/day in 3-4 divided doses for 3-8weeks.
 Sulpride and chlorpromazine
 Gh
 TRH
 Oxytocin

37.  Herbal /natural galactogogues:-
 satavari
 Fenugreek
 anise,
 basil,
 fennel seeds
 Garlic
 Ginger
 Jaggery
 Coconut
 Bajra
 Khaskhas
 Pepper
 Panjeer
 Sonth
 Jeevanthi
 Panjeeri

38. BEST GALACTOGOGUE- BABY
SUCKLING at THE BREST in correct
position..

39. Important
 Confidence
 Support of family members
 Regular f/u if possible

40. MANAGEMENT OF BIOLOGICAL
CAUSES

41. Flat nipple
Anatomical nipple forms
only 1/3rd of the teat of the
breast tissue in baby’s
mouth.
Reassuarance
Inverted
nipple
Nipple does not
protract, on attempt to
pull out the nipple, it
goes deeper into breast.
SYRINGE METHOD

42. SYRINGE METHOD

43. ENGORGED BREAST
 If baby is able to suckle, mother should feed
frequently.
 If pain and tightness does not allow suckling express
milkcomfortable breast feed
 Cold compress
 Paracetamol for pain and fever.

44. DIFFERENCES BETWEEN FULL AND
ENGORGED BREASTS
 Full Breasts Engorged Breasts
 Hot Painful
 Heavy Oedematous
 Hard
 Tight, especially nipple
 Shiny
 May look red
 Milk flowing Milk NOT flowing
 No fever May be fever for 24 hours

45. Mastitis and abscess
 Mastitis supportive counselling and improved
drainage of milk from affected part of breast by breast
feeding/expressing
 Indication for antibiotics
Lab tests show infection
Severe symptoms/ symptoms do not improve after 12
hrs of milk removal
• Analgesic and warm compress for pain relief
• Abscess incision and drainage.

46. Sore /cracked nipple
 Mc cause of sore nipple- poor attachment.
 Improving infant’s attachment to breast relieves the
pain.
 Hind milk rich in fat should be applied.
 Oral thrush 1% gentian violet should be applied over
nipple as well as inside baby’s mouth.

47. Systemic illness
Endocrinopathies and other chronic illness needs to be
managed along with other measures for encouraging
breast feed.

48. Studies
 Lactation failure by G.P mathur published in IAP-partial
lactation failure(94.7%) was more common than complete
lactation failure(5.3%). An attempt at relactation was
successful in 69.3% cases, failed in 4% cases and the
remaining were lost to follow up.
 LACTATION MANAGEMENT CLINIC-POSITIVE
REINFORCEMENT TO HOSPITAL BREASTFEEDING
PRACTICES by Nanavti and Mondkar78.1% mothers
practised EBF on subsequent visits, 21.2% were partially
successful in lactation and only 3 mothers had lactation
failure.

49. Conclusion
 Supportive breastfeeding policies in hospital
constitute the foundation for initiation of successful
breastfeeding by mothers, constant reinforcement and
support to all lactating mothers is essential to
maintain lactation.

50. REFERENCES
 Relactation: review of experience and recommendation for
practice, WHO
 IAP textbook
 Breast feeding in practice: a manual for health workers
 Training manual on breast feeding management(UNICEF)
 Breast feeding medicine, vol 4(ABM protocols)
 Avery’s diseases of newborn
 Meherban singh for newborne
 thank you....