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STAGES OF LACTATION AND LACTATIONAL FAILURE.pptx
- 1. STAGES OF LACTATION AND LACTATIONAL FAILURE
- 4. Definition • Lactation - production of breast milk and its secretion from the mammary gland after delivery • Mother’s Milk – The best milk
- 5. Structure of breast • Parenchyma- 10-15 lactiferous ducts extending from the nipple • Each duct defines a lobe made of 20-40 lobules. • Each lobule has 10-100 alveoli • Lobules are separated by fat and connective tissue - stroma • Main duct from each lobe opens separately on the tip of nipple • Ductal lobular unit is the functional unit of breast
- 8. Stages of lactation – 5 phases • Mammogenesis • Lactogenesis • Galactokinesis • Galactopoiesis • Involution
- 9. Mammogenesis • Involves growth of ductal lobular unit • Birth to puberty and continues in pregnancy (till 2nd trimester
- 10. Stage I mammogenesis Prepubertal and pubertal period • Type 1 lobule develops into more mature type 2 & 3 lobule through alveolar budding • Estrogen and progesterone
- 11. During pregnancy (Stage II mammogenesis) Ductal sprouting – 1st trimester Lobular sprouting – 2nd trimester Estrogen: stimulates ductal system to grow and differentiate Progesterone: growth of alveoli and lobes Prolactin : growth and differentiation of both alveoli and ducts
- 12. Lactogenesis - 2 stages • Stage 1 lactogenesis / Secretory initiation/differentiation • Stage 2 lactogenesis / Secretory activation
- 13. Mature breast resemblesa flowering tree with numerous lobular alveolar complexes– TDLUs (remains quiescent) During pregnancy Progesterone,prolactin, placental lactogen Expansion of TDLUs Mid pregnancy Rise in mRNA for many milk proteins and enzymes – called secretory differentiation Stage 1
- 14. Stage 1 • During mid-pregnancy - small amount of milk that only contains lactose and casein • Insulin and serum growth factor also plays role • High levels of circulating progesterone supplied by placenta inhibit copious production of milk
- 15. Role of prolactin • Milk initiation – through receptors on alveolar surfaces • Stimulates synthesis of lactalbumin • Increases lipoprotein activity in the mammary gland • In conjunction with estrogen and progetserone it attracts and retain Ig-A immunoblasts • Inhibited by PIF
- 16. Stage 2 / secretory activation • Birth to Day 8 postpartum • Triggered by rapid decline in progesterone that follows delivery of placenta • Requires presence of elevated levels of prolactin, cortisol, insulin and GH.
- 17. STAGE 2
- 18. The rate of secretion of milk volume and macronutrients in milk during the first 8 d postpartum.
- 19. Lactogenesis III • Under autocrine (local) control • Milk synthesis is controlled at breast level. • Milk removal is the primary control mechanism for supply.
- 20. Current thought… • Small whey protein called Feedback Inhibitor of Lactation (FIL) – slows milk synthesis when breast is full • Wall of lactocytes contain prolactin receptor sites – when alveolus is full of milk, the walls expand/stretch and alter shape of receptors
- 22. Pathways of milk secretion by mammary epithelial cells 1. Exocytosis 2. Reverse pinocytosis 3. Apical transport 4. Transcytosis 5. Paracellular
- 23. Hormonal preparation of breast during pregnancy for lactation
- 24. Galactokinesis • Suckling + myoepithelial cell contraction • Cell contraction by oxytocin • Milk let down/ejection reflex
- 26. Galactopoesis • Prolactin is the hormone for maintenance of lactation • Sucking is essential for maintenance of milk secretion • Periodic breast feeding relieves pressure in the ducts and promotes more secretion
- 28. Involution • Apoptotic cell death and tissue remodeling post lactation • Requires a combination of lactogenic hormone deprivation and local signals to undergo regression and atrophy
- 30. When mother is not able to provide enough milk for her baby
- 31. Lactation failure is defined as the need to start top feeds for the baby within 3 months of delivery because of inadequate breast milk supply Sultana etal 2013
- 32. • Total lactation failure was defined as either a total absence of milk flow or secretion of just a few drops of breast milk following suckling for at least 7 days • Partial lactation failure was defined as either inadequate milk output or the need for supplemental feedings to sustain growth
- 33. Major obstacles • Mother’s feel they don’t have enough milk • Inaccurate/inadequate medical advice • Working mothers • Societal and commercial pressure to stop breastfeeding including aggressive marketing and promotion by formula producers.
- 34. Obstacles to breast feeding initiation and continuation
- 35. • Insufficient milk supply is a major reason given by mothers for discontinuation of breastfeeding during first 6-8 weeks postpartum. • Upto 80% women feel that their milk supply was inadequate at some stage during first 4 months. • True lactation failure is rare.
- 36. What is enough milk • Initial weight loss upto 10% • Baby regains the birthweight by 10-14 days. • Urinating at least 6-7 times in 24 hour period, sleeps 2-3hrs after feed and is gaining weight. • Baby doubles her birth weight in about 5 months
- 37. Physiological basis for insufficient milk • Milk production in 1st week is highly variable. • Following 3-5 weeks, milk output is progressively calibrated to the baby’s need • Interferences with calibration of the breasts during this time can cause breasts to calibrate at an inappropriate level.
- 38. Such interferences include… • Supplemental feeds • Unrelieved engorgement. • A mother of a preterm infant who does not express her milk to her peak yield • Scheduled feeding. • Feedings that are not long enough. • Pacifiers. • Mother and baby separation.
- 39. Reasons for low supply Pathophysiological lactational failure/primary lactational failure Inadequate sucking stimulus – secondary lactational failure
- 40. Causes of lactational failure Maternal factors Infant factors
- 41. Maternal factors Delayed lactogenesis 2 Prolonged labor Emergency LSCS Instrumental delivery Lack of initiation within 1hr Type I DM PCOD Obesity Primi parity Maternal illness Thyroid disorder DM,HTN Hypo-pituitarism Infections Anemia Autoimmune disease Connective tissue disease Renal failure Maternal medications Diuretics Bromocriptine,cabergoline Ergot derivates Levodopa Contraceptives - estrogen Pyridoxine Tamoxifen Maternal nipple abnormalities Sore nipple Retracted nipple
- 42. • Painful conditions of the breast • Maternal breast anatomy • Psychosocial factors • Lack of confidence
- 43. Neonatal factors • Neonatal illness – early separation interferes with initiation of lactation • Neonatal disorders – cleft, micrognathia, ankyloglossia, choanal atresia • Medications causing drowsiness • Neonatal asphyxia, preterm birth, down syndrome
- 44. When to suspect lactation failure? Symptoms • Infant not satisfied after feeds, cries a lot • Wants to nurse more frequently • Improper weight gain • Takes very long feeds • Infrequent bowel movement • Less need to change diaper (6-8)
- 45. Signs indicating lactation failure • Weight loss >10% • Not gaining birth weight by 2weeks • No urine output for 24hrs • Absence of yellow stools in the first week • Clinical signs of dehydration
- 46. Management • To recognise who is at risk, anticipating insufficient milk • Prenatal breastfeeding education • Therapeutic interventions • Supplementary nursing systems • Galactogogues
- 47. Potential indicators for those at risk for insufficient milk • Mothers who are less informed about breastfeeding. • Less confident. • Less encouragement from family • Poor health • Maternal labour medications, birth injuries. • Primigravida • LSCS
- 48. Antenatal screening for risk factors • Breast examination • Evaluation of systemic illness • Maternal general condition and dietary habits • Education – advantages of breast feeding, disadvantages of topup feeds.
- 49. Prenatal breast feeding education • A prenatal educational program is the most effective intervention to promote initiation of breastfeeding • A systematic review and meta-analysis found that for every 3-5 women attending a program, one additional mother would initiate and continue breastfeeding for up to 3 months*. *Guise et al, 2003
- 50. Instructions to mother… • 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
- 51. Natal and immediate postnatal • Medicated and interventional labour avoided as far as possible • Initiate breast feeding soon • Feeding on demand – regular breast drainage and stimulation promote lactogenesis • Rooming in – same bed • Proper positioning, attachment, latching on supervised. • Address biological causes- flat nipple, inverted nipple, sore/crack nipple, engorged breast, mastitis and abscess
- 52. Inverted nipple – syringe/double syringe; nipple puller Sore / crack nipple • MCC poor attachment • Purified lanolin or expressed hind milk applied after feeding hastens recovery. Engorged breast • Usually day 3-5 postpartum • If baby able to suck, feed frequently • If pain and tightness does not allow suckling, express milk • Cold compress • Paracetamol for pain and fever
- 53. Mastitis • Inflammatory and/or infectious breast condition • Usually affects one breast • Rapid onset of fatigue, body aches, headache, fever and tender reddened breast area. • Bed rest, continued breast feeding • Frequent and efficient milk removal • Antibiotics • Analgesics, moist heat/massage to breast
- 54. If baby is unwilling/unable to suck • Ensure baby is not sick • Skin to skin contact • Offer breast at any time baby is interested to suck • Breast feeding supplementer method • Drop and drip method
- 55. Breast feeding supplementer method
- 57. Drop and drip method
- 58. Galactagogues Galactagogues are medications or other substances believed to assist initiation, maintenance, or augmentation of maternal milk production.
- 59. Classes of galactagogues Synthetic galactagogues o Dopamine antagonists • Domperidone and metoclopramide o Antipsychotics • Chlorpromazineand sulpride o Hormone synthetic analogues • Human GH • Oxytocin • TRH • Recombinantbovine somatotropin • Medroxyprogesterone Herbal galactagogues
- 60. Drug Mechanism Dose Adverse effects Metoclopromide D2R antagonist, increase PRL secretion 10mg PO TID Sedation, anxiety, depression, extrapyramidal symptoms Domperidone D2R antagonist, increase PRL secretion 10mg PO TID Xerostomia, abd cramps, headaches, cardiac arrythmias Chlorpromazine D2R antagonist, increase PRL secretion 25mg PO TID Mother – extrapyramidal Infants – lethargy Sulpride D2R antagonist, increase PRL secretion 50mg PO TID Headache, fatigue, extrapyramidal side effects
- 61. Herbal galactogogues • Shatavari • Fenugreek • Garlic • Alfalfa • Red clover • Marshmallow roots • Goats rue
- 62. Best galactogogue – baby sucking at breast in correct position
- 63. MBFHI Breastfeeding support in OP clinics
- 65. • Perceived or real low milk supply is a common concern of women and is a major cause to start supplementary feeding • Early breastfeeding follow-up • Proper positioning and latch-on…Examination of the diad together • Training of the health professionals • Support the mother
Editor's Notes
- Quoted by coello novello So a baby who received breast milk upto 2yrs is the luckiest baby.
- And is the birth right of every baby.
- No milk can substitute breast milk for babies.
- provides all the essential nutrients necessary for the growth and development of the newborn infant for first 6 months.
- Main duct from each lobe opens separately on the tip of nipple and possesses a dilated sinus just before its termination in the subareolar tissue.
- Parenchyma and stromal element. Parenchyma – lobes and ducts, stroma- fat and connective tissue. The epithelial lining of alveoli(mammary epithelium) consists of two differentiated cell types developing from multipotent stem cell organised into 2 cell layers, an inner layer of luminal A cells and outer layer of myoepithelial cells in direct contact with BM
- A multipotent stem cell present during development gives rise to luminal epithelial and basal stem cells, which further divide into luminal and basal progenitors during puberty. Luminal progenitors differentiate to hormone + and –ve ductal and alveolar cells. Basal progenitor develops to myoepithelial cells.
- Mammogenesis- Preparation of breast for milk secretion. Lactogenesis-Synthesis and secretion of milk Galactokinesis-Ejection of milk outside the breast Galactopoiesis-Maintenance of lactation Involution-regression and atrophy post lactation
- Changes in the level of estrogen and progesterone during each menstrual cycle stimulates lobule 1 to produce new alveolar buds and eventually evolve to more mature structure, type 2 and 3 lobules. Once puberty is reached, no further change occurs to breast until pregnancy. Prolactin, somatotropin, ACTH and TSH have minimal role.
- When the hypophyseal-ovarian –uterine cycle is established, there is extensive branching of the duct system and parenchymal proliferation and canalization of the lobuloalveolar units controlled by estrogen and progesterone
- Before pregnancy, breast is predominantly adipose tissue without extensive glandular or ductal development. Under the influence of uninterrupted and rising concentrations of estrogen, progesterone and prolactin during pregnancy, the breast increases in water, electrolyte and fat content; and increase in vascular supply.
- Lactogenesis – synthesis and secretion of milk – maturation of alveolar cells
- The breast reaches a stage of quiescence marked by some waxing and waning of the TDLU driven by the hormonal changes of the menstrual cycle. During mid-pregnancy, secretory differentiation begins with a rise in mRNA for many milk proteins and enzymes important to milk formation
- Stage I takes place during second half of pregnancy. The placenta supplies high levels of progesterone which inhibit further differentiation. In this stage small amounts of milk can be secreted as early as 16weeks and by late pregnancy some women can express colostrum.
- Lactalbumin - regulatory protein of the lactose synthetase enzyme system Its inhibited by prolactin inhibiting factor under control of catecholamines in the hypothalamus.
- Stage 2 lactogenesis is marked by copious secretion of milk following delivery of placenta.
- During pregnancy, progesterone is maintained at higher level by placenta, following birth there is rapid decline in level of progesterone and is lowest at 2-3days postpartum. Elevated levels of prolactin, cortisol and insulin along with low progesterone stimulates stage 2 lactogenesis.
- Milk production is initially not a demand and supply process. Stage 1 & 2 are hormonally driven – is called endocrine control system- they occur whether or not a mother is breast feeding her baby. After stage 2 – there is a switch to autocrine control, now it becomes a demand and supply process.
- Current research suggests that there are two factors that control milk synthesis. FIL acts by reversible blockade of constitutive secretion in mammary epithelial cells.
- Milk protein and lactose are transported in golgi derived secretory vesicles, with water and electrolytes into the alveolar lumen. Lipid formed in SER forms droplets and covered by phospholipid membrane transported as milk fat globules. Direct movement of ions,water and glucose across apical membrane of cell Na+, K+, Cl-, some monosaccharides and water P pathway for some interstitial fluid components and leukocytes to pass by diapedesis thru tight junctions.
- Milk is secreted continuously into the alveoli of the breasts, but milk does not flow easily from the alveoli into the ductal system and no leak occurs. Milk is forced down into the ampulla of lactiferous ducts, from where it can be either expressed by the mother or sucked by baby. This occurs between 30-60secs. So actually no milk flows during first 30secs of breast feeding.
- Lactogenic hormone deprivation and local autocrine signals to undergo regression and atrophy by apoptotic cell death.
- It's a heartbreaking problem that involves emotional stress and possibly even depression, adding to the stress of having to care for a new baby
- Maternal misperception
- Supplemental feeds can cause breasts to make less milk or calibrate at an inappropriate level. A mother of a preterm infant who does not express her milk to her peak yield, just to the transient limited needs of the small baby at the time.
- Maternal breast anatomy – insuffiecient glandular tissue, cosmetic breast surgery Lack of confidence – cause of most early discontinuations, early postpartum follow up visits, at 3-5days and at 7-14days can provide an opportunity for physician to intervene.
- To prevent lactational failure, management shud start before delivery, like to recognise mothers who are at risk for insufficient milk, providing prenatal breast feeding education.
- Breast shud be examined for retracted nipple, flat nipple, any local infections and appropriate treatment shud be initiated. Any systemic illness(endocrinopathies or chronic systemic illness) can impede breast milk production, so evaluation and treatment
- Instructions to mother for successful establishment of lactation Minimum anticipated feeding frequency – 8 times /24hr.
- * Interferes with instinctive behaviour to locate and latch onto breast. *early breast stimulation intiates early lactation *separation impedes drainage and stimulation. * Flat nipple - reassurance
- Prepare a cup of milk containing the amount of feed that her baby needs for one feed, a nasogastric is taken, one end placed in the container and other end attached near nipple so that baby sucks breast and the tube at the same time. Adjust flow of milk by rising or lowering the container. Control flow of milk so that baby sucks for ~30min.
- Drip the milk so that it flows top of breast to the nipple.