blood to the
at the breast
from ant part
in alveoli flows
at the breast
nipple to brain
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.
Maternal: Psychological and
Refusal by baby(4%/2%)
Illness of the mother(4%/-)
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
Fixed schedule feeding
No night feeds
Maternal: Biological causes(local)
Sore and cracked nipple (38%)
Mastitis and abscess(14%)
Anatomically abnormal breast( insufficient glandular
tissue) very rare
Endocrinopathies- thyroid, pituitary, ovarian
Chronic maternal illness- DM, SLE,HTN (do not affect
Complications of pregnancy- GDM, PIH early maternal
infant separationinterferes with initiation of lactation.
Contraindications of breast feeding.
Neonatal illness early maternal/infant
separationinterferes with initiation of lactation.
Neonatal disorders associated with poor suck(cleft lip
and/or palate, short frenulum, micrognathia, choanal
maternal or infant medication that causes drowsiness
neonatal asphyxia, preterm birth, Down’s syndrome etc
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.
When to suspect lactation failure?
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
Less need to change diaper(6-8)
SIGNS INDICATING LACTATION FAILURE IN 1ST
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.
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
ANTENATAL SCREENING FOR RISK
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.
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
Combined mother infant nursing institution of patient centred
Address local problems(biological causes immediately)
Counselling regarding diet of mother.
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
Mothers should be explained that it takes time for
proper milk formation
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
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.
• Infant wt loss<7%+good breast feeding skills
• Plan discharge+ lactation assessment on f/u
• Infant weight loss<7%+poor breast feeding
• Extended hospital stay
• Infant weight loss>7%
• Breast feeding assesssment+extended
Planning hospital discharge
(for mother with lactation failure on post natal
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)
Oxytocin- Imp for milk removal.
BEST WAY OF STIMULATION+REMOVAL OF MILK:-
APPROACH TO A MOTHER WITH
HISTORY +CLINICAL EXAMINATION
TRUE LACTATIONAL FAILURE OR NOT
YES NO COUNSEL
PLAN FOR ESTABLISHMENT OF RELACTATION
FACTORS WHICH AFFECT SUCCESSFUL
Willingness to suck
Breast feeding gap
during the gap
RELATED Woman’s motivation
Condition of breasts
Previous experience of
Ability to interact
responsively with her
Support from family,
If infant is willing to suck
Encourage the woman:-
Put infant to breast frequently(1-2 hrly/8-10 times in
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.
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
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
Supplement- cow’s milk diluted till 2 m of
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.
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.
Galactogogues (or lactogogues) are medications or other
substances believed to assist initiation, maintenance, or
augmentation of maternal milk production.
Metoclopramide- antagonizes dopamine in cns, hence increases
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
Anatomical nipple forms
only 1/3rd of the teat of the
breast tissue in baby’s
Nipple does not
protract, on attempt to
pull out the nipple, it
goes deeper into breast.
If baby is able to suckle, mother should feed
If pain and tightness does not allow suckling express
milkcomfortable breast feed
Paracetamol for pain and fever.
DIFFERENCES BETWEEN FULL AND
Full Breasts Engorged Breasts
Tight, especially nipple
May look red
Milk flowing Milk NOT flowing
No fever May be fever for 24 hours
Mastitis and abscess
Mastitis supportive counselling and improved
drainage of milk from affected part of breast by breast
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.
Sore /cracked nipple
Mc cause of sore nipple- poor attachment.
Improving infant’s attachment to breast relieves the
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.
Endocrinopathies and other chronic illness needs to be
managed along with other measures for encouraging
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 Mondkar78.1% mothers
practised EBF on subsequent visits, 21.2% were partially
successful in lactation and only 3 mothers had lactation
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
Relactation: review of experience and recommendation for
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