[52] Lactation Flashcards
What is lactation?
The maternal physiological response whereby milk is secreted from the mammary glands to feed the infant
What % of people in the UK breastfed in the UK in 2010?
81%
What proportion of mothers in the UK were still breast-feeding after 6 months?
1/3
What % of mothers in the UK were exclusively breastfeeding after 6 months?
1%
Which mothers are more likely to breastfeed?
- Those from a minority ethnic groups
- Those in managerial and professional occupations
- Aged over 30
- First-time mothers
Where are the mammary glands?
Embedded in the breasts
What do the mammary glands comprise of?
15-20 lobulated masses of tissue with fibrous tissue connecting the lobes, and adipose tissue in between
What are the lobes of the breast made up of?
Alveoli, blood vessels, and lactiferous ducts
How many ducts are present in the breast at birth?
Only a few
What happens to the ducts in the breast at puberty?
Oestrogen causes the ducts to sprout, and the ends form masses of cells that later become alveoli
What happens to the breasts with each menstrual cycle?
There are cyclic changes
What causes the cyclic changes in the breast during the menstrual cycle?
Changes in oestrogen and progesterone
What happens to the breasts during pregnancy?
- There is significant hypertrophy of the ductal-lobular-alveolar system
- Prominent lobules form
- From mid-gestation, alveolar cells differentiate to be capable of milk production
Is there milk secretion during pregnancy?
A little
Why is there only a little milk secretion during pregnancy?
Due to the high progesterone:oestrogen ratio, which favours growth rather than secretion
What cells are responsible for milk production?
The alveolar epithelial cells
Describe the alveolar epithelial cells of the breast
They are polarised, highly differentiated cells
What is the function of the alveolar epithelial cells of the breast?
To accumulate, synthesise, package, and export the components of milk
What do the breasts start producing soon after birth?
40ml/day of colostrum
What does colostrum contain more of than normal milk?
- Proteins, particularly immunoglobulins
- Fat soluble vitamins
What does colostrum contain less of than normal milk?
- Water soluble vitamins
- Fat
- Sugar
What does mature breast milk contain?
- Water
- Lactose
- Fat
- Protein
- Minerals
- Vitamins
What % of mature breast milk is water?
90%
What % of mature breast milk is lactose?
7%
What % of mature breast milk is fat?
2%
What % of mature breast milk is protein?
1%
What % of mature breast milk is minerals?
0.2%
What vitamins are found in mature breast milk?
- A
- B
- B2
- C
- D
- E
- K
What controls the regulation and content of breast milk?
Largely under hormonal control, primarily prolactin
Describe the hormones in pregnancy?
There is a high progesterone:oestrogen ratio
What is the result of the high progesterone:oestrogen ratio in pregnancy on the breasts?
Favours the development of alveoli, but not secretin of milk
What causes the change in oestrogen:progesterone ratio after pregnancy?
The delivery of the placenta
Why does the delivery of the placenta change the hormone balance in pregnancy?
Because the placenta is the source of a large amount of circulating steroids (more so progesterone), and so its removal changes the ratio
What is the result in the reduction in progesterone after the delivery of the placenta?
It allows the alveoli to respond to prolactin
How long after pregnancy does breast milk begin to form?
24-48 hours
What is prolactin?
A polypeptide hormone
What is prolactin secreted by?
The anterior pituitary gland
What controls prolactin section by the anterior pituitary gland?
Dopamine
What is dopamine also known as?
Prolactin-inhibiting hormone
It actually is i checked it even tho this seems kinda fake news?
Where is dopamine secreted from?
- Hypothalamus
- Decidual cells
What do factors that promote secretion of prolactin do?
Reduce dopamine secretion
What is prolactin stimulation promoted by?
Suckling
What kind of reflex is the sucking causing prolactin stimulation?
Neuro-endocrine reflex
How does suckling stimulate prolactin?
It mechanically stimulates receptors in the nipple and impulses pass up the brainstem and to the hypothalamus to reduce the secretion of dopamine and increase vasoactive intestinal protein
What does vasoactive intestinal protein do?
Promotes prolactin secretion
What does suckling at one feed do?
Promotes prolactin release, which causes production for the next feed
What happens to the next feed after it is stimulated by suckling at the previous feed?
It accumulates in alveoli and ducts, causing turgor
What is responsible for milk delivery to the infant?
Mechanical stimulation of the nipple
Do babies suck milk out of the breast?
No
If the babies don’t suck the milk out of the breast, how does it get into their mouth?
Ive really given up on these questions
It is ejected by the let-down reflex
How does the let-down reflex work?
In response to suckling, oxytocin is released from the pituitary gland which stimulates myoepithelial cells that surround alveoli to contract, thus squeezing milk out of the breasts
Other than suckling, what can stimulate the let-down reflex?
The reflex can be conditioned (think Pavvys dogs), and the cry or sight of an infant and preparation of the breast for nursing may cause let down
What may inhibit the let-down reflex?
- Pain
- Embarrassment
- Alcohol
What is the key to maintaining milk production?
Sufficient suckling stimulation at each feed
Why is sufficient suckling at each feed important to maintain milk production?
- Maintains prolactin secretion
- Removes accumulated milk
What happens if suckling stops?
Milk production ceases gradually
Why does milk secretion gradually cease when there suckling stops?
Due to turgor-induced damage to secretory cells and low prolactin levels
How can milk suppression be achieved iatrogenically?
Steroids
Why is there reduced fertility whilst breatfeeding?
Prolactin secretin during lactation reduces fertility
What are the social advantages of breastfeeding?
- Breastmilk is free and available with preparation
- No need to buy steriliser, bottles, or formula milk
- Does not need to be pre-warmed
What are the medical advantages of breastfeeding for the child?
- Immunity/infection prevention
- Protective effect of breastfeeding for severe eczema
- Protective against childhood asthma
- Reduction in SIDS
- Positive effect on child’s intelligence
- Confers protection from future diabetes
Give 3 infections that breast-fed children have lower rates of
- Otitis media
- Lower respiratory tract infections
- Gastroenteritis
What are the medical advantages of breastfeeding for the mother?
- Reduction in rates of breast cancer
- Reduction of rates of T2DM
- Reduction in ovarian cancer
- Can be used as contraception
When can breastfeeding be used as contraception?
- Child is up to 6 months old
- Mother is amenorrhoeic
- Child is exclusively breast fed
What are the social disadvantages of breastfeeding?
Breastfeeding in public can be socially taboo
What are the medical disadvantages of breastfeeding?
- Transmission of HIV
- Breastmilk is low in vitamin D
- Certain bacterial infections in the mother can be transmitted
What reduces the risk of transmission of HIV through breastfeeding?
ARV drug interventions
What are current recommendations regarding breastfeeding and HIV?
Mothers with known HIV, regardless of maternal viral load and ARV therapy, should refrain from breastfeeding
What is recommended as a result of breastmilk being low in vitamin D?
Vitamin D supplementation is recommended for all pregnant women and breastfeeding mothers
What bacterial infections can be transmitted through breastmilk?
- Neisseria gonorrhoae
- Haemophilus influenza
- Group B streptococci
- Staphylococci
- TB
How can transmission of bacterial infections through breastmilk be prevented?
Should stop for 24 hours, or longer with TB
What problems are common in breastfeeding mothers?
- Cracked/sore nipples
- Blocked ducts and breast engorgement
- Mastitis/abscess
- Insufficient milk/hungry baby
Is nipple soreness common?
Yes, very common
When is nipple soreness common?
During first few weeks of breastfeeding
How might nipple soreness be described?
As pinching, itching, or burning
What can nipple soreness in breastfeeding be caused by?
- Improper position of the baby
- Improper feeding techniques
- Improper nipple care
How can nipple soreness be relieved if it is due to improper position of the baby?
Altering feeding position may help reduce soresness, providing a good attachment is maintained
How can nipple soreness be caused by incomplete feeding techniques?
May be caused by incomplete suction release at the end of the baby’s feeding
How can nipple soreness caused by incomplete suction release at the end of feeding be improved?
Gently inserting finger into the side of the mouth to break the suction may help
How can improper nipple care cause nipple soreness in breastfeeding?
Excessively dry or excessively moist skin can cause nipple soreness
How can nipple soreness caused by improper nipple care be improved?
Ointments containing lanolin may be helpful, as may olive oil and expressed milk
What normally happens to nipple soreness caused by breastfeeding?
Regardless of treatment, for most women the initial pain reduces to mild levels 7-10 days postpartum
What are blocked ducts caused by in breastfeeding?
Poor drainage of breast
How does blocked ducts from breastfeeding present?
- Breasts feel swollen, hard, and painful
- Redness
- Systemic symptoms
- Nipples cannot protrude to allow baby to latch on, and feeding becomes difficult
What are the common causes of blocked ducts in breastfeeding?
- Pressure on the breast, e.g. poorly fitting bra or seatbelt
- Prolonged gaps between feeds
How often should the mother be advised to nurse to prevent blocked ducts?
8 times or more in 24 hours, for at leat 15 minutes for each feed
How can breast engorgement be relived if it does occur?
Manual expression of milk or use breast pump
What might help relieve the pain associated with breast engorgemeny?
Alternative warm showers followed by cold compress
What might develop if breast engorgement persists?
- Mastitis
- Milk/milk products may get into bloodstream
What happens if milk/milk products get into bloodstream as a result of breast engorgement?
Leads to flu-like symptoms, similar to those of incompatible blood transusion
What is mastitis?
Inflammation of breast
In what % of breastfeeding women does mastitis occur in?
20%
What increases the risk of mastitis in breastfeeding women?
- Nipple damage
- Over-supply of milk
- Use of nipple shields
- Nipple carriage of staph aureus
Is mastitis infectious or non-infectious?
Can be either
What contiuum does mastitis exist on?
From blocked ducts and engorgement, to mastitis, to abscess
When is an infectious cause of mastitis more common?
In the presence of a cracked nipple
What bacteria most commonly causes infectious mastitis?
S. Aureus
Where does the infection take place in infectious mastitis?
In the parenchymal tissue of the breast
How does infectious mastitis cause symptoms?
The infection causes swelling which pushes on the milk ducts, causing pain and swelling
What may the treatment of mastitis include?
Antibiotics
Give an example of an antibiotic used in the treatment of mastitis?
Flucloxacillin
When are antibiotics used in mastitis?
When symptoms haven’t resolved within 24 hours
What management may be required for breast abscess?
Aspiration, or incision and drainage
Should breastfeeding or pumping continue whilst receiving treatment for mastitis?
Yes
Why is not producing enough milk an important thing to consider in breastfeeding women?
It is a common reason women give for giving up breastfeeding
What is usually the case when a woman feels she is not producing enough milk?
She is actually producing enough milk, but doesn’t think she is
Why might a breast-feeding woman not think she is producing enough milk?
- Lacks confidence in her ability to maintain her milk supply
- Not be aware her breasts will soften as feeding becomes established
- Not know it is perfectly normal for some breast-fed babies to feed 10 times a day
How can a good milk supply be maintained?
- Frequent feeding
- Offering both breasts at each feed
- Adequate rest
- Good nutrition
- Adequate fluid intake
- Expressing after feeds
What can determine if the baby is getting enough milk?
Checking weight and growth
What does WHO recommend, regarding establishing breastfeeding?
- Should start within 1 hour of birth
- Should be ‘on demand’, as often as child wants, day and night
- Bottles or pacifiers should be avoided if possible
What do mothers need to be given in order for successful breastfeeding to occur?
Support, confidence, and encouragement
When should breastfeeding support be available after delivery?
Immediately, even if by C-section
What are the requirements for a baby to be able to establish breastfeeding or bottle feeding?
Able to co-ordinate sucking, swallowing, and breathing
At what gestation are babies likely to be able to co-ordinate sucking, swallowing, and breathing?
> 34 weeks
When might babies require total parenteral nutrition?
Extremely pre-term babies, or those expected to have a prolonged stay in neonatal intensive care
What is the problem with pre-term breast milk?
Compared to artificial formula milk, it may not provide sufficient nutrition for preterm or low-birth weight infants
What may be required with pre-term breast milk?
May need fortification
