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Postpartum Issues > Breastfeeding > Flashcards

Breastfeeding Flashcards

1
Q

Describe the embryological origins of the breast

A
  • Arises from single ectodermal bud.
  • Milk streak develops as an ectodermal thickening extending from axilla to pelvis (galactic band).
  • Most of the band atrophies leaving a mammary ridge in the pectoral region.
  • Squamous cells -> form mammary ducts
  • Mesenchymeal cells differentiate into smooth muscle of nipple and areola.
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2
Q

What hormone is responsible for pubertal breast development?

A

Oestrogen.

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3
Q

What are the main changes in breast development at puberty?

A

Increase in fat deposition and glandular development. Areola and nipple enlargement.

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4
Q

What changes occur to the breast during pregnancy?

A

Under influence of progesterone, estrogen, GH and prolactin causes hypertrophy of existing alveolar-lobular structures in the breast. There is also formation of new alveolae by budding from the lactiferous ducts, with proliferation of milk-collecting ducts.

Prolactin and human placental lactogen stimulates milk protein synthesis and colostrum. Milk production and secretion is inhibited by high progesterone and oestrogen, until it falls portpartum.

Weight increases from 200g pre-pregnancy to 500 mg in pregnancy. Lactating breast weights 600-800g.

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5
Q

Outline the flow of milk from production to ejection and associated structures.

A
  • Milk made in alveoli - Flow from alveoli to lactiferous duct - Stored in reservoir at tip of duct called lactiferous sinus. - Flow from lactiferous sinus to milk duct - Flow from milk duct out nipple
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6
Q

What is the innervation of the breast?

A
  • Anterior and lateral cutaneous branches of the 4th - 6th intercostal nerves
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7
Q

What is the lymphatic drainage of the breast?

A
  • Lateral (>75%): axillary –> clavicular –> subclavian lymphatic trunk.
  • Medial (10-25%): parasternal lymph nodes or opposite breast.
  • Inferior: to abdominal lymph nodes and para-aortic nodes
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8
Q

What is the vasculature of the breast?

A
  • Lateral mammary branches of lateral thoracic artery - branch of axillary artery
  • Perforating arteries of 2/3/4th intercostal arteries
  • Medial mammary branches of internal thoracic artery, arising from sublavian artery
  • Venous drainage mirrors arterial. Drains into the axillary vein, 2-4th intercostal veins and internal thoracic veins.
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9
Q

What is lactogenesis stage I?

A

Starts from mid trimester.

Hormones: oestrogen, progesterone, prolactin, human placental lactogen, GH.

Development of: - Mammary lobules under progesterone. - Lactiferous ducts under oestrogen. Start production of milk protien and colostrum. Full lactation function suppressed in pregnancy by high levels of progesterone.

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10
Q

What is lactogenesis stage II?

A

Starts post-partum.

Hormones: prolactin, cortisol. Loss of inhibition of progesterone due to loss of placenta.

Increase in prolactin stimulating milk production. Increase in mammary blood flow, oxygen and glucose uptake. Increased lactose production, has osmotic effect drawing fluid into alveoli and increasing milk volume.

Colostrum production (up to 400 mL/day) increases to 500-700 mL/day by day 2-5.

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11
Q

What is the main differences between colostrum and mature milk?

A

Colostrum has:

  • More protein including IgA
  • More lactose
  • Less fat
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12
Q

What is lactogenesis stage III?

A

Long term maintenance of milk production; changes from endocrine to local/autocrine control (i.e. production and flow controlled by local suckling). Occurs around day 10 postpartum.

Hormones: prolactin, oxytocin.

Stimulation of nipple/areola and infant behavioural cues cause oxytocin release and contraction of myoepithelial cells surrounding the alveoli triggering milk ejection.

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13
Q

What is lactogenesis stage IV?

A

Involution and cessation of breastfeeding. Occurs around 40 days after stopping vreast feeding.

Hormones: lactation inhibitory factor.

Decrease breastfeeding (<6x/day or <400 mL/day) leads to fall in prolactin levels. After 24-48 hrs of no milk transfer, increased intraductal pressures and release of lactation inhibitory factor causes alveolar secretory epithelium apoptosis.

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14
Q

How much of total birthweight does a breastfeeding infant lose in the first week of life? What is the upper limit of tolerance of weight loss in the first week?

A

7%. Upper limit 10% of birthweight.

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15
Q

How often does a neonate need to be fed?

A

Every 2-3 hours 8-12 times a day. Duration usually 20 mins per feed

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16
Q

List the maternal benefits of breastfeeding:

A
  • Reduced risk of premenopausal breast cancer, ovrarian and endometrial cancer: dose-dependent effect with duration of BFing.
  • Reduced risk of cardiovascular disease.
  • Reduced risk of T2DM.
  • Cost-effective for family and society
  • Enhances postpartum weight loss
  • Contraceptive (LAM)
  • Improves maternal-infant bonding
  • More environmentally friendly
17
Q

List the maternal risks of breastfeeding

A

• Transient nipple pain • Persistent painful nipples Mastitis

18
Q

List the neonatal benefits of breastfeeding

A
  • Safe supply, correct temperature
  • Improves maternal-infant bonding
  • Passive immunity and bioactive compounds to help protect against infection
  • Appropriate nutrients and calories: ○ Faster gastric emptying. ○ Faster linear and head growth whereas formula-fed infants have greater weight gain and fat deposition.
  • Improves gut microbiome and GI function. Contains immunomodulatory proteins that protect against NEC.
  • Reduces risk of obesity and T2DM.
  • Reduces severity of atopic conditions: eczema, asthma, and autoimmune conditions.
  • Reduces risk of SUDI
19
Q

List the neonatal risks of breastfeeding

A

Transmission of candida, HIV and Hep B.

Transmission of drugs (particularly meth amphetamine).

20
Q

How long is breastfeeding recommended for?

A

Exclusively first 6 months of life. Continued up to 12 months of life.

21
Q

What are risk factors for failure to initiate and maintain breastfeeding?

A
  • LSCS
  • Teenage mothers
  • Ethnicities
  • Breast-reduction surgery / Breast augmentation
  • Failure of breasts to enlarge during pregnancy, small tubular breasts
  • Unsuccessful breastfeeding with prior child.
  • Social/emotional stressors
22
Q

What are the contraindications for breastfeeding?

A
  • HIV / AIDS
  • drugs - antineoplastic drugs, lithium
  • Untreated active TB
  • Active HSV infection on nipple
  • Neonatal galactosaemia
23
Q

List the WHO ten steps to successful breastfeeding

A
  1. Have a written policy to support breastfeeding.
  2. Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding.
  3. Inform all pregnant women about the benefits of breastfeeding.
  4. Initiate breastfeeding and skin-to-skin within 1 hour after birth.
  5. Support mothers to initiate and maintain breastfeeding and manage common difficulties.
  6. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.
  7. Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day.
  8. Encourage breastfeeding on demand and support mothers to recognize and respond to their infants’ cues for feeding.
  9. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.
  10. Coordinate discharge so that parents and their infants have access to ongoing support and care.
24
Q

List two galactogogues to improve breast milk production.

A
  • Metoclopramide and Domperidone and chlorpromazine: blocks dopamine receptors and thus increases prolactin production by anterior pituitary.
25
Q

List ways to reduce breast pain during breastfeeding

A

Assessment of technique and advice on nursing technique and lactation consultant input:

  • Correction of latching
  • Rotation of nursing position
  • Frequent nursing to reduce engorgment
  • Prefeeding manual expression
  • Initiation of nurse on painful side first (whilst suck more powerful), to encourage unblocking of ducts and reduce engorgement
  • Simple analgesia
  • Assess and treat infant tongue tie
  • Treat associated infections and mastitis
  • warm compresses before to iprove milk flow, then cold compresses after to minimise inflammation
  • Trial nipple shields
  • Treatment of cracked nipples
26
Q

Summary of the DAME 2017 trial.

A
  • Multicentre RCT in Australia.
  • Recruited singleton pregnancies at 34-37 weeks, with GDM or pre-exisitng DM
  • comparing antenatal expression from 36 weeks vs routine antenatal care

Findings:

  • no difference in the proportion of infants admitted to the NICU
  • no difference in the mean gestational age at birth
  • moderate evidence of association between allocation to antenatal expressing during pregnancy and the proportion of infants receiving exclusive breastmilk in the first 24 hours of life
27
Q

Anatomical changes of the breast in pregnancy

A

• During pregnancy many breast changes occur:

o Breast size increases

o Areola enlarges and becomes darker

o Montgomery glands (combination of sebaceous & milk glands) increase in size

• Secretory / glandular tissue hypertrophies and grows new tissue, which is believed to occur by fatty infiltration

o By term, glandular tissue completely replaced by fatty tissue

  • During the first half of pregnancy, extension and branching of the ductal system occurs, along with lobular-alveolar growth (mammogenesis)
  • By week 16 of gestation, colostrum present in alveoli and milk ducts
  • In 3rd trimester division and differentiation of mammary epithelial cells and pre-secretory alveolar cells into secretory milk-producing alveolar cells
28
Q

Physiological changes of the breast in pregnancy

A

Placenta: hPL and progesterone

Ant pit: Prolactin

Stimulate growth of glandular tissue and alveolar cells to make milk

  • Oestrogen → causes duct development
  • Progesterone → alveoli development
  • Prolactin → stimulates glandular activity and colostrum secretion
  • Mammary blood flow doubles in volume
29
Q

Anatomy of the breast

A
  • Overlies pectoralis major fascia from 2nd to 6th rib
  • Divided into ~20 fat-filled lobules made up of alvioli, with a lactiferous duct and sinus that extends radially to the nipple and opens onto the surface
  • Areolar glands also open open around the nipple and secrete a protective lubricant
  • Lobules are separated from each other by fibrous tissue that form suspensory ligaments extending from pec major fascia to the skin overlying the breast.
30
Q

List the factors associated with development of breast engorgement / non-infective mastitis

A
  • Not demand feeding baby
  • Incorrect latch
    • Poor technique by baby and/or mother
    • Tongue tie: anterior, posterior or labial
  • First few days of baby’s life, as “milk comes in”
  • If baby is not feeding as much as usual e.g. unwell with reduced appetite
  • Baby taking small feeds that do not empty breast well
  • Mismatch between breast storage capacity and the amount baby takes in at a feed
31
Q

Risk factors for infective mastitis.

A
  • nipple damage
  • increased and sustained engorgement of breasts
  • a history of problems with latching baby on the breast
  • stressed and exhausted
  • missed or reduced feeds and milk stasis
  • have a previous mastitis history with other babies
  • use a manual breast pump
32
Q

2 types of mastitis.

A

Non infective and infective

  • Non infective: due to engorged and blocked ducts, causing increased pressure within alveoli and ducts, causing leakage of milk into surrounding connective tissue casuing inflammation and swelling
  • If untreated progresses to infective: if there is stasis of milk this can then become infected with bacteria (most commonly staph. A.)
33
Q

Causes of milk stasis?

A

poor latch on and/or effective sucking by your baby

inefficient positioning between mother and baby during breastfeeding

scheduled or restricted feeds, long gaps without feeding, missed or short feeds

sudden cessation of breastfeeding

overabundant milk supply

breast engorgement

blocked milk duct

pressure on a particular area of the breast caused by a tight bra, gym/swimwear, breast shells, car seatbelt, bag strap across your breasts, your sleeping position or holding your breast firmly during feeding

stress and fatigue that leads to less time for breastfeeding

separation from baby

sleep training programmes that discourage night-time breastfeeding

unusual stress and fatigue or a weakened immune system in the mother.

34
Q

Compare fore milk and hind milk.

A

Fore milk - higher water and lactose content.

Hind milk - higher fat, iron and calorie content. Important for growth.

35
Q

Treatment for mastitis.

A

Empty your breast by breastfeeding on the affected side. If this is not possible, hand express or use a pump to help get the milk moving.

Try gentle massage. Doing this under heat can be helpful to liquefy the fat within the milk and help move it through. This is best done in a shower.

Use cold compresses after feeds.

Get rest.

Consider taking ibuprofen to help with swelling and pain.

Antibiotics if infected - fluclox first line; augmentin second line.

USS and drainage if breast abscess suspected.

36
Q

Advice to give women who have mastitis.

A

Breastfeed on demand, starting with the sore breast.

Make sure your baby is latched on correctly (mouth covering almost the entire areola, not just the nipple) and drains your breast well.

Make sure your breast feels soft and comfortable after feeding.

It is recommended and safe to feed your baby from the affected breast.

Try different feeding positions to improve drainage (baby’s chin near the inflamed area).

Wear loose-fitting clothes and a bra that is well-fitting and does not dig in anywhere (obstructing the flow of milk).

Change breast pads or bras frequently if you are leaking milk.

Warm compresses could be used to assist milk flow before feeding or expressing (eg, a warm shower, or covered hot water bottle, or wrapped wheat bag). Make sure none of these are too hot.

Gentle massage of the affected breast and lying flat prior to a feed can be helpful. The fingers (not tips) can be used in firm stroking movements towards your sternum and armpit.

Care must be taken to avoid massage that is too firm as this can cause trauma and undue pressure and increase inflammation.

Cold packs can also be quite soothing when placed on the breast after feeding.

A soft stretchy support such as tubigrip or boob tube may be better than a bra at this time.

37
Q

Describe process of milk let down reflex.

A
  • It is a positive feedback loop
  • Mechanoreceptors from nipple send nervous signal to hypothalamus
  • Prolactin released from anterior pitutary and oxytocin released from posterior pituitary and hypothlamus
  • Lactocytes under influence of nervous impulses from mechanoreceptors and prolactin stimulate milk production
  • Oxytocin stimulates myoepithelial cells to contract and release milk into lactiferous ducts
  • Reflex takes <1 minute
38
Q

What are the protective mechanisms of breast milk?

A
  • lactoferrin in breast milk binds iron, preventing the proliferation of E.coli, which is an iron-dependent organism
  • it encourages colonisation of the neonatal gut by non-pathogenic flora, which competitively inhibit pathogenic strains
  • bacteriocidal enzymes are present
  • living lymphocytes, polymorphs and plasma cells that may play a part in cell mediated immunity in the neonate are present
  • specific immunoglobulins are present (>90% IgA, rest IgG)

Postpartum Issues (5 decks)

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