Breastfeeding

Question 1

Describe: Lactogenesis I

Answer 1

• Differentiation/development of glands to produce colostrum
  
  • Contains relatively high concentrations of Na, Cl, and protective substances like immunoglobulins and lactoferrin.
• Occurs approximately midpregnancy (or 12 - 16 wks depending on the source)
• Prolactin responsible for milk production
• Milk secretion held in check by high progesterone and possibly estrogen

Question 2

Define: Lactogenesis II

Answer 2

• Usually about 3 - 8 days after birth (or 2 - 4 depending on source referenced)
• Onset of copious milk production
  
  • By day 5, typically 500 – 750 mL/ day
  • By day 8, about 600 – 700 mL/day
• Triggered by 10-fold drop of progesterone levels and increase in prolactin levels post placental expulsion
  
  • Change in several processes including:
    
    • Changes in the permeability of the paracellular pathway between epithelial cells
    • Changes in the secretion of protective substances, such as immunoglobulins, lactoferrin, and complex carbohydrates
    • Increased rate of secretion of all milk components

*

Question 3

Describe the hormonal basis for lactation

Answer 3

• Expulsion of the placenta → rapid decline in progesterone, estrogen, HPL → increased prolactin → milk production
  
  • Suckling/removal of milk from breast → even more prolactin
• Other hormones involved too like cortisol and insulin

Question 4

Describe normal breast anatomy

(start with nipple and go inward)

Answer 4

• Tip of the nipple contains openings (pores of 15 to 20 milk ducts
• Milk ducts (5-10 main ones) widen into lactiferous sinuses → lactiferous ducts → lobes
• Lobes - clusters of alveoli
  
  • Alveolus - milk-secreting unit, surrounded by a rich vascular supply and smooth muscle myoepithelial cells.
    • Myoepithelial cells contract under the influence of oxytocin and push the milk down the ductwork to the nipple, (let down)
• Breast is made up of glandular tissue (makes/transports milk) surrounded by fatty tissue and supported by fibrous tissue and suspensory ligaments (Cooper’s ligaments).

Question 5

Hormones that induce breast development during pregnancy:

Answer 5

• Progesterone
• Prolactin
• Human placental lactogen
• Growth hormone
• Insulin-like growth factor

Question 6

Breast weight

(non-pregnant, pregnant, lactating)

Answer 6

• Nonpregnant - 200 g
• Pregnant - 400 - 600 g
• Lactating - 600 - 800 g

Question 7

NIpple anatomy

(non-pregnant, pregnant, lactating)

Answer 7

• Size
  
  • Non-pregnant state: 15 – 16 mm
  • Pregnant state: > 5 cm
  • During lactation: 6.4 cm (average)
• Each contain 14 – 18 lactiferous ducts
• Has 4-9 pores that empty from the milk ducts to the surface.
  
  • Pores: 0.4 - 0.7 mm
  • Milk ducts: 2 - 4 mm
• Contains erectile smooth muscle tissue which contract with stimulation.
• Growth influenced by prolactin level increase

Question 8

Areola anatomy

Answer 8

• Center darker pigmented area of the breast
• Size increases from 34 mm in early pregnancy → 50 mm postpartum
• Montgomery glands (tubercles) - sebaceous glands that lubricate nipple and areola during infant suckling
  
  • Secrete antiinfective substances (IgA) that protect the nipple and areola
  • Wash away easily with soap or alcohol-containing compounds,→ nipple prone to cracking/infection
• Pigmentation increases in pregnancy and postpartum
• Growth influenced by hPL

Question 9

What is a great determinant of breast size?

Answer 9

Adipose tissue

(also protects breast from injury)

Question 10

Risk factors for delayed lactogenesis II

Answer 10

• Overweight
• Obese
• Diabetic
• Cesarean birth
• Retained placental fragments

Question 11

Contents, appearance and duration of:

• Colostrum

Answer 11

Duration: Birth until milk comes in (Day 2 - 5)

Appearance: Yellow color from beta carotene, thicker than mature milk

Contents:

• Higher in: protein, Na+, Cl-, K+, carotenoids, and fat-soluble vitamins (than mature milk)
• Lower in: sugars, fat, and lactose (than mature milk)
• Abundant amounts of antioxidants, antibodies, and immunoglobulins, with especially secretory IgA.
• Interferon with its strong antiviral activity
• Fibronectin - makes certain phagocytes more aggressive
• Pancreatic secretory trypsin inhibitor (PSTI) - protects and repairs the delicate intestines of the newborn, preparing this organ to process future foods.
• Mild laxative effect

Question 12

Lactogenesis III and IV

Answer 12

• Lactogenesis III
  
  • Day 9-10 postpartum until the mother and infant decide to wean
  • Stage of producing and maintaining milk production
• Lactogenesis IV
  
  • Involution and cessation of breastfeeding

Question 13

When should a breast-fed baby have returned to its birthweight?

Answer 13

10 days per Jamille (or 14 days, per Gabbe)

Question 14

Where is prolactin secreted from?

Answer 14

Anterior pituitary

Question 15

When do prolactin levels go back to normal, non-pregnant levels?

Answer 15

About a week after weaning

Question 16

Where is oxytocin released?

Answer 16

Posterior pituitary in pulsitile waves as a result of sucking

Question 17

What hormone causes the “let down” reflex and how does it work?

Answer 17

Oxytocin

• Nipple stimulation → oxytocin release by posterior pituitary →
  
  • Contraction of myoepithelial cells eject the milk from the alveoli in the breast into the ducts → milk travels out into the nipple
  • Uterine contractions/cramping
• Plays a role in maternal bonding (love hormone)
• Increases pain tolerance
• Stimulates growth in the # of intestinal villi → increasing surface area for caloric absorption

Question 18

Physiology of weaning/decreased milk production

Answer 18

• Colostrum/milk not removed from breasts → distended alveoli → pressure on blood vessels → reduced blood flow → prolactin can’t reach secretory cells
• Lack of nipple stim → release of prolactin inhibiting factor → milk production gradually decreases

Question 19

Contents, appearance and duration of:

• Transitional milk
• Mature milk

Answer 19

Transitional milk: Day 2- 5, may be yellow/gold but transitioning to blue/white

Mature Milk

• Appears Day 2 - 5
• 87.5% water, with all other components either dissolved, dispersed, or in suspension
• Lipids/fats provide about 50% of the energy in milk
  • Fat content varies throughout a feeding or pumping session
    
    • Foremilk (early milk) is more dilute → thirst quencher
    • Hind milk has a higher fat content → thicker, “dessert”
  • Triacylglycerols most abundant fat
• Doesn’t generally have enough Vitamin D → AAP recommends 400 IU/day after first few days of life

Question 20

Infant stomach size

Answer 20

Baby needs less than a teaspoon of colostrum at each feeding in the first few days of life

Question 21

Describe the immunologic properties of breast milk

Answer 21

Major mechanisms for the protective properties of breast milk include:

• Antimicrobial proteins: lactoferrin, sIgA, lysozyme, alpha- lactalbumin, lactadherin, defensins, and others.
  
  • Protect infant from a # of bacteria and also provide some protection from viruses and fungi
• Human-specific oligosaccharides - blocks the binding of the microbe to the infant’s mucosal receptors, thereby limiting microbe virulence
• Active leukocytes

Question 22

Identify the nutritional requirements of the lactating woman

Answer 22

• Average lactating person puts out about 800 calories of breastmilk/day
• Continue to take PNV - vitamin/mineral requirements still up
• *Should take 1 g folic acid/day
• *Vitamin D 600 IU
• No general food restrictions as long as not allergic to certain foods and tolerates the food or beverage
• Once lactation established, overweight women may restrict their energy intake by 500kcal/day to promote a weight loss of 0.5kg/week without affecting the growth of their infants
• Moderate exercise ok

Question 23

Describe variations in nipples and breasts

Answer 23

• Nipple inversion - congenital tethering of the nipple to underlying fascia
  
  • Dx by squeezing the outer edge of the areola → normally the nipple will protrude. Severe tethering is manifested by an inverted nipple. most severe forms of tethering occur in fewer than 1% of women.
  • Breast shells and Hoffman exercises dont help (per Gabbe)
• Breast hypoplasia (glandular hypoplasia) very rare
  
  • Must wait until pregnancy (ie 36 weeks to really assess)
• Previous breast surgery

Question 24

Describe different maternal and neonatal positions for breastfeeding

Answer 24

Question 25

Describe characteristics of effective neonatal latch, suck and swallow

Answer 25

Characteristics of a correct latch:

• Infant’s mouth opened wide enough (angle of corner of mouth = about 160°)
• Nipple and at least 1/4 to 1/2” inch of areola drawn into the infant’s mouth and remain in place during sucking
• The nipple should not be flattened, distorted, blanched, creased, or demonstrate blisters, fissures, or cracks when babe comes off
• Swallowing should be either heard or seen
• Both the upper and lower lips should be flared out (not rolled or tucked under) and form a complete seal with no leakage of milk at the corners of the mouth.
• Cheek line should be smooth (not dimpled or drawn in) during sucking.
• No smacking or clicking sounds during sucking (indicates that the tongue is losing contact with the nipple/areola)

Question 26

Identify best practices to promote, assess and support the breastfeeding mother

Answer 26

All health-care providers should have basic core competencies in providing evidence-based breastfeeding care

Helpful:

• Prenatal information regarding the realities of breast- feeding
• Practical help with positioning and latch-on
• Provision of effective interventions for early problems
• Evidence-based answers to questions such as how long and how often to breastfeed, when to switch breasts, and whether nipple shields and supplementing with bottles of formula will undermine breast- feeding.
• Remaining with the mother during early feedings, assuring correct latch, and documenting milk transfer

Unhelpful

• Inconsistent advice about breastfeeding techniques
• Quick intervention with a bottle when feeding diffculties present
• Lack of skilled assistance
• Rough handling of breast

Question 27

Common breastfeeding problems:

Low supply

Answer 27

• Medical causes:
  
  • Maternal hypothyroidism
  • PCOS
  • Previous breast surgery
  • Breast hypolplasia
  • Sheehan’s Syndrome
  • Retained placenta
• Any reason that may limit the infant’s ability to breastfeed effectively and frequently
  
  • Poor latch
  • Early use of pacifiers
  • Prematurity, Late pre-term
  • Mother and infant being separated
    
    • NICU, employment
• Supplementation with formula
• Delayed milk ejection secondary to stress and pain
• Maternal medications

Question 28

Average infant weight loss by 72 hours of life?

Answer 28

7%

shouldn’t be > 10%

Question 29

Infant weight gain goals

Answer 29

15 – 30 g/day weight gain from day 5 – 2 months

Question 30

Signs of adequate breastfeeding

Answer 30

• Audible swallowing sounds while breastfeeding
• Adequate weight gain of > 4 – 7 ounces/week after Day 4
• Adequate amount of wet diapers
• Stools that transition from dark, tarry (meconium) to greenish, yellow to soft, seedy, yellow-mustard stools by the 5th day of life
• Normal skin turgor

Question 31

Non-pharm ways to increase milk supply

Answer 31

• Facilitate frequent feeding and oxytocin release
  
  • Skin-to-skin
  • Self-breast massage
  • Relaxation techniques
• Help mother-infant dyad to achieve optimal latch-on
• Emphasize unrestricted frequency and duration of BF
• Advise mother to reduce or stop unnecessary supplementation
• Address medical reason, if treatment available
• Acupuncture has been successfully used in China since ancient times

Question 32

Pharm methods to increase milk supply

Answer 32

Galactagoges:

• Research on use inconclusive
• Have potential side effects
• If prescribing, counsel re: efficacy, timing of use, and duration of therapy
• Monitor mother closely
• Make peds aware
• Prescribe lowest dose for shortest period of time
• Gradual discontinuation

Domperidone (Motilium)

• 10 mg PO TID x 14 days
• SE: drymouth, HA, abdominal cramps
• May have “responders” and “non-responders”

Metoclopramide (Reglan)

• 10 mg PO TID or QID x 7-14 days
• SE: sedation, anxiety, depression, agitation, gastric cramping, diarrhea

Question 33

Herbals, foods, beverages to increase milk supply

Answer 33

• Not a lot of research, traditional use demonstrate safety and possibly efficacy
• No standard dosing
• Herbs
  • Fenugreek - 1200mg capsule 2-3x daily
  • Goat’s rue - 1 tsp of dried herb steeped in 1 cup of water BID or 1–2 mL of tincture TID
  • Milk thistle (Silybum marianum)
  • Oat, dandelion, seaweed, anise, basil, blessed thistle, fennel seeds, marshmallow, and many others.
• Beer (alcohol could potentially lower production)
  
  • A barley component of beer (even nonalcoholic beer) can increase prolactin secretion, but not good studies

Question 34

Treatments for flat or inverted nipples

Answer 34

• Breast Pump
  
  • Can be used to draw out the nipple immediately before breastfeeding
• Evert-it Nipple Enhancer
  
  • Designed by lactation consultants, the Evert-It consists of a syringe with a soft, flexible tip made of silicone, either end of which may be used to provide suction to help nipples protrude for easier latch-on
• Nipple stimulation before feedings
  
  • Roll nipple between the thumb and index finger for a minute or two. Afterwards, quickly touch it with a moist, cold cloth or with ice that has been wrapped in a cloth
  • Avoid prolonged use of ice, as numbing the nipple and areola could inhibit the let-down reflex.

Question 35

Common breastfeeding problems:

Sore nipples

Answer 35

Causes

• Incorrect latching or unlatching
  
  • higher risk with flat/inverted nipples
• Vasospasm (Reynaud-like phenomenon) – causes the baby to compress the breast so tightly as to interrupt blood flow to the nipple
• Ankyloglossia

Relief measures

• Alter breast technique
• Pain relief
• Healing nipple skin
• Lanolin
• Hydrogel
• Peppermint water
• Interruption/Rest from breastfeeding

Question 36

Common uses for nipple shield

Answer 36

• To improve latch-on when mother has flat nipples.
• To overcome latch-on problems due to engorgement.
• To assist infants who are nipple confused, preferring an artificial nipple to the mother’s breast.
• To aid premature infants with tiny mouths, reduced or impaired suck mechanisms, or other physical challenges.
• To protect sore or damaged nipples.
• To prevent sore nipples (claimed by manufacturers but not proven)

Question 37

Common breastfeeding problem:

Yeast infection of breast

Answer 37

• Due to Candida albicans
• Symptoms:
  
  • Superficial nipple pain
  • Deep breast pain
  • Shooting, burning, stabbing pain
  • Red, shiny, flaky areola
• Treatment
  
  • Topical Miconazole 2% - remove excess
  • Gentian violet painted on areola and nipples – 0.5 – 1.0% strength for 4 – 7 days (potential for toxicity if used for a long period of time).
    
    • Dilution pf 0.25% - 0.5% can be used on infant’s mouth 1-2 x daily fro 3 – 7 days
  • Fluconazole 400 mg loading dose then 100 mg BID x 14 days
  • Newman’s APNO ointment (mupirocin 2%, betamethasone 0.1%, miconazole powder) – apply sparingly after each feeding until pain free (dont wash off)

Question 38

Common breastfeeding problem:

Plugged duct

Answer 38

• Tender small lumps in breasts usually related to the blockage of a milk duct
  
  • Possibly due to large milk supply or pressure from outside the breasts (from bra straps, backpack, purse straps) resulting in a physical obstruction of milk flow and a large collection of milk products
• Management:
  
  • Warm compress
  • Direct massage over the lump while infant is suckling
  • Prompt attention needed to prevent cascade of engorgement and mastitis
  • Lecithin (phospholipid used by food industry as an emulsifier to keep fat dispersed and suspended in water rather than aggregated in a fatty mass). 1 tbsp/day of oral granular lecithin has been reported to relieve plugged ducts and prevent their recurrence

Question 39

Common breastfeeding problems:

Engorgement

Answer 39

• Typically occurs 3 to 5 days after birth (or first 2 wks)
• Breasts are swollen, firm, tender, and warm to touch
• Sudden increase in milk volume, lymphatic and vascular congestion, and interstitial edema
  • Milk production increases rapidly → milk volume outpaces capacity of alveoli to store → alveolar overdistension →
    
    • Flattens milk-secreting cells (can rupture)
    • Capillary blood circulation surrounding the alveolar cells partially or completly occluded.
    • Congested blood vessels leak fluid into the surrounding tissue space,→ edema → obstruct lymphatic drainage → predisposed to mastitis
• Makes it hard to feed, very painful
• Treatment:
  
  • Feed Q2H, feeding through the pain
  • Feed on 1st breast until it softens before switching to other side
  • Warm shower or warm packs before feeding to relax ptlet-down
  • Massage to soften breast
  • Ibuprofen to reduce pain and swelling
  • Chilled cabbage leaves in bra (evidence mixed)

Question 40

Common breastfeeding problems:

Mastitis

(symptoms and predisposing factors)

Answer 40

• Tender, hot, swollen, wedge-shaped area of breast associated with a temperature of >101° F, chills, flu-like aching and systemic illness.
• Occurs most frequently in the first 2-4 wks pp
• Predisposing factors:
  • Nipple trauma, especially if colonized with Staphylococcus aureus
  • Infrequent feedings or scheduled frequency or duration of feedings
  • Maternal stress and fatigue ( and not feeding infant as much)
  • Poor nursing technique – weak latch, uncoordinated suckling, inefficient removal of milk
  • Oversupply of milk
  • Rapid weaning
  • Blocked nipple or duct
  • Nipple piercing
  • Insulin dependent diabetes

Question 41

Common breastfeeding problems:

Mastitis

(Supportive measures)

Answer 41

• Effective milk removal
• Rest
• Fluids
• Nutrition
• Practical help around the house to allow mother to have adequate rest
• Application of heat (hot shower or hot pack) prior to breastfeeding
• Cold packs in between feedings

Question 42

Common breastfeeding problems:

Mastitis

(Pharm management)

Answer 42

• Analgesia such as acetaminophen and ibuprofen
• Antibiotics
  
  • Non-severe infection without risk for MRSA:
    
    • Cephalexin [Keflex] 500 mg QID x 10 -14 days
    • Dicloxacillin [Dynapen] 500 mg QID x 10 – 14 days
    • Clindamycin 300 mg QID x 10 – 14 days
  • Non-severe infection WITH risk for MRSA:
    
    • Trimethoprim-sulfamethoxazole (Bactrim) 1 – 2 tabs BID
    • Cephalexin [Keflex] 500 mg QID x 10 -14 days
  • Severe infection: Intravenous therapy
    
    • Vancomycin 30 mg/kg IV in two divided doses Q 24 hours

Question 43

Common breastfeeding problems:

Mastitis

(Follow up, complications)

Answer 43

• If sx do not resolve within several days of management, consider differential dx: resistant bacteria, abscess formation, underlying mass, or inflammatory or ductal carcinoma
• Complications
  
  • Early cessation of breastfeeding
  • Abscess
  • Candida infection
  • Recurrance/resistance - milk culture, infant naso/oropharynx culture

Question 44

Common breastfeeding problems:

Breast abscess

Answer 44

• Localized collection of pus in breast tissue
• Most common organism: staph aureus (60% MRSA)
• Ultrasound: rounded anechoic image with defined walls.
• Management:
  
  • Drainage and antibiotic therapy
  • Needle-point aspiration
  • Surgical drainage
• Complication of surgical drainage:
  
  • Milk fistula
  • Poor cosmetic outcome

Question 45

Common breastfeeding problems:

Fussy baby

Answer 45

• Pain from birth injuries - be careful about positioning
  
  • Vacuum extraction associated with poor feeding/breastfeeding cessation by 10 days)
• Oral aversion - from NICU care like suctioning, intubation, or just soreness of mouth
  
  • Have baby cuddle, play at breast, try cup feeding
• Pre/perinatal medication - hypertonia and
  
  • Ilicit drugs - irritibility, thrashing, clamp down on nipple, nasal stuffiness
  • Tobacco - excitability, need holding
  • SSRIs - agitation, tremors, irritability, and sleep disturbances → try to feed drowsy, low stim
• Hunger - poor feeding or limited milk transfer

Question 46

Common breastfeeding problems:

Sleepy baby

Answer 46

• Not an indicator that an infant has received enough milk
• Sleep more: late preterm, jaundice (including those undergoing phototherapy), born by c-section, and heavier infants of diabetic mothers
• May be related to the normal release of cholecystokinin (CCK) - occurs with breastfeeds.
  
  • GI hormone released in response to fat
  • Enhances gut maturation, promotes glucose-induced insulin release, enhances sedation, thought to play a role in regulating food intake by signaling satiety
• Keep skin-to-skin as much as possible during the day
• Feeding can be subtle:
  
  • Rapid eye movements under the eyelids
  • Tongue, hand-to-mouth, or body movements,
  • Small sounds
• Can use supplemental nursing system

Question 47

Common breastfeeding problems:

Slow weight gain

Answer 47

Factors associated with slow weight gain:

• Gestational age
• Size for gestational age
• Oral malformations - cleft lip/palate
• Neuro alterations
• Increased energy requirements - cardiac disease, respiratory disease, and metabolic disorders
• Infant illness or condition
• Maternal medications
• Intrapartum factors - cesarean birth, fetal hypoxia during labor, maternal medications during labor, epidural analgesia, forceps delivery, and vacuum extraction that may interfere with alertness and ability to feed
• Iatrogenic - ie separation

Supplemental feedings breast milk are ideal if supply is suffcient. Start with a minimum of 50–100mL/kg/day divided into 6 to 8 feedings

Question 48

Common breastfeeding problems:

Preterm and late preterm infants

Answer 48

• Breast milk is very important
• Should begin pumping within 6 hours of birth
• Late preterm infants:
  • Born with low energy stores, high energy demands, and poor feeding ability
  • Sleepy/tire easily when feeding
  • Weak suck and low tone
  • Easily overstimulated
  • More prone to positional apnea due to airway obstruction
    
    • Should be breastfed in a clutch, cross-cradle, or ventral position
• May need to pump for weeks or months until infant can breastfeed or to provide as much breast milk for as long as possible.
  
  • Need to have an effcient, automated hospital-grade pump that cycles ~ 48–50 times per minute, with vacuum that does not exceed 240 mmHg.
  • Double collection kit that pumps both breasts simultaneously and fits properly should be used.
  • Pump more milk faster when double pumping, esp w/ breast massage.