Module 5: Breast Anatomy and Physiology

Question 1

Describe lactogenesis stage 1

Answer 1

prolactin stimulates mammary secretory epithelial cells to produce milk, occurs after 16 weeks gestation, alveoli become distended and milk droplets move to ductules

Question 2

Describe lactogenesis stage 2

Answer 2

Occurs day 2-8 pp, results from delivery of the placenta, copious amounts of milk, delays may be caused by disruption of hormone cascade

Progesterone and estrogen levels drop →prolactin from ant pituitary continues to rise → suckling causes oxytocin release from the posterior pituitary → milk ejection reflex and contraction of myoepithelial cells equals milk

Question 3

Describe galactopoesis

Answer 3

maintenance of milk supply, autocrine (baby) driven, vs endocrine driven

Question 4

How does oxytocin affect lactation?

Answer 4

Released from Posterior pituitary by nb suckling

Causes contraction of the smooth muscle around the alveolus and forces milk out of the breast

Question 5

How does prolactin affect lactation?

Answer 5

Released from anterior pituitary gland

-Milk synthesis
-Inhibited by progesterone, estrogen and dopamine
-With milk removal, hypothalamus inhibits dopamine release
-Nipple stim doubles plasma concentration (lidocaine on the nipples results in no prolactin release)
-Greater than 8 feedings/24 hours prevents prolactin decline
-Levels at night are higher than daytime

At separation of placenta a drop in progesterone and rise in prolactin

Question 6

List the immune and antiallergic properties in breastmilk.

Answer 6

-Immunoglobulins
Antibodies are synthesized and stored in the breast
Milk-dose dependent
Mothers will produce higher concentration in response to poor suckling or newborn infection
Lymphocyte pathway results in specific IgA production following exposure to gut or respiratory-born antigen (sigma)

Question 7

List the nutritional properties of breastmilk.

Answer 7

-Water 87.5%
-Vitamins A, C, E
-Proteins: whey, Immunoglobulins SIgA, IgM, IgG, Lactoferrin (inhibits adhesion of e-coli to cells), lysozome (bactericidal and anti-inflammatory, increases in concentrations after 6 months), taurine, casein
-Lactose
-Fats: primary source of calories, long chain poly unsaturated fatty acids (cognitive ability), free fatty acids (anti-infective)
-Growth factors
-Enzymes
-prostaglandins/cytokines
-phagocytes/lymphocytes
-B12- CNS development (Vegan diet may result in breastmilk deficiency)
-Vitamin K (Several days of breastmilk in the gut promotes normal colonization for vitamin k synthesis)
-Iron: absorbed 5x as well from breastmilk than formula

Question 8

Review the evidence for breastfeeding. What are the AAP and WHO recommendations?

Answer 8

The AAP reaffirms its recommendation of exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 2 years

Question 9

Compare the risk and costs of using manufactured infant milk with human breast milk to the infant and the family.

Answer 9

A detailed pediatric cost analysis based on the AHRQ report concluded that if 90% of US mothers would comply with the recommendation to breastfeed exclusively for 6 months, there would be a savings of $13 billion per year.24 The savings do not include those related to a reduction in parental absenteeism from work or adult deaths from diseases acquired in childhood, such as asthma, type 1 diabetes mellitus, or obesity-related conditions. Strategies that increase the number of mothers who breastfeed exclusively for about 6 months would be of great economic benefit on a national level.

Question 10

Define the Healthy People 2020 objectives for breastfeeding.

Answer 10

●Increasing initiation and early bf to 81.9%
●Increasing duration of breastfeeding to We 60.6 at six months and 34.1 at one year

Question 11

Review the Baby Friendly Hospital Initiative.

Answer 11

●Baby friendly standards promote exclusive breastfeeding by following 10 steps designed to promote successful breastfeeding

Question 12

What are the guiding principles related to OTC and prescription medications and breastfeeding?

Answer 12

In general, breastfeeding is not recommended when mothers are receiving medication from the following classes of drugs: amphetamines, chemotherapy agents, ergotamines, and statins. (from Breastfeeding and use of human milk)

Smallest dose for shortest length possible, instruct mother to take after feeding and before longest infant sleep period, choose a drug with a short half life, if contraindicated pump and discard,

Question 13

What are the recommendations related to recreational/drugs of abuse and breastfeeding safety?

Answer 13

Maternal substance abuse is not a categorical contraindication to breastfeeding. Adequately nourished narcotic-dependent mothers can be encouraged to breastfeed if they are enrolled in a supervised methadone maintenance program and have negative screening for HIV and illicit drugs.96 Street drugs such as PCP (phencyclidine), cocaine, and cannabis can be detected in human milk, and their use by breastfeeding mothers is of concern, particularly with regard to the infant’s long-term neurobehavioral development and thus are contraindicated.97 Alcohol is not a galactogogue; it may blunt prolactin response to suckling and negatively affects infant motor development.98,99 Thus, ingestion of alcoholic beverages should be minimized and limited to an occasional intake but no more than 0.5 g alcohol per kg body weight, which for a 60 kg mother is approximately 2 oz liquor, 8 oz wine, or 2 beers.100 Nursing should take place 2 hours or longer after the alcohol intake to minimize its concentration in the ingested milk.101 (from Breastfeeding and use of human milk)

Question 14

Study the breastfeeding practices of women with viruses such as HIV

Answer 14

In the industrialized world, it is not recommended that HIV-positive mothers breastfeed. However, in the developing world, where mortality is increased in non-breastfeeding infants from a combination of malnutrition and infectious diseases, breastfeeding may outweigh the risk of the acquiring HIV infection from human milk. Infants in areas with endemic HIV who are exclusively breastfed for the first 3 months are at a lower risk of acquiring HIV infection than are those who received a mixed diet of human milk and other foods and/or commercial infant formula.89 Recent studies document that combining exclusive breastfeeding for 6 months with 6 months of antiretroviral therapy significantly decreases the postnatal acquisition of HIV-1.

Question 15

Study the breastfeeding practices of women with viruses such as CMV

Answer 15

There is no contraindication to breastfeeding for a full-term infant whose mother is seropositive for cytomegalovirus (CMV). There is a possibility that CMV acquired from mother’s milk may be associated with a late-onset sepsis-like syndrome in the extremely low birth weight (birth weight <1500 g) preterm infant. Although not associated with long-term abnormalities, such a syndrome may warrant antiviral therapy.92 The value of routinely feeding human milk from seropositive mothers to preterm infants outweighs the risks of clinical disease, especially because no long-term neurodevelopmental abnormalities have been reported.93 Freezing of milk reduces but does not eliminate CMV.94

Question 16

Study the breastfeeding practices of women with viruses such as varicella

Answer 16

Mothers who develop varicella 5 days before through 2 days after delivery should be separated from their infants, but their expressed milk can be used for feeding

Question 17

Study the breastfeeding practices of women with viruses such as HSV

Answer 17

Breastfeeding should not occur if the mother has active (infectious) untreated tuberculosis or has active herpes simplex lesions on her breast; however, expressed milk can be used because there is no concern about these infectious organisms passing through the milk.

Question 18

Study the breastfeeding practices of women with viruses such as Hepatitis

Answer 18

The woman who is a Hepatitis B or Hepatitis C carrier is encouraged to breastfeed. The baby should be immunized within 12 hours of birth. There is no need to delay the initiation of breastfeeding, however good nipple care is encouraged to prevent cracking and bleeding

Question 19

What are some feeding/huger cues?

Answer 19

Increasing alertness, rooting, flexing, flexed arm or closed fist, sucking, mouthing, fussing or restless, full cry

Question 20

Describe a good latch

Answer 20

Angle of the open mouth should be greater than 90 degrees (usually 130-150) with both lips flared outward

Question 21

Discuss positioning that can be used for BF and the benefits of multiple positions

Answer 21

Most infants can move to the breast and self-attach if the mother is in a semi-reclining position and the infant is lying prone on the womans body with access to her uncovered breasts.

Cradle or madonna position, cross-cradle, football or clutch, semi-reclining, side-lying or recovery position, australian or baby on top

Question 22

What is engorgement?

Answer 22

Hard, enlarged, shiny, bilateral erythema, occasional transient fever “milk fever” <38.4 resolves within 24-48 hours, associated with the onset of lactogenesis II

Question 23

How can nipple pain be prevented with BF?

Answer 23

○instruct on optimal position and latch
○Place infant in ventral or prone position for gravity assistance
○Make sure mouth is open to 160 deg with lips flared outward and neck slightly extended
○Avoid pacifiers until breastfeeding is well established
○Correct ankyloglossia
○Apply topical peppermint oil

Question 24

How can nipple pain without damage be managed?

Answer 24

○Apply warm water compresses
○Apply warm green tea bag compresses
○Apply topical coconut oil
○Apply hydrogel dressing
○Use a nipple shield if the above measures do not provide relief

Question 25

How can a cracked nipple be treated?

Answer 25

○Wash with soap and water once each day
○Apply topical mupirocin
○Avoid pacifier use and wash pacifiers thoroughly with soap and water
○Apply topical peppermint oil
○Apply topical low-strength steroids for inflammation

Question 26

Identify nutritional needs of the breastfeeding mom.

Answer 26

●Maternal nutrient requirements are heightened during lactation.
●Some nutrients including vitamins A, D, B1, B2, B6, and B12, fatty acids, and iodine are required in the maternal diet to ensure optimal levels in breast milk and, thus, the goal for infant dietary intake.
●Specific attention should be paid to maternal food sources that contain vitamins A, B1, B2, B3, B6, B12, C, and D, fatty acids, and iodine, as the concentration of these nutrients in human milk are at least partially dependent on maternal diet and body stores. Conversely calories, protein, folate, minerals, and trace elements in human milk are not dependent on maternal diet. Nevertheless, to avoid depletion of maternal nutrient stores, the recommended dietary intakes of these nutrients are greater for lactating women than for an average adult.

Question 27

Review strategies for managing breastfeeding and return to work.

Answer 27

●Help mothers assess the type and extent of breastfeeding support they will need for their particular situation.
●Mothers should inform their employer that they will be expressing milk when they return to work and should be aware of any work-site protection laws that apply to them.
●A place to pump milk should be arranged for as well as breaks of sufficient length to accommodate pumping.
●Childcare arrangements should be made before the infant is born or look into onsite childcare.
●Mothers should obtain a multiuser grade electric breast pump with the feature of being able to pump milk from both breasts simultaneously.

Question 28

What are some factors that affect breastfeeding in which healthcare providers have no influence.

Answer 28

●Breast reduction surgery and breast augumentation
●Maternal-Newborn separation secondary to illness
●Expressing milk for bottle feeding
●Adopting and relactation