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Lactation and
Breastfeeding
Obstetrics and Gynecology
Breastfeeding
Infant Health Benefits
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COLOSTRUM
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Small amount for the immature digestive system
‘paints’ the digestive tract
Low fat for easy digestion
Contains mothers antibodies which boost infants’
immune system
Acts as a laxative to ease passage of meconium
Breastfeeding
Infant Health Benefits
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The milk comes in
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Transitional milk for up to 2 weeks
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May still have yellow appearance
Amounts increase quickly as infant hungers and
digestive system matures
Mother's" milk making” changes from endocrine to
autocrine system
Mature milk
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Supply/demand system engorgement decreases
Properties of fore milk and hind milk present
Breastfeeding
Infant Health Benefits
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Lower risk of
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Diarrhea
Constipation
Infections
 Ear, respiratory, meningitis, urinary tract
SIDS
Allergic diseases
Chronic digestive diseases
Juvenile onset diabetes
Acute leukemia
Adult obesity
Breastfeeding
Infant Health Benefits
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Provides immunologic protection while the
infant’s immune system is maturing
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Antimicrobial agents
Anti-inflammatory agents
Immunomodulating agents
Breastfeeding
Infant Health Benefits
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Preterm Infants
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Decreased necrotizing enterocolitis
Decreased ROP
Decreased infection rates
Better able to tolerate feedings
Increased IQ rates
Contains long chain polyunsaturated fatty acids that
help the infant’s brain develop – these are normally
provided by the mother in late pregnancy, therefore
preterm infants miss this
Breastfeeding
Mother Health Benefits
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Less postpartum bleeding
More rapid uterine involution
Weight loss
Decreased premenopausal breast cancer
rates
Decreased ovarian cancer rates
Lactational amenorrhea
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Should still use progesterone only contraceptives
Combined contraceptives dry up milk
Breastfeeding
Parent Benefits
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Saves money
Saves time
Babies love it
Lactation
Anatomy and Physiology
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Breast enlargement
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During pregnancy and lactation indicates the
mammary glands are becoming functional
Breast size before pregnancy does not determine
the amount of milk a woman will produce
Lactation
Anatomy and Physiology
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Hormones during pregnancy
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Estrogen stimulates the ductile systems to grow,
then estrogen levels drop after birth
Progesterone increases the size of alveoli and
lobes
Prolactin contributes to increasing the breast
tissue during pregnancy
Lactation
Anatomy and Physiology
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Alveoli secrete milk and contract when
stimulated
Oxytocin stimulates milk secretion and is
released during the ‘let down’ or milk ejection
reflex
After let down, milk travels into the ductules,
then to the larger – lactiferous or mammary
ducts
Lactation
Anatomy and Physiology
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Hormones during breastfeeding
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Prolactin levels rise with nipple stimulation
Alveolar cells make milk in response to prolactin
when the baby sucks
Oxytocin causes the alveoli to squeeze the newly
produced milk into the duct system
Lactation
Anatomy and Physiology
Latch On and sucking
Oxytocin Release
Releases Milk
Infant Empties Breast
Production Increases
Milk Production Occurs
Interference with this cycle decreases the milk supply.
Breastfeeding
Barriers
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Early breastfeeding failures deprive infants of
the benefits, and leave many mothers
disappointed
It is a natural process, but many mothers
need a lot of help
Breastfeeding
Barriers
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Must educate mothers regarding:
 Positioning the baby
 Latching on
 Normal nipple soreness
 Cramping with breastfeeding
 How often to feed the baby
 Need to wake the baby
 Alerting techniques
 Rooting
 Sucking
 Listening for swallows
 Preventing engorgement
 Nutrition
 Supply and demand
 Infant cues
Breastfeeding
Barriers
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Breast Pathology
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Hormonal pathology
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Smoking, anemia, poor nutrition, depression
Psychosocial
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Failure of lactogenesis, hypothyroidism
Overall health
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Flat/inverted nipples, breast reduction surgery that severed
milk ducts, previous breast abscess, extremely sore
nipples (cracked, bleeding, blisters, abrasions)
Restrictive feeding schedules, mother without support
system, not rooming in with baby, bottle supplementing
when not medically required
Other
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Previous breastfed infant who failed to gain weight well,
perinatal complication (hemorrhage, htn, infection
Breastfeeding
Teaching methods
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With infant in mother’s arms
Consistent information
Repeat information in a variety of ways
Watch the mother feed the baby and help
Let the mother know she may have difficulties at first
Remind mom that baby is learning with her
Praise the mother’s progress, help build confidence
Provide discharge support
Breastfeeding
The Results
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Baby gains weight
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No more than 7% weight loss
Back to birth weight in 2 weeks
1oz per day weight gain for the first three months
Mother is comfortable and satisfied
If baby is still loosing weight on the 4th day of life:
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Get feeding evaluation
Remember to:
 1. fed the baby
 2. maintain the milk supply
 3. continue breastfeeding
Breastfeeding
Complications
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Infants at risk for poor weight gain
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Premature (less than 38 weeks)
Difficulty latching on
Ineffective or unsustained sucking
Oral anatomic abnormalities (cleft lip/palate, short frenulum, receding chin)
Multiples
Jaundice
Cystic fibrosis
Infection
Cardiac disorders
Neurologic problems – downs, hypo or hypertonia
Poor apgars
Long labor
Sleepy, nondemanding, passive temperament
Separation from mother early after delivery
Infants less than 5 lbs
Breastfeeding
Hospital Discharge Support
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Mother breastfeed longer if they:
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Are confident at hospital discharge
Have a good support system after discharge
Receive follow up after discharge
Upon discharge
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Give written information
Recommend mom to keep breastfeeding record
Give mom phone number for a telephone helpline
Lactation consultant follow-up
Breastfeeding
Hospital discharge support
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Support the mothers breastfeeding efforts
Provide accurate current breastfeeding
information
Breastfeeding
Resources for Mothers
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Books:
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Websites
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The Womanly Art of Breastfeeding – LeLeche League
So that’s what they’re for! Breastfeeding Basic by Janet Tamaro
The Breastfeeding Book by Martha and William Sears
Nursing Mother Companion - Huggins Howard Common Press
The Breastfeeding Answer Book – LeLeche Legue
Medication and Mothers Milk – Thomas Gele PhD., a manual of lactational
pharmacology 9th Ed.
Breastfeeding and Human Lacation – 2nd Ed. Jan Rioden and Kathleen G. Auerbach
Breastfeeding Triage Tool - Sanie Jollay and Ellen Phillips-Angeles, M.S. Ches 4th Ed.
LeLecheLeague.org
Medela.com
Parents.com
[email protected]
Groups
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LeLeche League
WIC – Public Health Department
Carle’s Breast Feeding Clinic
Twin clubs
References
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Slusser Wndelin, Ms, MD and Powers Nancy G MD;
Breastfeeding Update 1: Immunology, Nutrition and
Advocacy; Pediatrics Review Vol 18 No. 4
Neifert, Marianne M.D., Early Assessment of
Breastfeeding Infant, Contemporary Pediatrics Oct.
1996
The Breastfeeding Answer Book, LeLeche League
International
AWHONN – Association of Women’s Health,
Obstetric and Neonatal Nurses Independent Study
Module for the Clinical Management of
Breastfeeding for Health Professionals 1999
Clinical Case
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You are seeing a 22 yo G1 P0 woman in your
office for her first prenatal visit at 12 weeks
gestation. When you ask her if she intends to
breastfeed her baby, she replies that she is
concerned that she will not be able to due to
the fact she is a chronic Hepatitis B carrier.
She is also concerned about the fact that her
friend told her that, if she breastfeeds, she
will need to do so every hour and thus will be
unable to do anything else.
Clinical Case
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Prenatal Labs
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Hct 33%
WBC 5600/cmm (normal differential)
Plt 224,000/cmm
Blood type A +
Antibody screen: negative
Rubella titer: immune
UA and Cx – negative
Varicella-zoster titer: immune
VDRL test: negative
HBsAg: positive
Clinical Case
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How would you counsel this patient?
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What infant and maternal benefits are there
to breastfeeding.
Clinical Case
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Counseling the patient:
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Prevalence of HBV infection in pregnancy
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Symptomatic – 1 to 1:1000
Asymptomatic – 5 to 15:1000
Perinatal transmission of HBV without intervention
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Seropositive for HBsAg only – 15-20% risk
Seropositive for HBsAg and HBeAg – 85-90% risk
Clinical Case
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Counseling the patient:
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Immunoprophylaxis for prevention of perinatal
transmission of HBV
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Treat neonates immediately after birth with HBIG and
HBV vaccine (must give HBIG within 12 hrs of birth)
Reduces the risk of transmission to <5%
First dose of HBV vaccine prior to hospital discharge,
2nd and 3rd doses administered at 1 and 6 months of
age
CDC recommends universal vaccination of all infants
Clinical Case
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Counseling the patient:
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Breastfeeding is not contraindicated in chronic
Hep-B carriers if the infant receives the HBIG and
is vaccinated
Clinical Case
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Based on your advice, the pt decides to
breastfeed. She and her infant have now
been successfully nursing for over 3 weeks.
One morning she wakes to discover a red,
wedge-shaped area in her right breast. She
also has a fever to 101 degrees.
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What is the most likely diagnoses?
How would you treat her?
Clinical Case
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Treating the patient:
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Most likely diagnosis = Mastitis
Give antibiotics that cover S. aureus –
antistaphylococcal penicillin or first-generation
cephalosporin, continue treatment for 10 days
Patient should continue breastfeeding
Review Question #1
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1. How many calories should a lactating
woman increase above her non-pregnant
baseline calorie consumption?
Answer #1
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400 calories
Review Question #2
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Match the following response associated with the
following conditions
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i. May breast feed
ii. Breastfeeding not encouraged
iii. Breastfeeding contraindicated
 A. Acute mastitis
 B. HSV infection
 C. CMV infection
 D. two alcoholic beverages consumed per day
 E. Tetracycline
 F. Clindamycin
 G. Smoking two packs of cigarettes per day
 H. Use of sub 50mg oral contraceptives
 i. HTLV 1 infection
 J. HBeAg + hepatitis
Answer #2
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A–i
B–i
C–i
D–i
E – iii
F–i
G–i
H–i
I – iii
J - ii
Answer #2
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Breastfeeding is contraindicated in very few
situations. Most viral infections are not considered
contraindications. CMV has been transmitted in
breast milk, but the effect on the healthy term
neonate is relatively minor if breastfeeding is
allowed to continue. Active acute hepatitis B
(particularly if the E antigen is present), HIV, HTLV
1, cyclophosphamide, tetracycline, oral
metronidizole, lithium carbonate, and radioactive
agents are considered to be contraindicated during
pregnancy. Puerperal mastitis is not a
contraindication to breastfeeding.
Review Question #3
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Select the 3 correct statements comparing
human mature breast milk to cow’s milk
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i. Calories are increased
ii. Proteins are decreased
iii. Fat is increased
iv. Carbohydrate is increased
v. Iron is increased
Answer #3
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i, iii, iv
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Human milk is significantly different from both
cow’s milk and formula with iron. Human milk has
75 calories per 100ml as compared to 69 calories
for cow’s milk. The protein content is
approximately one third more than cow’s milk.
The fat is increased by one third in human milk.
Carbohydrate levels 100% increased. Although
the concentration of iron I slow in human’s milk, it
is more efficiently absorbed.
Review Question #4
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The principle function of prolactin is?
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A. Ensure lactation
B. Sensitize the pituitary to LRH
C. Increase the number of estrogen and prolactin
receptors in alveolar cells
Answer #4
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A.
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LRH causes an increase in the serum prolactin level
greater in pregnancy than in nonpregnancy. Prolactin
insures lactation by promoting DNA synthesis in the
glandular epithelial cells of the breast. It also increases the
number of estrogen prolactin receptors in those cells.
Prolactin promotes galactopoiesis and the production of
casein and other breast products. The concentration of
prolactin is approximately 10 times greater in pregnancy
than it is in nonpregnancy. High concentrations of prolactin
in the fetus and in amniotic fluid may have a role in
preserving fetal fluid balance, preventing fetal dehydration.