WHa 1.5 Breast feeding

There is a loss of distinction between which two breast structures in early pregnancy?

Late pregnancy: loss of distinction between lobules/ducts

What are the maternal benefits of breastfeeding?

• Weight loss • Uterine involution • Contraception • Reduction in breast and ovarian cancer (>2 years duration or under 20 yo) • Psychological- hard to determine true effect vs bias

What are some of the benefits of breast feeding?

1• Cheap; convenient; ideal nutritional composition 2• Reduces GI morbidity (6 months exclusive vs 3-4 months); inc. NEC in preterm infants. (Necrotizing enterocolitis (NEC), typically occurs in 2nd-3rd wk of life in premature, formula-fed infants. = variable damage to intestinal tract: mucosal injury to full-thickness necrosis + perforation.) 3• Reduces duration of otitis media; lower respiratory tract infection 4• Reduces atopic dermatitis and wheezing under 2yo, but not asthma 5• Small reductions in ALL/AML (Acute lymphocytic leukemia (ALL)/acute myeloid leukemia (AML), 6• Unproven- obesity

Describe Breast Milk Composition?

1• Low solute fluid- water, nutrient, cells, proteins 2• Macronutients- CHO- lactose; protein- casein, whey proteins incl immunologically active agents; fats- type affected by maternal stores (though not amount) 3• Micronutrients- Vitamins A, D, E, K; B and C. Common deficiencies in K (due to liver immaturity); D (low sun exposure) and B12 (dietary or absorptive deficiency states); Minerals- Fe, Ca, Zn 4• Cells- mainly macrophages, lymphocytes and neutrophils- act as non-specific anti-microbials, via phagocytosis and production of lactoferrin, lysozyme. 5• Immunoglobulins- secretory IgA- stops pathogens adhering to mucosa 6• eory IgA

All women, regardless of breast size, have the same number of lobes, approximately __A__. __B__ major ducts exit the nipple. __C__ fills each lobe. __D__ at the end of __C__ produce milk.

A. 15-25. B. 6-10. C. lobules. D. sacs.

After birth, when do prolactin levels drop, and rise, and peak?

Basal prolactin levels gradually drop (with peaks associated with feeding) over weeks, and maintenance of supply is reliant on regular emptying of the breast. =========== Mediated via FIL- Feedback Inhibitor of Lactationa substance in milk which is secreted in response to increased pressure in the alveoli. Importance of regular breast emptying (incl. expressing). (ie too much pressure from full breasts = FIL release --> decrease milk produced.)

Explain lactogenesis 1:

Lactogenesis 1 - during late pregnancy, human placental lactogen (HPL) causes the alveoli to secrete colostrum, a protein and immunoglobulin rich fluid. 'colleseum = lots of fighters, colostrum = lots of immunoglobulins'

What can delay 'Lactogenesis 2'?

Lactogenesis 2 occurs 2-3 days post natal, and can be delayed by retained placental tissue, low prolactin, long/stressful labour, IDDM, preterm delivery. ============== note: u can use combined contraceptive pill in *established* feeding. Pill interferes with lactation initiation by prolactin suppression. But if continued lactation only dependant on emptying breast, then can use pill no problems. & no side effects to baby that we know too.

Explain lactogenesis 2:

Lactogenesis 2- after birth, the delivery of the placenta removes the source of progesterone and estrogen, inhibitory hormones on breast milk production. High levels of prolactin (from anterior pituitary) plus cortisol and insulin, act on the breast to make copious quantities of breast milk, which contains significant amounts of osmotically active lactose. (Lactose = osmotically active therefore pulls a lot of fluid out with it.)

Which hormone during early pregnancy causes lobular numbers to increase?

Oestrogen.

The glandular cells around the aveoli secrete fluid, and are assisted by myoepitheial cell contraction in response to which hormone?

oxytocin Glandular cells around alveoli secrete fluid, assisted by myoepithelial cells which contract in response to oxytocin.

What 2 hormones involved in let-down reflex? What does each hormone do?

oxytocin prolactin Prolactin stimulates milk production. Oxytocin causes let-down (push out milk) reflex. Both released by pituitary gland into bloodstream --> reach breast. ============== The let-down reflex makes the milk in your breasts available to your baby. Cells around the alveoli contract and squeeze out the milk, pushing it down the ducts towards the nipple. Oxytocin also makes the milk ducts widen, making it easier for the milk to flow down them. The let-down may happen if you see or hear your baby or even just think about him. The let-down can also be triggered by touching your breast and nipple area with your fingers or by using a breast pump. let-down may not work as well if you are very anxious, extremely tired, upset or in pain. The truth is that breastfeeding is a powerful process.

What are some maternal problems with breast feeding?

• Despite wanting to, many women do not achieve the aim of 6/12 exclusive breast feeding. Reasons for failure to do so are mainly attachment and supply problems • Attachment- allow skin to skin 1 -2 hours from birth; assist with attachment; antenatal classes. • Problems- cracked nipples; inadequate stimulation of let-down reflex • Management- lactation consultation • Supply- commonest reason for early weaning- "poor supply" ============================== • Often perception of poor supply- crying baby = hungry baby; normal breast softening after initial post natal filling; lack of preparedness for 8-12 feeds per day; changes at 4-8 weeks • True poor supply- unsettled baby; poor urine output; poor weight gain; failure of breast filling by Day 3-4; persistent meconium • Causes- inadequate sucking; inadequate gland response • Inadequate sucking- limiting feeds, complementary feeding, sedated/ill baby, poor suck; Management- encourage demand feeding; lactation consultant review; express after feed; limit complementary feeds; ?galactogogue ============================== • Inadequate gland response- prior surgery; hypoplasia • Mastitis- often a result of blocked duct ("stasis is the basis of infection") or nipple damage; systemic symptoms and local inflammation; usually Staph. aureus; occ streptococcus. Management- continue feeding both sides; express blocked ducts; antibiotics. Can be complicated by abscess requiring surgical drainage

What are some infant problems with breast feeding?

• Gastro-oesphageal reflux- common (almost ubiquitous) in mild degrees; severe 1/500. Symptoms- may be positional- vomiting post feed; heartburn (sleep disturbance/irritability/breast refusal); can cause FTT/hematemesis/ aspiration. Clinical diagnosis; management- alter feeding regimen (may need to express to maintain supply or prevent engorgement). • Lactose intolerance- congenital- lifelong avoidance of lactose if symptoms severe; acquired (following GI infection)- lactose free diet if severe symptoms and resume feeding after resolution.