Lactation failure

lactation failure in short from mechanism and causes to management

1. LACTATION FAILURE Sonali singh Resident Paediatrics Grant medical college, mumbai

2. LACTATION It is the process of secreting milk from breast. It is a physiological process under neuroendocrine control. LACTATION FAILURE Condition where mother is not able to produce milk.

3. Physiology of lactation

4. PROLACTIN REFLEX

5. OXYTOCIN REFLEX

6. IMPORTANT Oxytocin reflex is positively affected by mother’s sensation and feelings like thinking lovingly about the baby,touching , smelling or seeing the baby or hearing the baby cry. If mother is emotionally disturbed or experiencing pain or discomfort oxytocin reflex doesn’t work well and baby has problem getting milk.

7. Maternal: Psychological and social causes(81%) Insufficient milk(80%/75%) Unsuitable milk(38%/50%) Refusal by baby(4%/2%) Illness of the mother(4%/-) Maternal employment(8%/2%) Advice by relative or friend(12%/-) Ill infant (43%/25%) Advice by doctor/nurse(7%/-) Dislike for breast feeding Fixed schedule feeding Previous unsuccessful breast feeding experience Lack of confidence,shyness Worry,stress Tired Religious customs

8. MATERNAL:BREASTFEEDING RELATED Delayed start Fixed schedule feeding Infrequent feeds No night feeds Short feeds Poor attachment Bottle/pacifier Other food Other fluid

9. Maternal: Biological causes(local) Sore and cracked nipple (38%) Inverted nipple(27%) Engorged breast(18%) Mastitis and abscess(14%) Others(3%) Burn/scarring Breast surgery Anatomically abnormal breast( insufficient glandular tissue)  very rare Retained placentarare

10. Maternal: biological causes(systemic) Endocrinopathies - thyroid, pituitary, ovarian dysfunction. Chronic maternal illness- DM, SLE,HTN (do not affect lactation . Physical disability. Complications of pregnancy- GDM, PIH  early maternal infant separationinterferes with initiation of lactation. Contraindications of breast feeding. Psychiatric disorder

11. DRUGS CAUSING SUPPRESSION OF LACTATION Calcitonin Diuretics- loop, thiazide Dopamine receptor agonist- bromocriptine , cabergoline . Ergotamine Levodopa Contraceptives Pseudoephedrine Pyridoxine Tamoxifen

12. Neonatal causes Neonatal illness  early maternal/infant separationinterferes with initiation of lactation. Neonatal disorders associated with poor suck (cleft lip and/or palate, short frenulum , micrognathia , choanal atresia ) maternal or infant medication that causes drowsiness neonatal asphyxia, preterm birth, Down’s syndrome etc Breast rejection

13. The complaint of “insufficient milk” is more often than not a wrong perception of the mother, fostered by the mother’s uncertainty about her capacity to feed her baby properly, no knowledge about the normal behavior of a baby (who usually nurses frequently) and negative opinions of significant persons. The wrong perception by the mother  leads to the introduction of complementary feeding  negatively affects milk production.

14. When to suspect lactation failure? SYMPTOMS Infant is not satisfied after feeds, cries a lot. Wants to nurse frequently. Takes very long feeds. Improper weight gain Infrequent bowel movement- small in amount, dry and hard. Less need to change diaper(6-8)

15. SIGNS INDICATING LACTATION FAILURE IN 1 ST WEEK Weight loss greater than 10% of the birthweight , not regaining birth weight up to two weeks of life, no urinary output for 24 hours. absence of yellow stools in the first week Clinical signs of dehydration.

16. MANAGEMENT OF LACTATION FAILURE

17. The concept of breast feeding kinetics as developed by Livingstone conveys the idea that there is dynamic interaction between a breast feeding mother and her infant over time. Most disorders of lactation are iatrogenic because of impeded establishment of lactation/ inadequate ongoing stimulation and drainage of breast. Most breast feeding difficulties are due to lack of knowledge, poor technical skills/ lack of support. Almost all problems are reversible. Prevention, early detection and management should become a routine part of maternal and child health care.

18. ANTENATAL SCREENING FOR RISK FACTORS BREAST EXAMINATION EVALUATION OF SYSTEMIC ILLNESS MATERNAL GENERAL CONDITION AND DIETRAY HABITS LACTATION ASSESSMENT IN 3 RD TRIMESTER BREAST FEEDING EDUCATION EDUCATION REGARDING ADVANTAGES OF BREAST FEEDING TO BABY, MOTHER AND TO SOCIETY EDUCATION REGARDING DISADVANTAGES OF TOP FEEDS COUNSELLING TO MOTHER WITH PREVIOUS UNSUCCESSFUL BREAST FEEDING EXPERIENCE IMPORTANT - mother should be accompanied by other influential members of the family as attitude and knowledge of mother as well as her near ones should be changed in order to have successful breast feeding.

19. NATAL AND IMMEDIATE POST NATAL- what to do? Medicated and interventional labor should be avoided as far as possible  interferes with instinctive rooting behaviour to locate and latch onto the breast. Initiate breastfeeding as soon as possible after complete delivery of placenta early breast stimulation  initiates early lactation. Breast feeding on demand regular breast drainage and stimulation promotes lactogenesis ( initially hormonal based, later autocrine ) Proper positioning, attachment, latching on supervised. Rooming in (24 hrs)- same bed. Separation impedes drainage and stimulation. Combined mother infant nursing  institution of patient centred teaching. Address local problems(biological causes immediately) Counselling regarding diet of mother.

20. Instructions to be given to mother for successful establishment of lactation. Positioning, attachment, latch-on. Frequency- on demand usually2-3 hourly(≥8 feeds), including night feeds. Duration- varies between mother-infant pair. Pattern of breast use- 1 st breast comfortably drained followed by switching to 2 nd Feeds not to be terminated prematurely in sleeping infants. Mothers should be explained that it takes time for proper milk formation

21. Baby friendly hospital initiative(1992) Written breast feeding policy. Training of health care staffs. Information to all pregnant ladies regarding breast feeding. Breast feeding within half an hour of birth. No food or drink other than breast milk to the baby, unless medically indicated. Show mothers how to breast feed and to maintain lactation even if they should be separated. Rooming in. Breast feeding on demand. No artificial teats or pacifiers or prelacteal feeds to the baby. Mother support group.

22. Planning hospital discharge

23. Establishing relactation (for mother with lactation failure on post natal follow up)

24. Physiological basis of lactation on which relactation depends. Breast feeding requires:- Growth of secretory alveoli in glandular tissue of breast. Secretion of milk. Removal of milk Depends on hormone Prolactin - Imp for:- development of secretory alveoli; . secretion of milk Stimulus- nipple stimulation Most effective stimulus-suckling of an infant (daytime<night time suckling)

25. Oxytocin - Imp for milk removal. BEST WAY OF STIMULATION+REMOVAL OF MILK:- SUCKLING INFANT.

26. APPROACH TO A MOTHER WITH LACTATION FAILURE HISTORY +CLINICAL EXAMINATION NO DISEASE TRUE LACTATIONAL FAILURE OR NOT YES NO COUNSEL CHECK FOR:-POSITION,ATTACHMENT,SUCKLING NIGHT FEEDS? FREQUENCY? NO PROBLEM PLAN FOR ESTABLISHMENT OF RELACTATION

27. FACTORS WHICH AFFECT SUCCESSFUL RELACTATION

28. If infant is willing to suck Encourage the woman:- Put infant to breast frequently(1-2 hrly /8-10 times in 24 hrs) Sleep with infant and breast feed at night Ensure good attachment Let infant suckle at both breasts, for as long as possible Feed infant supplements separately using a cup.

29. Infant is unwilling/unable to suck Ensure child is not sick Skin to skin contact Offer breast any time child is interested to suck Breast feeding supplementer method Drop and drip method

30. Breast feeding supplementer method

31. Drop and drip method

32. Supplementing the infant While mother’s breastmilk supply is becoming established, it is essential to ensure that the child receives adequate nutrition( through wati and spoon/breastfeeding supplementer ) Supplement- cow’s milk diluted till 2 m of age(150ml+50mlwater+5g sugar) To begin with supplement should be full (150cc/kg/day divided in atleast 8 feeds) As breast milk increases supplement should be reduced. child’s weight should be regularly monitored.

33. How to reduce supplement In some cases child shows less interest by refusing supplement/ refusal to suck on 2 nd breast. Reduce total amount of supplement in 24hrs by 50ml. Continue reduced feed for next few days If by behaviour and weight gain(125g/week) feed appears to be sufficient reduce it further else continue the same for 1 more week.

34. GALACTOGOGUES Galactogogues (or lactogogues ) are medications or other substances believed to assist initiation, maintenance, or augmentation of maternal milk production. MEDICATIONS Metoclopramide - antagonizes dopamine in cns , hence increases prolactin level. Dose- 30-45mg/day in 3-4 divided doses. Given for 7-14 days then taper off in next 5-7 days. Domperidone - dopamine antagonist  increases prolactin level. Dose-10-20mg/day in 3-4 divided doses for 3-8weeks. Sulpride and chlorpromazine Gh TRH Oxytocin

35. Herbal /natural galactogogues :- satavari Fenugreek anise, basil, fennel seeds Garlic Ginger Jaggery Coconut Bajra Khaskhas Pepper Panjeer Sonth Jeevanthi Panjeeri

36. BEST GALACTOGOGUE- BABY SUCKLING at THE BREST in correct position..

37. Important Confidence Support of family members Regular f/u if possible

38. MANAGEMENT OF BIOLOGICAL CAUSES

39. SYRINGE METHOD

40. ENGORGED BREAST If baby is able to suckle, mother should feed frequently. If pain and tightness does not allow suckling  express milkcomfortable  breast feed Cold compress Paracetamol for pain and fever.

41. DIFFERENCES BETWEEN FULL AND ENGORGED BREASTS Full Breasts Engorged Breasts Hot Painful Heavy Oedematous Hard Tight, especially nipple Shiny May look red Milk flowing Milk NOT flowing No fever May be fever for 24 hours

42. Mastitis and abscess Mastitis  supportive counselling and improved drainage of milk from affected part of breast by breast feeding/expressing Indication for antibiotics Lab tests show infection Severe symptoms/ symptoms do not improve after 12 hrs of milk removal Analgesic and warm compress for pain relief Abscess incision and drainage.

43. Sore /cracked nipple Mc cause of sore nipple- poor attachment. Improving infant’s attachment to breast  relieves the pain. Hind milk rich in fat should be applied. Oral thrush 1% gentian violet should be applied over nipple as well as inside baby’s mouth.

44. Systemic illness Endocrinopathies and other chronic illness needs to be managed along with other measures for encouraging breast feed.

45. Studies Lactation failure by G.P mathur published in IAP-partial lactation failure(94.7%) was more common than complete lactation failure(5.3%). An attempt at relactation was successful in 69.3% cases, failed in 4% cases and the remaining were lost to follow up. LACTATION MANAGEMENT CLINIC-POSITIVE REINFORCEMENT TO HOSPITAL BREASTFEEDING PRACTICES by Nanavti and Mondkar 78.1% mothers practised EBF on subsequent visits, 21.2% were partially successful in lactation and only 3 mothers had lactation failure.

46. Conclusion Supportive breastfeeding policies in hospital constitute the foundation for initiation of successful breastfeeding by mothers, constant reinforcement and support to all lactating mothers is essential to maintain lactation.

47. REFERENCES Relactation : review of experience and recommendation for practice, WHO IAP textbook Breast feeding in practice: a manual for health workers Training manual on breast feeding management(UNICEF) Breast feeding medicine, vol 4(ABM protocols) Avery’s diseases of newborn Meherban singh for newborne thank you....