STAGES OF LACTATION AND LACTATIONAL FAILURE.pptx

Lactation

1. STAGES OF LACTATION AND LACTATIONAL FAILURE

2. Objectives Understand the structure of the breast Describe the stages of lactation Lactational failure

3. Definition Lactation - production of breast milk and its secretion from the mammary gland after delivery Mother’s Milk – The best milk

4. Optimal source of nutrition. Species specific, provides all the essential nutrients necessary for the growth and development of the newborn infant. Best suited to serve the nutritional and biological needs of her baby.

5. Structure of breast Parenchyma- 10-15 lactiferous ducts extending from the nipple Each duct defines a lobe made of 20-40 lobules. Each lobule has 10-100 alveoli Lobules are separated by fat and connective tissue - stroma Main duct from each lobe opens separately on the tip of nipple Ductal lobular unit is the functional unit of breast

6. Stages of lactation – 5 phases Mammogenesis Lactogenesis Galactokinesis Galactopoiesis Involution

7. Mammogenesis Involves growth of ductal lobular unit Birth to puberty and continues in pregnancy (till 2 nd trimester)

8. Stage I mammogenesis Prepubertal and pubertal period Type 1 lobule develops into more mature type 2 & 3 lobule through alveolar budding Estrogen and progesterone

9. Pubertal growth H ypophyseal-ovarian –uterine cycle is established Extensive branching of the duct system, parenchymal proliferation and canalization of the lobuloalveolar units.

10. During pregnancy (Stage II mammogenesis ) Ductal sprouting – 1 st trimester Lobular sprouting – 2 nd trimester Estrogen: stimulates ductal system to grow and differentiate Progesterone: growth of alveoli and lobes Prolactin : growth and differentiation of both alveoli and ducts

11. Lactogenesis - 2 stages Stage 1 lactogenesis / Secretory initiation/differentiation Stage 2 lactogenesis / Secretory activation

12. Mature breast resembles a flowering tree with numerous lobular alveolar complexes – TDLUs (remains quiescent) During pregnancy Progesterone, prolactin, placental lactogen Expansion of TDLUs Mid pregnancy Rise in mRNA for many milk proteins and enzymes – called secretory differentiation Stage 1

13. Stage 1 During mid-pregnancy - small amount of milk that only contains lactose and casein Insulin and serum growth factor also plays role High levels of circulating progesterone supplied by placenta inhibit copious production of milk

14. Role of prolactin Milk initiation – through receptors on alveolar surfaces Stimulates synthesis of lactalbumin Increases lipoprotein activity in the mammary gland In conjunction with estrogen and progetserone it attracts and retain Ig-A immunoblasts Inhibited by PIF

15. Stage 2 / secretory activation Birth to Day 8 postpartum Triggered by rapid decline in progesterone that follows delivery of placenta Requires presence of elevated levels of prolactin, cortisol, insulin and GH.

16. STAGE 2

17. The rate of secretion of milk volume and macronutrients in milk during the first 8 d postpartum.

18. Lactogenesis III Under autocrine (local) control Milk synthesis is controlled at breast level. Milk removal is the primary control mechanism for supply.

19. Current thought… Small whey protein called Feedback Inhibitor of Lactation (FIL) – slows milk synthesis when breast is full Wall of lactocytes contain prolactin receptor sites – when alveolus is full of milk, the walls expand/stretch and alter shape of receptors

20. Stage 2 mammogenesis

21. Pathways of milk secretion by mammary epithelial cells Exocytosis Reverse pinocytosis Apical transport Transcytosis Paracellular

22. Hormonal preparation of breast during pregnancy for lactation

23. Galactokinesis Suckling + myoepithelial cell contraction Cell contraction by oxytocin Milk let down/ejection reflex

24. Galactopoesis Prolactin is the hormone for maintenance of lactation Sucking is essential for maintenance of milk secretion Periodic breast feeding relieves pressure in the ducts and promotes more secretion

25. Involution Apoptotic cell death and tissue remodeling post lactation Requires a combination of lactogenic hormone deprivation and local signals to undergo regression and atrophy

26. Lactational failure

27. When mother is not able to provide enough milk for her baby

28. Lactation failure is defined as the need to start top feeds for the baby within 3 months of delivery because of inadequate breast milk supply Sultana etal 2013

29. Total lactation failure was defined as either a total absence of milk flow or secretion of just a few drops of breast milk following suckling for at least 7 days Partial lactation failure was defined as either inadequate milk output or the need for supplemental feedings to sustain growth

30. Major obstacles Mother’s feel they don’t have enough milk Inaccurate /inadequate medical advice Working mothers Societal and commercial pressure to stop breastfeeding including aggressive marketing and promotion by formula producers.

31. Obstacles to breast feeding initiation and continuation

32. Insufficient milk supply is a major reason given by mothers for discontinuation of breastfeeding during first 6-8 weeks postpartum. Upto 80% women feel that their milk supply was inadequate at some stage during first 4 months. True lactation failure is rare.

33. What is enough milk Initial weight loss upto 10% Baby regains the birthweight by 10-14 days. Urinating at least 6-7 times in 24 hour period, sleeps 2-3hrs after feed and is gaining weight. Baby doubles her birth weight in about 5 months

34. Physiological basis for insufficient milk Milk production in 1 st week is highly variable. Following 3-5 weeks, milk output is progressively calibrated to the baby’s need Interferences with calibration of the breasts during this time can cause breasts to calibrate at an inappropriate level.

35. Such interferences include… Supplemental feeds Unrelieved engorgement. A mother of a preterm infant who does not express her milk to her peak yield Scheduled feeding. Feedings that are not long enough. Pacifiers. Mother and baby separation.

36. Reasons for low supply Pathophysiological lactational failure/primary lactational failure Inadequate sucking stimulus – secondary lactational failure

37. Causes of lactational failure Maternal factors Infant factors

38. Maternal factors Delayed lactogenesis 2 Prolonged labor Emergency LSCS Instrumental delivery Lack of initiation within 1hr Type I DM PCOD Obesity Primi parity Maternal illness Thyroid disorder DM,HTN Hypo- pituitarism Infections Anemia Autoimmune disease Connective tissue disease Renal failure Maternal medications Diuretics Bromocriptine,cabergoline Ergot derivates Levodopa Contraceptives - estrogen Pyridoxine Tamoxifen Maternal nipple abnormalities Sore nipple Retracted nipple

39. Painful conditions of the breast Maternal breast anatomy Psychosocial factors Lack of confidence

40. Neonatal factors Neonatal illness – early separation interferes with initiation of lactation Neonatal disorders – cleft, micrognathia, ankyloglossia, choanal atresia Medications causing drowsiness Neonatal asphyxia, preterm birth, down syndrome

41. When to suspect lactation failure? Symptoms Infant not satisfied after feeds, cries a lot Wants to nurse more frequently Improper weight gain Takes very long feeds Infrequent bowel movement Less need to change diaper (6-8)

42. Signs indicating lactation failure Weight loss >10% Not gaining birth weight by 2weeks No urine output for 24hrs Absence of yellow stools in the first week Clinical signs of dehydration

43. Management To recognise who is at risk, anticipating insufficient milk Prenatal breastfeeding education Therapeutic interventions Supplementary nursing systems Galactogogues

44. Potential indicators for those at risk for insufficient milk Mothers who are less informed about breastfeeding. Less confident. Less encouragement from family Poor health Maternal labour medications, birth injuries. Primigravida LSCS

45. Antenatal screening for risk factors Breast examination Evaluation of systemic illness Maternal general condition and dietary habits Education – advantages of breast feeding, disadvantages of topup feeds.

46. Prenatal breast feeding education A prenatal educational program is the most effective intervention to promote initiation of breastfeeding A systematic review and meta-analysis found that for every 3-5 women attending a program, one additional mother would initiate and continue breastfeeding for up to 3 months*. *Guise et al, 2003

47. Instructions to mother… 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- 1st breast comfortably drained followed by switching to 2nd Feeds not to be terminated prematurely in sleeping infants. Mothers should be explained that it takes time for proper milk formation

48. Natal and immediate postnatal Medicated and interventional labour avoided as far as possible Initiate breast feeding soon Feeding on demand – regular breast drainage and stimulation promote lactogenesis Rooming in – same bed Proper positioning, attachment, latching on supervised. Address biological causes- flat nipple, inverted nipple, sore/crack nipple, engorged breast, mastitis and abscess

49. Inverted nipple – syringe/double syringe; nipple puller Sore / crack nipple MCC poor attachment Purified lanolin or expressed hind milk applied after feeding hastens recovery. Engorged breast Usually day 3-5 postpartum If baby able to suck, feed frequently If pain and tightness does not allow suckling, express milk Cold compress Paracetamol for pain and fever

50. Mastitis Inflammatory and/or infectious breast condition Usually affects one breast Rapid onset of fatigue, body aches, headache, fever and tender reddened breast area. Bed rest, continued breast feeding Frequent and efficient milk removal Antibiotics Analgesics, moist heat/massage to breast

51. If baby is unwilling/unable to suck Ensure baby is not sick Skin to skin contact Offer breast at any time baby is interested to suck Breast feeding supplementer method Drop and drip method

52. Breast feeding supplementer method

53. Drop and drip method

54. Galactagogues Galactagogues are medications or other substances believed to assist initiation, maintenance, or augmentation of maternal milk production.

55. Classes of galactagogues Synthetic galactagogues Dopamine antagonists Domperidone and metoclopramide Antipsychotics Chlorpromazine and sulpride Hormone synthetic analogues Human GH Oxytocin TRH Recombinant bovine somatotropin Medroxyprogesterone Herbal galactagogues

56. Drug Mechanism Dose Adverse effects Metoclopromide D2R antagonist, increase PRL secretion 10mg PO TID Sedation, anxiety, depression, extrapyramidal symptoms Domperidone D2R antagonist, increase PRL secretion 10mg PO TID Xerostomia, abd cramps, headaches, cardiac arrythmias Chlorpromazine D2R antagonist, increase PRL secretion 25mg PO TID Mother – extrapyramidal Infants – lethargy Sulpride D2R antagonist, increase PRL secretion 50mg PO TID Headache, fatigue, extrapyramidal side effects

57. Herbal galactogogues Shatavari Fenugreek Garlic Alfalfa Red clover Marshmallow roots Goats rue

58. Best galactogogue – baby sucking at breast in correct position

59. MBFHI Breastfeeding support in OP clinics

60. Perceived or real low milk supply is a common concern of women and is a major cause to start supplementary feeding Early breastfeeding follow-up Proper positioning and latch-on…Examination of the diad together Training of the health professionals Support the mother