Management of lactation

1. MANAGEMENT OF LACTATION
PREPARED BY:
JYOTI RANABHAT

2. Anatomy of breast

3. Anatomy of breast

4. CONTD..
• There are many different parts to female breast
anatomy, including:
• Lobes: Each breast has between 15 to 20 lobes or
sections. These lobes surround the nipple like
spokes on a wheel.
• Glandular tissue (lobules): These small sections
of tissue found inside lobes have tiny bulblike
glands at the end that produce milk.
• Milk (mammary) ducts: These small tubes, or
ducts, carry milk from glandular tissue (lobules)
to nipples.

5. CONTD..
• Nipples: The nipple is in the center of the areola.
Each nipple has about nine milk ducts, as well as
nerves.
• Areolae: The areola is the circular dark-colored
area of skin surrounding the nipple. Areolae have
glands called Montgomery’s glands that secrete a
lubricating oil. This oil protects the nipple and
skin from chafing during breastfeeding.
• Blood vessels: Blood vessels circulate blood
throughout the breasts, chest and body.

6. CONTD..
• Lymph vessels: Part of the lymphatic system,
these vessels transport lymph, a fluid that
helps your body’s immune system fight
infection. Lymph vessels connect to lymph
nodes, or glands, found under the armpits, in
the chest and other places.
• Nerves: Nipples have hundreds of nerve
endings, which makes them extremely
sensitive to touch and arousal.

7. PHYSIOLOGY OF LACTATION
• Breastfeeding and breastmilk must be
considered in the context of maternal
physiology and infant development rather
than just the narrow role of optimizing infant
nutrition. The lactating breast has a high
metabolic activity.

8. PHYSIOLOGY OF LACTATION contd…
• Successful lactation requires the development
of fully functional mammary glands. Whereas
other major organs are morphologically and
functionally relatively mature at birth, the
mammary gland undergoes very limited
structural development in utero, with the
most dramatic changes in women occurring
during puberty, pregnancy, lactation, and
weaning.

9. 1.Mammogenesis
• Mammogenesis is the process of growth and
development of the mammary gland in
preparation for milk production. This process
begins when the mammary gland is exposed to
estrogen at puberty and is completed during
the third trimester of pregnancy.

10. CONTD..
• The mammary gland develops the histologic
and biochemical capacity to synthesize and
secrete milk during pregnancy. Histologic
studies have separated mammary
development during pregnancy into two
distinct phases: mammogenesis and
lactogenesis 1.

11. CONTD..
• Mammogenesis occurs from early pregnancy and
is characterized by proliferation of the distal
elements of the ductal tree, creating multiple
alveoli (acini) of variable size and shape .
• Lactogenesis 1 occurs in the later stages of
pregnancy and is characterized by the
differentiation of resting mammary cells into
lactocytes, with the potential to secrete the
unique fats, carbohydrates, and proteins
characteristic of milk

12. CONTD..
• Initially, mammary development during pregnancy
appears to be an acceleration of the parenchymal
hypertrophy associated with the menstrual cycle.
• Indeed, an increase in the sensitivity and tenderness
of the breast, and nipple sensitivity in particular, is
often one of the first indications of pregnancy, and
this can occur within a few days of conception and
before the due date of the next menstrual period.

13. CONTD..
• Thus, the factors initiating mammogenesis at this
time must be closely related to those responsible for
the mother’s recognition of her pregnancy.
Subsequently, the subcutaneous veins become
enlarged and visible through the skin, and the areola
usually enlarges and becomes more darkly
pigmented.
• Extensive lobulo-alveolar growth occurs during the
first half of pregnancy, and in the third trimester
there is a further increase in lobular size associated
with hypertrophy of the lactocytes and the
accumulation of secretion in the lumina of the alveoli
.

15. 2. LACTOGENESIS
• The pituitary hormone prolactin is instrumental in
the establishment and maintenance of breast milk
supply. It also is important for the mobilization of
maternal micronutrients for breast milk.
• Near the fifth week of pregnancy, the level of
circulating prolactin begins to increase, eventually
rising to approximately 10–20 times the pre-
pregnancy concentration. We noted earlier that,
during pregnancy, prolactin and other hormones
prepare the breasts anatomically for the secretion of
milk.

16. • The level of prolactin plateaus in late
pregnancy, at a level high enough to initiate
milk production. However, estrogen,
progesterone, and other placental hormones
inhibit prolactin-mediated milk synthesis
during pregnancy. It is not until the placenta is
expelled that this inhibition is lifted and milk
production commences.

17. CONTD..
• The mammary epithelium remains a
presecretory tissue until the abrupt
diminution in plasma estrogen and
progesterone concentration that occurs at the
time of delivery. Without the inhibitory
influence of progesterone on mammary
epithelium, prolactin and the other hormones
active in the initiation of milk production can
exert their effects on acinar cells.

18. CONTD..
• By 4–5 days postpartum, estrogen and
progesterone concentrations in the plasma are
less than normal follicular phase levels and
the transition in the acinar epithelium from a
presecretory to a secretory state is complete.
• The initiation of milk production (lactogenesis)
requires 2–5 days in the human being. This is
the length of time necessary for complete
secretory maturation of acinar epithelium.

19. CONTD..
• The inhibition of lactogenesis before delivery
appears to be a consequence of high
circulating levels of progesterone, which
competitively inhibits the binding of cortisol
to an intracellular receptor.
• The only other specific hormone required for
lactogenesis is oxytocin.

20. 3. GALACTOKINESIS
Milk let down reflex
• After childbirth, the baseline prolactin level
drops sharply, but it is restored for a 1-hour
spike during each feeding to stimulate the
production of milk for the next feeding. With
each prolactin spike, estrogen and
progesterone also increase slightly.
• When the infant suckles, sensory nerve
fibers in the areola trigger a neuroendocrine
reflex that results in milk secretion from
lactocytes into the alveoli.

21. Contd…
• The posterior pituitary releases oxytocin,
which stimulates myoepithelial cells to
squeeze milk from the alveoli so it can drain
into the lactiferous ducts, collect in the
lactiferous sinuses, and discharge through the
nipple pores. It takes less than 1 minute from
the time when an infant begins suckling (the
latent period) until milk is secreted (the let-
down).

22. Oxytocin “milk ejection” reflex

23. `
Figure 28.6.1 – Let-Down Reflex: A positive feedback loop ensures
continued milk production as long as the infant continues to
breastfeed.

24. 4.GALACTOPOIESIS
• Galactopoiesis is the maintenance of milk
production once it has been established by
completion of lactogenesis.
• The single most important factor in successful
galactopoiesis is regular and frequent milk
removal from the mammary gland.

27. CONTD..
Milk removal stimulates further milk
secretion by at least three mechanisms.
First, regular suckling promotes the regular
synthesis and release of both prolactin and
oxytocin, which are necessary for continued
milk secretion.

28. CONTD..
• Second, the breast has the capacity to store
milk for a maximum of 48 hours before there
is a substantial decrease in production.
• This reduced milk production is caused by
the diminished stimulation of the glandular
epithelium by prolactin and the vascular stasis
caused by increased intramammary pressure
resulting from distention of the mammary
ducts and alveoli with stored milk

29. CONTD..
• Blood flow to the mammary glands is
significantly reduced by this increased
intramammary pressure, which diminishes the
nutrient and hormonal supply necessary for
milk production.

30. CONTD..
Third, the amount of milk produced daily is fairly
closely related to the demand (i.e. the amount of
milk removed the previous day), as long as the
nutritional and hormonal requirements are met.
Normal levels of prolactin (5–20 ng/ml), with
surges of prolactin and oxytocin at the time of
suckling, are also necessary for the maintenance
of normal milk production.

33. Introduction
• Human breast milk is the healthiest form of milk for
babies.
• There are few exceptions, such as when the mother is
taking certain drugs or is infected with human T-
lymphotropic virus, HIV, or has active untreated
tuberculosis.
• Breastfeeding promotes health and helps to prevent
disease.
• Artificial feeding is associated with more deaths from
diarrhea in infants in both developing and developed
countries.

34. • Colostrum, the yellowish, sticky breast milk
produced at the end of pregnancy, is
recommended by WHO as the perfect food for
the newborn, and feeding should be initiated
within the first hour after birth.
• Successful lactation is determined by early
initiation of breastfeeding and continuation of
lactation and again that is determined by
positioning. Positioning is key to get Latch on.

35. Attitude of the
Mother
Factors
Position

36. Breastfeeding Positions
• It will be easier for your baby to latch-on if he
or she is in a good position for feeding. The
most common breastfeeding positions include
the following:

37. Cradle hold
• The baby is held in the crook or elbow area of
the arm on same side as breast to be used for
feeding; mother supports breast with opposite
hand; baby's body is rolled in toward mother's
body so they are belly-to-belly.

38. Cross-cradle
• The baby's head is supported by the hand opposite
the breast to be used for feeding; mother supports
breast with hand; baby is rolled in toward mother's
body belly-to-belly.

39. Football or clutch hold
Baby's head is supported by the hand on the same side
as breast to be used for feeding; baby's body is
supported on a pillow and tucked under the arm on the
same side as breast to be used for feeding.

40. Side-lying position
• The side-lying position is best when the
mother needs some rest while nursing her
baby. It is a bit tricky, but once both the
mother and her baby gets hang of it, it will
become the most favorable position. It is best
recommended for those who have undergone
a c-section.

41. Side-lying using modified cradle
• In this position, the baby lies next to the mother with their
bodies facing each other. If a pillow under your arm is
uncomfortable, try placing your baby in the crook of your arm.
This way, you will not be likely to roll over on the baby should
you doze off. This position also keeps the baby's head at a
good angle to bring baby and breast together, with the baby's
head higher than his or her tummy, which can be helpful for
babies who are more likely to spit up.

42. Upside down side-lying
• Follow the directions for traditional side lying, but
your bottom arm is raised up and positioned above
your head along your pillow.
• Baby lies on his/her side with tummy, knees, and
chest facing your body, his/her lower arm tucked
under your breast, baby's top arm on top of your
breast.

43. • Baby's face is looking at your breast with
his/her mouth level with your nipple.
• Baby's body is horizontal to your body with
his/her feet pointing towards the top of your
bed.
• If baby's mouth is lower than your nipple,
place a folded towel or baby blanket under
your baby's head.

44. • You may place a tightly rolled towel or baby
blanket behind your baby to keep baby from
rolling onto his/her back.
• When nursing the right breast, you will hold
your breast with your left hand in "C" hold,
shaping the breast and areola into a sandwich
for your baby to grasp while your lower arm is
up and under your pillow.

45. • This is a helpful position to drain the top
quadrants of your breast and may be very
comfortable after a cesarean delivery if your
tummy is sore and swollen.
• You may need help with placing your baby into
this position and keeping baby close
throughout the feeding.
• Turn onto your left side and reverse the hands
for nursing the left breast.

46. Laid-back breastfeeding
In this position, you are leaning back in a
recliner or reclining in bed. Your baby is lying on
his or her stomach and is pressed against you.
You can support the side of your baby's head if
your baby cannot hold it him- or herself. In this
position, both you and your baby can relax. You
can allow your baby to explore your breast and
latch on at his or her leisure. This is a great
position if you have had a cesarean delivery.

48. Help mother breastfeed
• For all breastfeeding positions, bring your baby to the
breast--not the breast to the baby--by sitting in a roomy
and comfortable chair or sofa and using a bed pillow, sofa
cushion, or special breastfeeding pillow on your lap to raise
the baby. Your baby must be held in good alignment if he or
she is to suck, swallow and breathe during feedings. When
in good alignment, you should be able to draw a straight
line down your baby's body from earlobe to hip no matter
which feeding position you use. You should not be able to
see the baby's arm closest to your body when using a
cradle or cross-cradle hold. For you, being in a comfortable
position means that your feet are supported, your back is
supported, you are sitting up straight and not leaning over
your baby and your shoulders are relaxed.