The Anatomy, Physiology and Philosophy of BreastfeedingHiltrud Dawson, RN, BT, IBCLC2008

Why do we need to know about breastfeeding?

What do we need to know about breastfeeding?Benefits of breastfeedingHazards of formula feeding Anatomy and physiology of lactationBiochemistry of human milkInfant anatomy and physiology affecting suck and feeding behaviour

And more Early post-partum practices that promote success Skills to assess and facilitate effective breastfeeding Prevention and management of common problemsMedical indications for supplementationCommunity resources for breastfeeding

AgendaHow does breastmilk differ from formula?How is breastmilk made?What are the benefits of breastmilk and breastfeeding?Breastfeeding trends in OntarioInterventions that might increase breastfeeding rates

Agenda Clinical problems and how to address themPrescribing for breastfeeding mothersHot topicsCommunity resourcesEducational resources

How does breastmilk differ from formula?Lactation is species specificBreastmilk contains all the nutrients a growing baby needsFormula is artificially manufactured to resemble breastmilkSynthetically manufactured nutrients may not have the same effects as naturally occurring nutrients and are often more difficult to digest Breastmilk provides immunity

From: Newburg J. Nutr. 2005

What is breastmilk composed of?Lactose Supplies energy at about 20 calories per oncePromotes growth of lactobacillus bifidusPromotes calcium absorptionProtein Serves nutritional and immunological purposeCasein whey ratio is 40:60Easy to digestLipids Contains all essential fatty acidsContains docasahexaenoic acid (DHA) and alpha-linoleic acic (ALA) MicronutrientsPresent in small amountsHighly bio-available

Micro nutrients who needs supplementation?Most mothers have adequate micronutrient status but should be supplemented if their status is lowIt is important for mothers to have a good nutritional status during their pregnancy to allow babies to store micronutrients during the 3rd trimester Babies need vitamin D supplementation from birth to one year or until they are taking adequate amounts of fortified dairy productsIron stores are used by 6 months and infants need to be started on iron-rich supplements at this time

How do the breasts work?

Breast development starts between the 4th and 7th week of an embryos life. A milk line extending from the armpit to the groin (mammary ridge) gradually fades away but a small portion remains in the chest forming 16- 24 buds that develop into milk ducts and alveoli.

Examples of nipple and breast tissue that has developed along the original milk line

The stages of lactationMammogenesisBegins prior to menarche signaled by breast growthLactogenesis stage 1Begins around 16 20 weeks of gestation signaled by production of clear fluid (colostrum)Lactogenesis stage 2Begins 24 72 hours post delivery signaled by onset of production of copious amounts of milkGalactopoisisBegins around day 10 -14 post delivery and indicates a change hormone control from endocrine to autocrineInvolutionIs complete around 40 days past active lactation

The breast is composed of:Outside:Nipple and areola with Montgomerys GlandsInside:Fat and supporting tissue that give the breast its size and shapeNerves which transmit messages from the breast to the brain to trigger the release of lactation hormonesArteries, veins and capillaries that carry nutrients and water to the breastMilk ducts that carry milk to the nipple Little sacs of milk-producing cells or Alveoli that produce milk

Parts of the Breast6/1Adapted from Breastfeeding Counselling: a training course, WHO/CHD/93.4, UNICEF/NUT/93.2

The glandular tissue is made up of alveoli which secrete and store milkA network of blood vessels around the alveolus brings nutrients to the cells to make milkEach alveolus is surrounded by myo-epicilial tissue that contracts to squeeze the milk out into the ducts

Hormones of LactationAfter delivery, the hormones of pregnancy decrease. With expulsion of the placenta, progesterone rapidly decreases allowing prolactin and oxytocin to be become important in the production and flow of milk.The hormone Feedback Inhibitor of Lactation (FIL) also helps to control milk production volumeOther hormones involved are: cortisol, thyroid stimulating hormone and prolactin inhibiting factor.

ProlactinProlactin is the hormone that drives the alveoli to produce milk.It works after the baby has fed to make milk for the next feed. Makes mothers feel sleepy and relaxedIt is highest in the 1st 2 hours after birth and is also higher at night.

OxytocinOxytocin causes the muscle cells around the alveoli to contract and makes milk flow down the ductsThe Milk Ejection Reflex (MER) or letdown reflex is triggered by oxytocin. Signs of oxytocin release are: uterine contractions, a sudden thirst, milk spray from breast, leaking from other breast, pins and needles feeling in the chest, change in suck-swallow ratio

What can inhibit oxytocin releaseExtreme pain from C/S incision or episiotomy, or damaged nippleStress from any cause including doubts, embarrassment or anxietyNicotine and alcohol Remember how you communicate with the mother can either inhibit or stimulate release of oxytocin.

Feedback Inhibitor of Lactation (FIL)This hormone is partly responsible for the supply and demand theory.Milk left in the breast has a higher level of FIL which down-regulates supply.

To prevent FIL from collecting and reducing milk productionMake sure that the baby is well attached.Encourage frequent feedsAllow baby to feed for as long as he or she wants at each breastLet the baby finish the 1st breast before offering the 2nd breastIf the baby is not suckling effectively to remove milk, express the milk so breastmilk production continues

If the milk is not removed from the breast, more milk is not madeThis is probably the most important concept in all of when establishing and protecting a mothers milk supply

The babys sucklingControls the prolaction productionStimulates the oxytocin releaseRemoves the FIL within the breast

The babys role in milk production and transferThe baby is really in the drivers seat!

Risks of Formula FeedingManufacturers mistakesContaminationUnsafe storage/reconstitutionEarly introduction of inappropriate substitutesRespiratory infections, otitis media, GI infections, necrotising entero-colitis, diabetes for mom and baby, atopic diseaseFor mom: greater risk of osteo porosis, ovarian and breast cancer

Health benefits of breastfeedingThe AAP lists breastfeeding benefits is the following article:Http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496Listing child and maternal health benefitsOutcomes of Breastfeeding Versus Formula Feeding Most recent update June 2007 by Ginna Wall Is a collection of summaries from research articles listing effects of the infant and the mother

Breastfeeding trends in CanadaDuration rates are still lagging behind

What encourages breastfeeding?Social attitudes and peers breastfeedingAcceptance of breastfeeding in publicSupportive professionals Breastfeeding policies such as maternity leavesThe WHO code The Baby-Friendly Initiative

Which mothers are more at risk of not breastfeeding or early weaning?Lower educationLow socio-economic statusYounger ageLess social support

Clinical problemsSore nipples/poor latchFlat/inverted nipplesRefusal to latchEngorgement/plugged ducts/mastitisBreast pain/thrushNot enough milkPoor weight gain

3 Keys to SuccessMother and baby togetherSkin-to-skinRooming-inEvaluate and treat bothFeed the babyLatch and suckAlternate feeding methodsStimulate the milk supplyFeed early and oftenPump to imitate feeding pattern

What can you see?Good attachmentPoor attachment6/3Breastfeeding Counselling: a training course, WHO/CHD/93.4, UNICEF/NUT/93.2

How can you decide if a baby is latched properly?

Latch Sequence

The action of sucklingWhen the breast touches the babys lip, she will put her head back slightly, open her mouth wide and put her tongue down and forward , to seek the breast. This is the rooting reflex.When the baby latches deeply, taking a large enough mouthful of aerola and nipple tissue, the nipple is stretched back to the soft palate. This stimulates the sucking reflex.

Signs that baby is suckling effectivelyBaby takes slow, deep sucks with occasional pausesYou can see or hear the baby swallowingCheeks are full and not dimpledBaby releases the breast and appears contented and satisfied

Infant milk needs per day

DayMilk ml/dayStomach size110-1005-7ml210-10010-13ml320022-27ml440032-36ml560043-57ml6700-80043-57ml6-6months750 or 24ounces> 60ml

Red flags of ineffective breastfeedingLess than 3 stools per day by day 4 Delayed lactogenesis II past 72 hoursWeight gain of > 10%

Sore Nipples/Poor LatchCheck position/latchImprove position/latchChange positionUse colostrum/EBM/lanolin/air dryPump prior to feeding/use breast shellsConsider nipple shield

Babys positionMany positions can be used but 4 key points should be stressed

The ear, shoulder and hip should be in a lineThe babys body should be close to moms bodyThe shoulders and neck not the head should be supportedThe nose is facing the nipple to get an asymmetrical, effect latch

In lineCloseSupported Facing

Football positioning

Flat or inverted nipplesGood positioningStimulate nippleIt may help to use a breastpump prior to feedingOnce milk supply has been stimulated a nipple shield can be used to get baby to feed at the breastLater he can transition from shield to breastShield use is associated with decreased production and decreased breast emptying, pumping to reduce both risks is recommended

Engorgement/Plugged Ducts/MastitisCool compressCabbage leaves RestEmpty breastMassageContinue breastfeeding or pumpingIf symptoms of mastitis treat with ABxUnresolved lumps must be investigated

Breast Pain, ThrushCan be associated with let-downBurning pain after feeds usually due to thrushTreat both mother and baby for thrush

Breast RefusalUse alternate feeding method to feed babyStart pumping earlyPump to replace feeds (7-8 day)Can last days or weeksCan be one or both breasts Give support +++

Poor weight gain and/or perceived inadequate milk supplyAssess mother for physical and psycho/social concernsAssess infantAssess latch, assess feedingAssess output, number of feeds and intake at feedingsWays to improve intakeBetter latch, increased number of feedsBreast compression, super switchingPumping, supplementing

Increasing milk productionExpress milk after feeding attempts and use EBM to supplement using a cup, short term finger feeding or SNS ( lactation device at breast)More skin-to-skin contact also increases hormonal stimulationWork with her family supports so she has time for resting and feeding. Responsibilities for childcare and housework delegated to others.Use of herbs and/or Domperidone to increase supply provided adequate breast emptying occurs.

If a mother makes an informed decision not to breastfeed she also needs informationHer milk will naturally dry up if her baby does not remove it by sucklingThis happens because the Feedback Inhibitor of Lactation (FIL) stops the breast from producing milk if the breast is overfullFull involution takes about 4-6 weeks Pain medication and cold compresses can be used for comfort

Choices of SupplementsMothers own milk or colostrumPasteurized donor breast milk Cows milk formulaVegetable based soy formulaAny other fluids are unsuitable

Alternate Feeding MethodsLactation aid at breastFinger feedingCup feedingSyringe or eye dropperNipple shieldBottle feeding

Prescribing for breastfeeding mothers Many drugs are compatible with breastfeeding (e.g. SSRIs)Use caution with:New drugs without substantial dataEstrogen containing contraceptivesDiureticsRadio-active substancesMothers who use nicotine, alcohol and other substances may need more education and support but that is not a contraindication

Drugs that are contra-indicatedChemotherapyLithium

Motheriks hotline: 416 813 6780www.motherisk.org

Thomas Hale: Medications and Mothers milkhttp://neonatal.ttuhsc.edu/lact/

Breastfeeding mothers need on-going professional and community supportNot all problems can be solved before hospital dischargeProfessional support can be given by primary care giver, hospital or community lactation consultants, public health nurses, parenting group facilitatorsPeer support through phone volunteers, parenting groups, La Leche League, friends of family

Where to get more infoThe Academy of Breastfeeding Medicinewww.bfmed.orgThe Journal of Human LactationQuintessence Foundationwww.babyfriendly.caThe Breastfeeding Committee for Canadawww.breastfeedingcanada.caThe Ontario Breastfeeding Committeewww.breastfeedingontario.org

ResourcesILCA; Clinical Guidelines for the Establishment of Exclusive Breastfeeding, Second Edition, June 2005 (lists research evidence with source and strength)The Best Start Resource Centre, www.beststart.orgHamilton Regional Lactation Committee: Breastfeeding booklet and fact sheets available through the public health department or SJH and MUMC

***Particularly important are those nerves at the 4th intercostal space to trigger the oxytocin to get letdown*Tell story about how these pictures anotomically were developed wax injected into cadavers*New research by Hartmann and Ramsay points to actual absence of lacterferous sinuses Glandular tissue is found closer to nipple than perviously belived***REM sleep more quickly*More signs of oxytocin are feelings of relaxation and sleepiness*****There are different storage capacity in each breast. There can be difference in size and shape. None should be a nursing concern but may be a concern to the mother.*Talk about cues baby is really telling us something 5 signs mouthing movements, small sounds rapid eye movement , stirring and hand to mouth movements. Crying is a late cue what interrupts these cues Separation, tight bundling, soother use. Crying is never good leads to high cortisol levels and disorganized behavior Breast milk is anti-microbial; bacteria proliferates in formulaBone density increases /after/ breast-feeding

*****The nipple is actually elongated to almost double the resting length to reach the juction of the hard and soft palate**Show size of stomach using belly balls, stones chick pea analogy. Point out Best Start posterUse water bottle and 2 ounce measure to address frequency of feeds ( 1.5 water bottles) if you divide 750 ml by 60 you get 12.5 feeds per day.*Last point requires supervisory support as to when to wean from galactogues.*Drugs to dry up milk are no longer used namely Bromocriptine side effects include, strokeSeizure and deathUse just a supportive bra no breast bindersOccasionally express small amounts for relief of pressure in a shower.Nipple confusion no use of fake nipples in first months**