Lactation failure
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LACTATION FAILURE
Sonali singhResidentPaediatricsGrant medical college, mumbai
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LACTATIONIt is the process of secreting milk from
breast. It is a physiological process under neuroendocrine control.
LACTATION FAILURECondition where mother is not able to
produce milk.
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Physiology of lactation
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PROLACTIN REFLEXProlactin goes in blood to
the breast
Makes milk
secreting cells
produce milk
Baby suckles at the breast
Sensory impulse
from nipple to
brain
Prolactin secreted from ant part of
pituitary
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OXYTOCIN REFLEXOxytocin secreted
from posterior part of
pituitary
Oxytocin makes
muscle cell around alveoli
contract
Milk collected in alveoli flows along duct
towards nipple
Baby suckles at the breast
Sensory impulse
from nipple to brain
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IMPORTANTOxytocin 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.
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Causes of lactation failure
Causes related to
mother
Psychological and social
Biological
Causes related to the baby
biological
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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
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MATERNAL:BREASTFEEDING RELATED
Delayed startFixed schedule feedingInfrequent feedsNo night feedsShort feedsPoor attachmentBottle/pacifierOther foodOther fluid
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Maternal: Biological causes(local)Sore and cracked nipple (38%)Inverted nipple(27%)Engorged breast(18%)Mastitis and abscess(14%)Others(3%)Burn/scarringBreast surgeryAnatomically abnormal breast( insufficient
glandular tissue) very rareRetained placentarare
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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 separationinterferes with initiation of lactation.
Contraindications of breast feeding.Psychiatric disorder
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DRUGS CAUSING SUPPRESSION OF LACTATION1. Calcitonin2. Diuretics- loop, thiazide3. Dopamine receptor agonist- bromocriptine,
cabergoline.4. Ergotamine5. Levodopa6. Contraceptives7. Pseudoephedrine8. Pyridoxine9. Tamoxifen
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Neonatal causesNeonatal illness early maternal/infant
separationinterferes 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
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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.
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When to suspect lactation failure?SYMPTOMSInfant is not satisfied after feeds, cries a lot.Wants to nurse frequently.Takes very long feeds.Improper weight gainInfrequent bowel movement- small in
amount, dry and hard.Less need to change diaper(6-8)
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SIGNS INDICATING LACTATION FAILURE IN 1ST 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 weekClinical signs of dehydration.
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MANAGEMENT OF LACTATION FAILURE
PRIMARY PREVENTION
SECONDARY PREVENTION
TERTIARY PREVENTION
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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.
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ANTENATAL SCREENING FOR RISK FACTORSBREAST EXAMINATIONEVALUATION OF SYSTEMIC ILLNESSMATERNAL GENERAL CONDITION AND DIETRAY HABITSLACTATION ASSESSMENT IN 3RD TRIMESTERBREAST FEEDING EDUCATIONEDUCATION REGARDING ADVANTAGES OF BREAST
FEEDING TO BABY, MOTHER AND TO SOCIETYEDUCATION REGARDING DISADVANTAGES OF TOP FEEDSCOUNSELLING TO MOTHER WITH PREVIOUS
UNSUCCESSFUL BREAST FEEDING EXPERIENCEIMPORTANT- 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.
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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.
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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- 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
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Baby friendly hospital initiative(1992)
1. Written breast feeding policy.2. Training of health care staffs.3. Information to all pregnant ladies regarding
breast feeding.4. Breast feeding within half an hour of birth.5. No food or drink other than breast milk to the
baby, unless medically indicated.6. Show mothers how to breast feed and to maintain
lactation even if they should be separated.7. Rooming in.8. Breast feeding on demand.9. No artificial teats or pacifiers or prelacteal feeds
to the baby.10.Mother support group.
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•Infant wt loss<7%+good breast feeding skills
•Plan discharge+ lactation assessment on f/u
•Infant weight loss<7%+poor breast feeding skills
•Extended hospital stay
•Infant weight loss>7%•Breast feeding assesssment+extended
hospital stay
Planning hospital discharge
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Establishing relactation(for mother with lactation failure on post natal follow up)
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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 milkDepends on hormoneProlactin- Imp for:- development of secretory alveoli;
. secretion of milk
Stimulus- nipple stimulation Most effective stimulus-suckling of an infant (daytime<night time suckling)
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Oxytocin- Imp for milk removal. BEST WAY OF STIMULATION+REMOVAL OF
MILK:-SUCKLING INFANT.
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APPROACH TO A MOTHER WITH LACTATION FAILUREHISTORY +CLINICAL EXAMINATION NO DISEASETRUE LACTATIONAL FAILURE OR NOT
YES NO COUNSEL
CHECK FOR:-POSITION,ATTACHMENT,SUCKLINGNIGHT FEEDS?FREQUENCY? NO PROBLEMPLAN FOR ESTABLISHMENT OF RELACTATION
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FACTORS WHICH AFFECT SUCCESSFUL RELACTATION
Willingness to suckAgeBreast feeding gapGestational age
Feeding experience during the gapIntake of complementary food
INFANT RELATED
Woman’s motivationLactation gapCondition of breastsPrevious experience of lactationAbility to interact responsively with her childSupport from family, community,health workers
MOTHER RELATED
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If infant is willing to suckEncourage the woman:-Put infant to breast frequently(1-2 hrly/8-10
times in 24 hrs)Sleep with infant and breast feed at nightEnsure good attachmentLet infant suckle at both breasts, for as long
as possibleFeed infant supplements separately using a
cup.
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Infant is unwilling/unable to suckEnsure child is not sickSkin to skin contactOffer breast any time child is interested to
suckBreast feeding supplementer methodDrop and drip method
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Breast feeding supplementer method
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Drop and drip method
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Supplementing the infantWhile 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.
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How to reduce supplementIn some cases child shows less interest by
refusing supplement/ refusal to suck on 2nd breast.
Reduce total amount of supplement in 24hrs by 50ml.
Continue reduced feed for next few daysIf by behaviour and weight gain(125g/week) feed
appears to be sufficient reduce it further else continue the same for 1 more week.
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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
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Herbal /natural galactogogues:-satavariFenugreek anise, basil, fennel seedsGarlicGingerJaggeryCoconutBajraKhaskhasPepperPanjeerSonthJeevanthiPanjeeri
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BEST GALACTOGOGUE- BABY SUCKLING at THE BREST in correct position..
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ImportantConfidenceSupport of family membersRegular f/u if possible
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MANAGEMENT OF BIOLOGICAL CAUSES
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Flat nipple
Anatomical nipple forms only 1/3rd of the
teat of the breast tissue in baby’s
mouth.
Reassuarance
Inverted nippleNipple does not
protract, on attempt to pull out the nipple, it goes
deeper into breast.
SYRINGE METHOD
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SYRINGE METHOD
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ENGORGED BREASTIf baby is able to suckle, mother should feed
frequently.If pain and tightness does not allow suckling
express milkcomfortable breast feedCold compressParacetamol for pain and fever.
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DIFFERENCES BETWEEN FULL AND ENGORGED BREASTSFull 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
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Mastitis and abscessMastitis supportive counselling and
improved drainage of milk from affected part of breast by breast feeding/expressing
Indication for antibioticsLab tests show infectionSevere symptoms/ symptoms do not improve
after 12 hrs of milk removal• Analgesic and warm compress for pain relief• Abscess incision and drainage.
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Sore /cracked nippleMc 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.
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Systemic illnessEndocrinopathies and other chronic illness
needs to be managed along with other measures for encouraging breast feed.
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StudiesLactation 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 Mondkar78.1% mothers practised EBF on subsequent visits, 21.2% were partially successful in lactation and only 3 mothers had lactation failure.
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ConclusionSupportive 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.
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REFERENCESRelactation: review of experience and
recommendation for practice, WHOIAP textbookBreast feeding in practice: a manual for health
workersTraining manual on breast feeding
management(UNICEF)Breast feeding medicine, vol 4(ABM protocols)Avery’s diseases of newbornMeherban singh for newborne
thank you....