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Let’s talk about how the process of breastfeeding actually works. The tissue of the breast is arranged in clusters of alveoli consisting of glandular cells, which produce the milk, and myoepithelial cells, which contract around the ductile system to expel the milk into the ductules. The ductules lead to larger ducts. The glandular tissue undergoes proliferation during puberty, during pregnancy, and in the early stages of lactation. Much of the size of the breast in the nonpregnant/nonlactating state is due to the supporting structures and not the actual glandular tissue, so the size of the breast does not affect the ability of the breast to produce adequate milk to nourish the infant. While the size of the breast does not affect the volume of milk that can be produced, women with smaller breast size may have reduced storage capacity for milk. Women with smaller breasts may need to breastfeed their infants more often, while women with larger breasts may have longer intervals between feedings. Breasts that are extremely small or have an unusual shape may have inadequate glandular tissue, so these mother-baby pairs should be followed closely. Most women experience an increase in the size of the breasts during pregnancy, as well as increased breast tenderness. Copyright © 2003, Rev 2005 American Academy of Pediatrics
These changes in the breasts during pregnancy are good signs that glandular tissue is present and responding to the maternal hormones of pregnancy. If the mother does not require a larger bra size when pregnant, she should be followed carefully in the early postpartum period. When the baby latches on and suckles at the breast, the baby’s mouth should be wide open and the baby’s tongue should extend over the baby’s lower gum and under the breast tissue. The lactiferous sinuses, which act as temporary storage reservoirs, are compressed by peristaltic motion of the tongue. Notice that there are multiple openings in the nipple through which the milk passes. Copyright © 2003, Rev 2005 American Academy of Pediatrics
prolactin and oxytocin.Pituitary releases prolactin and oxytocin. Stimulation of nerve endings in mother’s nipple/areola sends signal to mother’s hypothalamus/ pituitary. Hormones travel via bloodstream to mammary gland to stimulate milk production and milk ejection reflex (let-down). As the infant suckles at the breast, the nerve endings in the breast send a signal to the mother’s brain, resulting in the release of prolactin from the anterior pituitary and oxytocin from the posterior pituitary. Prolactin surges result in increased production of milk in the alveolar tissue of the breast. Oxytocin has multiple effects. In the brain, oxytocin receptors bind the oxytocin, causing strong feelings of attachment and love for the nursing infant. In the breast, oxytocin causes the myoepithelial cells surrounding the glandular tissue to contract and increase the milk flow to the baby, in what is called the milk ejection reflex (commonly referred to as “let-down”). In the mother’s uterus, oxytocin causes uterine contractions that result in constriction of the myoepithelial cells of the uterus, decreasing the risk of hemorrhage. Milk production also depends on many other maternal hormones, including adequate thyroid hormone. Infant suckles at the breast. Copyright © 2003, Rev 2005 American Academy of Pediatrics
Maternal Factors That Support Optimal LactationNormal breast anatomy Intact neuroendocrine reflex Good general health and nutritional status Effective support system Many mothers believe they must be in perfect health and have a perfect diet to breastfeed. In fact, the breasts produce high-quality milk in adequate quantity under a wide variety of conditions. Previous surgery to the breasts or lack of normal glandular tissue in the breasts may interfere with milk production. Women who have undergone breast reduction surgery are at higher risk of having had interruption of the innervation, or nervous supply, and of the glandular or ductular systems of the breast. Their babies should be monitored closely, especially during the early stages of lactation. A supportive family, especially the father of the baby, helps to instill confidence and reduce anxiety for the breastfeeding mother. Assistance with other household tasks is especially helpful to allow the breast-feeding mother to relax and concentrate on breastfeeding in the early weeks. Copyright © 2003, Rev 2005 American Academy of Pediatrics
Nutrition During LactationGenerally healthy diet Drink fluids to thirst Adequate protein and calories Calcium Multivitamin supplement During pregnancy, most women develop healthy eating habits. The same healthy eating habits should continue during lactation. Lactating women should drink to thirst. Having a beverage when the baby nurses is a good reminder to drink. Forcing fluids is not recommended, but drinking water, juice, or other beverages as desired is helpful. Mothers do not need to drink cow’s milk or consume dairy products to produce human milk. Occasionally, infants are actually sensitive to excessive consumption of cow’s milk by the nursing mother. Mothers do need a source of calcium in the diet. This can come from dairy sources, supplements, or other foods in the diet. A daily multivitamin or prenatal vitamin will ensure continued adequacy of vitamins and minerals during lactation. For most women, an additional 300 to 500 calories in the diet will adequately support lactation. Copyright © 2003, Rev 2005 American Academy of Pediatrics
Maternal Medications Most are compatible with breastfeeding.Medication use in pregnancy is not the same as medication use in lactation. Weigh benefits against risks. Many health care professionals are not knowledgeable about the use of medications during lactation. Information about use of medications in pregnancy is not necessarily appropriate to use for lactation. During pregnancy, the fetus is exposed to most substances in the maternal circulation via the placenta. During lactation, the mammary gland must take up the substance and secrete it into breastmilk. Many pharmacokinetic factors affect the amount of the medication that is actually present in the breastmilk. Drugs, including over-the-counter and herbal medications, should be used only if needed and with the physician’s approval during lactation. Very few drugs are absolutely contraindicated during lactation. While the majority of drugs are safe to take while breastfeeding, the health care professional should weigh the benefit of breastfeeding against the risks of the medication and not receiving mother’s milk. Copyright © 2003, Rev 2005 American Academy of Pediatrics
Maternal Medications Choose the safest drug available.Prescribe medications for the shortest length of time appropriate. Use short-acting formulations. Administer just after breastfeeding. Monitor infant for side effects. Report adverse effects to the proper authorities. In general, when medication use is required during lactation, the safest drug possible should be chosen for the shortest length of time possible. Short-acting drugs are preferable and should be administered just after the breastfeeding session to minimize the amount of medication that is transmitted in the breastmilk at the next feeding. The mother should be advised to watch the infant for any side effects and report concerns to the pediatrician or family physician. Significant adverse events should be reported to the proper authorities to assist in making clinical decisions about lactation and medication use in the future. Copyright © 2003, Rev 2005 American Academy of Pediatrics
Maternal Medications References AAP Committee on DrugsHale: Medications and Mothers’ Milk Lawrence and Lawrence: Breastfeeding: A Guide for the Medical Profession Briggs, Freeman, and Yaffe: Drugs in Pregnancy and Lactation Lactation Study Center Drug Data Bank, University of Rochester, NY Current references should be consulted to give appropriate advice to mothers who are breastfeeding. For example, the American Academy of Pediatrics issued a revised statement, “The Transfer of Drugs and Other Chemicals Into Human Milk,” in the September 2001 issue of Pediatrics. (American Academy of Pediatrics, Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics. 2001;108:776–789) Copyright © 2003, Rev 2005 American Academy of Pediatrics
Breastfeeding CounselingAdvise moderation in caffeine intake Avoid alcohol Encourage smoking cessation or limited use Moderate intake of caffeinated beverages by the mother does not usually have a significant effect on the nursing infant. Excessive consumption may cause agitation, irritability, or decreased sleep in the breastfeeding infant. Alcohol passes readily into breastmilk; therefore, its use is not recommended. Binge drinking or chronic ethanol exposure may cause developmental problems. Ingestion of occasional alcohol in limited quantity has not been shown to be harmful. If mothers do choose to take an occasional alcoholic beverage, they should avoid breastfeeding for 2 hours after consuming. Small amounts of nicotine also pass into breastmilk; moreover, secondhand smoke can cause health risks to the child. If mothers cannot stop smoking, they should smoke the minimum amount, smoke immediately after the infant has breastfed, and never smoke in the infant’s presence. Smoking cessation should be discussed during breastfeeding counseling; however, the many benefits of breastfeeding outweigh the potential risk of exposure to small amounts of alcohol and tobacco. Copyright © 2003, Rev 2005 American Academy of Pediatrics
Human Milk Colostrum Present in small volume before delivery and in first days after delivery High in host defense proteins and immunoglobulins Transitional milk By approximately 2 to 4 days after delivery, the mother’s milk production should increase, causing a greater volume of milk and a change from the thick yellow colostrum to a thinner, more copious, creamy-appearing transitional milk. During this time, the mother experiences swelling and mild tenderness in the breasts. Early initiation of feedings at the breast and frequent feedings by the newborn help the mother to produce adequate volumes of milk for her newborn and minimize breast engorgement and discomfort. Copyright © 2003, Rev 2005 American Academy of Pediatrics
Human Milk Colostrum Present in small volume before delivery and in first days after delivery High in host defense proteins and immunoglobulins Transitional milk Mature breastmilk As the milk matures, by about 10 to 14 days after delivery, the volume continues to increase and the consistency becomes thinner. At this stage, mothers mistakenly may perceive that their milk is not good anymore or is like “skim milk” because they have become accustomed to the creamy texture of the transitional milk. After the first several weeks, the breasts may become less firm, although they are continuing to produce adequate amounts of milk for the infant. Around 2 to 3 weeks postpartum, some mothers also may feel that their milk supply is decreasing when the milk production becomes more synchronous with the infant’s needs and engorgement is uncommon. About this same time, the infant also may experience a growth spurt, during which the infant wants to feed more frequently to increase the mother’s supply and meet the infant’s growth needs. These are all normal physiologic adjustments, but some mothers mistakenly feel that something is going wrong with breastfeeding. It is helpful for mothers to be educated about what to expect as their breasts undergo these changes. Copyright © 2003, Rev 2005 American Academy of Pediatrics
Premature infant breastfeedingTwins breastfeeding Premature infant breastfeeding Once the milk supply is well established, most mothers produce an average of 24 to 32 oz of milk per day. However, with good support, mothers of twins or triplets can produce enough milk to nourish all of the babies. Some mothers find it helpful to feed both babies at the same time, such as the mother of twins shown on the left side of this slide. On the right side of the slide we see a premature infant being breastfed. Premature infants usually can begin to feed directly at the breast by around 32 weeks of gestational age. Prior to this time, the mother may express milk to be fed to her premature infant via a gavage tube. Photo © Nancy Wight, MD, FAAP Photo © Ruth A. Lawrence, MD, FAAP Copyright © 2003, Rev 2005 American Academy of Pediatrics
Breastfeeding PositionsMother comfortable Infant head in straight line with body Tummy-to-tummy or chest-to-chest Mothers can feed in a variety of positions (eg, sitting up comfortably or lying in bed). It is essential for the mother to obtain a comfortable, relaxed position before attempting to latch the infant. Pillows may be helpful to support the newborn or young infant at the level of the breast, eliminating strain on the mother’s back or shoulders. When beginning a feeding, it is important that the mother is comfortable, with shoulders relaxed. The infant should be aligned so that the head is in line with the body and the ear is in a straight line with the infant’s shoulders and hips. The infant should be turned facing the mother, chest-to-chest or tummy-to-tummy. The mother can provide gentle support to the breast as needed, especially if the mother has large, pendulous breasts. She should not depress the breast with her hands because this can interfere with milk flow and may predispose her to plugging of the ducts, engorgement, or mastitis. Photo © Ruth A. Lawrence, MD, FAAP Copyright © 2003, Rev 2005 American Academy of Pediatrics
Cradle Position Let’s take a look at the various breastfeeding positions. The cradle position is the traditional “Madonna” hold and is the position most people associate with breastfeeding. The position can be used in a rocker or glider, or while semi-reclining or seated in bed. Copyright © 2003, Rev 2005 American Academy of Pediatrics
Cross-cradle or Transitional PositionThis slide demonstrates the cross-cradle or transitional position. The cross-cradle position provides more control and support of the infant’s back and neck. It is particularly useful for newborns and young infants. Notice how the infant is being held by the mother’s opposite hand and arm instead of the arm on the same side as the breast being offered. Photo © La Leche League International Copyright © 2003, Rev 2005 American Academy of Pediatrics
Side-lying Position The side-lying position can be used to allow the mother to rest during the day or for nighttime feedings. This also is a useful position for cesarean deliveries. The baby can be supported by placing a pillow behind the baby’s back or underneath to raise the baby to the proper position. To feed at the other breast, the mother can either hug the baby to her chest and roll to the other side, repositioning the baby and pillows, or simply roll her body forward until the baby can latch onto the other breast. Photo © Roni M. Chastain, RN Copyright © 2003, Rev 2005 American Academy of Pediatrics
Clutch or Football PositionThe clutch or football position keeps the weight of the infant off of the mother’s abdomen and is particularly useful for cesarean deliveries. Premature infants can be easily supported in this position. Mothers should be taught at least 2 different positions prior to hospital discharge. They should rotate breastfeeding positions to encourage optimal draining of milk from all segments of the breast and to help to eliminate nipple or breast discomfort during the early days of breastfeeding. Photo © Lori Feldman-Winter, MD, MPH, FAAP Copyright © 2003, Rev 2005 American Academy of Pediatrics
Latch Stimulate rooting reflex. Take sufficient areola into mouth.Flange lips around the breast— “fish lips.” Have wide angle at corner of mouth. Latching onto the breast can be stimulated by gentle stroking of the middle of the bottom lip with the nipple. As the infant opens the mouth widely in response to the rooting reflex, the mother should draw the infant to the breast. The newborn should not be attached just to the nipple, but should have sufficient areolar tissue in the mouth so that the mother’s nipple is actually positioned near the junction of the newborn’s hard and soft palates. In this position, the nipple should not be traumatized. The angle of the mouth should be as wide as possible and the lips should be everted or turned outward. The baby’s nose, mouth, and chin all should be touching or very close to the tissue of the breast as the baby latches. Illustration by Tony LeTourneau Copyright © 2003, Rev 2005 American Academy of Pediatrics
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