1. 1

2. Mammary Glands (Breast) The breast or mammary gland is a highly efficient organ mainly used to produce milk and is a mass of glandular, fatty, fibrous tissues. Mammary glands are exocrine glands that are enlarged and developmentally are modified sweat glands that are actually part of the skin. They are also classified as tubualveolar glands and are located in the breast lying on the top of the pectoralis major muscles. 2

3. Anatomy of breast 3

4. 4

5. Breast Anatomy  The breast is internally composed of the following parts: 1.Lobes and Lobules Internally, the mammary gland is composed of 15-25 lobes that radiates around the nipple. Each lobe consists of about 20-40 lobules, a smaller milk duct that contains 10-100 supporting alveoli. 2.Glandular tissue Glandular tissues are responsible for milk production and transportation which is composed of: Alveoli – epithelial grape-like cluster of cells where milk is produced. 5

6. Ductules – branch-like tubules extending from the clusters of alveoli and empties to larger ducts called lactiferous ducts. Lactiferous ducts – widen underneath the areola and nipple to become lactiferous sinuses. Lactiferous sinuses – collect milk from lactiferous ducts and narrows to an opening in the nipple (nipple pore). 6

7. 3.Connective tissue – Connective tissue supports the breast. Cooper’s ligaments are fibrous bands that attach the breast to the chest wall and keep the breast from sagging. 4.Blood supply – nourishes breast tissue and supplies the nutrients to the breast needed for milk production. – Internal and external mammary arteries & upper intercostals arteries – Venous drainage through corresponding vessels into internal mammary and axillary veins 7

8. 5.Nerves – make the breast sensitive to touch, hence allowing the baby’s suck to stimulate the release of hormones that trigger the let-down or milk ejection reflex (oxytocin) and the production of milk (prolactin). – Largely controlled by hormone activity – The skin is supplied by thoracic nerves – Some sympathetic nerves supply the nipple and areola 8

9. 6.Lymph nodes: – removes waste products – Lymphatic drainage largely into axillary gland – Some into liver and mediastinal gland – The lymphatic vessels of each breast communicate with one another 7.Adipose tissue (fat) – protects the breast from injury. 9

10.  The breast is externally composed of the following parts: 1.Axillary tail – Is breast tissues extending toward the axilla 2.Areola – – circular pigmented area 2.5 cm in diameter at the center of each breast. – In the areola are small glands called Montgomery's glands which secrete an oily fluid to keep the skin healthy 10

11. 3.Nipple – protruding area at the center of each breast areola at level of 4 th rib – A protuberance of 6mm in length, composed of pigmented erectile tissues – The surface of nipple is perforated by small orifice of lactiferous ducts – It is covered with epithelium 11

12. Anatomy and Physiology Breast enlargement – During pregnancy and lactation indicates the mammary glands are becoming functional – Breast size before pregnancy does not determine the amount of milk a woman will produce 12

13. Lactation anatomy and Physiology  Hormones during pregnancy – Estrogen stimulates the ductile systems to grow, then estrogen levels drop after birth – Progesterone increases the size of alveoli and lobes – Prolactin contributes to increasing the breast tissue during pregnancy 13

14. Lactation anatomy and Physiology  Hormones during breastfeeding – Prolactin levels rise with nipple stimulation – Alveolar cells make milk in response to prolactin when the baby sucks – Oxytocin causes the alveoli to squeeze the newly produced milk into the duct system 14

15. Enhancing factors Hindering factors Emptying of breast Good attachment & effective suckling Early initiation of breastfeeds Frequent feeds including night feeds Delay in initiation of breastfeeds, Pre-lacteal feeds, Bottle feeding, Incorrect positioning, Painful breast Sensory impulse from nipple Prolactin in blood Prolactin “milk secretion” reflex 15

16. Lactation anatomy and Physiology  Lactogenesis I : production start Initiation of milk production which occurs in second trimester of pregnancy  Lactogenesis II : full production Postpartum initiation of high volume milk production which occurs as transition from low volume colostrum 16

17. Lactation anatomy and Physiology Cont.. Lactogenesis II initiated by falling progesterone levels in the presence of high prolactin levels. Progesterone levels fall 10 fold in first 4 days postpartum. Breast milk changes in constituents with decreased concentration of secretory IgA and lactoferrin. 17

18. Lactation anatomy and Physiology cont..  Alveoli secrete milk and contract when stimulated  Oxytocin stimulates milk secretion and is released during the ‘let down’ or milk ejection reflex  After let down, milk travels into the ductules, then to the larger – lactiferous or mammary ducts 18

19. Baby sucking Sensory impulse from nipple to brain Oxytocin contracts myoepithelial cells Oxytocin “milk ejection” reflex 19

20. Thinks lovingly of baby Sound of the baby Sight of the baby CONFIDENCE Worry Stress Pain Doubt Stimulated by Inhibited by Oxytocin reflex 20

21. Lactation anatomy and Physiology Latch On and sucking Oxytocin Release Releases Milk Infant Empties Breast Production Increases Milk Production Occurs Interference with this cycle decreases the milk supply. 21

22. Evidence-based early care Latch Moving Milk Let Down Breastfeeding Success Start out right: establish normal physiology 22

23. Breast milk composition difference( dynamics): Gestational age at birth ( preterm and full term) Stage of lactation ( colostrum and mature milk) During a feed ( foremilk and hind milk) 23

24. Colostrum : Is the breast milk that women produce in the first few days after delivery. It is thick and yellowish or clear in colour. It contains more protein than mature milk. Small amounts but close to stomach capacity 24

25. Colostrum Property Antibody-rich  Many white cells  Purgative  Growth factors  Vitamin-A rich Importance protects against infection and allergy protects against infection clears meconium; helps prevent jaundice helps intestine mature; prevents allergy, intolerance reduces severity of some infection (such as measles and diarrhoea); prevents vitamin A-related eye diseases 25

26. Mature milk Is the breast milk that is produced after a few days. The quantity becomes larger, and the breasts feel full, hard and heavy. Some people call this the breast milk ‘coming in’. Foremilk is the milk that is produced early in a feed. Hindmilk is the milk that is produced later in a feed. Volume produced: 1 st 24 hrs: 7 ml / feed 2 nd 24 hrs: 14 ml / feed At six month: 800 ml / day 26

27. Foremilk looks thinner than hind milk. It is produced in larger amounts, and it provides plenty of protein, lactose, and other nutrients. Because a baby gets large amounts of foremilk, he gets all the water that he needs from it. Babies do not need other drinks of water before they are six months old, even in a hot climate. If they satisfy their thirst on water, they may take less breast milk. 27

28. Hind milk Is the milk that is produced later in a feed. Hind milk looks whiter than foremilk, because it contains more fat. This fat provides much of the energy of a breastfeed. This is an important reason not to take a baby off a breast too quickly. The baby should be allowed to continue until he has had all that he wants. 28

29. Breast milk composition Mature milk in 10 days All necessary nutrient and fluid in 6 month 88% water 4.5% fat – Makes up 1/2 of calories in breast milk – Supplied the energy or rapid growth, more produced at night – Cholesterol is optimal for brain development 29

30. Breast milk composition cont.. Fat (4% concentration provides up to 50% of caloric needs, cholesterol levels constant, lipolytic enzymes aid in fat digestion) Carbohydrates (lactose = milk sugar predominantly in human milk, 7% concentration provides up to 40% caloric needs, essential for development of CNS, enhances calcium & iron absorption) 30

31. Breast milk composition cont.. Carbohydrates (Bifidus factor = growth factor present only in human milk required for establishing an acidic environment in the gut to inhibit growth of bacteria, fungi and parasites) Protein – Cystine, taurine ( brain development) and casein – Lactoferin 31

32. Breast milk composition cont.. – Secretory IGA => Most important immunoglobulin, breast milk is only source for first 6 weeks – 100 amino acid, mineral and vitamins – Iron supplement at 4 – 6 months – Consider vitamin D 32

33. Properties of breast milk Biologic specificity => Long-chain omega-3 Fatty Acids Important for brain and retinal development Higher IQs 33

34. Immunologic specificity Protection against pathogens & allergens Kills pathogenic organisms or modifies their growth. Stimulates epithelial maturation for future defence. First immunization Protection against common respiratory and intestinal diseases. 34

35. Immunologic specificity cont.. Colostrum = Baby’s first vaccination Less risk of illness such as: Ear infections, pneumonia, crohn’s disease and other bowel illnesses, stomach flu and other intestinal illnesses, ear infections, childhood cancers, diabetes, arthritis, allergies, asthma and eczema. 35

36. Breastfeeding Best for baby Reduces incidence of allergies Economical - no waste. Antibodies - greater immunity to infections Stool inoffensive - never constipated. Temperature always correct and constant. 36

37. Breastfeeding Fresh milk - never goes sour in the breast Emotionally bonding Easy once established Digested easily within two to three hours Immediately available Nutritionally balanced Gastroenteritis greatly reduced 37

38. Terms for infant feeding Exclusive breastfeeding: The feeding of an infant or young child with breast milk directly from female human breasts rather than from a baby bottle or other container "an infant's consumption of human milk with no supplementation of any type (no water, no juice, no nonhuman milk, and no foods) except for vitamins, minerals, and medications." 38

39. Terms for infant feeding cont.. Predominant breastfeeding Means breastfeeding the baby but also giving the baby small amount of water or water based drink such as tea Full breastfeeding Means breast feeding either exclusively or predominantly 39

40. Terms for infant feeding cont.. Bottle feeding Means feeding the baby from the bottle, whatever in the bottle including expressed milk Artificial feeding Means feeding a baby on artificial feed, not breastfeeding at all 40

41. Benefits of breastfeeding Ecological: – Saves resources – Less waste – No refrigeration – No manufacturing – No bottles, cans – No trucking – No handling 41

42. Benefits of breastfeeding cont.. For Society – Smarter – Healthier – Less cost to healthcare system – Stronger families 42

43. Benefits of breastfeeding cont.. To Families – Less trips to doctors, hospitals – Less prescriptions – Less stress – Less illness – More bonding – Inexpensive 43

44. Benefits of breastfeeding cont.. Benefits to baby: – Better dental health – Increased visual acuity – Decreased duration and intensity of illnesses – Less allergies – Better health & less risk of illnesses 44

45. Benefits of breastfeeding cont.. Benefits to mother: – Psychological (Attachment, bonding, security, skin to skin, fulfillment of basic needs, relationship) – Easier weight loss. – Decreased risk of illness (breast cancer, osteoperosis, hemmorhage, ovarian cancer) – Birth control. – Involution of the uterus – Pride, empowerment, fulfillment 45

46. Benefits of breastfeeding cont.. Benefits to the hospital: – Warmer and calmer emotional environment. – No nurseries, more hospital space. – Fewer neonatal infections. – Less staff time needed. – Improved hospital image and prestige. – Safer in emergencies. 46

47. For successful breastfeeding A willing and motivated mother. An active and sucking newborn. A motivator who can bring both mother and newborn together ( health professional or relative ). 47

48. Management of breastfeeding T en steps to successful breastfeeding: 1.Have a written breastfeeding policy that is routinely communicated to all health care staff. 2.Train all health-care staff in skills necessary to implement this policy. 3.Inform all pregnant women about the benefits of breastfeeding. 4.Help mothers initiate breastfeeding within a half-hour of birth. 48

49. 5.Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants. 6.Give newborn infants no food or drink other than breast milk unless medically indicated. 7.Practice rooming-in — allow mothers and infants to remain together 24 hours a day. 8.Encourage breastfeeding on demand. 49

50. 9.Give no artificial teats or pacifiers (also called dummies and soothers) to breastfeeding infants. 10.Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. 50

51. Preparation for breastfeeding cont.. Increases duration of breastfeeding Allows skin-to-skin contact for warmth and colonization of baby with maternal organisms Provides colostrums as the baby’s first immunization Takes advantage of the first hour of alertness Babies learn to suckle more effectively Improved developmental outcomes 51

52. The proper way to breastfeed Stimulate the baby mouth to open by touching the nipple. Let the baby open the mouth wider. Bring the baby near to the breast Latch the baby to the breast 52

53. positioning Mother: Make the mother sit in a comfortable and convenient position (she can feed in lying down position) Ensure that she is relaxed and comfortable Baby: Baby’s head and body are in a straight line Baby’s whole body is supported Baby’s face is opposite the nipple and the breast Baby’s abdomen touches mother’s abdomen 53

54. Positioning of breastfeeding 54

55. Side lying position 55

56. Cross cradle hold position 56

57. Saddle Hold 57

58. Twin Football Hold 58

59. 59

60. 1.Baby’s mouth is wide open 2.Baby’s chin touches the breast 3.Baby’s lower lip is curled outward 4.Usually the lower portion of the areola is not visible Key points of good attachment 60

61. Good attachment baby’s mouth is wide openlower lip is curled outward lower portion of the areola is not visible chin touches the breast 61

62. 62 Good and poor attachment

63. Effective suckling For an infant who shows signs of good attachment, the next step would be to assess suckling: If the infant takes several slow deep sucks followed by swallowing and then pauses, then he/she is sucking effectively 63

64. Signs that the baby is getting enough breast milk 1.He is contented for 1-2 hours after a feed 2.He passes clear dilute urine 5-6 times a day 3.He passes bright yellow watery stools 6-8 times a day 4.He regains birth weight after 2weeks 64

65. Signs that the baby is getting enough breast milk cont. 5.Gains weight at 10-15 gm /kg/day 6.Audible visible swallowing 7.Latch the entire nipple and most of areola 8.8- 12 feeding / day, on demand 9.Tongue under the nipple 10.The nipple looked long and round after breastfeed. 65

66. Barriers to Bonding * A Bottle places a physical barrier between mom and baby *Less skin to skin contact *Less eye contact * The hormonal connection between the breastfeeding mother and baby cannot be experienced by the bottle feeding mother 66

67. 67 Management of “Not enough milk” Put baby to breast frequently Baby to be correctly attached to breast Build mother’s confidence “ Adequate weight gain and urine frequency 5-6 times a day are reliable signs of enough milk intake”

68. Breast milk supply can be increased by: 1.Frequent feeds day and night. 2.Allowing unlimited breastfeeding to satisfy baby’s suckling needs. 3.Mother to eat and drink sufficient quantities to satisfy baby’s suckling, her hunger and thirst 4.Cultural foods like ginger and rice are compatible with breastfeeding. 68

69. Recommendations Exclusive breast feeding until 6 months of age Introduce complimentary foods with continued breastfeeding Optimum to breastfeed for 2 years or longer 69

70. Nutrition while breastfeeding Eat a well-balanced, varied diet Breastfeeding mothers burn 500+ calories daily Check with doctor about taking a multivitamin with iron Drink eight glasses of fluid (eight ounces each) daily Avoid or limit caffeinated drinks Avoid alcohol or limit it. 70

71. Breastfeeding Barriers Early breastfeeding failures deprive infants of the benefits, and leave many mothers disappointed It is a natural process, but many mothers need a lot of help 71

72. Contraindication to Breastfeeding HIV (Adult T-cell lymphoma virus) Active Tuberculosis. Herpes lesions on mother’s breast. Infant with Inborn error of metabolism; galactosemia, phenylketonuria. Mothers on certain medications ; anticancer therapy, radioactive isotope. 72

73. Expressed breast milk Indications – Sick mother, local breast problems – Preterm / sick baby – Working mother Storage – Clean wide-mouthed container with tight lid – At room temperature: 6 hrs – Refrigerator: 24 hours; Freezer (20°C): for 3 months 73

74. 74

75. Alternatives to artificial teats cup spoon dropper Syringe 75

76. Why some mothers choose formula vs. breast milk Distressed by physical discomfort of early breastfeeding problems. Convenience issues Pressures of employment/school Worries that breast shape will change Formula manufacturers manipulate people through their ads Doctors and nurses need more lactation training 76

77. Why some mothers choose formula vs. breast milk Mother given very little time to adjust to changes of postpartum Family demands Non-supportive family/health professionals Embarrassment Lack of confidence in self Feeling that one cannot produce enough milk 77

78. Mother’s milk vs. formula milk Formula milk for 3 days old babies is no different than formula milk for 3 months old infants. Breast milk is ingeniously different every single day; adapted to the changing needs of the baby. 78

79. Common Problems Encountered in Breast Feeding 79

80. Sore and cracked nipple Causes Incorrect attachment : Nipple suckling Frequent use of soap and water Candida (fungal) infection Thrush Dry skin Dermatitis Biting 80

81. Treatment Continue breastfeeding and correct the position & attachment Apply hind milk to the nipple after a breastfeed, warm soaks rotation during breastfeeding Expose the nipple to air between feeds 81

82. Treatment of inverted nipple Treatment should begin after birth Syringe suction method Manually stretch and roll the nipple between the thumb and finger several times a day Teach the mother to grasp the breast tissue so that areola forms a teat, and allows the baby to feed 82

83. Treatment of inverted nipple by syringe method STEP 1 STEP 3 STEP 2 Cut along this line with blade Mother gently pulls the plunger Insert the plunger from cut end Use 10 or 20cc syringe Before the feeds 5- 8 times a day 83

84. Breast engorgement Causes Delayed and infrequent breastfeeds Incorrect latching of the baby Treatment Give analgesics to relieve pain Apply warm packs locally Gently express milk prior to feed Put the baby frequently to the breast 84

85. Mastitis Definition: tender, swollen, wedge-shaped area of breast, usually unilateral, with fever, malaise, chills, and systemic symptoms Incidence: 3 to 20% Treatment – Rest, fluids – Antibiotics – Dicloxicllin 500mg QID x 10- 14d 85

86. – Empty the breast Evaluate latch Continue frequent breast feeding Milk is not harmful to healthy, term infant Abrupt weaning slows maternal recovery Poor response requires further evaluation 86

87. Breast abscess 3% of women with mastitis Diagnosis – Hard, red, tender mass after appropriate treatment – Diagnostic ultrasound Treatment – Needle aspiration for culture / treatment – Surgical drainage for large or multiple abscesses Follow-up care – Antibiotics – Continue breastfeeding 87