Anatomy and Physiology of Lactation

 

4/11/2012

 An ato m y and Phy Physi si ol og y of Lactation

Linda Wright RN, BSN, IBCLC

Objectives 

To better understand how anatomy and physiology may impact the outcomes of breastfeeding

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To increase and update breastfeeding knowledge and skills

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To outline the importance of early skin to skin and early establishment of milk supply.

Key Message: Message: Making Milk is Easy 

Moms body is built for lactation - Effici Efficient ent nutrient nutrient utili utilizatio zation n - Diet, fluid intake intake only minimally minimally important - “Stress” only only minimally minimally important important

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Most women only use 2/3 of capacity!

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Baby takes about 2/3 of milk available

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Most who can gestate – can lactate

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Then Failures” ilures” ? Then why the “ Fa 

Scheduled Feeds !!!

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Marketing of substitutes to mother’s milk

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Lactation poorly researched in mothers

 Assumed failure was “attitude” “attitude” of mom

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 Assumed all babies babies could suck well

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Inadequate education for health professionals

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Myths and “tales” abound

Causes Ca uses of Breastf Breastf ee eeding ding “ Fa Failu ilu re” Insufficient Milk Supply (not enough) - Real or or im imag agin ine ed - Do Docu cume ment nted ed thr throu ough gh his histo tory ry  Pain - Bre reas astt or Ni Nip pple  Disapproval or social ostracism - Bla Blamin ming g Brea Breastf stfeed eeding ing for nor normal mal inconveniences 

General Agreement on Supply 

Supply is related to infant demand / appetite ( Dewey, Neifert, Hartmann)

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Early and frequent feedings establish supply

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Engorgement and unrelieved milk stasis will Engorgement reduce supply

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Importance of the issue

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#1 Cause of BF Failure is “not enough milk”

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Disagreement is on the Disagreement Mechanism(s) 

How important important is the Let - down reflex?

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Role of Prolactin

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Is mother’s diet and fluid intake important?

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What role does the baby play?

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Does “Supply and Demand still apply?

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Do theories concur with mom’s experience’s?

“Lactation is the physiologic completion of the reproductive cycle” Dr. Ruth Lawrence

Mammogenesis Ma mmogenesis – the development of the mammary gland (building the “Factory”) 

Embryo to Puberty Puberty – rudiments of ducts

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Puberty Pube rty to Pregnancy – duct framework

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Pregnancy Pre gnancy – Lactoge Lactogenisis nisis 1

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Secretory cells -placental lactogen, prolactin , estro estro gen, progesteron develop the cells - cell growth continues 4-6 4-6 postbirth or longer  - mate maternal rnal nutrition – no effect effect on cell growth

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Breast Size Changes Changes 

Pre pregnancy: fatty tissue supports

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Pregnancy: glandular tissue grows

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Growth patterns in pregnancy vary

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Storage capacity varies - Average 196g; 196g; may increase with with demand - Size NOT related related to overall overall milk production capacity; may affect patterns of feeding

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Productio uction n starts: The Lactogenisis 1 – Prod initial of pregnancy milk components begins in 2nd synthesis trimester of

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Lactogenesis Lactogene sis II – Full Produc Production tion - the onset of copious milk production 2-3 days postpartum. - Trigg Trigger: er: delivery delivery of the the placent placenta a - a rapid rapid drop of serum progesterone (removes the t he brakes on Prolactin)

Prolactin 

Essential for i nitiating and maintaining Essential milk production

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Plasma prolactin levels increase the most in the imm edia ediate te postpartum how eve everr ri se and fall fall in proport ion to frequency, intensity and duration of nipple stimulation

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Concentration in the blood doub les in Concentration response to suckling and peaks approx 45 mins after the beginning of a feeding session

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Prola rolactin ctin - Endocrine

Oxytocin In response to baby suckling, the posterior pit uitary releases releases oxytocin triggering the milk ejection reflex (MER) or letdown  Re Released leased in pul se like waves  Women may feel areolar pressur e, tingling , and/or and/or a warm sensation during a milk ejection  Ma May y experience several let downs during a feed 

LET DOWN REFLEX

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Summary of mi lk production Summary 

Endocrine ( Hormonal driven): dri ves cell proliferation duri ng pregnancy and early ea rly postpartum

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 Au to cr in e (Bab y Driv Dr iv en): ret ain ed mil m il k in alveoli cl osely regulates the rate of synthesis hour by hour at the lobular level.  Physical pressure from retained milk affects secretory secretory funct ion

Breast Structure 

Overlies Ove rlies ri bs & p ectoral muscles

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Skin, Cooper’s Cooper’s ligaments support

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Duct Framework

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Nipple-areola complex

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Blood and lymph supply

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Nerve Ne rve pathw ays

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Fatt and gl andular tissue Fa

Breast Brea st structure (Old concept)

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Ultrasound (N (New) ew) Lactiferous Duct

Ultrasound (new) Lactiferous Duct

Ramsay D et al. Anatomy of the lactating human breast redefined redefined wit h ultrasound imaging. J.  Anato my 2005; 206: 525–534 

9 lobes & openings (range 4-16 4-16))

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Ducts 2 mm; di late with MER

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Easily compressed

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Near the skin surface

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Begin branching under areola

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2/3 glandular ti ssue under areola & nippl e

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No “sinuses” “sinuses”

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Fat interspersed throughout breast

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The Brea Breast st – mamma mammary ry gl and

-a conglomeration of independent glands

The breast breast (continued) 

Mature breast weighs 150 - 250 g

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During Lactation Lactation weighs 400 – 500 g

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Size of breast not indicative of ability to lactate

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Highly vascular 

 Areol  Ar eol a – ci rc ul ar pi gm ent ented ed area Usually pink or light brown before pregnancy  Turns reddish brown or darkens during pregnancy  Enlarges during during pregnancy pregnancy ( ½ - 2”)  Darker coloration important as a visual guide for baby to find and grasp the nipple 

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Montgomery’s Tubercles/Glands 

Located on the areola – ductular openings openings of sebaceous and lactiferous glands

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Become enlarged during pregnancy and lactation

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Lubricates and protects the nipple and areola

 Antimicrobial and acid ph ph

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Nipple

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conic elevation in the center of the areola

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Openings in the the nipple vary in number - 9

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Condensation Condensa tion of epithelial cells

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Protractility Protractili ty – impo important rtant – help baby baby to find target.

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Nipple Feeding

Breastfeeding Dr J Newman permission granted

Nipple Types

Breast and Nipple Variations

c Linda Wright

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Milk Line Sites of supernumerary nipples along “milk line”

Invisible Structures 

Muscles

- located in the superficial superficial fascia between between the 2nd and 6th intercostal cartilage -

superficial to the pectoralis major muscle

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Breast if fixed by fibrous bans called Cooper’s Ligaments (super sensory)

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Supported by muscles attached to ribs, collar bone, and bones of upper arm

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Lymph Supply 

Extensive – Main drainage drainage to axillary nodes and to paracostal nodes in the thoracic cavity

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Lymph nodes filter and destroy invading bacteria and are the production site of lymphocytes and antibodies

Lymph Dra Drainage inage of the Breast

Nerve Supply 

Nerves of the breast are from the 2nd to 6th intercostal nerves

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Sensory innervation of the nipple and areola is extensive ( to the surface)

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4th intercostal supplies the greatest amount of sensation to nipple

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Sensitive – Responsiveness to infant infant sucking – release of oxytocin and prolactin

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Nerves

Blood supply 

Internal mammary artery (supplies 60% to the breast tissue) and lateral thoracic artery

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Highly vascular 

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Blood supply to the nipple extensive

Mammary Ma mmary Gland 

Milk is produced in the alveolus alveolus.. The alveoli is the basic unit of the mature glandular tissue The milk is produced by the gland cells. Surrounding the gland cells are the myoepithelial cells which contract to cause milk ejection into the milk duct. The milk then travels down the lactiferous ducts.

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 A c r os oss-s s-s ect io n vi ew o f t he alveolus

Lobule 10 – 100 alveol alveolii comprise a lobule lobules form form  20 – 40 lobules a lobe lobe – make up the functioning part of the breast  Majority of lobules concentrated in the lower half of chest 

It is the quantity and quality of infant suckling or mi lk removal removal that governs breast milk synthesis.

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Milk Product ion Summary of Milk What doesn’t matter ( matter  ( re milk volume) - Mother’s food food quality or quantity quantity - Moth Mother’s er’s fluid fluid intake intake - Mother’s emotional emotional status unless it affects her willingness to bring baby to the breast  What does Matter : frequent and thorough removal of milk from the breast by any method (preferably (preferably the baby) baby ) 

Hand Expression

c L Wright

If all goes go es Well Well 

Baby takes most of the milk produced

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Cells gear up to full production over 5 days

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Baby’s stomach grows along with supply

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Stooling and urination well established

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Frequent contact good for both - Prolactin continues building “factory” - Oxytocin contracts uterus and and more…

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Factors for Low Milk Supply Risk Factors Genetic  Environmental  Physical damage prior to first pregnancy - surge surgery, ry, accidents, accidents, burns to chest - chem chemical ical (chemotherapy) (chemotherapy)  Pituitary infarct (Sheehan’s syndrome)  Hormone exposure and therapy  MILK STASIS STASIS – Prolonged engorgemen engorgementt 

Risk Factor Factor s, continu ed Birth Related Risks  Agents that may Reduce Reduce supply  Behavioral Factors: - Scheduled Feeds! Length & frequency - Supp Suppleme lements nts or bottles used - Nipp Nipple le shield shield use use - Pac Pacifi ifier er use - Nipple pain or damage (esp (esp early onset) - sepa separatio ration n of mom and baby baby 

Common Fa False lse Alarms 

Baby fussy in the evening

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Baby feeds “frequently”

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2-3 days of increased feedings

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Baby will take a bottle after 

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No leaking or dripping of milk

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Not much obtained with pumping

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Low Milk Supply – Re Rea al Signs Baby pulls off, cries, fights breast - immediate hunger after after feedings feedings - Few or no no swallow swallow heard - Few or no stools daily in the first month month less than ½ - 1 oz per day  Gain of less  Very long feedings ( >30 min)  Baby consistently unhappy, fretful, worried or withdrawn and sleepy 

Engorgement is an emergency emergency 

Changes at birth

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Suddenly there’s more milk

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Supply gets ahead of the baby

 Areolar Compression

c L Wright

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What go es Wrong? What 

Events transpire to leave milk in breast

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Milk stasis blocks rising milk synthesis

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Edema happens - Extracellular fluid congests lymph and blood vessels - Block Blocks s ductal ductal system system - Causes or or exacerbates exacerbates milk stasis

Fewer Prolactin Surges 

Baby not at breast = fewer prolactin surges

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Which reduces lactose syntheseis

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Which reduces osmosis of water into cell

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Result: fluid stays in extracellular extracellular space

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WHICH MAKES EDEMA WORSE

Fewer Fe wer Oxytoc Oxytoc in Bur sts 

Baby not at breast = fewer oxytocin bursts

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Reduced smooth muscle contraction

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Which reduces lymph contraction

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Which reduces lymph drainage

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Leaving excess fluid in extracellular space

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WHICH MAKES EDEMA WORSE

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Prevention of Engor geme Prevention gement nt 

Prevent Edema - Norma Normall hydration dur ing labor 

-Esta Good nugood nutrition tritionmilk for mother’s sake sake Establish blish fl ow/remova ow/removal l ASAP - Skin to Skin early, offer breast early - Combi ombine ned d Care Care – Roomi ooming ng In - 8 or more effective feeds feeds per 24 24 hours  Av  Averag erage e 140 minu mi nu tes or mo more re o f eff ect ectiv iv e removal 

Treatment of Engorgement  Addr  Ad dr ess EDEMA as n eeded

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- Re Rest, st, Ice, Compression, Compression, Elevation Elevation - Ca Cabbage bbage leaves( leaves( d/c d/c w hen successful) 

Continue breastfeeding and/or pumping

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Continue normal fluid intake & nutriti on

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Close Clos e (daily) (daily) follow- up!!!

Increasing Increa sing Milk Supply Remove milk more thor oughly Remove - Remove milk more frequently - No long periods periods ( > 5 hours) hours) without removal - Change/ad Change/add d removal methods  Discontinue hormonal medications  Check for thyroid, pregnancy  Encourage more mom/baby skin to skin  Collaborate with others ( MD, LC) 

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Implications for Practice Implications 

Establish Best Practice Policies ( WHO) and the 10 steps

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Breastfeed Early and Often

 Assess baby’s ability to get milk

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If baby can’t get milk, use something else

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Treat edema quickly and appropriately ------------ 5 day window ----------------------- Catch the Wave of Lactogenis is----is----------

Implications f or Practice, cont 

Help He lp mom lea learn rn to interpret baby’s cues

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Whateverr you do is ea Whateve easier sier wit h high supply

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Supply is the easier easier part to f ix - Don’t rely on baby unless unless suck is effective - Combine methods methods of removal: baby, massage & hand expression, pump - Drugs may help; help; consider side effects effects

Whatt Drives Milk Supply Wha Importance of the topic  How milk i s made in the Breast  Ongoing regulation regulation of mil k volume - The Theories ories on what does and and does not matter   Implication for clinical practice  Its still “ Supply and Demand” Demand”  “ Use it or Lose it” or  

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The mil k in you r breast wasn’t put th ere to stay More milk isn’t made until you give some away. away.

 An ato atomy my and Phy Physi siol olog og y o f Suck Su ck Mechanisms of Milk Transfer  Is Mom and Baby Connected?

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Prenatal Development Prenatal Developm ent of SS SSB B Swallow r eflex at 16 weeks  Breathing at 18-26 18-26 weeks 

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Infant swallows and breathes amniotic fluid

Suck develops at 28-36 weeks 

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Sucking releases gut hormones in presence of calories  Abl e to br breast east feed ear li er t han b ot tl e-feed (Meier, 1987)

Nyqvist KH, Sjö P-O, Ewald U. The development of preterm infants' breastfeeding behaviour. Early Hum Dev. 1999;55:247-264

Birt h: Transition to External Feeding Feeding 

Respect the baby’s oral cavity!

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Immediate & extended skin-to-skin

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Self-attachment Self-a ttachment w ithin 7-70 minutes

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Brain-wiring from multisensory input

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Bolus of IgA-rich colostrum primes the gut

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Oral muscles establis h SSB patterns patterns

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Colonization Coloniza tion wi th mother’s normal flora

 Any di sr up ti tion on s alter al ter or oral al r espo ns e and m or ore e

Suck-Swallow -Breathe (SSB) (SSB) Suck is a patterned respon se, not a reflex  Brea Breathing thing affects suck and swallow  Tongue & pharynx muscles coordinate coordina te suck suck - swallo swallow w - bre breathe athe  Ne Nerve rve function & blood f low affect muscles  Drugs & nutri tion affect nerves nerves & muscles 

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Gag respons es protect airw ay Gag 

Swallow Swa llow is still a reflex reflex • Ultrasound studies: Woolridge, Baum, Weber  Weber 

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 Ac ti ve deli d eli ver very y o f l iq ui uid d t o mou m ou th by feeder (breast (breast or device)  

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Mom’s milk ejection reflex (MER) is norm Flow rate of feeding feeding devices sh ould mimic brea breast st Too-fast Toofast or too-slow flow stresses baby

Breathing overrul es eating eating 

Maintain airway

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Suck components 

Negative oral pressure (suction) • Extends nipple into oral cavity • Draws milk into mouth dur ing MER

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Mechanical: tongue & jaw drop • Opens Opens oral space for mil k flow • Rises during swallowing • Function is precursor of speech development

Suck-swallow-breathe Suck-swallow-brea the triad Motor: CN V CN VII CN XII

sucking Sensory: CN VII

Sensory: CN IX Motor: C 1-3

Sensory: CN V

breathing swallowing

Motor: C 3-7 T 1-12

Sensory: CN X Motor: CN IX, CN X

c L Smith

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Suck-Swallow-Breathe 

 Air pat hw ay cr os ses with food pathway in pharynx

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Epiglottis and soft palate control access to air pathway

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Nerve & muscle function control epiglottis & pala palate te c L Smith

 Note flat septum  Note shape of palate

Soft palate Epiglottis

Advanced tip of tongue

Atlas picture demonstrating close relationship of epiglottis and soft palate and palate shape. (Rohen/Yokocki) c Dr B Palmer 

Anatomy of the throat of an adult cadaver. Eustachian tube

Soft palate

Posterior (back) 1/3 of tongue is the anterior (front) wall of oropharynx (throat)!

Epiglottis Tongue attached to mandible.

c Dr B Palmer  

Brian Palmer, DDS

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KEY COMPARISON  between the oropharynx of a newborn and an adult. CANNOT  compare OSA research between humans and other mammals! mammals!  Brian

Palmer, DDS

Dr Bri an Palmer  Palmer 

www.brianpalmerdds.co

60 Muscl es used in i n SSB 

Neck & jaw muscles stabilize bony structures

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Extrinsic muscles maintain airway patency

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Internal muscles coordinate SSB

 All are affected by mechanics, mechanics, drugs, nutrition, maturation, insults/injury

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Elements of Milk Transfer  Elements 

Mother: Milk Ejection Reflex (MER) (MER) “pu shes” 

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Volume consumed related to # of MER’s

Baby: Suction (negative pressure) draws nipple into a teat and draws milk forw ard during MER

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Milk flows faste fastest st / in large bolus 

During MERs

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When posterior tongue DROPS

Swallow occ urs w hen tongue RISES, RISES, compresses nipple & stops milk f low, and breath is held

Sucking at the breast is mo re than moving milk Fat level variations trigger satiation  Spray-cleans entire oral / nasal cavity  Release of gut hormones, insulin, oxytocin  Interrelated with breathing and swallowing  Nipple tip placement stimulates pituitary  Facial & dental structural development   Air way paten cy ; af fec ts sl eep pat ter terns ns  Eye-hand coordination and reading ability  Trust and autonomy 

 Al t ern ate Feedi Feed i ng Meth od s  Al l ar e “ in ter tervent vent io ns ”

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Identify the problem before picking a Identify device

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Know t he drawbacks/risks drawbacks/risks of device devices s

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Non-invasive devices: cups, spoons

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Invasive devices: teats (bottles), tubes

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No “ bes best” t” meth method od if BF isn’t possible

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Normalizing Infant Feeding 

Respect baby’s oral cavity!

 ABC Protocol

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 

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 Acc ess : Is th e baby in th e Restau ran t? Breastmilk transfer: Is the baby is actually eating? Comfort: Is the cook happy?

Close follow-up and referral to Mother Support Groups

Coach Coa ch Smit h’s Rules 

#1 - Fe Feed ed the baby. baby.

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#2 - The mother is right.

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#3 – It is her her baby.

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#4 - Nobody knows everything. everything.

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#5 – The There re is another way.

Summary Summa ry of sucking 

Bony structures affect oral function

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6 cranial nerves control SSB

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Complex muscle patterns

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Elements of milk transfer 

Milk flows w hen tongue drops

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Large boluses, mult iple MER’s MER’s

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tongue ris es to STOP STOP flow & allow b reath

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Making the Connection Positioning and Latch-on  As ses sessi sing ng a breast br eastfeed feed Special Spe cial si tuations

 As ses sess s t he Dy ad - Mot her   Ass ur ure e saf ety (including privacy)  Posture and comfort for mother 

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Semi-reclining or Semi-reclining reclining may help Limbs supported

Start w ith skin-to-skin Start Ventral-to-ventral (heart (hea rt t o heart) Baby leads; mother helps

c M Fjeld, Permission Permission granted

 As ses s th e Dyad - Bab y 

Skin-to-skin!

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Early feeding cues (don’t wait for cries!) 

hands to mouth, hand passing mouth

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Rooting, groping, mouthing, pecking

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Let the baby self-attach

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Maintain open airway 

Support head/ne head/neck ck – “ Ma Make ke a second neck”

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Lead with chest and chin (asymmetric)

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Latch “ technique Latch technique”” 

Breasts remain in natural position

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Facilitate baby self-attachment  

Mother guides baby gently May Ma y bob, squir m, throw self over 

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Comfortable for mother & baby

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“HOT” technique (keep your hands off!)

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NEVER FORCE BABY ONTO BREAST

Coaching Coa ching t ips for h elpe elpers rs Position your head lower than mother’s  Quietly observe an entire feed  Point out effective patterns to the mother   “Pretty good” is OK, unless painful  Pain tells you something is not quite right 

 

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If painful, break break suction quickly Try something differe different nt

Follow the baby’s pace

MOTHER’S HAND POSITION

c L Wright Wright

Mother’s hand does no t support the breast well and keeps the baby from latching deep

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MOTHER’S HAND POSITION

Mother’s hand position too close into the areola c L Wright Wright

Oralmot Ora lmot or: Inside the mouth 

Check for comfort – ask – ask mother! 

Lips flanged out (lower is often hidden)

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Chin touching or presse pressed d into brea breast st

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Wide gape (>120(>120-160 160°° angle of j aw)

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Full rounded cheeks

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Observe changes in suck rhythms

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Teach mom to follow baby’s pace

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Dr J Newman permission granted

Video clip : 2 day old baby nursing Mom has sore nipples

c L Wright

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c L Wright

c L Wright

Football Hold

The mother runs her nipple along the baby’s upper  (not lower) lip. The Baby will usually usually open wide if the mother waits. Wait for baby to REACH

Dr J Newman permission granted

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Signs o f Effectiv e Feeding Feeding 

Smooth suck-swallow-breathe rhythm

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Long sucking bursts 

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Slight pause & resumes pattern

40-60 cycles per minute 

Slows as milk i ncrea ncreases ses in fat

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Self-detachmentt in obvious satiation Self-detachmen

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Video clip: Baby 10 hours old

 Af t er t he f eed 

Mother’s breast(s) are softer  

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Usually Usua lly not “ emptie emptied” d”

Nipple intact and same shape 

no distor tion, pain, wounds, or damage

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Baby is satisfied & content

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Mother and baby are calm; often fall asleep

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Hold baby after for same duration as feed

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Pillows and aids 

Pillows support the mother, not the baby

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Deep attachment attachment is KEYKEY- It is called

breastfeeding, not nipple feeding  Creative positioning 

Baby’s jaw = most mil k drainage

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Use furnitur e and props as needed

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 App ly pr in ci pl ples es o f po si ti on in g

Semi-reclining may be better than sitting up

Special Spe cial situ ations 

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Mother unable to use one or both arms 

More pillows

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Slings, helpers, helpers, positioni ng

Baby immobile 

Bring mother to baby

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More pillows

Eliminate policies that separate the dyad

In Summary

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Baby Led

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Keep the dyad together 

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Help mother get comfortable Skin-to-skin for self-attachment

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Smooth, comfortable feeding for both

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Self-detachment with satiation

1. Milk Supply Supply – Mak aking ing Milk Milk It is the EASIEST and most reliable part of breastfeeding. "Not enough" is the primary reason for breastfeeding failure. Include what doesn't matter (mom’s diet or fluid f luid intake) and what really DOES matter: frequent and thorough milk removal. Spend more time thoroughly explaining the role of adequate milk transfer and milk removal from the breast to increase and maintain supply.

2. Comfort Pain is the second most common cause of breastfeeding failure. If there is pain something is not right. Investigate, assess then review comfortable latch/positioning. Give moms the information so they can learn how to nurse without pain.  Encourage mothers to get help quickly if breastfeeding is not comfortable right from the start. 

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Problems have solu tions If #1 and #2 are thoroughly understood, problems are rare. Just the IDEA that problems can be solved is enough at first. Provide detailed information on getting help.

c L Wright

If breastfeeding hurts or a mother is not making enough milk, it doesn't matter how wonderful her milk is Think differently: “increasing BF to 75%” means “reducing artificial feeding to 25%.”

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4/11/2012

Empowerment

If we teach the why more thoroughly the how's become become more workable. Spend most of your time on the HOW-TO part. Teach the most important skills early and repeat them at the end of your session.

Learned Art Breastfeeding is a learned physical skill requiring a little bit of instruction and a lot of practice. Therefore, DO IT A LOT. (i.e., You can't learn to play a piano by listening to music. If you want to make the swim team, you have to get wet. You don’t learn to ski by watching someone else)

c M Fjeld, Permiss Permission ion granted

Do we Value Value Human Milk ? Do we Value Value Skin t o Skin? Do we Value Famil Famil y Centered Care?

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4/11/2012

Promote, Protect and Support Together we can make Changes

Questions

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