advantages of BF for mom
- Helps control bleeding after delivery and uterine involution.
- Helps body return to pre-pregnancy state (more rapid pp weight loss)
- Reduces risk of diseases.
- Decreased risk of PMD when BF difficulties are appropriately addressed
- Baby will always have food in case of disaster.
Contraindications to BF
- HIV (maternal)
- Active TB (maternal) - not in treatment
- Herpes lesion(s) on breast (maternal)
- Cancer therapy (maternal)
- Diagnostic and therapeutic radioactive isotopes (maternal)
- Human T-cell leukemia virus type 1 (maternal)
- Galactosemia-classic- (infant can’t process galactose)
- Maternal substance use
non contraindications to BF
- Cytomegalovirus (CMV)
- Hepatitis A or C (maternal)
- Hepatitis B (maternal)
- Fever (maternal)
basic breast anatomy
fatty tissue, alveoli, lobules, ducts, montgomery glands
- Fatty tissue: fills the space around the ducts and lobules
- Alveoli: produce milk
- Lobules: contain many alveoli
- Ducts: carry breast milk to the nipple –> There are 15-25 lactiferous ducts
- Montgomery glands: small raised bumps on the areola that lubricate nearby tissue
stages of milk production
lactogenesis 1
Lactogenesis I – Secretory differentiation
- (2nd half of pregnancy to ~48-36 hrs PP):
- 1st stage of milk production,
- epithelial cells change into milk producing cells (lactocytes)
- production of colostrum begins around 16 weeks gestation
- By birth, colostrum is produced in small but suitable quantities (2-20ml/feed)
stages of milk production
lactogenesis 2
Lactogenesis II – secretory activation
- (48-72hhrs PP to 8 days):
- Triggered by drop in Progesterone & Estrogen levels after delivery of placenta.
- Prolactin levels rise (no longer inhibited by PIF, Progesterone & Estrogen) –> stimulates the alveoli to produce and secrete milk.
- Rapid increase in milk volume that then levels off –> Referred to as “milk coming in”
stages of milk production
Lactogenesis III or Galactopoesis
Lactogenesis III or Galactopoesis
- (~9 days PP ):
- Maintenance stage
- Shift from endocrine to autocrine control
- Supply driven by demand
- Milk production regulated by: FIL (Feedback Inhibitor of Lactation)
- Frequent milk removal is essential for lactation maintenance and adequate milk supply to meet the infant’s needs.
- Prolactin peak at night
stages of milk production
9 days onward
volumeof milk? how many feeds?
- First 2 weeks after birth is a time of rapid increase in milk volume, from drops of colostrum to appox. 750ml/24 hours.
- Can take up to 6 weeks to establish and stabilize milk supply
- 8-12 feeds/24 hours (until start of complementary solids at 6 months)
- On average every 2-4 hrs (huge variation in what’s normal) + cluster feeding
stages of milk supplu
(lactogensis) stage 4
Stage IV - Involution
- Gradual apoptosis of milk-producing cells in the mammary gland occurs when weaning begins.
- Cell death begins within 2 days.
- The mammary gland returns to a pre-pregnancy state.
- The breast returns to being influenced by hormonal changes of the menstrual cycle
- Usually a gradual process around 6 months (solid food)
- Involution occurs approx. 40 days after last breastfeed
- Cessation of milk secretion.
types of milk
colostrum and transitional milk
Colostrum
- Thick, small amount
- Helps build immune system and establish a healthy microbiome
- helps clear meconium which has a high concentration of bile (reduces risk of jaundice)
- Contains essential nutrients
Transitional Milk
- Milk volume gradually increases
- Concentration of fat, lactose and the amount of calories gradually increases
- Concentration of immunoglobulins gradually decreases
- Gradually transitions to mature milk
types of milk
mature milk and teaching implications
Mature Milk
- Always changing to meet infant/child’s needs
- Foremilk: Higher concentration of protein, lactose, and water
- Hindmilk: Higher concentration of fats- happens gradually throughout the feed
- Immunological benefits continue
Teaching implication:
- For baby to receive foremilk and hindmilk, encourage mothers to let baby drain first breast before offering
- the second breast then next feed start on the second breast so it gets both
horomones
prolactin
Prolactin
- Hormone that stimulates the mammary glands to produce milk
- Released from the anterior pituitary gland
- Inhibited during pregnancy by Progesterone, Estrogen and Prolactin-inhibiting factor (dopamine) (PIF)
- Levels rise with delivery of the placenta (P&E and PIF levels drop- Prolactin levels rise)
horomones
oxytocin
Oxytocin
- Hormone for milk ejection reflex
- Sends messages to the alveoli to release milk into ducts (milk ejection reflex {MER}
- Released from posterior pituitary during labour, BF, skin to skin, orgasm, when thinking about baby, etc.
- Sends messages to uterus to contract
- Decreases cortisol levels
Golden hour -> 9 stages of readiness to feed
if mom is seperated?
- Birth Cry
- Relaxation
- Awakening
- Active
- Resting
- Crawling
- Familiarization
- Suckling
- Sleeping
if mom seperared
- hand expression pumping to save ebm
baby led vs mother led BF
Baby led
- Hold baby skin to skin, tummy to tummy with you, with their head between your breasts.
- Support baby’s back and bottom.
- Allow baby to move towards the breast.
- Support the breast with one hand as needed, fingers away from the areola.
mother led
- Hold baby tummy to tummy, nose to nipple
- Use a sandwich hold and tickle baby’s upper lip with your nipple
- Bring baby towards the breast (not the breast towards baby)
- Continue to hold your breast in the sandwich hold until you feel baby suckling rhythmically.
signs of effective latching and milk transfer
good (deep) latch
- not painful.
- Most of the areola is in baby’s mouth, not just the nipple.
- Baby’s chin touches the breast, nose is free
- Nipple is round when released from baby’s mouth, not pinched.
Effective breast milk transfer
- Baby goes from quick, shallow sucks to slower deeper suckling pattern
- Cawing sound –> audible swallows
- Baby relaxes into feed
LATCH assessment
L (characteristics of latch-on)
A (degree of audible swallowing)
T (type of nipple)
C (maternal comfort)
H (holding skills)
Assessment with mother.
normal weight gain
- Day 4 onwards: gain of 20-35gr (~1oz)/day
- Discuss supplementation after 10% weight loss (careful- birth weight not always accurate- 24 hr weight is a better baseline)
supplmenentation
medical indications ?
EBM is usually first choice
Medical Indications include:
- 10% or more weight loss
- Inadequate weight gain
- Hypoglycemia
- Still passing meconium at day 3-4 (or no stooling in 24hrs+ during first week)
- Signs of dehydration or inadequate urine output
factors with negative impact on BF
- Induction of labour
- Labour interventions like epidural
Instrumental delivery (forceps and vacuum), Birth injury, C-section anc IV fluids (>1225 ml during labour associated with increased edema and BF difficulties, >7% wt loss - Separation
- Preterm or late preterm infant
- Maternal medical history ex. insulin-dependent diabetes, PCOS, BMI >30, breast surgery
pumping and EBM
How often to pump? amount of ebm at diff ages? storage?
- Pumping minimum 6X/day (or Q4hrs) ~ 15-20 minutes (until MER stops)
- Essential to pump at night (at least once at night) if aiming for full milk supply and to decrease risk of complications from milk stasis.
EBM
- 1 to 2 weeks: 60-90ml
- 2wks to 2 months: 60-150ml
- 2 to 4 months: 120-180ml
- 4 to 12 months: 150-240ml
Storage
- Room temperature: ideally 3-4 hrs, 4-8 hrs still considered safe
- Fridge: 3-8 days (healthy term baby)
- Freezer: 3-6 months
plugged/blocked duct
Plugged/blocked milk duct
- Swollen, tender lump
- Mother afebrile (if fever present, assess for Mastitis)
- Usually the result of inadequate emptying of breast
Management:
- Warm compress before BF and massage site during BF to encourage draining
- Frequent feeding
- Point baby’s chin to affected area.
- cold after BF
Mastitis
- Infection in the breast
- Localized breast pain and tenderness, area red and hot
- Infective: Sudden onset of flu-like symptoms (fever, chills, body aches, headache)
Management:
- Effective draining of breasts
- no extra draining (no extra pumping, this would worsen the issue)
- Cool compress after and in between feedings (No warm compres)
Antibiotics (if no improvement after 24 hours or high fever is one of symptoms)
legal rights to BF
- Parents have the protected legal right to breastfeed anywhere in public.
- In Canada, it is illegal to ask a breastfeeding parent to vacate a premises because they are breastfeeding their baby or to ask them to feed her baby in the bathroom.
- Parents can choose whether or not to use a covering.
- Many locations have a breastfeeding room/space if parents would prefer breastfeeding in private
