4/11/2012

1
Anatomy and Physiology
of
Lactation
Linda Wright RN, BSN, IBCLC
Objectives
To better understand how anatomy and
physiology may impact the outcomes of
breastfeeding
To increase and update breastfeeding
knowledge and skills
To outline the importance of early skin to
skin and early establishment of milk
supply.
Key Message: Making Milk is Easy
Moms body is built for lactation
- Efficient nutrient utilization
- Diet, fluid intake only minimally important
- Stress only minimally important
Most women only use 2/3 of capacity!
Baby takes about 2/3 of milk available
Most who can gestate can lactate
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Then why the Failures ?
Scheduled Feeds !!!
Marketing of substitutes to mothers milk
Lactation poorly researched in mothers
Assumed failure was attitude of mom
Assumed all babies could suck well
Inadequate education for health
professionals
Myths and tales abound
Causes of Breastfeeding Failure
Insufficient Milk Supply (not enough)
- Real or imagined
- Documented through history
Pain
- Breast or Nipple
Disapproval or social ostracism
- Blaming Breastfeeding for normal
inconveniences
General Agreement on Supply
Supply is related to infant demand /
appetite ( Dewey, Neifert, Hartmann)
Early and frequent feedings establish
supply
Engorgement and unrelieved milk stasis will
reduce supply
Importance of the issue
#1 Cause of BF Failure is not enough milk
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Disagreement is on the
Mechanism(s)
How important is the Let - down reflex?
Role of Prolactin
Is mothers diet and fluid intake important?
What role does the baby play?
Does Supply and Demand still apply?
Do theories concur with moms
experiences?
Lactation is the physiologic completion of
the reproductive cycle
Dr. Ruth Lawrence
Mammogenesis the development
of the mammary gland
(building the Factory )
Embryo to Puberty rudiments of ducts
Puberty to Pregnancy duct framework
Pregnancy Lactogenisis 1
Secretory cells
-placental lactogen, prolactin, estrogen,
progesteron develop the cells
- cell growth continues 4-6 postbirth or longer
- maternal nutrition no effect on cell growth
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Breast Size Changes
Pre pregnancy: fatty tissue supports
Pregnancy: glandular tissue grows
Growth patterns in pregnancy vary
Storage capacity varies
- Average 196g; may increase with demand
- Size NOT related to overall milk
production capacity; may affect patterns of
feeding
Lactogenisis 1 Production starts: The
initial synthesis of milk components begins
in 2
nd
trimester of pregnancy
Lactogenesis II Full Production - the
onset of copious milk production 2-3 days
postpartum.
- Trigger: delivery of the placenta - a rapid
drop of serum progesterone (removes the
brakes on Prolactin)
Prolactin
Essential for initiating and maintaining
milk production
Plasma prolactin levels increase the most
in the immediate postpartum however rise
and fall in proportion to frequency,
intensity and duration of nipple stimulation
Concentration in the blood doubles in
response to suckling and peaks approx 45
mins after the beginning of a feeding
session
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Prolactin - Endocrine
Oxytocin
In response to baby suckling, the
posterior pituitary releases oxytocin
triggering the milk ejection reflex (MER)
or letdown
Released in pulse like waves
Women may feel areolar pressure,
tingling, and/or a warm sensation
during a milk ejection
May experience several let downs
during a feed
LET DOWN REFLEX
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Summary of milk production
Endocrine ( Hormonal driven): drives
cell proliferation during pregnancy and
early postpartum
Autocrine (Baby Driven): retained milk
in alveoli closely regulates the rate of
synthesis hour by hour at the lobular
level.
Physical pressure from retained milk
affects secretory function
Breast Structure
Overlies ribs & pectoral muscles
Skin, Coopers ligaments support
Duct Framework
Nipple-areola complex
Blood and lymph supply
Nerve pathways
Fat and glandular tissue
Breast structure
(Old concept)
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Ultrasound (New)
Lactiferous Duct
Ultrasound
(new)
Lactiferous
Duct
Ramsay D et al. Anatomy of the lactating human
breast redefined with ultrasound imaging. J.
Anatomy 2005; 206: 525534
9 lobes & openings (range 4-16)
Ducts 2 mm; dilate with MER
Easily compressed
Near the skin surface
Begin branching under areola
2/3 glandular tissue under areola & nipple
No sinuses
Fat interspersed throughout breast
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The Breast mammary gland
-a conglomeration
of independent glands
The breast (continued)
Mature breast weighs 150 - 250 g
During Lactation weighs 400 500 g
Size of breast not indicative of ability to
lactate
Highly vascular
Areola circular pigmented area
Usually pink or light brown before
pregnancy
Turns reddish brown or darkens during
pregnancy
Enlarges during pregnancy ( - 2)
Darker coloration important as a visual
guide for baby to find and grasp the nipple
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Montgomerys Tubercles/Glands
Located on the areola ductular openings
of sebaceous and lactiferous glands
Become enlarged during pregnancy and
lactation
Lubricates and protects the nipple and
areola
Antimicrobial and acid ph
Nipple
conic elevation in the center of the areola
Openings in the nipple vary in number - 9
Condensation of epithelial cells
Protractility important help 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 fascia between
the 2nd and 6th intercostal cartilage
- superficial to the pectoralis major muscle
- Breast if fixed by fibrous bans called
Coopers Ligaments (super sensory)
- Supported by muscles attached to ribs,
collar bone, and bones of upper arm
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Lymph Supply
Extensive Main drainage to axillary
nodes and to paracostal nodes in the
thoracic cavity
Lymph nodes filter and destroy invading
bacteria and are the production site of
lymphocytes and antibodies
Lymph Drainage of the Breast
Nerve Supply
Nerves of the breast are from the 2
nd
to 6
th
intercostal nerves
Sensory innervation of the nipple and
areola is extensive ( to the surface)
4
th
intercostal supplies the greatest
amount of sensation to nipple
Sensitive Responsiveness to 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
Highly vascular
Blood supply to the nipple extensive
Mammary Gland
Milk is produced in the 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 cross-section view of the
alveolus
Lobule
10 100 alveoli
comprise a lobule
20 40 lobules form
a 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 milk removal
that governs breast milk synthesis.
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Summary of Milk Production
What doesnt matter ( re milk volume)
- Mothers food quality or quantity
- Mothers fluid intake
- Mothers 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 the baby)
Hand
Expression
c L Wright
If all goes Well
Baby takes most of the milk produced
Cells gear up to full production over 5 days
Babys stomach grows along with supply
Stooling and urination well established
Frequent contact good for both
- Prolactin continues building factory
- Oxytocin contracts uterus and more
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Risk Factors for Low Milk Supply
Genetic
Environmental
Physical damage prior to first pregnancy
- surgery, accidents, burns to chest
- chemical (chemotherapy)
Pituitary infarct (Sheehans syndrome)
Hormone exposure and therapy
MILK STASIS Prolonged engorgement
Risk Factors, continued
Birth Related Risks
Agents that may Reduce supply
Behavioral Factors:
- Scheduled Feeds! Length & frequency
- Supplements or bottles used
- Nipple shield use
- Pacifier use
- Nipple pain or damage (esp early onset)
- separation of mom and baby
Common False Alarms
Baby fussy in the evening
Baby feeds frequently
2-3 days of increased feedings
Baby will take a bottle after
No leaking or dripping of milk
Not much obtained with pumping
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Low Milk Supply Real Signs
Baby pulls off, cries, fights breast
- immediate hunger after feedings
- Few or no swallow heard
- Few or no stools daily in the first month
Gain of less than - 1 oz per day
Very long feedings ( >30 min)
Baby consistently unhappy, fretful, worried
or withdrawn and sleepy
Engorgement is an emergency
Changes at birth
Suddenly theres more milk
Supply gets ahead of the baby
Areolar
Compression
c L Wright
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What goes Wrong?
Events transpire to leave milk in breast
Milk stasis blocks rising milk synthesis
Edema happens
- Extracellular fluid congests lymph and
blood vessels
- Blocks ductal system
- Causes or exacerbates milk stasis
Fewer Prolactin Surges
Baby not at breast =fewer prolactin
surges
Which reduces lactose syntheseis
Which reduces osmosis of water into cell
Result: fluid stays in extracellular space
WHICH MAKES EDEMA WORSE
Fewer Oxytocin Bursts
Baby not at breast =fewer oxytocin bursts
Reduced smooth muscle contraction
Which reduces lymph contraction
Which reduces lymph drainage
Leaving excess fluid in extracellular space
WHICH MAKES EDEMA WORSE
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Prevention of Engorgement
Prevent Edema
- Normal hydration during labor
- Good nutrition for mothers sake
Establish good milk flow/removal ASAP
- Skin to Skin early, offer breast early
- Combined Care Rooming In
- 8 or more effective feeds per 24 hours
Average 140 minutes or more of effective
removal
Treatment of Engorgement
Address EDEMA as needed
- Rest, Ice, Compression, Elevation
- Cabbage leaves( d/c when successful)
Continue breastfeeding and/or
pumping
Continue normal fluid intake & nutrition
Close (daily) follow- up!!!
Increasing Milk Supply
Remove milk more thoroughly
- Remove milk more frequently
- No long periods ( >5 hours) without
removal
- Change/add 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
Establish Best Practice Policies ( WHO)
and the 10 steps
Breastfeed Early and Often
Assess babys ability to get milk
If baby cant get milk, use something else
Treat edema quickly and appropriately
------- 5 day window-------
------- Catch the Wave of Lactogenisis--------
Implications for Practice, cont
Help mom learn to interpret babys cues
Whatever you do is easier with high
supply
Supply is the easier part to fix
- Dont rely on baby unless suck is
effective
- Combine methods of removal: baby,
massage & hand expression, pump
- Drugs may help; consider side effects
What Drives Milk Supply
Importance of the topic
How milk is made in the Breast
Ongoing regulation of milk volume
- Theories on what does and does not
matter
Implication for clinical practice
Its still Supply and Demand
Use it or Lose it or
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The milk in your breast
wasnt put there to stay
More milk isnt made
until you give some away.
Anatomy and Physiology of Suck
Mechanisms of Milk Transfer
Is Mom and Baby Connected?
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Prenatal Development of SSB
Swallow reflex at 16 weeks
Breathing at 18-26 weeks
Infant swallows and breathes amniotic
fluid
Suck develops at 28-36 weeks
Sucking releases gut hormones in
presence of calories
Able to breastfeed earlier than bottle-feed
(Meier, 1987)
Nyqvist KH, Sj P-O, Ewald U. The development of preterminfants'
breastfeeding behaviour. Early HumDev. 1999;55:247-264
Birth: Transition to External Feeding
Respect the babys oral cavity!
Immediate & extended skin-to-skin
Self-attachment within 7-70 minutes
Brain-wiring from multisensory input
Bolus of IgA-rich colostrum primes the gut
Oral muscles establish SSB patterns
Colonization with mothers normal flora
Any disruptions alter oral response and more
Suck-Swallow-Breathe (SSB)
Suck is a patterned response, not a
reflex
Breathing affects suck and swallow
Tongue & pharynx muscles
coordinate suck - swallow - breathe
Nerve function & blood flow affect
muscles
Drugs & nutrition affect nerves &
muscles
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Gag responses protect airway
Swallow is still a reflex
Ultrasound studies: Woolridge, Baum, Weber
Active delivery of liquid to mouth by
feeder (breast or device)
Moms milk ejection reflex (MER) is norm
Flow rate of feeding devices should
mimic breast
Too-fast or too-slow flow stresses baby
Breathing overrules eating
Maintain airway
Suck components
Negative oral pressure (suction)
Extends nipple into oral cavity
Draws milk into mouth during MER
Mechanical: tongue & jaw drop
Opens oral space for milk flow
Rises during swallowing
Function is precursor of speech
development
Suck-swallow-breathe triad
sucking
swallowing
breathing
Sensory: CN VII
Motor: C 3-7
T 1-12
Motor:
CN V
CN VII
CN XII
Sensory:
CN IX
Motor: C
1-3
Sensory: CN V
Sensory: CN X
Motor: CN IX, CN X c L Smith
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Suck-Swallow-Breathe
Air pathway crosses
with food pathway in
pharynx
Epiglottis and soft
palate control access
to air pathway
Nerve & muscle
function control
epiglottis & palate
c L Smith
Atlas picture demonstrating close relationship of epiglottis
and soft palate and palate shape. (Rohen/Yokocki)
Soft palate
Epiglottis
Noteshape
of palate
Advanced tip
of tongue
Noteflat
septum
c Dr B Palmer
Anatomy of the
throat of an adult
cadaver.
Epiglottis
Posterior (back) 1/3 of tongueis the
anterior (front) wall of oropharynx (throat)!
Soft palate
Eustachian tube
Tongueattached to mandible.
BrianPalmer, DDS
c Dr B Palmer
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KEY COMPARISON
between the oropharynx of a
newborn and an adult.
BrianPalmer, DDS
CANNOT compare OSA
research between humans and
other mammals!
www.brianpalmerdds.co
Dr Brian Palmer
60 Muscles used in SSB
Neck & jaw muscles stabilize bony
structures
Extrinsic muscles maintain airway patency
Internal muscles coordinate SSB
All are affected by mechanics, drugs,
nutrition, maturation, insults/injury
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Elements of Milk Transfer
Mother: Milk Ejection Reflex (MER) pushes
Volume consumed related to # of MERs
Baby: Suction (negative pressure) draws
nipple into a teat and draws milk forward
during MER
Milk flows fastest / in large bolus
During MERs
When posterior tongue DROPS
Swallow occurs when tongue RISES,
compresses nipple & stops milk flow, and
breath is held
Sucking at the breast is more
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
Airway patency; affects sleep patterns
Eye-hand coordination and reading ability
Trust and autonomy
Alternate Feeding Methods
All are interventions
Identify the problem before picking a
device
Know the drawbacks/risks of devices
Non-invasive devices: cups, spoons
Invasive devices: teats (bottles), tubes
No best method if BF isnt possible
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Normalizing Infant Feeding
Respect babys oral cavity!
ABC Protocol
Access: Is the baby in the Restaurant?
Breastmilk transfer: Is the baby is actually
eating?
Comfort: Is the cook happy?
Close follow-up and referral to Mother
Support Groups
Coach Smiths Rules
#1 - Feed the baby.
#2 - The mother is right.
#3 It is her baby.
#4 - Nobody knows everything.
#5 There is another way.
Summary of sucking
Bony structures affect oral function
6 cranial nerves control SSB
Complex muscle patterns
Elements of milk transfer
Milk flows when tongue drops
Large boluses, multiple MERs
tongue rises to STOP flow & allow breath
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Making the
Connection
Positioning and Latch-on
Assessing a breastfeed
Special situations
Assess the Dyad - Mother
Assure safety
(including privacy)
Posture and comfort
for mother
Semi-reclining or
reclining may help
Limbs supported
Start with skin-to-skin
Ventral-to-ventral
(heart to heart)
Baby leads; mother
helps
c M Fjeld, Permission granted
Assess the Dyad - Baby
Skin-to-skin!
Early feeding cues (dont wait for cries!)
hands to mouth, hand passing mouth
Rooting, groping, mouthing, pecking
Let the baby self-attach
Maintain open airway
Support head/neck Make a second neck
Lead with chest and chin (asymmetric)
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Latch technique
Breasts remain in natural position
Facilitate baby self-attachment
Mother guides baby gently
May bob, squirm, throw self over
Comfortable for mother & baby
HOT technique (keep your hands off!)
NEVER FORCE BABY ONTO BREAST
Coaching tips for helpers
Position your head lower than mothers
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
If painful, break suction quickly
Try something different
Follow the babys pace
MOTHERS HAND POSITION
Mothers
hand
does not
support
the breast
well and
keeps the
baby from
latching
deep
c L Wright
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MOTHERS HAND POSITION
Mothers
hand
position
too close
into the
areola
c L Wright
Oralmotor: Inside the mouth
Check for comfort ask mother!
Lips flanged out (lower is often
hidden)
Chin touching or pressed into breast
Wide gape (>120-160 angle of jaw)
Full rounded cheeks
Observe changes in suck rhythms
Teach mom to follow babys 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
Football Hold
c L Wright
The mother runs her nipple along the babys upper
(not lower) lip. The Baby will usually open wide
if the mother waits. Wait for baby to REACH
Dr J Newman permission granted
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Signs of Effective Feeding
Smooth suck-swallow-breathe rhythm
Long sucking bursts
Slight pause & resumes pattern
40-60 cycles per minute
Slows as milk increases in fat
Self-detachment in obvious satiation
Video clip: Baby 10 hours old
After the feed
Mothers breast(s) are softer
Usually not emptied
Nipple intact and same shape
no distortion, pain, wounds, or damage
Baby is satisfied & content
Mother and baby are calm; often fall
asleep
Hold baby after for same duration as feed
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Pillows and aids
Pillows support the mother, not the baby
Deep attachment is KEY- It is called
breastfeeding, not nipple feeding
Creative positioning
Babys jaw = most milk drainage
Use furniture and props as needed
Apply principles of positioning
Semi-reclining may be better than sitting up
Special situations
Mother unable to use one or both arms
More pillows
Slings, helpers, positioning
Baby immobile
Bring mother to baby
More pillows
Eliminate policies that separate the dyad
In Summary
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Baby Led
Keep the dyad together
Help mother get comfortable
Skin-to-skin for self-attachment
Smooth, comfortable feeding for both
Self-detachment with satiation
1. Milk Supply Making 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 (moms diet or fluid
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 solutions
If #1 and #2 are thoroughly understood,
problems are rare.
J ust 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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Empowerment
If we teach the why more thoroughly the
how's 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 dont learn to ski by
watching someone else)
Do we Value Human Milk?
Do we Value Skin to Skin?
Do we Value Family Centered Care?
c M Fjeld, Permission granted
4/11/2012
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Promote, Protect and Support
Together we can make Changes
Questions