1. Lactation (and its troubles)
Ann Peery, RN, IBCLC
University of Virginia Health System

2. Endocrine Control of Lactation
Growth and proliferation of the ductal tree during the first half of pregnancy
Secretory activity resulting in colostrum production/collection in alveoli
Also referred to as Stage 1 or lactogenesis 1
Accounts for ability to provide milk at 16 wks even if pregnancy does not progress

3. Endocrine Control of Lactation
Stage 2 or lactogenesis 2 refers to onset of copious milk secretion 36 to 96 hours following birth
Progesterone/estrogen levels fall without placenta, prolactin now dominant
Milk matures as protein and salts decrease, fats and sugars increase

4. Autocrine Control of Lactation
Whenever the pathway between the hypothalamus and the pituitary is disrupted, prolactin levels rise
Nipple stimulation and removal of milk causes hypothalamus to inhibit dopamine
Low level dopamine stimulates prolactin release

5. Autocrine Control of Lactation
Prolactin levels rise and fall in proportion to the frequency, intensity and duration of nipple stimulation and milk removal
Prolactin levels fall about 50% in first week in breastfeeding women
Prolactin levels reach nonpregnant levels in 7 days in non-breastfeeding women

6. Prolactin Levels
Decline slowly over the course of lactation but remain elevated for as long as mother bf
Associated with frequency – more bf, higher levels of serum prolactin
Higher in amenorrheic than cycling women during first year postpartum
Not related to degree of pp engorgement

7. Prolactin Levels
Mothers who smoke have lower prolactin levels than non-smoking mothers
Mothers who drink beer have higher prolactin levels
Multiparous women have lower prolactin levels than primiparous …. prolactin receptor theory

8. Breastfeeding Basics
Breastfeed every 2-3 hours for a total of feedings in 24 hours at least through the first week pp – not ad lib on demand
Latch-on must cover the milk sinuses with the gums – not the lips
Positioning must insure adequate latch-on for entire feeding

9. Problems Observed Poor response from baby
Difficult breast anatomy or mouth anatomy
Sub-optimal breastfeeding management
Absent root reflex and suck – mucous or blood in the stomach, IV narcotics
Tongue thrusting or gagging – protective behaviors that follow oral suctioning **
Stiff or inelastic areola, nipples with tight adhesions that “turtle” when areola compressed
Tight frenulum, tongue sucking, prominent alveolar ridge
Supplements introduced

10. Clinical Presentation
Nipple pain or trauma
Breast pain
Infant weight loss >10% from BW
Failure to regain to BW at 2 wks age
Neonatal hyperbilirubinemia
Mother typically interprets nipple pain as a baby problem since they are the cause
Observe during nursing for latch on and positioning yields valuable information
Cracked nipples, creases and other nipple injury can reveal how the woman is nursing
Looking at technique allows for intervention at a primary level and prevent recurrent problems.

11. Problem Solving and Tools
Breast shells
Nipple shields
Breast pumps

12. Inflammatory Breast Pain
Engorgement – bilateral, congestion due to increased vascularity, edema and milk
Plugged ducts – unilateral, localized area of tenderness, can be a lump or wedge
Mastitis – unilateral, segmental induration, erythema, tenderness, high fever, shaking chills

13. Engorgement Prevention by maintaining adequate drainage of breast
Ice packs, frozen food, cabbage leaves
Warm compress or shower
Massage with open palm prior to nursing or pumping

14. Plugged Ducts
Prevention by maintaining adequate drainage of the breast
Soak breast in dependent position – lean breast into bowl of warm water
Direct massage with open palm from periphery to nipple
Nurse with infant chin to affected site
Use massage each feeding 2 days post relief

15. Mastitis 1- 6 % of lactating mothers
Only ¼ of these women have concurrent nipple trauma
Maternal condition / host resistance most likely risk factors

16. Mastitis
Vast majority of breast infections caused by staphylococcal or streptococcal species. E. coli, Klebsiella or anaerobes are rare causes of mastitis
Dicloxacillin, erythromycin or clindamycin should be used for 14 days
Bed rest, fluids, acetaminophen, freq nursing

17. Thomsen et al., 1984
Non-infectious inflammation of breast (leukocytes and bacteria = 106 or less)
No treatment, but continue frequent breast emptying = 23/24 returned to normal
No treatment, but poor breast emptying = 5/24 returned to normal and most progressing to infectious mastitis(leukocytes and bacteria >106 )

18. Thomsen et al., 1984
Adequate breast drainage and dicloxacillin 53/55 returned to normal lactation
No treatment resulted in 10% progressing to abscess formation
Recurrence rate for mastitis is 10% and is likely due to noncompliance with day regimen or poor drainage of breast

19. Treatment for Breast Abscess
Supportive measure for acute bacterial mastitis
Confirm fluctuance with US or aspiration
Peripheral/radial incision
IV antibiotics – Vancomycin or Nafcillin
Continue nursing or pumping both breasts

20. Candida Mastitis
Sharp burning pain not necessarily associated with nursing, “red hot poker”, “piece of glass in the breast”
Nipple reddening, fine wet ulcers, pruritis
Oral thrush, diaper rash
Recent antibiotics, vaginal candidiasis

21. Early Candidiasis
Superficial skin infection – peeling, pink/red shiny skin, sunburn type itching
Nystatin cream or ointment to nipples after each feeding
Oral nystatin swabbing of infant mouth pc
Treat at least 7 days
Reduce re-exposure in environment

22. Early Candidiasis
2% ketoconazole, miconazole nitrate, and clotrimazole can be used on nipples if nystatin fails
Gentian violet can be used on nipples and mouth concurrently with other antifungals
0.5% or 1% solution once a day for no more than 3 days

23. Ductal Yeast Intense burning pain Loading dose 200mg fluconazole
Maintenance dose 100mg/d for two weeks following cessation of symptoms
Infant may need own fluconazole treatment since load in breast milk is sub therapeutic