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Updated: Nov 29 2021

Lactation and Breastfeeding

  • Snapshot
    • A 28-year-old G1P1 woman presents to her primary care physician with evaluation of low supply of breast milk. She is a first time mother and had previously been evaluated by a lactation consultant. Her 8-week-old baby had been feeding and gaining weight well until the past 2 weeks, when the mother observed less wet diapers and a decreased volume of milk that she was able to pump. The woman notes that she had a normal course of pregnancy with no complications and had an unremarkable labor and delivery. Her breast examination in the clinic today is normal.
  • Introduction
    • Overview
      • breastfeeding is recommended for newborn infants as breast milk provides the ideal nutrition for the baby to grow and has benefits for both the baby and the mother
    • Physiology
      • lactogenesis begins in late pregnancy
      • copious milk secretion begins around day 2-3 after birth
        • endocrine control switches to autocrine (supply-demand) control
          • mammary gland receives hormonal signals, which ↑ in direct response to stimulation of the nipple and areola (through the infant's suckling)
            • lactation occurs with help of 2 hormones - prolactin and oxytocin
              • prolactin is secreted by the anterior pituitary
                • decreased GnRH release can lead to amenorrhea
              • oxytocin is secreted by the posterior pituitary
        • milk production is associated with maternal well-being
          • ↑ levels of dopamine and norepinephrine inhibit prolactin synthesis
            • stress and fatigue may ↓ a woman's milk supply
      • galactopoiesis occurs after 9 days after birth, maintaining milk secretion
      • involution occurs around 40 days after last breastfeeding
        • milk secretion ↓ with the buildup of inhibiting peptides
    • Contraindications
      • Active, untreated tuberculosis
      • Active varicella infection within 5 days before delivery or 2 days after delivery
      • Untreated brucellosis
      • Maternal infection with HIV or Ebola
      • Herpetic lesions of the bresat
      • Active abuse of illicit drugs including PCP and cocaine
        • Methadone use as part of a supervised clinic is not a contraindication
      • Infants with classic galactosemia
  • Epidemiology
    • Incidence
      • among infants born in the US in 2015, over 80% of babies started out breastfeeding
  • Complications
    • Inadequate milk intake
      • possible contributing factors
        • inadequate maternal milk production
          • previous maternal breast surgery
          • maternal medications that interfere with establishment of milk supply
            • oxytocin
            • selective serotonin reuptake inhibitors
            • dopamine agonists (i.e., bromocriptine)
            • estrogen-containing oral contraceptives
        • poor infant milk extraction
          • oral-motor, neurologic, abnormalities, or anatomic abnormalities (i.e., cleft palate)
          • feeding difficulties due to prematurity
    • Breast milk jaundice
      • persistence of benign neonatal hyperbilirubinemia beyond the first 2-3 weeks of age
    • Lactation failure jaundice
      • lactation failure leads to ↓ neonatal fluid and calorie intake, leading to hypovolemia and weight loss, which then results in hyperbilirubinemia and jaundice
        • late preterm infants (gestational age between 34-36 weeks) have ↑ risk of difficulty establishing successful breastfeeding compared to term infants
    • Nipple and breast pain
      • possible contributing factors
        • nipple injury due to inadequate infant latch-on
        • nipple vasoconstriction
          • cutaneous vasospasm may occur in mothers with Raynaud phenomenon or cold sensitivity
        • engorgement
        • plugged ducts
          • due to localized areas of milk stasis within the ducts that cause distention of mammary tissue
        • nipple and breast infections
          • lactational mastitis
            • presents with fever and a firm, red, and tender area of one breast
          • breast abscess
            • often preceded by mastitis
            • presentation similar to mastitis, with an additional tender and palpable mass
        • excessive milk supply
          • may be caused by drugs that ↑ milk production (i.e., dopamine antagonists and certain herbs, such as fenugreek)
        • nipple or areolar dermatitis
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