Lactation Breast

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Lactation Breast Powered By Docstoc
					Breast Is Best!

         Stephanie Calkins, MD
               MDFPR
            March 24, 2008
      Breast Is Best

   Why Breastfeed?
   Lactation Anatomy and Physiology
   What the Provider Needs to Know
   Problem Solving in the Lactating
    Patient
Why Breastfeed?
   Advantages for the newborn
   Advantages for the mother
   Advantages to society and family
Advantages for the
Newborn
   Natural
   Baby’s body systems developed to
    expect
   Intelligence and cognitive development
   Enhanced neurodevelopmental
    performance
   Effectiveness of vaccines
   Normal development of jaw and facial
    muscles
Lower Incidence:
       Allergies and          IBD
        asthma                 Iron deficiency
       Bacteremia,             anemia
        meningitis             Respiratory
       Botulism                infections 66%
       Lymphoma 30%           Nectrotizing
       Constipation            enterocolitis
       Diabetes               OM 50%
       GI infections 45%      SIDS
       Eczema                 UTI
                 Advantages for the
                 Mother
   Convenience
   Cost savings
   Breastfeeding “breaks”;
    calming effect
   Emotional, Bonding
   Decreased breast CA,
    uterine CA, ovarian CA,
    osteoporosis
   Weight Loss (500 cal/day)
   Lower postpartum anemia
   Aid in child spacing
Advantages to society and family
   Economic savings: Formula $1,500 for first year
     Savings   in environmental burden
   Reduced employee absenteeism for child illnesses
   Reduced health care costs from fewer
    physician/hospital visits
     $3.6   billion saving for annual U.S. health care
                    Anatomy   Alveolus: Production unit of
                              lactocytes transporting
                              nutrients from maternal
                              blood



                                 Terminal duct lobular units:
                                     Branching ductules and
15-25 lactiferous                    alveolar clusters
ducts openings at
nipple




                              Ducts
  Subareolar Sinuses             Lines by myoepithelial
                                 cells that contract with
                                 oxytocin induced let-
                                 down
Anatomy
    Areola
       Hair, sebaceous,sweat glands
       Montgomery tubercles
           ductular opening of lactiferous ducts and
            sebaceous glands
           secretes lubricants/scent protecting
            areola/nipple
       Dark color ?visual signal
    Nipple
       15-25 ducts
       dermis rich w/ sensory nerve endings
       radial/longitudinally placed smooth muscle
        fibers
    Mammogenesis in
    Pregnancy
   Pregnancy
      1st Trimester:
             Progesterone, placental lactogen, and prolactin
             increase ductal sprouting,branching lobular
             formation.


       2nd Trimester:
            Placental lactogen stimulate colostrum secretion
             @ 16 wks
            Estradiol-17B stimulate ductal elongation,
             potentiates prolactin


       3rd Trimester:
            Alveolar distension w/ early colostrum with
             differentiation into secreting alveoli
            Decreasing adipose and increasing breast
             parenchyma.
    Lactation
   Establishment and Maintenance of
    Mature milk requires intact
    Hypothalamic-pituitary axis regulating
    Prolactin and oxytocin.

       Prolactin: milk synth/secretion
          Milk always synthesized
          concentration not directly related to milk
           volume

       Oxytocin: Let-down reflex
        Prolactin
   Continuous secretion with surges 7-20 times
    daily
     Results in continuous milk production with
      surges
     Related directly to nipple stimulus
           to intensity of nipple stimulation (i.e. twins)
     Prolactin surge within 40 minutes of stimulus
     Circadian surges

   Milk volume ENTIRELY regulated by infant
    demand
   A “stretched” alveolar cell released prolactin
    INHIBITING factor
Prolactin Surges
             Prolactin Stimulators
 Breast stimulate/nursing
 Sleep,circadian rhythm
 pregnancy
 intercourse
 neuroleptic drugs
 histamine
 Acetacholine
 Fenugreek
 TRH/TSH Norepi/Serotonin
 Metoclopramide, domperidone **
 estrogens: during mammogenesis only
 hypoglycemia
 phenothiazines,butyrophenones,
  reserpine
      via inhibit catecholamines thereby inhib PIF
Prolactin suppressors
   L-Dopa
   Ergot
    @   hypothalamus
   clomiphene citrate
   pyridoxine
   MOAI’s
   Prostaglandin E& F2 alpha
   Estrogens
     antag   via inhib milk secretion
          Oxytocin
   Contraction of myoepithelial cells around the
    alveoli, expelling milk into ducts and subareolar
    sinuses
   Neuroendocrine reflex:
       Sensory stimulation to CNS promotes oxytocin
        release from post. Pituitary
   Stimulates maternal behavior
       ?oxytocin improves bonding
   Accompanied decreased pulses in ACTH and
    cortisol (decresses maternal stress)
       ?oxytocin decreases PP depression
   Uterine contractions
Oxytocin Inhibitors
    Sensory pathways
    Stress: pain, cold,
     hypovolemia,exercise
    Opioids
    Alcohol
      dose    related effect on CNS
         No   inhib up to 0.45g/kg (BAL 0.1%)
Got
Milk?
Colostrum: small amount,
but close to stomach capacity
   Antibodies!!!
   Immune-competent white cells
   Ployunsaturated fatty acids
   Vitamin K
   Very high protein
   Natural laxative
Milk Composition
   88% water
   4.5% fat
      Makes up ½ calories in breastmilk
      Cholesterol is optimal for brain development
   Macronutrients:
      Lactose (principal sugar)
      Milk fat (triglycerides)
      Proteins: cystine, taurine (brain
       development), casein
             LOW casein versus cow milk
        100 amino acids, vitamins, minerals
             Iron: supplement at 4-6 months age
             Consider vitamin D (MVI)
Milk Comparison
        Protective Factors
   Antibodies (secretory IgA)
   Glycoconjugates (glycoproteins,
    glycolipids, glycosaminoglycans,
    oligosaccharides)
     Protect   against several bacteria, esp GI
      bugs
   Lipids (monoglycerides and unsaturated
    fatty acids)
     Enveloped    viruses
   Intestinal microflora
     Probiotics
Anti-Inflammatory
Factors
   Antioxidants
   Lactoferrin
   Catalase
   Prostaglandins
   Histaminase
   Aryl Sulfates
   Tumor Necrosis Factor alpha
   IL-1 receptor antagonist
   IL-10
More About Breastmilk
   Foremilk
     1/3of the feeding
     Starts high fat, ends up low fat

   Hindmilk
     Higher   in fat
   Volume milk produced:
     At6 months: 800 mL/d
     Wet nurses: 3.5 L/d
What The Provider
Needs to Know

         Prenatal
         Birth
         Hospital Discharge
         First 2 Weeks
         Well Child Checks
Prenatal
   Discuss at first appointment!
   Breast changes in pregnancy
   Evaluate for problems of nipple
    and breast
   Colostrum
   Breastfeeding class
   The working mom
Potential Contraindications
           HIV, human T-cell leukemia, HSV
            lesions
           Maternal drug abuse
           Medications: antineoplastic,
            anticonvulsants, ergot alkaloids,
            amiodarone, lithium
           Galactosemia (Absolute)
                   Birth
   Include breastfeeding in birth plan
   Immediate/early skin contact
   Position and correct latch on in first hour
               Hospital Discharge
   Encourage patient to
    commit to 2 weeks
   Supply and demand
    production
   Adequate intake
   Engorgement and sore
    nipples
   Contraception: wait 6
    weeks until hormones
   Lactation consult?
         First 2 Weeks

   Correct latch on and feeding
   Begin weight regain 4-5 days
   Exceed birth weight 10-14 days
   Avoid other nipples
   Jaundice
   Breastfeeding support group
   Lactation consult?
                 Well Child Checks
   Breastfeeding success in first 6
    weeks strongest indicator for long
    term success
   Ask every time!
   Growth spurts
   What about solids?
   What about other nipples?
   How long?
Signs of Adequate
Breastfeeding
   8-12 feedings/day, on demand
   Mouth wide open before latch on
   Latch entire nipple, most of areola
   Tongue under nipple
   Audible/visible swallowing
   Movement of TMJ
   6-8 wet diapers per day
   Adequate weight gain
                 Problem Solving
   Incorrect latch on
   Sore nipples
   Engorgement
   Blocked ducts
   Mastitis
   Thrush
   Going back to work
   “My baby’s hungry all the time”
Dr. Newman’s All-Purpose Nipple
          Ointment

       Mupirocin 2% ointment (15 g)
       Nystatin Ointment 100,000u/ml (15 g)
       Betamethasone 0.1% ointment (15 g)
Other Nipple Treatments
      Candidiasis:
        Gentian  Violet qd 3 days to nipple
        Fluconazole 100 mg qd x 10 days
        Topical:
           Hydrocortisone  1%
           Polysporin ointment

           Miconazole cream
Poor Weight Gain: case
       Birthweight 8/1:
       9/2: 3957 g, 8’11.3”
       9/7: 4042 g, 8’14.3”
       9/9: 9 lb 1.5 oz
       Goal weight gain: 30 g/day
       110-150 kcal/kg/d; 20 kcal/oz in
        formula
         22   oz/day, 8-10 feedings
Dietary protein-induced
colitis
   3 month old presents with bloody,
    mucousy stools
   Colitis caused by cow’s milk proteins
   Mom needs to avoid lactose/dairy,
    casein, whey, soy
     Or switch to protein hydrolysate
      formula
   Most sensitivities resolve in 1-2 years
Breast Milk Jaundice
   Begins in 3-5 days
   Peaks in 2 weeks
   increased concentration of beta-
    glucuronidase in breast milk
   Beta-glucuronidase deconjugates
    intestinal bilirubin, increasing its
    ability to be absorbed (ie,
    increasing enterohepatic
    circulation)
Breastfeeding Failure
Jaundice
   increased enterohepatic circulation
    together with a reduced enteral
    intake is thought to be primarily
    responsible for increased total
    serum bilirubin
Birth Control
   Avoid estrogen-containing
    products
   Progestin only preferred
     Progestin  receptors not present in
      “lactating”tissues
Antibiotics
   Penicillins
   Cephalosporins
   Zithromax (except early
    postpartum)
     Avoid   erythromycin
   Fluoroquinolones (use cipro
    cautiously)
   metronidazole
Antidepressants
   Sertraline preferred SSRI
   Venlafaxine
   buproprion
Analgesics
   Codeine
   Hydrocodone
   Morphine
   Fentanyl levels are low
   Ibuprofen
   Acetaminophen
Herbal Remedies
   Probably safe:
     Echinacea
     Fenugreek
     Calendula
     Ginseng
     Evening  primrose oil
     St. John’s Wort
     Gingko Biloba
Antihypertensives
   Aldomet, hydralazine are fine
   Preferred beta blockers:
       Propranolol, matoprolol, labetalol, sotalol
   Preferred calcium channel:
       Nifedipine, verapamil, nitrendipine
   Preferred ACE inhibitors
     Captopril, enalapril, benazepril
     Avoid during last trimester and preterm
      infants
X-rays
   X-rays PASS through the body
   No hazard to breastmilk
             References:

   Breastfeeding: A Guide for the Medical Profession

   Neville, Margaret, PhD, “The Evidence for Breastfeeding:Anatomy and
    Physiology of Lactation,” Pediatric Clinics of North America, vol. 48:1, Feb.
    2001

   Newman, Jack MD, The Ultimate Breastfeeding Book of Answers, 2000.

   Sinusas, Keith MD and Gagliardi, Amy MA, “Initial Management of
    Breastfeeding,” American Family Physician, Sept. 15, 2001; vol64:6.

   Thomas W. Hale, Ph.D. , Medications and Mother’s Milk.