Lactation and its troubles Ann Peery RN IBCLC

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

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

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

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

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

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

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

Breastfeeding Basics Breastfeed every 2 -3 hours for a total of 8 -10 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 latchon for entire feeding

Problems Observed Poor response from baby Difficult breast anatomy or mouth anatomy Sub-optimal breastfeeding management

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

Problem Solving and Tools Breast shells Nipple shields Breast pumps

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

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

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

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

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

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 )

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 1014 day regimen or poor drainage of breast

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

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

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

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

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