Week 11: Problems with breastfeeding and lactation
Breastfeeding and Lactation disorders
Objectives:
To be able to
 discuss the physiology and pathophysiology of normal and abnormal
lactation;
 know the effect of maternal and infant factors on the let-down and milk
production reflexes;
 be able to recognize and effectively deal with problems of lactation;
 know and discuss the conditions associated with “insufficient milk”, breast
engorgement and mastitis and inadequate let-down reflexes
Illustrative Case Report:
Mrs Z has just delivered her first baby at term, birth weight 3.5 Kg. There were no problems
in the antenatal period. Apart from an episiotomy, labour and delivery went well. Mild
jaundice was seen on day 3, for which the attending paediatrician prescribed phototherapy
for 24 hours.
While in the hospital, Mrs Z breastfed her baby. He seemed to take the
breast well and there were no problems. He had already started to gain
weight when she was discharged home to her 3-roomed flat in Sunnyside on
day 5.
One week later, the City Health Department’s Nurse came on a home visit. At
this stage, Mrs Z appeared to be tired and down-hearted. Her baby was
crying a lot, did not sleep well, and was not gaining weight well. Even though
mother seemed to have so much milk that the breasts were engorged and
quite sore, baby was not satisfied. He would start well, but soon stop,
apparently because he was not getting enough. He would then cry and be
reluctant to take the breast again. As a consequence, he would still be
hungry and not sleep well.
Mrs Z’s neighbour has suggested that her breastmilk is not agreeing with
baby and that she should start a bottle. Mrs Z is desperate because she had
actually so wanted to feed this baby on her breast, and has therefore made
an appointment to see her doctor.
Introduction
Even though lactation is a perfectly normal physiological process, successful
breastfeeding has to be learnt by both the mother and the baby. It may
therefore be expected that first-time breastfeeding mothers may have more
difficulties than those with prior experience.
Task
Review the physiology of normal lactation with particular emphasis on the milk production
reflex mediated by prolactin and the milk ejection reflex (let-down reflex) mediated by
oxytocin. Concentrate on the factors which may hinder or interfere with the above reflexes.
What other factors influence production of milk? List the factors which might have interfered
with breastfeeding reflexes in the case report above.
Prior to the development of
 baby feeding bottles,
 hygienic methods of preparation and storage of milk, and
 safe formula feeds,
all neonates were absolutely dependent on their mother’s milk for survival. In
fact, by the end of the 19th century, virtually 100% non-breastfed babies were
still doomed to die because of infection.
The rapid introduction of bottle feeding has been associated with huge
increases in infant malnutrition during the 20th century. Previously, breastfed
infants were largely protected from malnutrition until the weaning stage; once
bottle-feeding was being “modelled” in societies by the affluent members of
that society, diluted contaminated formula feeding was a potent source of
illness and death through malnutrition and diarrhoeal disease.
Today, we are witnessing the reverse trend amongst women who have a
choice on how they want to feed their babies. The breastfeeding decision is
being taken by the more affluent, educated, stable women of society because
they have come to realise that breastmilk is the right food designed by nature
for human infants for the following reasons:
 Better protein compatibility: All non-human milk formulae are based on
animal milk or vegetable protein with the consequent risk of earlier
development of sensitisation and allergy;
 Non-protein nitrogen components including growth factors and
nucleotides have direct influence on gastrointestinal mucosal growth and
differentiation as well as on certain immune parameters
 Better balance of essential and protective fatty acids
 Presence of live immunocompetent cells primed for colonisation and
protection of the gut in the vulnerable developing phase
 Better performance indicators right up to probable effect on intelligence
 Breastfed babies are less vulnerable to child abuse, sudden infant death,
emotional and physical neglect
 Breastfed babies have less risk of infection even in well-resourced
communities.
What about HIV ? Can breastfeeding be risky?
A number of drugs and viruses have been shown to cross into the breast
milk and can therefore affect the baby.
 Cytotoxic drugs
 Psychotropic drugs
 Laxatives
 Salicylates
 Some antibiotics eg Chloramphenicol, Tetracycline
 HIV, CMV, Hep B, Hep C
The mother may be so debilitated by disease that the extra energy needed
for her breastmilk production will place an intolerable burden on her own
health
Contraindications to breastfeeding
Maternal:
 Psychosis
 Carcinoma of the breast
 Cytotoxic drug therapy for malignant disease
 Antithyroid drugs and Radio-iodine
Infant
 Inherited disorder involving galactose or lactose
Eg Galactosaemia
Risk factors for breastfeeding
Maternal
 Maternal debilitating disease
 Maternal virus infection
Eg HIV infection
Infant
 Abnormal mouth and swallowing mechanism
Eg Cleft lip/palate
Exclusive breastfeeding
This refers to the practice of giving nothing else but breastmilk by mouth.
This means nothing, not even added water and no pacifiers/dummies.
Shown to be completely sufficient for all the babies’ nutritional needs for at
least 4 months in healthy thriving babies. Shown to supply the water needs
of babies even in hot environments because of the fact that breastmilk is a
low osmolality feed.
The big advantage is the fact that exclusive breastfeeding protects the
developing gut from exposure to any injurious influence including infective
and antigenic contamination, osmotic or other stresses. There is some
suggestive evidence that exclusive breastfeeding may even be protective
against HIV infection provided it is really exclusive.
Risks of not breastfeeding
Depend on the socio-economic situation of the family.
In impoverished families without access to safe water and adequate
sanitation, failure to breastfeed may result in catastrophic increases in gut
infections, malnutrition, morbidity and deaths. This may completely negate
any positive effect of potentially preventing HIV infection.
Task
Assume the following statistics apply at an antenatal clinic in a peri-urban
informal settlement: Antenatal clinic HIV prevalence 25%. HIV Mother-to-child
transmission rate with breastfeeding 30%. Transmission rate 15% without
breastfeeding.
Example (a)
If all mothers at the above antenatal clinic decided to stop breastfeeding because
of their fear of the risk of transmission of HIV, calculate the number of babies who
would be placed at risk.
All mothers of unknown HIV status : 25% positive, therefore 75% negative
Of 25% positive mothers, transmission rate 30% with breastfeeding, ie 30%
of 25 = 8 affected babies, 70% of 25 = 17 unaffected babies
Of 75% negative mothers, transmission rate 0, ie 75 unaffected babies
Therefore, of mothers attending antenatal clinic, 8% babies will be HIV
infected if breastfeeding is uniformly chosen, 92% unaffected.
If all mothers decide to stop breastfeeding, only 15% of exposed babies will
be infected. In the example, this reduces the number of babies eventually
infected from 8% to 4% of the total group of mothers. Therefore, 96% of
babies would be deprived of breastfeeding even though they are not at risk of
contracting HIV at this stage.
Example (b)
If the clinic mentioned above offers HIV testing, and all HIV positive mothers are
counselled to stop breastfeeding, what proportion of their babies would be at
nutritional risk?
At the clinic, 25% are HIV positive. With breastfeeding, the transmission rate
is 30%, ie 70% children of HIV positive mothers are unaffected. Without
breastfeeding, transmission rate is now 15%, ie 85% of babies of HIV positive
mothers are uninfected and placed at nutritional risk from not breastfeeding.
If malnutrition or infection-related death rates of non-breastfed babies of HIV
positive mothers exceed 15%, such mothers should not be advised to stop
breastfeeding without guaranteeing safe alternative feeding
Lactation disorders
Mrs Z has encountered problems in feeding her baby on the breast, even
though it seemed as if lactation had been successfully established in the
maternity hospital. A week later, the baby is crying a lot, is not sleeping and
gaining weight well. Mother’s breasts are engorged and painful. Could it be
that breastmilk is not agreeing with him?
Reference Coovadia 5th ed pp 175 - 185
Successful lactation is not only instinctual behaviour; it has to be learnt by
both mother and baby. It is further dependent on regular frequent emptying
of both breasts and on a mutually satisfying relationship and interaction
between mother and child. Many first mothers will need up to 2 – 3 weeks
before lactation and regular breastfeeding is fully established.
Successful initiation
First feed serves to stimulate the milk-producing reflex and the secretion of
oxytocin. The earlier the baby is put to the breast after birth while still wide
awake in the first half hour or so, and before it falls asleep, the stronger it
suckles. Such mothers are usually able to breastfeed for longer periods.
Difficulties arise when baby is too small, immature, asphyxiated, physically
abnormal (cleft palate), hypotonic, sick or sedated and cannot latch onto the
breast well, or where there are maternal factors such as anaesthesia,
sedation, illness, pain, severe anxiety in a mother who is very young, alone or
emotionally disturbed.
Exclusive demand feeding
In the first few days, not much colostrum and milk is secreted. Baby
therefore needs frequent opportunities to suckle and stimulate prolactin
secretion to allow milk to “come in”. In view of the newborn infant’s sleeping
pattern of 16 – 18 hours per day, this is best done “on demand” when baby is
optimally awake and hungry. “Clocking systems” of offering the breast at set
times will often mismatch the physiological responses.
Babies who are offered bottles of water or milk formula will frequently be
sleepy not yet hungry and therefore not feed adequately when put to the
breast. Supplementing baby feeds in the onset phase of lactation will result in
earlier cessation of lactation.
If babies are expected to conform to set times for feeding, they may miss the
best awake time for suckling and be excessively unhappy/crying, or have
gone back to sleep.
If mother has no help and has to return to household chores or work
obligations before lactation has been truly established, conflicting schedules
for mother and baby may mean that baby’s feeding loses out against
domestic obligations.
Normal milk production and let-down reflexes
Prolactin mediated milk production is dependent on suckling and regular
emptying of the breast.
After milk production has begun within a few days after birth, the breast has
to be emptied regularly in order to maintain milk production. Infrequent
emptying or breast engorgement limits milk production.
Oxytocin secretion for the let-down reflex is mediated via suckling and
stimulation of the areola skin but also via higher centres such as thinking
about feeding the baby. The onset of this reflex is delayed for a few days
after birth.
Breastfeeding reflexes, especially the let-down reflex, are inhibited through
unfavourable effects on the higher centres: Anxiety, tiredness, emotional
tenseness, sickness and pain. All these may operate in a first time mother
discharged home who perhaps has inadequate support, help, rest and who is
frightened and uncertain.
Drugs may affect milk production negatively: oestrogens as in contraceptive
pills, sedatives in high doses( as well as possibly affecting the baby through
breast milk) or positively, such as metoclopramide for milk secretion,
oxytocin for the let down reflex.
A primiparous mother may thus have problems of insufficient or delayed
milk production (inadequate prolactin effect) or breast engorgement (letdown not established yet or inhibited, infrequent emptying). This may lead to
the possibility of mastitis with painful lumpiness in the breast not emptying
completely with feeds. Risk of bacterial infection and abscess formation.
Associated fever and constitutional symptoms.
Engorged breasts and ineffectual suckling leads to cracked nipples, with
severe pain when baby suckles.
Baby-related feeding problems
Baby feeding problems relate to problems of positioning during feeds,
swallowing of air and difficulty with “burping”, as well as issues of disordered
gut motility related to the onset of feeding (regurgitation, slow or rapid
transit) and possibly influences related to drugs or chemical constituents
passing through breast milk (caffeine, cocoa). In addition, baby’s digestive
tract may show maturation-related problems such as insufficient lactase with
fermentative symptoms (bloating, cramps, loose stools)
Describe practical management to establish and maintain
successful breast feeding (primiparous mother)
Anticipation
During pregnancy : Establish positive attitude of support from mother and
family. Husband/care-taker support important
Reassure about incorrect perceptions regarding feeding : eg breast size,
quality of milk, advantages of breast feeding
Optimal management of labour
Putting baby to the breast early while baby and mother are both still wide
awake and on a “high” after birth. Adequate help available to help position
baby correctly (best done by an experienced older woman)
Early days while under supervision in hospital or at home
Frequent exclusive demand feeds. Adequate help at feed times for
positioning, reassurance.
Adequate rest and analgesia for mother if necessary
On discharge
Guarantee rest and help and knowledgeable support with demand feeding.
No supplements.
Reassurance. Encourage joyful anticipation. Maintain positive attitude, both
mother and baby will learn. Do not allow mother to become anxious about
quantity of milk taken. This can vary from feed to feed.
Engorged breasts: warm compresses before feed, cold compresses after feed.
Occasionally sublingual oxytocin helps with let-down reflex. Frequent suckling
to empty the breasts. Support breasts to reduce pain.
Mastitis: adequate hydration, analgesia. Cold packs to reduce pain and
swelling. Frequent emptying of breast. Only if abscess is present should
breast not be offered. Antibiotic therapy for fever and abscess.
Cracked nipples: prevent by attention to the way the baby places nipple and
part of areola into mouth, so that it does not suckle on nipple. Avoid too
frequent washing with soap; it removes protective fatty layers. Allow to airdry, breast milk onto nipple. Otherwise zinc-containing or lanolin ointments,
wipe off before feed. Analgesia and continue feeding.
Baby factors identified by detailed attention to the symptoms and evolution.
Position of comfort for both mother and baby during feed. No gurgling
sounds; should only hear sound of baby swallowing. Position for “burping”.
Cramping pains – identify possible maternal food or drink factors (coffee,
wine etc) Antispasmodics not usually necessary. Lactase deficiency not an
indication to stop breastfeeding unless baby not thriving and strongly positive
clinitest.
Many mothers feed their babies on formula not because they want to but
because of difficulties with breastfeeding. A majority of mothers start
breastfeeding but give up within a few weeks. This happens commonly
before breastfeeding has been well and truly established.
Common complaints include:
Baby is still hungry after breastfeeding, ie has not been getting
enough.
This may be a problem of supply ie production of milk, or of delivery, ie the
let-down reflex.
The breast milk supply is dependent on regular emptying of the breast by
suckling, which stimulates the production of oxytocin. Particularly in
situations where mothers substitute some bottle feeds for breastfeeding, the
breast milk supply is likely to diminish rapidly and the breasts stay empty.
When this happens, the milk supply can be improved by frequent suckling. At
the same time, the mother’s own fluid and food balance must be ensured and
she must be reassured and allowed to rest enough.
The breast cannot empty adequately if there are difficulties with the let-down
reflex. Such babies start suckling well, but even though there may be enough
milk in the breast, sometimes to the point of engorgement, there is
insufficient contraction of the myo-epithelial cells and the milk is not ejected
into the lacteals from where the baby expresses it into her mouth by the
normal chewing action of suckling. As a result, baby gives up suckling
because she gets too little. The normal sensation of breast duct contraction
is not achieved for the mother. If this continues for some days, the breast is
again not adequately emptied and reduces the milk output.
The essential information required by the doctor dealing with the above
complaints is therefore the state of fullness of the breast prior to the onset of
suckling: An empty breast needs attention to methods of increasing milk
production; an engorged breast needs attention to the let-down reflex.
Breasts are painfully engorged
This is a problem of early lactation, often before the cycle of production and
emptying has been established.
Engorged breasts may be so full that the flow of milk down the milk ducts is
hindered. They also hurt and therefore there is a further limiting influence on
the secretion of oxytocin from the posterior pituitary.
When milk engorgement leads to painful inflammation and fever, mastitis is
present. This is not always due to bacterial invasion, but bacteria may very
easily infect the engorged breasts. Such a patient’s breasts must be carefully
examined for the presence of cellulitis or an abscess and require antibiotic
therapy.
The management of engorged breasts consists of ensuring regular milk
drainage. Methods to relax breast ducts and help milk flow include warm
compresses, analgesia and frequent suckling by the baby.
Case Analysis
Baby Z is a healthy baby who had started to gain weight by the time he was
discharged from hospital. There is no problem with mother’s breast milk
supply. She even has somewhat engorged breasts. It appears the problem
has started with her coming home into a small flat where she is alone with
the baby all day. She is likely to be suffering from anxiety and tiredness.
There may be fears and her husband may not be as supportive as he might
need to be. The new baby is taking up a lot of time and seems to be so
terribly vulnerable.
In such circumstances, the mother’s oxytocin release is inhibited. This leads
to an inadequate let-down reflex. Now the breast milk is not so available to
the baby, who starts to suckle eagerly but then gives up disappointed and still
hungry. As a result, baby does not sleep well but wakes up more frequently
and yet does not seem to feed well. This is a vicious circle, not made any
better by suggestions that the milk is “not good for the baby” etc. Very many
mothers give up breastfeeding on their neighbour’s or the doctor’s advice at
this point.
She has a problem with the let-down reflex. She has to regain her confidence
in her ability to feed her baby, and she has to be helped to be relaxed about
it. She really needs a mother to “mother the mother” and take over some of
the other home responsibilities. Any pain should be anticipated and
paracetamol given. A warm wet towel packed on the breast helps to relax
milk ducts and start milk flowing. Baby should be put to the breast as often as
he wants. With reassuring support, the problem can be overcome within a
few days. She needs to be able to contact an experienced person for support
and advice. The La Leche League local counsellor can make an invaluable
contribution in this respect.