Breastfeeding

Structure and Development of the Female Breast During Pregnancy

Structure of the female breast

• The female breast is an exocrine gland that overlies the pectoral muscles.
• Lobes: Each breast is composed of 15–20 compartments called lobes.
  • Lobes are arranged radially around the nipple Nipple The conic organs which usually give outlet to milk from the mammary glands. Examination of the Breast.
  • Separated from each other by fibrous Fibrous Fibrocystic Change tissue
  • Each lobe has its own lactiferous duct that drains milk produced in the lobe at the nipple Nipple The conic organs which usually give outlet to milk from the mammary glands. Examination of the Breast.
  • Lobes are further divided into lobules Lobules Breasts: Anatomy.
• Lobules Lobules Breasts: Anatomy:
  • Individual milk-producing glands called mammary glands
  • Composed of clusters of acini:
    • Less mature lobules Lobules Breasts: Anatomy contain approximately 10 alveolar buds.
    • More mature lobules Lobules Breasts: Anatomy contain > 80 alveolar buds.
• Mammary alveoli Alveoli Small polyhedral outpouchings along the walls of the alveolar sacs, alveolar ducts and terminal bronchioles through the walls of which gas exchange between alveolar air and pulmonary capillary blood takes place. Acute Respiratory Distress Syndrome (ARDS):
  • Lined by cuboidal epithelium Epithelium The epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. Surface Epithelium: Histology
  • Surrounded by myoepithelial cells that have a contractile ability
  • Empty into the lactiferous ducts Lactiferous ducts Breasts: Anatomy
• Ductal system:
  • Forms the passage for the transport of milk from the alveoli Alveoli Small polyhedral outpouchings along the walls of the alveolar sacs, alveolar ducts and terminal bronchioles through the walls of which gas exchange between alveolar air and pulmonary capillary blood takes place. Acute Respiratory Distress Syndrome (ARDS) to the nipple Nipple The conic organs which usually give outlet to milk from the mammary glands. Examination of the Breast
  • Mammary alveoli Alveoli Small polyhedral outpouchings along the walls of the alveolar sacs, alveolar ducts and terminal bronchioles through the walls of which gas exchange between alveolar air and pulmonary capillary blood takes place. Acute Respiratory Distress Syndrome (ARDS) (i.e., acini) → lactiferous ducts Lactiferous ducts Breasts: Anatomy → lactiferous sinus → nipple Nipple The conic organs which usually give outlet to milk from the mammary glands. Examination of the Breast pores (at the central part of the areola Areola Examination of the Breast)
• Breast stroma (area between the glands) is composed mainly of fatty tissue and ligaments.
  • Breast size is determined by the amount of adipose tissue Adipose tissue Adipose tissue is a specialized type of connective tissue that has both structural and highly complex metabolic functions, including energy storage, glucose homeostasis, and a multitude of endocrine capabilities. There are three types of adipose tissue, white adipose tissue, brown adipose tissue, and beige or “brite” adipose tissue, which is a transitional form. Adipose Tissue: Histology and is not related to the amount of milk that the glandular components can produce.
  • Adipose tissue Adipose tissue Adipose tissue is a specialized type of connective tissue that has both structural and highly complex metabolic functions, including energy storage, glucose homeostasis, and a multitude of endocrine capabilities. There are three types of adipose tissue, white adipose tissue, brown adipose tissue, and beige or “brite” adipose tissue, which is a transitional form. Adipose Tissue: Histology makes up 80% of the tissue in nonbreastfeeding women.
  • Ligaments between lobules Lobules Breasts: Anatomy:
    • Known as suspensory ligaments of the breast Suspensory ligaments of the breast Breasts: Anatomy ( Cooper ligaments Cooper ligaments Breasts: Anatomy)
    • Provide structural support

Growth and development of breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy in pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care

Significant growth and maturation of the breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy occur during pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care as a result of hormonal secretion Secretion Coagulation Studies by the placenta Placenta A highly vascularized mammalian fetal-maternal organ and major site of transport of oxygen, nutrients, and fetal waste products. It includes a fetal portion (chorionic villi) derived from trophoblasts and a maternal portion (decidua) derived from the uterine endometrium. The placenta produces an array of steroid, protein and peptide hormones (placental hormones). Placenta, Umbilical Cord, and Amniotic Cavity.

• Important hormones Hormones Hormones are messenger molecules that are synthesized in one part of the body and move through the bloodstream to exert specific regulatory effects on another part of the body. Hormones play critical roles in coordinating cellular activities throughout the body in response to the constant changes in both the internal and external environments. Hormones: Overview and Types include:
  • Estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy
  • Progesterone Progesterone The major progestational steroid that is secreted primarily by the corpus luteum and the placenta. Progesterone acts on the uterus, the mammary glands and the brain. It is required in embryo implantation; pregnancy maintenance, and the development of mammary tissue for milk production. Progesterone, converted from pregnenolone, also serves as an intermediate in the biosynthesis of gonadal steroid hormones and adrenal corticosteroids. Gonadal Hormones
  • Chorionic gonadotropin
  • Human placental lactogen
  • Prolactin Prolactin A lactogenic hormone secreted by the adenohypophysis. It is a polypeptide of approximately 23 kd. Besides its major action on lactation, in some species prolactin exerts effects on reproduction, maternal behavior, fat metabolism, immunomodulation and osmoregulation. Breasts: Anatomy
  • Growth hormone
  • Insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin
  • Glucocorticoids Glucocorticoids Glucocorticoids are a class within the corticosteroid family. Glucocorticoids are chemically and functionally similar to endogenous cortisol. There are a wide array of indications, which primarily benefit from the antiinflammatory and immunosuppressive effects of this class of drugs. Glucocorticoids
• The hormones Hormones Hormones are messenger molecules that are synthesized in one part of the body and move through the bloodstream to exert specific regulatory effects on another part of the body. Hormones play critical roles in coordinating cellular activities throughout the body in response to the constant changes in both the internal and external environments. Hormones: Overview and Types cause:
  • Growth and branching of the ductal system
  • Budding Budding Mycology and development of alveoli Alveoli Small polyhedral outpouchings along the walls of the alveolar sacs, alveolar ducts and terminal bronchioles through the walls of which gas exchange between alveolar air and pulmonary capillary blood takes place. Acute Respiratory Distress Syndrome (ARDS) (after ductal growth):
    • Alveolar cells undergo active cell division Cell Division A type of cell nucleus division by means of which the two daughter nuclei normally receive identical complements of the number of chromosomes of the somatic cells of the species. Cell Cycle.
    • Individual cells increase in size.
  • By delivery: The breast consists almost entirely of glands with very little stroma.
• Early pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care:
  • Majority of the ductal and glandular development occurs in the 1st ½ of pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care.
  • Breast tenderness may occur (common symptom of early pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care).
• Later pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care:
  • Growth continues but is slow.
  • Secretions (colostrum) begin to accumulate in the ducts.
• Just before parturition Parturition The process of giving birth to one or more offspring. Normal and Abnormal Labor (delivery): another wave of growth
• During lactation: Growth and differentiation may continue until lactation stops.

Physiology of Lactation

Milk synthesis Synthesis Polymerase Chain Reaction (PCR)

• Breast milk is synthesized by the columnar epithelial cells in the mammary gland Mammary gland Glandular tissue in the breast of human that is under the influence of hormones such as estrogens; progestins; and prolactin. In women, after parturition, the mammary glands secrete milk for the nourishment of the young. Breasts: Anatomy acini.
• Released into the acini (but not into the ducts yet)
• Milk synthesis Synthesis Polymerase Chain Reaction (PCR) is stimulated by prolactin Prolactin A lactogenic hormone secreted by the adenohypophysis. It is a polypeptide of approximately 23 kd. Besides its major action on lactation, in some species prolactin exerts effects on reproduction, maternal behavior, fat metabolism, immunomodulation and osmoregulation. Breasts: Anatomy:
  • Prolactin Prolactin A lactogenic hormone secreted by the adenohypophysis. It is a polypeptide of approximately 23 kd. Besides its major action on lactation, in some species prolactin exerts effects on reproduction, maternal behavior, fat metabolism, immunomodulation and osmoregulation. Breasts: Anatomy is secreted by the anterior pituitary Pituitary A small, unpaired gland situated in the sella turcica. It is connected to the hypothalamus by a short stalk which is called the infundibulum. Hormones: Overview and Types gland.
  • Secretion Secretion Coagulation Studies begins around the 5th week of pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care.
  • Increases 10‒20 times of its normal level by delivery
• Milk synthesis Synthesis Polymerase Chain Reaction (PCR) is inhibited by estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy and progesterone Progesterone The major progestational steroid that is secreted primarily by the corpus luteum and the placenta. Progesterone acts on the uterus, the mammary glands and the brain. It is required in embryo implantation; pregnancy maintenance, and the development of mammary tissue for milk production. Progesterone, converted from pregnenolone, also serves as an intermediate in the biosynthesis of gonadal steroid hormones and adrenal corticosteroids. Gonadal Hormones:
  • Increased secretion Secretion Coagulation Studies by the placenta Placenta A highly vascularized mammalian fetal-maternal organ and major site of transport of oxygen, nutrients, and fetal waste products. It includes a fetal portion (chorionic villi) derived from trophoblasts and a maternal portion (decidua) derived from the uterine endometrium. The placenta produces an array of steroid, protein and peptide hormones (placental hormones). Placenta, Umbilical Cord, and Amniotic Cavity during pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
  • Hormone levels drop significantly after removal of the placenta Placenta A highly vascularized mammalian fetal-maternal organ and major site of transport of oxygen, nutrients, and fetal waste products. It includes a fetal portion (chorionic villi) derived from trophoblasts and a maternal portion (decidua) derived from the uterine endometrium. The placenta produces an array of steroid, protein and peptide hormones (placental hormones). Placenta, Umbilical Cord, and Amniotic Cavity at delivery.
• During pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care, placental hormones Hormones Hormones are messenger molecules that are synthesized in one part of the body and move through the bloodstream to exert specific regulatory effects on another part of the body. Hormones play critical roles in coordinating cellular activities throughout the body in response to the constant changes in both the internal and external environments. Hormones: Overview and Types ( estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy and progesterone Progesterone The major progestational steroid that is secreted primarily by the corpus luteum and the placenta. Progesterone acts on the uterus, the mammary glands and the brain. It is required in embryo implantation; pregnancy maintenance, and the development of mammary tissue for milk production. Progesterone, converted from pregnenolone, also serves as an intermediate in the biosynthesis of gonadal steroid hormones and adrenal corticosteroids. Gonadal Hormones) are dominant → overall effect of inhibition of milk synthesis Synthesis Polymerase Chain Reaction (PCR)
• At delivery, placental hormones Hormones Hormones are messenger molecules that are synthesized in one part of the body and move through the bloodstream to exert specific regulatory effects on another part of the body. Hormones play critical roles in coordinating cellular activities throughout the body in response to the constant changes in both the internal and external environments. Hormones: Overview and Types ↓, but prolactin Prolactin A lactogenic hormone secreted by the adenohypophysis. It is a polypeptide of approximately 23 kd. Besides its major action on lactation, in some species prolactin exerts effects on reproduction, maternal behavior, fat metabolism, immunomodulation and osmoregulation. Breasts: Anatomy (from the pituitary Pituitary A small, unpaired gland situated in the sella turcica. It is connected to the hypothalamus by a short stalk which is called the infundibulum. Hormones: Overview and Types) persists and becomes dominant:
  • The overall effect is stimulation of milk synthesis Synthesis Polymerase Chain Reaction (PCR).
  • Milk synthesis Synthesis Polymerase Chain Reaction (PCR) significantly increases during the 1st week postpartum.
• Prolactin Prolactin A lactogenic hormone secreted by the adenohypophysis. It is a polypeptide of approximately 23 kd. Besides its major action on lactation, in some species prolactin exerts effects on reproduction, maternal behavior, fat metabolism, immunomodulation and osmoregulation. Breasts: Anatomy surges:
  • Without inhibitory estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy and progesterone Progesterone The major progestational steroid that is secreted primarily by the corpus luteum and the placenta. Progesterone acts on the uterus, the mammary glands and the brain. It is required in embryo implantation; pregnancy maintenance, and the development of mammary tissue for milk production. Progesterone, converted from pregnenolone, also serves as an intermediate in the biosynthesis of gonadal steroid hormones and adrenal corticosteroids. Gonadal Hormones, baseline prolactin Prolactin A lactogenic hormone secreted by the adenohypophysis. It is a polypeptide of approximately 23 kd. Besides its major action on lactation, in some species prolactin exerts effects on reproduction, maternal behavior, fat metabolism, immunomodulation and osmoregulation. Breasts: Anatomy levels drop back to nonpregnant levels.
  • With nipple Nipple The conic organs which usually give outlet to milk from the mammary glands. Examination of the Breast stimulation (i.e., suckling), prolactin Prolactin A lactogenic hormone secreted by the adenohypophysis. It is a polypeptide of approximately 23 kd. Besides its major action on lactation, in some species prolactin exerts effects on reproduction, maternal behavior, fat metabolism, immunomodulation and osmoregulation. Breasts: Anatomy levels surge to 10‒20 times that of nonpregnant levels for approximately 1 hour to synthesize milk for the next feeding.
• Milk synthesis Synthesis Polymerase Chain Reaction (PCR):
  • Stops approximately after 1 week if there are no prolactin Prolactin A lactogenic hormone secreted by the adenohypophysis. It is a polypeptide of approximately 23 kd. Besides its major action on lactation, in some species prolactin exerts effects on reproduction, maternal behavior, fat metabolism, immunomodulation and osmoregulation. Breasts: Anatomy surges
  • Stops when:
    • Mother stops breastfeeding.
    • Prolactin Prolactin A lactogenic hormone secreted by the adenohypophysis. It is a polypeptide of approximately 23 kd. Besides its major action on lactation, in some species prolactin exerts effects on reproduction, maternal behavior, fat metabolism, immunomodulation and osmoregulation. Breasts: Anatomy surges are absent due to pituitary Pituitary A small, unpaired gland situated in the sella turcica. It is connected to the hypothalamus by a short stalk which is called the infundibulum. Hormones: Overview and Types damage.
• If the mother continues to breastfeed:
  • Milk production continues for a few years postpartum.
  • Quantity may gradually decline after 8–9 months.
• Prolactin Prolactin A lactogenic hormone secreted by the adenohypophysis. It is a polypeptide of approximately 23 kd. Besides its major action on lactation, in some species prolactin exerts effects on reproduction, maternal behavior, fat metabolism, immunomodulation and osmoregulation. Breasts: Anatomy also inhibits ovulation Ovulation The discharge of an ovum from a rupturing follicle in the ovary. Menstrual Cycle:
  • Prolactin Prolactin A lactogenic hormone secreted by the adenohypophysis. It is a polypeptide of approximately 23 kd. Besides its major action on lactation, in some species prolactin exerts effects on reproduction, maternal behavior, fat metabolism, immunomodulation and osmoregulation. Breasts: Anatomy inhibits the release of gonadotropins:
    • Follicle-stimulating hormone ( FSH FSH A major gonadotropin secreted by the adenohypophysis. Follicle-stimulating hormone stimulates gametogenesis and the supporting cells such as the ovarian granulosa cells, the testicular sertoli cells, and leydig cells. Fsh consists of two noncovalently linked subunits, alpha and beta. Within a species, the alpha subunit is common in the three pituitary glycoprotein hormones (TSH, LH, and FSH), but the beta subunit is unique and confers its biological specificity. Menstrual Cycle)
    • Luteinizing hormone ( LH LH A major gonadotropin secreted by the adenohypophysis. Luteinizing hormone regulates steroid production by the interstitial cells of the testis and the ovary. The preovulatory luteinizing hormone surge in females induces ovulation, and subsequent luteinization of the follicle. Luteinizing hormone consists of two noncovalently linked subunits, alpha and beta. Within a species, the alpha subunit is common in the three pituitary glycoprotein hormones (TSH, LH, and FSH), but the beta subunit is unique and confers its biological specificity. Menstrual Cycle)
  • Lactating mothers are typically amenorrheic for the 1st several months.
  • Approximately 5%‒10% of women become pregnant while nursing an infant full time.
  • Eventually, as prolactin Prolactin A lactogenic hormone secreted by the adenohypophysis. It is a polypeptide of approximately 23 kd. Besides its major action on lactation, in some species prolactin exerts effects on reproduction, maternal behavior, fat metabolism, immunomodulation and osmoregulation. Breasts: Anatomy levels drop, FSH FSH A major gonadotropin secreted by the adenohypophysis. Follicle-stimulating hormone stimulates gametogenesis and the supporting cells such as the ovarian granulosa cells, the testicular sertoli cells, and leydig cells. Fsh consists of two noncovalently linked subunits, alpha and beta. Within a species, the alpha subunit is common in the three pituitary glycoprotein hormones (TSH, LH, and FSH), but the beta subunit is unique and confers its biological specificity. Menstrual Cycle and LH LH A major gonadotropin secreted by the adenohypophysis. Luteinizing hormone regulates steroid production by the interstitial cells of the testis and the ovary. The preovulatory luteinizing hormone surge in females induces ovulation, and subsequent luteinization of the follicle. Luteinizing hormone consists of two noncovalently linked subunits, alpha and beta. Within a species, the alpha subunit is common in the three pituitary glycoprotein hormones (TSH, LH, and FSH), but the beta subunit is unique and confers its biological specificity. Menstrual Cycle are produced → ovulation Ovulation The discharge of an ovum from a rupturing follicle in the ovary. Menstrual Cycle

Milk ejection

Ejection of milk requires the pituitary Pituitary A small, unpaired gland situated in the sella turcica. It is connected to the hypothalamus by a short stalk which is called the infundibulum. Hormones: Overview and Types hormone oxytocin.

• Nipple Nipple The conic organs which usually give outlet to milk from the mammary glands. Examination of the Breast stimulation (via suckling or using a mechanical breast pump Pump ACES and RUSH: Resuscitation Ultrasound Protocols) → sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology signals travel to the hypothalamus Hypothalamus The hypothalamus is a collection of various nuclei within the diencephalon in the center of the brain. The hypothalamus plays a vital role in endocrine regulation as the primary regulator of the pituitary gland, and it is the major point of integration between the central nervous and endocrine systems. Hypothalamus and pituitary Pituitary A small, unpaired gland situated in the sella turcica. It is connected to the hypothalamus by a short stalk which is called the infundibulum. Hormones: Overview and Types → posterior pituitary Pituitary A small, unpaired gland situated in the sella turcica. It is connected to the hypothalamus by a short stalk which is called the infundibulum. Hormones: Overview and Types gland releases oxytocin
• Oxytocin:
  • Travels via the blood to reach the myoepithelial cells surrounding the outer wall of the alveoli Alveoli Small polyhedral outpouchings along the walls of the alveolar sacs, alveolar ducts and terminal bronchioles through the walls of which gas exchange between alveolar air and pulmonary capillary blood takes place. Acute Respiratory Distress Syndrome (ARDS)
  • Triggers the myoepithelial cells to contract → ↑ pressure in the acini → forces milk into the ductal system
• Milk flows into the lactiferous ducts Lactiferous ducts Breasts: Anatomy → lactiferous sinus → sucked out of the nipple Nipple The conic organs which usually give outlet to milk from the mammary glands. Examination of the Breast through nipple Nipple The conic organs which usually give outlet to milk from the mammary glands. Examination of the Breast pores by the infant or action of the pump Pump ACES and RUSH: Resuscitation Ultrasound Protocols
• Approximately 30 seconds from the onset of suckling to milk flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure (known as “let-down”)
• Oxytocin may also be released by:
  • A baby crying
  • Visual and psychogenic factors

Stages of lactogenesis

There are 2 stages of lactogenesis:

• Lactogenesis I:
  • Starts around mid-pregnancy
  • Represents the time when the gland is sufficiently differentiated to secrete small quantities of milk components
  • Milk secretion Secretion Coagulation Studies generally does not occur due to the inhibitory effects of estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy and progesterone Progesterone The major progestational steroid that is secreted primarily by the corpus luteum and the placenta. Progesterone acts on the uterus, the mammary glands and the brain. It is required in embryo implantation; pregnancy maintenance, and the development of mammary tissue for milk production. Progesterone, converted from pregnenolone, also serves as an intermediate in the biosynthesis of gonadal steroid hormones and adrenal corticosteroids. Gonadal Hormones.
• Lactogenesis II:
  • Starts shortly after delivery
  • Represents the time of copious milk secretion Secretion Coagulation Studies that occurs with the drop of estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy and progesterone Progesterone The major progestational steroid that is secreted primarily by the corpus luteum and the placenta. Progesterone acts on the uterus, the mammary glands and the brain. It is required in embryo implantation; pregnancy maintenance, and the development of mammary tissue for milk production. Progesterone, converted from pregnenolone, also serves as an intermediate in the biosynthesis of gonadal steroid hormones and adrenal corticosteroids. Gonadal Hormones

Sucking reflex of the infant

• Babies will suckle anything that comes into contact with the roof of their mouth.
• A primitive instinct present in all newborn Newborn An infant during the first 28 days after birth. Physical Examination of the Newborn mammals
• Development of sucking reflex:
  • Begins around 32 weeks’ gestation
  • Fully develops by approximately 36 weeks’ gestation
  • Premature Premature Childbirth before 37 weeks of pregnancy (259 days from the first day of the mother’s last menstrual period, or 245 days after fertilization). Necrotizing Enterocolitis babies may have difficulty sucking.
• Persists as a reflex until approximately 4 months of life → then, changes to a voluntary and conscious action

Breast Milk Versus Formula Feeding

Breast milk

• Contains all nutrients required by an infant (except vitamin D Vitamin D A vitamin that includes both cholecalciferols and ergocalciferols, which have the common effect of preventing or curing rickets in animals. It can also be viewed as a hormone since it can be formed in skin by action of ultraviolet rays upon the precursors, 7-dehydrocholesterol and ergosterol, and acts on vitamin D receptors to regulate calcium in opposition to parathyroid hormone. Fat-soluble Vitamins and their Deficiencies)
• Contains maternal antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins: Types and Functions that protect the infant from infection
• Changes in composition:
  • Depends on time of the day
  • During the course of a single feeding (e.g., by the end, there is less lactose and protein, but much more fat)
  • As the baby gets older
• Human breast milk consists of the following components:
  • Fats Fats The glyceryl esters of a fatty acid, or of a mixture of fatty acids. They are generally odorless, colorless, and tasteless if pure, but they may be flavored according to origin. Fats are insoluble in water, soluble in most organic solvents. They occur in animal and vegetable tissue and are generally obtained by boiling or by extraction under pressure. They are important in the diet (dietary fats) as a source of energy. Energy Homeostasis
  • Proteins Proteins Linear polypeptides that are synthesized on ribosomes and may be further modified, crosslinked, cleaved, or assembled into complex proteins with several subunits. The specific sequence of amino acids determines the shape the polypeptide will take, during protein folding, and the function of the protein. Energy Homeostasis
  • Carbohydrates Carbohydrates A class of organic compounds composed of carbon, hydrogen, and oxygen in a ratio of cn(H2O)n. The largest class of organic compounds, including starch; glycogen; cellulose; polysaccharides; and simple monosaccharides. Basics of Carbohydrates (primarily lactose)
  • Vitamins and minerals Minerals Electrolytes
  • Maternal antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins: Types and Functions
• Colostrum:
  • Fluid that collects in the lactiferous ducts Lactiferous ducts Breasts: Anatomy and sinuses prior to delivery
  • Extremely nutrient dense although low in volume
  • Sustains infants for the 1st few days of life until mature milk is produced at around day 3

Maternal benefits of breastfeeding

• Stimulates uterine contractions:
  • Less postpartum bleeding Postpartum bleeding Excess blood loss from uterine bleeding associated with obstetric labor or childbirth. It is defined as blood loss greater than 500 ml or of the amount that adversely affects the maternal physiology, such as blood pressure and hematocrit. Postpartum Complications
  • ↓ Risk of delayed postpartum hemorrhage Postpartum hemorrhage Postpartum hemorrhage is one of the most common and deadly obstetric complications. Since 2017, postpartum hemorrhage has been defined as blood loss greater than 1,000 mL for both cesarean and vaginal deliveries, or excessive blood loss with signs of hemodynamic instability. Postpartum Hemorrhage
  • ↓ Risk of anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview and Types
• ↓ Risk of postpartum depression Postpartum depression Depression in postpartum women, usually within four weeks after giving birth (parturition). The degree of depression ranges from mild transient depression to neurotic or psychotic depressive disorders. Postpartum Psychiatric Disorders
• Fewer urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
• Faster weight loss Weight loss Decrease in existing body weight. Bariatric Surgery/return to prepregnancy weight
• ↓ Unintended pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care (due to inhibition of ovulation Ovulation The discharge of an ovum from a rupturing follicle in the ovary. Menstrual Cycle by prolactin Prolactin A lactogenic hormone secreted by the adenohypophysis. It is a polypeptide of approximately 23 kd. Besides its major action on lactation, in some species prolactin exerts effects on reproduction, maternal behavior, fat metabolism, immunomodulation and osmoregulation. Breasts: Anatomy)
• ↓ Risk of medical conditions later in life:
  • Breast and ovarian cancers
  • Autoimmune diseases Autoimmune diseases Disorders that are characterized by the production of antibodies that react with host tissues or immune effector cells that are autoreactive to endogenous peptides. Selective IgA Deficiency
  • Endometriosis Endometriosis Endometriosis is a common disease in which patients have endometrial tissue implanted outside of the uterus. Endometrial implants can occur anywhere in the pelvis, including the ovaries, the broad and uterosacral ligaments, the pelvic peritoneum, and the urinary and gastrointestinal tracts. Endometriosis
  • Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
  • Hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
  • Cardiovascular diseases
• Cheaper

Benefits of breastfeeding to the infant

• Stronger immune system Immune system The body’s defense mechanism against foreign organisms or substances and deviant native cells. It includes the humoral immune response and the cell-mediated response and consists of a complex of interrelated cellular, molecular, and genetic components. Primary Lymphatic Organs:
  • ↓ Risk of infection due to maternal IgA IgA Represents 15-20% of the human serum immunoglobulins, mostly as the 4-chain polymer in humans or dimer in other mammals. Secretory iga is the main immunoglobulin in secretions. Immunoglobulins: Types and Functions antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins: Types and Functions:
    • Respiratory infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease: pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia, infection caused by respiratory syncytial virus Respiratory Syncytial Virus Respiratory syncytial virus (RSV) is an enveloped, single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae and the genus Orthopneumovirus. Two subtypes (A and B) are present in outbreaks, but type A causes more severe disease. Respiratory syncytial virus causes infections of the lungs and respiratory tract. Respiratory Syncytial Virus ( RSV RSV Respiratory syncytial virus (RSV) is an enveloped, single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae and the genus Orthopneumovirus. Two subtypes (A and B) are present in outbreaks, but type A causes more severe disease. Respiratory syncytial virus causes infections of the lungs and respiratory tract. Respiratory Syncytial Virus), pertussis Pertussis Pertussis, or whooping cough, is a potentially life-threatening highly contagious bacterial infection of the respiratory tract caused by Bordetella pertussis. The disease has 3 clinical stages, the second and third of which are characterized by an intense paroxysmal cough, an inspiratory whoop, and post-tussive vomiting. Pertussis (Whooping Cough)
    • Ear infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
    • Bacterial meningitis Bacterial meningitis Bacterial infections of the leptomeninges and subarachnoid space, frequently involving the cerebral cortex, cranial nerves, cerebral blood vessels, spinal cord, and nerve roots. Meningitis
  • Improved response to vaccines
• Promotes colonization Colonization Bacteriology of the intestine with beneficial bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology
• Easier to digest than cow’s milk
• Fewer GI symptoms, including:
  • Diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea or constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
  • Gastroenteritis Gastroenteritis Gastroenteritis is inflammation of the stomach and intestines, commonly caused by infections from bacteria, viruses, or parasites. Transmission may be foodborne, fecal-oral, or through animal contact. Common clinical features include abdominal pain, diarrhea, vomiting, fever, and dehydration. Gastroenteritis
  • GERD GERD Gastroesophageal reflux disease (GERD) occurs when the stomach acid frequently flows back into the esophagus. This backwash (acid reflux) can irritate the lining of the esophagus, causing symptoms such as retrosternal burning pain (heartburn). Gastroesophageal Reflux Disease (GERD)
  • Necrotizing enterocolitis Enterocolitis Inflammation of the mucosa of both the small intestine and the large intestine. Etiology includes ischemia, infections, allergic, and immune responses. Yersinia spp./Yersiniosis ( NEC NEC Necrotizing enterocolitis (NEC) is an intestinal inflammatory process that can lead to mucosal injury and necrosis. The condition is multifactorial, with underlying risk factors that include prematurity and formula feeding. The clinical presentation varies in severity from feeding intolerance, acute findings on abdominal exam, and systemic symptoms. Necrotizing Enterocolitis) in preterm infants
• Less atopic conditions, including:
  • Allergies Allergies A medical specialty concerned with the hypersensitivity of the individual to foreign substances and protection from the resultant infection or disorder. Selective IgA Deficiency
  • Eczema Eczema Atopic dermatitis, also known as eczema, is a chronic, relapsing, pruritic, inflammatory skin disease that occurs more frequently in children, although adults can also be affected. The condition is often associated with elevated serum levels of IgE and a personal or family history of atopy. Skin dryness, erythema, oozing, crusting, and lichenification are present. Atopic Dermatitis (Eczema)
  • Asthma Asthma Asthma is a chronic inflammatory respiratory condition characterized by bronchial hyperresponsiveness and airflow obstruction. The disease is believed to result from the complex interaction of host and environmental factors that increase disease predisposition, with inflammation causing symptoms and structural changes. Patients typically present with wheezing, cough, and dyspnea. Asthma
• Lower risk of:
  • Childhood cancers, especially leukemia and lymphoma Lymphoma A general term for various neoplastic diseases of the lymphoid tissue. Imaging of the Mediastinum
  • Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
  • Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
• Lower rates of infant mortality Mortality All deaths reported in a given population. Measures of Health Status and SIDS SIDS Sudden infant death syndrome (SIDS) describes the sudden death of an otherwise healthy infant (< 1 year of age) with no identifiable cause. Sudden infant death syndrome is the leading cause of death in children between 1 and 12 months of age in the United States. Sudden Infant Death Syndrome (SIDS)

Formula

• Many different types to choose from including:
  • Milk-based options: common 1st-line choice
  • Soy-based options: used when milk-based formulas are poorly tolerated
  • Specialized formulas: used when true allergies Allergies A medical specialty concerned with the hypersensitivity of the individual to foreign substances and protection from the resultant infection or disorder. Selective IgA Deficiency or specialized nutritional requirements exist
• Contains all necessary nutrients required by an infant
• Does not contain any antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins: Types and Functions
• Note: Formula companies will market themselves to parents in ways that may be misleading. To promote breastfeeding, it is best to avoid marketing materials in the hospital.

Indications for formula feeding Formula feeding Formulations for the nutrition of infants that are substituted for breast milk. Infant Care

Although usually “breast is best,” there are cases when breastfeeding is not recommended, in which case, “fed is best.” These cases include:

• Breastfeeding failure:
  • May be due to:
    • Milk not coming in (more common in women with a prior history of breast surgery)
    • Poor latch
  • May lead to dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration in the infant → hypernatremia Hypernatremia Hypernatremia is an elevated serum sodium concentration > 145 mmol/L. Serum sodium is the greatest contributor to plasma osmolality, which is very tightly controlled by the hypothalamus via the thirst mechanism and antidiuretic hormone (ADH) release. Hypernatremia occurs either from a lack of access to water or an excessive intake of sodium. Hypernatremia → seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures
  • Ideally, women have access to lactation support to prevent this situation.
• Severe jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice/ kernicterus Kernicterus A term used pathologically to describe bilirubin staining of the basal ganglia; brain stem; and cerebellum and clinically to describe a syndrome associated with hyperbilirubinemia. Clinical features include athetosis, muscle spasticity or hypotonia, impaired vertical gaze, and deafness. Nonconjugated bilirubin enters the brain and acts as a neurotoxin, often in association with conditions that impair the blood-brain barrier (e.g., sepsis). This condition occurs primarily in neonates, but may rarely occur in adults. Hyperbilirubinemia of the Newborn:
  • Breastfeeding increases the risk of jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice:
    • Inadequate milk intake delays the passage of meconium Meconium The thick green-to-black mucilaginous material found in the intestines of a full-term fetus. It consists of secretions of the intestinal glands; bile pigments; fatty acids; amniotic fluid; and intrauterine debris. It constitutes the first stools passed by a newborn. Prenatal and Postnatal Physiology of the Neonate (contains large amounts of bilirubin Bilirubin A bile pigment that is a degradation product of heme. Heme Metabolism) → ↑ intestinal reabsorption of bilirubin Bilirubin A bile pigment that is a degradation product of heme. Heme Metabolism
    • Typically occurs in the 2nd week of life
  • Infants may need formula supplementation (or a short interruption in breastfeeding) until bilirubin Bilirubin A bile pigment that is a degradation product of heme. Heme Metabolism levels improve.
• Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation to breastfeeding exist.

Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation to breastfeeding

True contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation to breastfeeding are rare, but include:

• Maternal HIV HIV Anti-HIV Drugs in developed countries:
  • HIV HIV Anti-HIV Drugs may be passed to the infant through breast milk.
  • In developed countries, with reliable clean water and access to formula, the risks outweigh the potential benefits of breastfeeding.
  • In developing countries, the benefits of breastfeeding may outweigh the risks.
• Current maternal drug use → infant will be exposed to the drug through breastmilk
• Some maternal medicines:
  • In many cases, alternative medicines that are safe in breastfeeding can be used.
  • Common instances where substitutions are not possible: chemotherapy Chemotherapy Osteosarcoma

Clinical Approach to Breastfeeding

Breastfeeding recommendations

Breastfeeding is recommended by the WHO, US CDC, and United Nations International Children’s Emergency Fund (UNICEF). Specifically, these organizations recommend the following:

• Initiation of breastfeeding within 1 hour of birth
• Exclusive breastfeeding for 6 months of life
• Continuation of breastfeeding (with complimentary food) until at least 12 months of age
• Benefits continue with breastfeeding up to 2 years and beyond.

Ways to promote breastfeeding

• Have a breastfeeding policy in your hospital.
• Educate staff on ways to promote breastfeeding.
• Establish breastfeeding as early as possible (ideally within 30‒60 minutes of birth).
• Allow infants to stay in the same room with the mother in the hospital.
• Mother/infant “skin-to-skin” time (helps babies stay warm and also facilitates bonding)
• Lactation consultants teach parents how to breastfeed well, including the implementation of different breastfeeding positions:
  • Cross-cradle position
  • Supine position
  • Football hold
• Make lactation support available to families after discharge as well.
• Prevent formula companies from giving free samples to parents.
• Avoid giving formula unless medically necessary.
• Educate parents on the benefits of breastfeeding ahead of time.
• Set expectations for the family.

Expectations for the 1st few days of life

• The mother will only produce colostrum for the 1st few days:
  • Low volume
  • Provides adequate nutrition and hydration to infants despite the low volume
  • Weight loss Weight loss Decrease in existing body weight. Bariatric Surgery is expected due to the low volume of colostrum:
    • Infants are born with extra fluid to compensate for low hydration during the 1st few days of life.
    • Infants should not lose more than 7% of their birth weight.
    • Infants should regain their birth weight within 14 days of life.
• Continued feeding/ nipple Nipple The conic organs which usually give outlet to milk from the mammary glands. Examination of the Breast stimulation releases hormones Hormones Hormones are messenger molecules that are synthesized in one part of the body and move through the bloodstream to exert specific regulatory effects on another part of the body. Hormones play critical roles in coordinating cellular activities throughout the body in response to the constant changes in both the internal and external environments. Hormones: Overview and Types necessary to produce mature milk.
• Infants should feed 8–12 times a day, every 2–3 hours.
• 1st 2 days:
  • 1–2 wet diapers per day
  • 1–2 stools per day
• Warning signs of breastfeeding problems:
  • The baby still seems hungry after most feedings.
  • Has not regained birth weight by 2 weeks
  • Failure to express milk even after 5 days of regular Regular Insulin stimulation (every 2–3 hours, including overnight).
  • Severe breast engorgement Engorgement Mastitis (may be a sign that the infant is not latching or suckling correctly)
  • Severe pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways with breastfeeding

Clinical Relevance: Medical Issues Associated With Breastfeeding

Agalactorrhea/lactation failure

• A medical condition characterized by insufficient milk production or absence of the let-down reflex in response to suckling
• The mother is, therefore, unable to breastfeed her newborn Newborn An infant during the first 28 days after birth. Physical Examination of the Newborn baby.
• Etiologies:
  • Most commonly due to inadequate nipple Nipple The conic organs which usually give outlet to milk from the mammary glands. Examination of the Breast stimulation/infrequent feeding shortly after delivery
  • Sheehan syndrome
  • Lymphocytic hypophysitis Lymphocytic Hypophysitis Adrenal Insufficiency and Addison Disease
  • Scar Scar Dermatologic Examination tissue from prior breast surgery
  • Idiopathic Idiopathic Dermatomyositis
• Workup: serum prolactin Prolactin A lactogenic hormone secreted by the adenohypophysis. It is a polypeptide of approximately 23 kd. Besides its major action on lactation, in some species prolactin exerts effects on reproduction, maternal behavior, fat metabolism, immunomodulation and osmoregulation. Breasts: Anatomy levels
• Management:
  • Galactagogues such as domperidone Domperidone A specific blocker of dopamine receptors. It speeds gastrointestinal peristalsis, causes prolactin release, and is used as antiemetic and tool in the study of dopaminergic mechanisms. Antiemetics
  • Certain antipsychotics
  • Avoid combined hormonal contraception (e.g., pills, patch Patch Nonpalpable lesion > 1 cm in diameter Generalized and Localized Rashes, ring).
  • Avoid placentophagia (consuming the placenta Placenta A highly vascularized mammalian fetal-maternal organ and major site of transport of oxygen, nutrients, and fetal waste products. It includes a fetal portion (chorionic villi) derived from trophoblasts and a maternal portion (decidua) derived from the uterine endometrium. The placenta produces an array of steroid, protein and peptide hormones (placental hormones). Placenta, Umbilical Cord, and Amniotic Cavity):
    • An alternative health practice that people engage in to try and decrease the risk of postpartum depression Postpartum depression Depression in postpartum women, usually within four weeks after giving birth (parturition). The degree of depression ranges from mild transient depression to neurotic or psychotic depressive disorders. Postpartum Psychiatric Disorders
    • Contains estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy (may suppress milk production)

Sore and/or cracked nipples

• A common issue typically related to an improper latch
• Good latch: The nipple Nipple The conic organs which usually give outlet to milk from the mammary glands. Examination of the Breast should be deep within the infant’s mouth.
• Other causes:
  • Ankyloglossia Ankyloglossia A severe congenital restriction of tongue movement, resulting from fusion or adherence of the tongue to the floor of the mouth. In partial ankyloglossia (tongue-tie) the lingual frenum is abnormally short, or is attached too close to the tip of the tongue. Omim: 106280. Physical Examination of the Newborn (tongue-tied)
  • Flat or inverted nipples
• Management:
  • Apply breast milk as an emollient to the nipples.
  • Use an emollient that is safe even if ingested (e.g., lanolin).
  • Try different nursing positions.
  • Use a nipple Nipple The conic organs which usually give outlet to milk from the mammary glands. Examination of the Breast shield.

Breast engorgement Engorgement Mastitis

• Occurs when the breast is too full
• Due to:
  • Inadequate frequency of breastfeeding (most common cause) → encourage the mother to feed more often
  • Ineffective feeding → work with a lactation consultant to improve feeding technique
  • Always feeding on the same side 1st → alternate the starting breast
• Clinical presentation:
  • Bilateral pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
  • Hard, firm breast
  • May have a low-grade fever Low-Grade Fever Erythema Infectiosum
  • No redness Redness Inflammation
• Treatment:
  • Empty the breast.
  • Increase breastfeeding frequency.
  • Warm compresses Warm Compresses Chalazion
  • Massage
  • Vary positions: Different positions allow the baby to suck at the breast from different angles, allowing the ducts to empty out.

Mastitis Mastitis Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). Mastitis

• An infection most commonly caused by Staphylococcus aureus Staphylococcus aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Brain Abscess
• Presentation:
  • Unilateral pain Unilateral Pain Cluster Headaches
  • Warmth
  • Erythematous streaking
  • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
• Treatment:
  • Antibiotics (e.g., dicloxacillin Dicloxacillin One of the penicillins which is resistant to penicillinase. Penicillins)
  • Continue breastfeeding:
    • Mastitis Mastitis Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). Mastitis occurs due to the transmission of an infection from the infant’s mouth to the breast.
    • Milk stasis → ↑ time for bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology to replicate
    • Emptying the breast frequently helps resolve/prevent infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease.

Galactocele Galactocele Benign Breast Conditions

• Cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change that form in the breast due to blocked lactiferous ducts Lactiferous ducts Breasts: Anatomy
• Presentation:
  • Palpable, tender, firm mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast
  • No fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
  • Unilateral
• Treatment:
  • The goal is to empty the milk duct.
  • Increased breastfeeding
  • Compresses: warm before breastfeeding, cool after breastfeeding
  • Massage
  • Try different breastfeeding positions.

Breast abscess Breast Abscess Benign Breast Conditions

• Infectious process
• Presentation:
  • Unilateral, fluctuant Fluctuant Dermatologic Examination, painful mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast
  • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever and malaise Malaise Tick-borne Encephalitis Virus
• Treatment:
  • Incision and drainage Incision And Drainage Chalazion
  • Antibiotics

Infantile jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice due to breastfeeding

Two types of infantile jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice are associated with breastfeeding:

• Breastfeeding/lactation failure jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice:
  • Occurs early, within the 1st week
  • Occurs when a baby is not eating enough and becomes dehydrated
  • Due to ↓ excretion and ↑ enterohepatic circulation Enterohepatic Circulation Recycling through liver by excretion in bile, reabsorption from intestines (intestinal reabsorption) into portal circulation, passage back into liver, and re-excretion in bile. Pharmacokinetics and Pharmacodynamics of bilirubin Bilirubin A bile pigment that is a degradation product of heme. Heme Metabolism
• Breast milk jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice:
  • Tends to occur at around 10–14 days of life
  • Transient and usually benign Benign Fibroadenoma
  • Etiology: incompletely understood, but a component of breast milk is thought to affect bilirubin Bilirubin A bile pigment that is a degradation product of heme. Heme Metabolism metabolism in the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy and ↑ enterohepatic circulation Enterohepatic Circulation Recycling through liver by excretion in bile, reabsorption from intestines (intestinal reabsorption) into portal circulation, passage back into liver, and re-excretion in bile. Pharmacokinetics and Pharmacodynamics
  • May take several weeks to resolve
• Management:
  • Check/follow bilirubin Bilirubin A bile pigment that is a degradation product of heme. Heme Metabolism levels.
  • Mothers should usually be advised to continue breastfeeding.
  • Phototherapy Phototherapy Treatment of disease by exposure to light, especially by variously concentrated light rays or specific wavelengths. Hyperbilirubinemia of the Newborn may be required.