OBS&GYN

Why Breastfeed?

Literature is replete with scientific evidence on the benefit of the most natural process of a mother-

breast feeding her baby

Exclusive breast feeding in the first six months of life can cut down under-five child mortality by

13-15%

Lactation Anatomy and Physiology

Breast enlargement

During pregnancy and lactation indicates the mammary glands

are becoming functional

Breast size before pregnancy does not determine the amount

of milk a woman will produce

Lactation Anatomy and Physiology

Hormones during pregnancy

Estrogen stimulates the ductile systems to grow, then

estrogen levels drop after birth

Progesterone increases the size of alveoli and lobes

Prolactin contributes to increasing the breast tissue during

pregnancy

Lactation Anatomy and Physiology

Alveoli secrete milk and contract when stimulated

Oxytocin stimulates milk secretion and is released

during the ‘let down’ or milk ejection reflex

After let down, milk travels into the ductules, then to

the larger – lactiferous or mammary ducts

Lactation Anatomy and Physiology

Hormones during breastfeeding

Prolactin levels rise with nipple stimulation

Alveolar cells make milk in response to prolactin when the

baby sucks

Oxytocin causes the alveoli to squeeze the newly produced

milk into the duct system

Lactation Anatomy and Physiology

Latch On and sucking

Oxytocin Release

Releases Milk

Infant Empties Breast

Production Increases

Milk Production Occurs

Interference with this cycle decreases the milk supply.

Advantages

Baby Mother Family

Breastfeeding Mother Health Benefits

Less postpartum bleeding

More rapid uterine involution

Weight loss

Decreased premenopausal breast cancer rates

Decreased ovarian cancer rates

Lactational amenorrhea Should still use progesterone only contraceptives

Combined contraceptives dry up milk

Advantages to the baby

Decreased incidence of infections- diarrhea, RTI, otitis media, NE, late onset sepsis in pre term

Reduction of both Type I and II diabetes, leukemias, lymphomas, asthma and obesity.

Enhances performance on cognitive development

Advantages to the family

Readily available

Hygienic

Economical

Keeps children healthy

The first few steps…..

Proper antenatal counseling

A well informed, supportive husband

Relative or nurse in the labour room

At The Earliest

In the healthy neonate suckling reflex is at its peak- 30 to 40 mins after birth

Early feeds stimulate production of prolactin and increases the mean duration of breast feeding

The first few steps…..

Placed prone on the mother’s abdomen

Feed in the 1st hr of delivery

on the labour table itself

Breast Feeding In Operative Delivery

Maintain skin to skin contact

Breast feeding within 1 hr when LSCS under spinal anesthesia; otherwise when the effect of GA weans off.

Women should not have pain, as it decreases production of milk

Position of baby is important

Frequency And Length Of Breast Feeding

Exclusive breast feeding for 6 months

On an average 650 to 850 ml milk is produced per day.

2 to 3 hourly or 8 feeds per day or feed on demand

Duration time is 25 to 30 min- both breasts should be fed each time

Indicators Of Adequate Feed

No of feeds each day (8 or on demand)

If baby sleeps well for 2 to 3 hours after feed

Urine output- 6 to 8 diapers per day

No of stools- 4 to 5 times per day

Weight gain- 30 gm per day

Care Of Mother

Calorie intake- 300 to 500 extra calories

( 2200 to 3000 kcal per day)

Balance diet and no weight reduction

Fluid intake : 22% from well balanced diet; increase fluid intake is essential)

Iron and Calcium Supplementation

GALACTOGOGUES

There is no ideal galactogogue

Chlorpromazine and metoclopromide- 10 mg 3 times daily for 7 days

Self confidence, freedom from anxiety, soothing environment with vigorously sucking by an active

baby are the most effective pre-requisites for successful establishment of lactation.

Chlorpromazine

Chlorpromazine is a dopamine antagonist

maternal side effects are more frequent

Adverse effects include extrapyramidal reactions, orthostatic hypotension, anticholinergic effects, and altered cardiac conduction.

This drug for selected refractory cases

Metoclopramide

Reproductive Considerations

Metoclopramide may increase prolactin concentrations;

hyperprolactinemia may suppress hypothalamic GnRH,

inhibit reproductive function by impairing gonadal steroidogenesis.

Amenorrhea and impotence have been reported.

Domperidone

is not currently approved in any country as a galactagogue (Sewell 2017).

Domperidone may increase prolactin concentrations and cause galactorrhea and gynecomastia

As such, it has been used off-label as a galactagogue in patients with insufficient milk production.

SUPPRESSION

Estrogen

Bromocriptin

Cabergolin

Thiazide

Pyridoxine

OCP

Testosterone

Breastfeeding Barriers

Early breastfeeding failures deprive infants of the

benefits, and leave many mothers disappointed

It is a natural process, but many mothers need a lot

of help

Breastfeeding Barriers

Breast Pathology Flat/inverted nipples, breast reduction surgery that severed

milk ducts, previous breast abscess, extremely sore nipples (cracked, bleeding, blisters, abrasions)

Hormonal pathology Failure of lactogenesis, hypothyroidism

Overall health Smoking, anemia, poor nutrition, depression

Psychosocial Restrictive feeding schedules, mother without support

system, not rooming in with baby, bottle supplementing when not medically required

Other Previous breastfed infant who failed to gain weight well,

perinatal complication (hemorrhage, htn, infection

Breastfeeding Hospital Discharge Support

Mother breastfeed longer if they: Are confident at hospital discharge

Have a good support system after discharge

Receive follow up after discharge

Upon discharge Give written information

Recommend mom to keep breastfeeding record

Give mom phone number for a telephone helpline

Lactation consultant follow-up

AN AC U T E I N F L AM M AT I O N O F T H E

I N T E R L O B U L AR C O N N E C T I V E T I S S U E W I T H I N

T H E M AM M A RY G L AN D

Mastitis

Mastitis

Normal breast

architecture

Outline

Epidemiology

Presentation

Predisposing factors

Microbiology

Treatment

Complications

Effect on breast milk

Epidemiology

Incidence 2-10%

Hospitalization is low (9 / 10000 delivery)

Most common worldwide <10%

Most common 2nd-3rd week postpartum 74-95% in first 12 weeks

Can occur anytime in lactation

Recurrence is more in prior history

Presentation

Systemic illness: Chills, myalgias

Fever of ≥ 38.5

Tender, hot, swollen wedge-shaped erythematous

area of breast

Usually one breast

Differential Diagnosis

Fullness: bilateral, hot, heavy, hard, no redness

Engorgement: bilateral, tender, +/- fever, minimal diffuse erythema

Blocked Duct: painful lump with overlying erythema, no fever, feel well, particulate matter in milk

Differential Diagnosis

Galactocele: smooth rounded swelling (cyst)

Abscess: tender hard breast mass, +/- fluctuance,

skin erythema, induration, +/- fever

Inflammatory Breast Carcinoma: unilateral, diffuse

and recurrent, erythema, induration

Causes

Milk Stasis

Stagnant milk increases pressure in breast leading to leakage

in surrounding breast tissue

Milk, itself, causes an inflammatory response

+/- Infection

Milk provides medium for bacterial growth

Causes

3 groups Milk stasis (bacteria<10^3, leuk<10^6)

Noninfectious inflammation (bacteria <10^3, leuk >10^6)

Infectious (bacteria >10^3, leuk>10^6)

Randomized treatment No intervention

Systematic emptying of breast

Infectious group with 3rd intervention: antibiotics and systematic emptying

Causes

“Poor results” Milk stasis 3 recurrences, 7 impaired lactation

Noninfectious 13 recurrences

Infectious 6 abscesses, 21 recurrences

Conclusion: Treat with antibiotics

Predisposing factors Improper nursing technique Timing of feeds Poor attachment

Oversupply of milk Overabundant milk supply Lactating for multiples Rapid weaning Blocked nipple pore or duct

Pressure on Breast Tight Bra Car seatbelt (yes, this is actually listed) Prone sleeping position

Predisposing factors

Damaged nipple (nipple fissure) Primiparity

Previous history of mastitis

Maternal or neonatal illness

Maternal stress

Work outside the home

Trauma

Genetic

Microbiology

Detection of pathogens difficult

Usually nasal/skin flora

Difficult to avoid contamination

Milk culture

Encouraged in hospital acquired, recurrent mastitis, or no

response in 2 days

Microbiology

Staph Aureus

MRSA (IMPORTANT PATHOGEN)

Coag neg staph

Also, Group A and B βhemolytic Strep, E Coli, H. flu

Fungal infections

TB where endemic – 1% of cases

Fungal infections

Based on case reports that anti-fungal cream improves

Case reports of cyptococcal infection Most common: Candida Albicans Genital tract Newborn oral colonization

May lead to nipple fissure Thought to be associated with deep, shooting

pains and nipple discomfort Most commonly treated with fluconozole to ,

oral nystatin to infant

Candida Infection

Treatment

Supportive Therapy Rest, fluids, pain medication, anti-inflammatory agents,

encouragement

Continue breast feeding

Antibiotics that cover Staph and Strep Culture results

Severe symptoms

Nipple fissure

No improved after 12-24 hours of milk removal

Treatment

Dicloxicillin 500 mg qid

Cephalexin 500 mg qid

Erythromycin 500 mg bid if PCN allergic

If resistant to treatment penicillinase-producing

staph, then vancomycin or cefotetan until 2 days

after infection subsides

Minimum treatment 10-14 days but 5-7 days enough

for good and fast response

( O T H E R B AD T H I N G S R E L AT E D T O M AS T I T I S )

Complications

Breast Abscess

Breast Abscess

Breast abscess

with early skin

necrosis

Abscess

Most common in first 6 weeks

0/1 % of mastitis cases

No differences b/t groups by age, parity,

localization of infection, cracked nipples, + milk

cultures, mean lactation time

Duration of symptoms: only independent variable

favoring abscess development

Breast Abscess

Inflammatory

breast cancer

Other Complications

Distortion of breast

Chronic inflammation

Granulomatous Mastitis

Noncaseating granulomas in a lobular distribution

Differential Diagnosis TB mastitis

Foreign body

Fat necrosis

Autoimmune: sarcoid, erythema nodusum, polyarthritis

Presentation Unilateral Breast lump

No infection identified at presentation

Granulomatous Mastitis

Can mimic Breast Ca on clinical, radiological, and cytological exams

Diagnosis: Histology

Treatment: Antibiotics not helpful

Corticosteroids

Excision biopsy

Limited literature, but no clear association with breast feeding, OCPs

Neonatal Mastitis

Occurs up to 5 weeks of age

Girls outnumber boys 2 : 1

Etiology: 85% S. aureus, also E. coli, group D

Streptococcus

Treatment:

Prompt antibiotics (IV?)

Careful needle aspiration if abscess

Effect on Milk

Increased HIV transmission risk

Alternating breast/bottle increased risk

Role of free virus vs cell bound virus unclear

If ♀ must breast feed, then pump on affected breast

(pasteurize) and feed on unaffected

RETRACTED NIPPLE

Antenatal examination and counseling for cleaning of nipples and their aversion is important

20 cc syringe may also be used for correcting retraction

Nipple shield

Use of breast pump

SORE NIPPLE

Commonest

Cause improper latching

Symptoms: pain

Signs: nipple is red, cracked, bruised, blistered and tender

Treatment: linolin/ emolient cream; air drying and applying own milk, nipple shield for time being, EBM

ENGORGEMENT

Swollen breast due to increased

milk production

Maybe early or late

Early engorgement resolves with baby sucking

Painful, swollen, warm, hard or rigid breasts needs treatment

Treatment: gentle massages, warm compresses, milk expression, breast support, oxytocics, NSAID

WEANING

Aim is to introduce- iron, calcium, vitamins and calories to baby in adequate quantity through liquid

and semisolid diet from 4 to 6 months of age

It should be done gradually

PREVENTION of lactational mastitis

administration of a Lactobacillus probiotic during late pregnancy may reduce the likelihood of lactational mastitis.

women who received oral Lactobacillus salivarius PS2 had a lower incidence of mastitis than those who received placebo

It is unknown whether administration of probiotic therapy would be beneficial for pregnant women with no history of lactational mastitis.