Lactation+and+breastfeeding

=Lactation and Breastfeeding=

What it is
The initiation of lactation (lactogenesis) is a natural process that is based on a complex interaction of hormones. Changes in estrogen and progesterone during pregnancy alter the morphologic structure of breast tissue. Increasing levels of the hormone prolactin is key in the initiation and maintenance of lactation and may play a role in the control of electrolyte composition and alteration in amino acid concentration of mature human breast milk. A significant increase in lactogenesis occurs following delivery with the concurrent decline in estrogen and progesterone. In addition, the tactile stimulus by the suckling baby causes a release of prolactin from the pituitary, which stimulates milk flow. This suckling induced prolactin release is a reflex related to hypothalamic serotoninergic neuron activation, accompanied by a concomitant increase of dopamine turn over. Babies delivered at less than 32 weeks gestation are not able to effectively coordinate sucking, swallowing and breathing. The lack of effective suckling that is associated with the delivery of a preterm baby as well as maternal stress, infection, or fatigue can lead to difficulties maintaining lactation.

Lactogenesis is a two-stage event. Lactogenesis I occurs during pregnancy and is the initiation of the synthetic capacity of the mammary glands. Lactogenesis II commences after delivery and is the initiation of plentiful milk secretion.Concurrent with the increase in milk secretion associated with lactogenesis II are significant changes in several milk constituents, termed “biomarkers of lactation,” as the transition from colostrum (high concentration of total protein, immunoglobulins, sodium, and chloride; low concentrations of lactose, potassium, glucose, and citrate) to mature milk (a reversal in concentration of these factors) takes place.These changes in milk composition—coupled with a sudden feeling of breast fullness—identify the onset of lactogenesis II, which usually occurs between 30 and 40 hours following the birth of full-term infants.
 * Lactogenesis**

Lactation is influenced by a complex hormonal milieu including reproductive hormones (estrogen, progesterone, placental lactogen, prolactin, and oxytocin) and metabolic hormones (glucocorticoids, insulin, growth, and thyroid). The reproductive hormones act directly on the mammary gland, whereas the metabolic hormones act indirectly by altering endocrine response and nutrient flux to the mammary gland.Ductal growth is primarily regulated by estrogen and growth hormone, and alveolar development requires progesterone, prolactin, and possibly placental lactogen.During pregnancy, the high levels of circulating progesterone inhibit the secretory process of the mammary gland. Once the placenta is expelled after birth, progesterone levels decline rapidly, and increasing prolactin levels trigger the beginning of lactogenesis II, which is the onset of copious milk secretion. Oxytocin is essential for milk removal from the mammary gland. In response to infant suckling, afferent impulses from sensory stimulation of nerve terminals in the areola travel to the central nervous system triggering the release of oxytocin from the posterior pituitary. In turn, oxytocin is carried through the bloodstream to the mammary gland where it interacts with specific receptors on the myoepithelial cells located on milk-secreting cells (alveoli) and ducts, initiating contraction of the cells, which results in expulsion of milk from the gland.
 * Lactation**

**Delayed/failed Lactogenesis II** Delayed lactogenesis II denotes a longer than usual interval between the colostrum phase and copious milk production, but whereby the mother has the ability to achieve full lactation. Failed lactogenesis II is a condition wherein the mother is either able to achieve full lactation but an extrinsic factor has interfered with the process, or one or more factors results in failure to attain an adequate milk production. Failed lactogenesis can be described further in the context of two types of conditions: a primary inability to produce adequate milk volume, or a secondary condition as a result of improper breastfeeding management and/or infant-related problems and decreased [|milk supply].

Correct Breastfeeding Technique
**Guidelines to Assess for Correct Breastfeeding Technique, Adequate Breast Stimulation, and Effective Milk Removal** 1. Mother is breastfeeding frequently at the first signs of hunger. Newborns usually feed 8 to 12 times per 24 hours. 2. When latching, the infant’s mouth opens and the tongue extends past the lower gum line. 3. Once latched the infant’s lips are flanged and covering at least 1 to 11⁄2 inch of the surrounding areola. 4. The infant sucks rhythmically without causing nipple discomfort and swallowing is heard. 5. While nursing, the infant is positioned ventrally with head, shoulders, and hips in line without rotation. 6. At each feeding, at least 10 minutes of active sucking occurs, the feeding is not timed or limited, and both breasts are offered. 7. Breast compression and massage can be used to assist with milk removal during feedings or while pumping. 8. If the infant is feeding, sucking, or latching inadequately, feeding less than 8 times per 24 hours or unable to breastfeed, the mother usually must double pump 8 to 10 times per day for 15 to 20 minutes with a hospital-grade, electric pump fitted with a flange for each breast.

Benefits of Breastfeeding
It is now clear that the composition of breast milk is uniquely appropriate for the neonate at a time when growth and development are occurring at very high rates, yet when many of the infant’s systems–such as the digestive, hepatic, neural, renal, vascular and immune systems–are functionally immature. Breastmilk is not only a high quality food but also contains many components (eg bile salt stimulated lipase, glutamate, certain polyunsaturated long chain fatty acids, low sodium, lysozyme, IgA, growth factors) which facilitate optimal function of the infant’s immature systems. Studies have shown that breastfeeding reduces the risk or severity of a number of disease states including: - physiological reflux - pyloric stenosis - respiratory illness, particularly in households where both parents smoke - gastrointestinal tract disease - inflammatory bowel disease - some childhood cancers - delayed onset of coeliac disease - otitis media - urinary tract infections - bacteraemia-meningitis - Sudden Infant Death Syndrome - a lower incidence of necrotizing enterocolitis in premature infants
 * Baby**

The development of insulin dependent diabetes mellitus (IDDM) is linked to the age at which cows’ milk is introduced to the infant’s food intake

These benefits are attributed to the infant’s immune system being relatively underdeveloped at birth. Breast milk contains factors which protect the infant from disease while her own immune system develops. Three months of full or even partial breastfeeding will give the infant these benefits

**Mother** - promotion of maternal recovery from childbirth - accelerated uterine involution and reduced risk of haemorrhaging (thus reducing maternal mortality) and preservation of maternal haemoglobin stores through reduced blood loss, leading to improved iron status - prolonged period of post-partum infertility (contraception), leading to increased spacing between pregnancies - possible accelerated weight loss and return to pre-pregnancy body weight - reduced risk of pre-menopausal breast cancer - possible reduced risk of ovarian Cancer - possible improved bone mineralisation and thereby decreased risk of post-menopausal hip fracture

Other Advice
//Every facility providing maternity services and care for new-born infants should:// 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within half an hour of birth 5. Show mothers how to breastfeed, and how to maintain lactation even if they are separated from their infants. 6. Give new-born infants no food or drink other than breastmilk, unless medically indicated. 7. Practise rooming-in (allow mothers and infants to remain together), 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospital or clinic.
 * Ten steps to successful breastfeeding**

Additional Resources
[|NHMRC - Infant feeding guidelines for health workers] [|eMedicine - Human milk and lactation] [|Colostrum]