Breastfeeding

Breastfeeding is often the primary source of nutrition for the newborn Newborn A neonate, or newborn, is defined as a child less than 28 days old. A thorough physical examination should be performed within the first 24 hours of life to identify abnormalities and improve outcomes by offering timely treatment. Physical Examination of the Newborn. During pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding has many benefits for the mother and baby, including a decreased risk of infections, GI distress, and atopic disease for the infant; and a decreased 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, cardiovascular disease, and breast and ovarian cancer Ovarian cancer Ovarian cancer is a malignant tumor arising from the ovarian tissue and is classified according to the type of tissue from which it originates. The 3 major types of ovarian cancer are epithelial ovarian carcinomas (EOCs), ovarian germ cell tumors (OGCTs), and sex cord-stromal tumors (SCSTs). Ovarian Cancer for the mother. True contraindications to breastfeeding exist but are quite rare. Important clinical conditions associated with breastfeeding include engorgement, 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, galactocele, breast abscess, and infant 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.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

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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.
    • Separated from each other by fibrous tissue
    • Each lobe has its own lactiferous duct that drains milk produced in the lobe at the nipple.
    • Lobes are further divided into lobules.
  • Lobules:
    • Individual milk-producing glands called mammary glands
    • Composed of clusters of acini:
      • Less mature lobules contain approximately 10 alveolar buds.
      • More mature lobules contain > 80 alveolar buds.
  • Mammary alveoli:
    • 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
    • Surrounded by myoepithelial cells that have a contractile ability
    • Empty into the lactiferous ducts
  • Ductal system:
    • Forms the passage for the transport of milk from the alveoli to the nipple
    • Mammary alveoli (i.e., acini) → lactiferous ducts → lactiferous sinus → nipple pores (at the central part of the areola)
  • 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 and is not related to the amount of milk that the glandular components can produce.
    • Adipose tissue makes up 80% of the tissue in nonbreastfeeding women.
    • Ligaments between lobules:
      • Known as suspensory ligaments of the breast (Cooper ligaments)
      • Provide structural support
Diagram of a sagittal cross section of the breast

Diagram of a sagittal cross-section of the breast

Image by Lecturio.

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 in pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine 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 occur during pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care as a result of hormonal secretion by the placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. 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 include:
    • Estrogen
    • Progesterone
    • Chorionic gonadotropin
    • Human placental lactogen
    • Prolactin
    • 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 cause:
    • Growth and branching of the ductal system
    • Budding and development of alveoli (after ductal growth):
      • Alveolar cells undergo active cell division.
      • Individual cells increase in size.
    • By delivery: The breast consists almost entirely of glands with very little stroma.
  • Early pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care:
    • Majority of the ductal and glandular development occurs in the 1st ½ of pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care.
    • Breast tenderness may occur (common symptom of early pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care).
  • Later pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care:
    • Growth continues but is slow.
    • Secretions (colostrum) begin to accumulate in the ducts.
  • Just before parturition (delivery): another wave of growth
  • During lactation: Growth and differentiation may continue until lactation stops.

Physiology of Lactation

Milk synthesis

  • Breast milk is synthesized by the columnar epithelial cells in the mammary gland acini.
  • Released into the acini (but not into the ducts yet)
  • Milk synthesis is stimulated by prolactin:
    • Prolactin is secreted by the anterior pituitary gland Pituitary gland The pituitary gland, also known as the hypophysis, is considered the "master endocrine gland" because it releases hormones that regulate the activity of multiple major endocrine organs in the body. The gland sits on the sella turcica, just below the hypothalamus, which is the primary regulator of the pituitary gland. Pituitary Gland.
    • Secretion begins around the 5th week of pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care.
    • Increases 10‒20 times of its normal level by delivery
  • Milk synthesis is inhibited by estrogen and progesterone:
    • Increased secretion by the placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity during pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
    • Hormone levels drop significantly after removal of the placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity at delivery.
  • During pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine 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 (estrogen and progesterone) are dominant → overall effect of inhibition of milk synthesis
  • 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 ↓, but prolactin (from the pituitary) persists and becomes dominant:
    • The overall effect is stimulation of milk synthesis.
    • Milk synthesis significantly increases during the 1st week postpartum.
  • Prolactin surges:
    • Without inhibitory estrogen and progesterone, baseline prolactin levels drop back to nonpregnant levels.
    • With nipple stimulation (i.e., suckling), prolactin levels surge to 10‒20 times that of nonpregnant levels for approximately 1 hour to synthesize milk for the next feeding.
  • Milk synthesis:
    • Stops approximately after 1 week if there are no prolactin surges
    • Stops when:
      • Mother stops breastfeeding.
      • Prolactin surges are absent due to pituitary damage.
  • If the mother continues to breastfeed:
    • Milk production continues for a few years postpartum.
    • Quantity may gradually decline after 8–9 months.
  • Prolactin also inhibits ovulation:
    • Prolactin inhibits the release of gonadotropins:
      • Follicle-stimulating hormone (FSH)
      • Luteinizing hormone (LH)
    • 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 levels drop, FSH and LH are produced → ovulation

Milk ejection

Ejection of milk requires the pituitary hormone oxytocin.

  • Nipple stimulation (via suckling or using a mechanical breast pump) → sensory 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 → posterior pituitary gland Pituitary gland The pituitary gland, also known as the hypophysis, is considered the "master endocrine gland" because it releases hormones that regulate the activity of multiple major endocrine organs in the body. The gland sits on the sella turcica, just below the hypothalamus, which is the primary regulator of the pituitary gland. Pituitary Gland releases oxytocin
  • Oxytocin:
    • Travels via the blood to reach the myoepithelial cells surrounding the outer wall of the alveoli
    • Triggers the myoepithelial cells to contract → ↑ pressure in the acini → forces milk into the ductal system
  • Milk flows into the lactiferous ducts → lactiferous sinus → sucked out of the nipple through nipple pores by the infant or action of the pump
  • Approximately 30 seconds from the onset of suckling to milk flow (known as “let-down”)
  • Oxytocin may also be released by:
    • A baby crying
    • Visual and psychogenic factors
The let-down reflex

The let-down reflex

Image: “A positive feedback loop ensures continued milk production as long as the infant continues to breastfeed” by OpenStax College. License: CC BY 4.0

Stages of lactogenesis

There are 2 stages of lactogenesis:

  • Lactogenesis I:
    • Starts around mid- pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
    • Represents the time when the gland is sufficiently differentiated to secrete small quantities of milk components
    • Milk secretion generally does not occur due to the inhibitory effects of estrogen and progesterone.
  • Lactogenesis II:
    • Starts shortly after delivery
    • Represents the time of copious milk secretion that occurs with the drop of estrogen and progesterone

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 A neonate, or newborn, is defined as a child less than 28 days old. A thorough physical examination should be performed within the first 24 hours of life to identify abnormalities and improve outcomes by offering timely treatment. Physical Examination of the Newborn mammals
  • Development of sucking reflex:
    • Begins around 32 weeks’ gestation
    • Fully develops by approximately 36 weeks’ gestation
    • Premature 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)
  • 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 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
    • Proteins
    • Carbohydrates Carbohydrates Carbohydrates are one of the 3 macronutrients, along with fats and proteins, serving as a source of energy to the body. These biomolecules store energy in the form of glycogen and starch, and play a role in defining the cellular structure (e.g., cellulose). Basics of Carbohydrates (primarily lactose)
    • Vitamins and minerals
    • 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
  • Colostrum:
    • Fluid that collects in the lactiferous ducts 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
    • ↓ 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
  • ↓ Risk of postpartum depression
  • Fewer urinary tract infections Urinary tract infections Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary Tract Infections
  • Faster weight loss/return to prepregnancy weight
  • ↓ Unintended pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care (due to inhibition of ovulation by prolactin)
  • ↓ Risk of medical conditions later in life:
    • Breast and ovarian cancers
    • Autoimmune diseases
    • 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
    • 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:
    • ↓ Risk of infection due to maternal IgA 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:
      • Respiratory infections: 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
      • Bacterial meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis
    • Improved response to vaccines
  • Promotes colonization 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: Overview
  • 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
    • Necrotizing enterocolitis Necrotizing enterocolitis 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 ( 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
    • 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
    • Diabetes
    • 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 and 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 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
  • 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

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 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:
    • 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 (contains large amounts of bilirubin) → ↑ intestinal reabsorption of bilirubin
      • Typically occurs in the 2nd week of life
    • Infants may need formula supplementation (or a short interruption in breastfeeding) until bilirubin levels improve.
  • Contraindications to breastfeeding exist.

Contraindications to breastfeeding

True contraindications to breastfeeding are rare, but include:

  • Maternal HIV in developed countries:
    • HIV 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

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 Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin-to- skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the 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.
Breastfeeding positions

Breastfeeding positions:
a. Cross-cradle position
b. Supine position
c. Football hold

Image by Lecturio.

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 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 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 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 stimulation (every 2–3 hours, including overnight).
    • Severe breast engorgement (may be a sign that the infant is not latching or suckling correctly)
    • Severe pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 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 A neonate, or newborn, is defined as a child less than 28 days old. A thorough physical examination should be performed within the first 24 hours of life to identify abnormalities and improve outcomes by offering timely treatment. Physical Examination of the Newborn baby.
  • Etiologies:
    • Most commonly due to inadequate nipple stimulation/infrequent feeding shortly after delivery
    • Sheehan syndrome
    • Lymphocytic hypophysitis
    • Scar tissue from prior breast surgery
    • Idiopathic
  • Workup: serum prolactin levels
  • Management:
    • Galactagogues such as domperidone
    • Certain antipsychotics
    • Avoid combined hormonal contraception (e.g., pills, patch, ring).
    • Avoid placentophagia (consuming the placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity):
      • An alternative health practice that people engage in to try and decrease the risk of postpartum depression
      • Contains estrogen (may suppress milk production)

Sore and/or cracked nipples

  • A common issue typically related to an improper latch
  • Good latch: The nipple should be deep within the infant’s mouth.
  • Other causes:
    • Ankyloglossia ( tongue Tongue The tongue, on the other hand, is a complex muscular structure that permits tasting and facilitates the process of mastication and communication. The blood supply of the tongue originates from the external carotid artery, and the innervation is through cranial nerves. Oral Cavity: Lips and 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 shield.

Breast engorgement

  • 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 Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Hard, firm breast
    • May have a low-grade 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
    • No redness
  • Treatment:
    • Empty the breast.
    • Increase breastfeeding frequency.
    • Warm compresses
    • Massage
    • Vary positions: Different positions allow the baby to suck at the breast from different angles, allowing the ducts to empty out.

Mastitis

  • An infection most commonly caused by Staphylococcus Staphylococcus Staphylococcus is a medically important genera of Gram-positive, aerobic cocci. These bacteria form clusters resembling grapes on culture plates. Staphylococci are ubiquitous for humans, and many strains compose the normal skin flora. Staphylococcus aureus
  • Presentation:
    • Unilateral pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Warmth
    • Erythematous streaking
    • Fever
  • Treatment:
    • Antibiotics (e.g., dicloxacillin)
    • Continue breastfeeding:
      • 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: Overview to replicate
      • Emptying the breast frequently helps resolve/prevent infections.

Galactocele

  • Cysts that form in the breast due to blocked lactiferous ducts
  • Presentation:
    • Palpable, tender, firm mass
    • 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

  • Infectious process
  • Presentation:
    • Unilateral, fluctuant, painful mass
    • Fever and malaise
  • Treatment:
    • Incision and drainage
    • 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 of bilirubin
  • 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
    • Etiology: incompletely understood, but a component of breast milk is thought to affect bilirubin 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 and ↑ enterohepatic circulation
    • May take several weeks to resolve
  • Management:
    • Check/follow bilirubin levels.
    • Mothers should usually be advised to continue breastfeeding.
    • Phototherapy may be required.

References

  1. Kalarikkal, S.M., Pfleghaar, J.L. (2021). Breastfeeding. In StatPearls. Treasure Island (FL): StatPearls Publishing. Retrieved October 22, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK534767/
  2. Dieterich, C.M., Felice, J.P., O’Sullivan, E., Rasmussen, K.M. (2013). Breastfeeding and health outcomes for the mother-infant dyad. Pediatr Clin North Am. 2013, 60, pp. 31–48. https://doi.org/10.1016/j.pcl.2012.09.010
  3. Hoddinott, P., Tappin, D., Wright, C. (2008). Breast feeding. BMJ, 336, pp. 881–887. https://doi.org/10.1136/bmj.39521.566296.BE
  4. Shamir, R. (2016). The benefits of breast feeding. Nestle Nutr Inst Workshop Ser. 2015, vol. 86, pp. 67–76. https://doi.org/10.1159/000442724
  5. Spencer, J. (2021). Common problems of breastfeeding and weaning. In UpToDate. Retrieved October 22, 2021, from https://www.uptodate.com/contents/common-problems-of-breastfeeding-and-weaning 
  6. Pillay, J., Davis, T.J. (2021). Physiology, Lactation. In StatPearls. Treasure Island (FL): StatPearls Publishing. Retrieved October 22, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK499981/ 
  7. Cleveland Clinic Health Library (2018). The benefits of breastfeeding for baby & for mom. Retrieved October 22, 2021, from https://my.clevelandclinic.org/health/articles/15274-the-benefits-of-breastfeeding-for-baby–for-mom 
  8. Center for Disease Control and Prevention (2021). Breastfeeding. Retrieved October 22, 2021, from https://www.cdc.gov/breastfeeding/index.htm 

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