LACTATION FAILURE

Sonali singhResidentPaediatricsGrant medical college, mumbai

LACTATIONIt is the process of secreting milk from

breast. It is a physiological process under neuroendocrine control.

LACTATION FAILURECondition where mother is not able to

produce milk.

Physiology of lactation

PROLACTIN REFLEXProlactin goes in blood to

the breast

Makes milk

secreting cells

produce milk

Baby suckles at the breast

Sensory impulse

from nipple to

brain

Prolactin secreted from ant part of

pituitary

OXYTOCIN REFLEXOxytocin secreted

from posterior part of

pituitary

Oxytocin makes

muscle cell around alveoli

contract

Milk collected in alveoli flows along duct

towards nipple

Baby suckles at the breast

Sensory impulse

from nipple to brain

IMPORTANTOxytocin reflex is positively affected by

mother’s sensation and feelings like thinking lovingly about the baby,touching, smelling or seeing the baby or hearing the baby cry.

If mother is emotionally disturbed or experiencing pain or discomfort oxytocin reflex doesn’t work well and baby has problem getting milk.

Causes of lactation failure

Causes related to

mother

Psychological and social

Biological

Causes related to the baby

biological

Maternal: Psychological and social causes(81%) Insufficient milk(80%/75%) Unsuitable milk(38%/50%) Refusal by baby(4%/2%) Illness of the mother(4%/-) Maternal employment(8%/2%) Advice by relative or friend(12%/-) Ill infant (43%/25%) Advice by doctor/nurse(7%/-) Dislike for breast feeding Fixed schedule feeding Previous unsuccessful breast feeding experience Lack of confidence,shyness Worry,stress Tired Religious customs

MATERNAL:BREASTFEEDING RELATED

Delayed startFixed schedule feedingInfrequent feedsNo night feedsShort feedsPoor attachmentBottle/pacifierOther foodOther fluid

Maternal: Biological causes(local)Sore and cracked nipple (38%)Inverted nipple(27%)Engorged breast(18%)Mastitis and abscess(14%)Others(3%)Burn/scarringBreast surgeryAnatomically abnormal breast( insufficient

glandular tissue) very rareRetained placentarare

Maternal: biological causes(systemic)Endocrinopathies- thyroid, pituitary, ovarian

dysfunction.Chronic maternal illness- DM, SLE,HTN (do not

affect lactation .Physical disability.Complications of pregnancy- GDM, PIH early

maternal infant separationinterferes with initiation of lactation.

Contraindications of breast feeding.Psychiatric disorder

DRUGS CAUSING SUPPRESSION OF LACTATION1. Calcitonin2. Diuretics- loop, thiazide3. Dopamine receptor agonist- bromocriptine,

cabergoline.4. Ergotamine5. Levodopa6. Contraceptives7. Pseudoephedrine8. Pyridoxine9. Tamoxifen

Neonatal causesNeonatal illness early maternal/infant

separationinterferes with initiation of lactation.Neonatal disorders associated with poor

suck(cleft lip and/or palate, short frenulum, micrognathia, choanal atresia)

maternal or infant medication that causes drowsiness

neonatal asphyxia, preterm birth, Down’s syndrome etc

Breast rejection

The complaint of “insufficient milk” is more often than not a wrong perception of the mother, fostered by the mother’s uncertainty about her capacity to feed her baby properly, no knowledge about the normal behavior of a baby (who usually nurses frequently) and negative opinions of significant persons.

The wrong perception by the mother leads to the introduction of complementary feeding negatively affects milk production.

When to suspect lactation failure?SYMPTOMSInfant is not satisfied after feeds, cries a lot.Wants to nurse frequently.Takes very long feeds.Improper weight gainInfrequent bowel movement- small in

amount, dry and hard.Less need to change diaper(6-8)

SIGNS INDICATING LACTATION FAILURE IN 1ST WEEK

Weight loss greater than 10% of the birthweight,

not regaining birth weight up to two weeks of life,

no urinary output for 24 hours. absence of yellow stools in the first weekClinical signs of dehydration.

MANAGEMENT OF LACTATION FAILURE

PRIMARY PREVENTION

SECONDARY PREVENTION

TERTIARY PREVENTION

The concept of breast feeding kinetics as developed by Livingstone conveys the idea that there is dynamic interaction between a breast feeding mother and her infant over time.

Most disorders of lactation are iatrogenic because of impeded establishment of lactation/ inadequate ongoing stimulation and drainage of breast.

Most breast feeding difficulties are due to lack of knowledge, poor technical skills/ lack of support.

Almost all problems are reversible. Prevention, early detection and management

should become a routine part of maternal and child health care.

ANTENATAL SCREENING FOR RISK FACTORSBREAST EXAMINATIONEVALUATION OF SYSTEMIC ILLNESSMATERNAL GENERAL CONDITION AND DIETRAY HABITSLACTATION ASSESSMENT IN 3RD TRIMESTERBREAST FEEDING EDUCATIONEDUCATION REGARDING ADVANTAGES OF BREAST

FEEDING TO BABY, MOTHER AND TO SOCIETYEDUCATION REGARDING DISADVANTAGES OF TOP FEEDSCOUNSELLING TO MOTHER WITH PREVIOUS

UNSUCCESSFUL BREAST FEEDING EXPERIENCEIMPORTANT- mother should be accompanied by other

influential members of the family as attitude and knowledge of mother as well as her near ones should be changed in order to have successful breast feeding.

NATAL AND IMMEDIATE POST NATAL- what to do?Medicated and interventional labor should be avoided as far as

possible interferes with instinctive rooting behaviour to locate and latch onto the breast.

Initiate breastfeeding as soon as possible after complete delivery of placenta early breast stimulation initiates early lactation.

Breast feeding on demand regular breast drainage and stimulation promotes lactogenesis( initially hormonal based, later autocrine)

Proper positioning, attachment, latching on supervised.Rooming in (24 hrs)- same bed. Separation impedes drainage

and stimulation.Combined mother infant nursing institution of patient centred

teaching.Address local problems(biological causes immediately)Counselling regarding diet of mother.

Instructions to be given to mother for successful establishment of lactation.

Positioning, attachment, latch-on.Frequency- on demand usually2-3 hourly(≥8

feeds), including night feeds.Duration- varies between mother-infant pair.Pattern of breast use- 1st breast comfortably

drained followed by switching to 2nd Feeds not to be terminated prematurely in

sleeping infants.Mothers should be explained that it takes

time for proper milk formation

Baby friendly hospital initiative(1992)

1. Written breast feeding policy.2. Training of health care staffs.3. Information to all pregnant ladies regarding

breast feeding.4. Breast feeding within half an hour of birth.5. No food or drink other than breast milk to the

baby, unless medically indicated.6. Show mothers how to breast feed and to maintain

lactation even if they should be separated.7. Rooming in.8. Breast feeding on demand.9. No artificial teats or pacifiers or prelacteal feeds

to the baby.10.Mother support group.

•Infant wt loss<7%+good breast feeding skills

•Plan discharge+ lactation assessment on f/u

•Infant weight loss<7%+poor breast feeding skills

•Extended hospital stay

•Infant weight loss>7%•Breast feeding assesssment+extended

hospital stay

Planning hospital discharge

Establishing relactation(for mother with lactation failure on post natal follow up)

Physiological basis of lactation on which relactation depends.Breast feeding requires:-Growth of secretory alveoli in glandular tissue of breast.Secretion of milk.Removal of milkDepends on hormoneProlactin- Imp for:- development of secretory alveoli;

. secretion of milk

Stimulus- nipple stimulation Most effective stimulus-suckling of an infant (daytime<night time suckling)

Oxytocin- Imp for milk removal. BEST WAY OF STIMULATION+REMOVAL OF

MILK:-SUCKLING INFANT.

APPROACH TO A MOTHER WITH LACTATION FAILUREHISTORY +CLINICAL EXAMINATION NO DISEASETRUE LACTATIONAL FAILURE OR NOT

YES NO COUNSEL

CHECK FOR:-POSITION,ATTACHMENT,SUCKLINGNIGHT FEEDS?FREQUENCY? NO PROBLEMPLAN FOR ESTABLISHMENT OF RELACTATION

FACTORS WHICH AFFECT SUCCESSFUL RELACTATION

Willingness to suckAgeBreast feeding gapGestational age

Feeding experience during the gapIntake of complementary food

INFANT RELATED

Woman’s motivationLactation gapCondition of breastsPrevious experience of lactationAbility to interact responsively with her childSupport from family, community,health workers

MOTHER RELATED

If infant is willing to suckEncourage the woman:-Put infant to breast frequently(1-2 hrly/8-10

times in 24 hrs)Sleep with infant and breast feed at nightEnsure good attachmentLet infant suckle at both breasts, for as long

as possibleFeed infant supplements separately using a

cup.

Infant is unwilling/unable to suckEnsure child is not sickSkin to skin contactOffer breast any time child is interested to

suckBreast feeding supplementer methodDrop and drip method

Breast feeding supplementer method

Drop and drip method

Supplementing the infantWhile mother’s breastmilk supply is becoming

established, it is essential to ensure that the child receives adequate nutrition( through wati and spoon/breastfeeding supplementer)

Supplement- cow’s milk diluted till 2 m of age(150ml+50mlwater+5g sugar)

To begin with supplement should be full (150cc/kg/day divided in atleast 8 feeds)

As breast milk increases supplement should be reduced.

child’s weight should be regularly monitored.

How to reduce supplementIn some cases child shows less interest by

refusing supplement/ refusal to suck on 2nd breast.

Reduce total amount of supplement in 24hrs by 50ml.

Continue reduced feed for next few daysIf by behaviour and weight gain(125g/week) feed

appears to be sufficient reduce it further else continue the same for 1 more week.

GALACTOGOGUES Galactogogues (or lactogogues) are medications or other

substances believed to assist initiation, maintenance, or augmentation of maternal milk production.

MEDICATIONS Metoclopramide- antagonizes dopamine in cns, hence

increases prolactin level. Dose- 30-45mg/day in 3-4 divided doses. Given for 7-14

days then taper off in next 5-7 days. Domperidone- dopamine antagonist increases prolactin

level. Dose-10-20mg/day in 3-4 divided doses for 3-8weeks. Sulpride and chlorpromazine Gh TRH Oxytocin

Herbal /natural galactogogues:-satavariFenugreek anise, basil, fennel seedsGarlicGingerJaggeryCoconutBajraKhaskhasPepperPanjeerSonthJeevanthiPanjeeri

BEST GALACTOGOGUE- BABY SUCKLING at THE BREST in correct position..

ImportantConfidenceSupport of family membersRegular f/u if possible

MANAGEMENT OF BIOLOGICAL CAUSES

Flat nipple

Anatomical nipple forms only 1/3rd of the

teat of the breast tissue in baby’s

mouth.

Reassuarance

Inverted nippleNipple does not

protract, on attempt to pull out the nipple, it goes

deeper into breast.

SYRINGE METHOD

SYRINGE METHOD

ENGORGED BREASTIf baby is able to suckle, mother should feed

frequently.If pain and tightness does not allow suckling

express milkcomfortable breast feedCold compressParacetamol for pain and fever.

DIFFERENCES BETWEEN FULL AND ENGORGED BREASTSFull Breasts Engorged Breasts Hot Painful Heavy Oedematous Hard Tight, especially nipple Shiny May look red Milk flowing Milk NOT flowing No fever May be fever for 24

hours

Mastitis and abscessMastitis supportive counselling and

improved drainage of milk from affected part of breast by breast feeding/expressing

Indication for antibioticsLab tests show infectionSevere symptoms/ symptoms do not improve

after 12 hrs of milk removal• Analgesic and warm compress for pain relief• Abscess incision and drainage.

Sore /cracked nippleMc cause of sore nipple- poor attachment.Improving infant’s attachment to breast

relieves the pain.Hind milk rich in fat should be applied.Oral thrush 1% gentian violet should be

applied over nipple as well as inside baby’s mouth.

Systemic illnessEndocrinopathies and other chronic illness

needs to be managed along with other measures for encouraging breast feed.

StudiesLactation failure by G.P mathur published in IAP-

partial lactation failure(94.7%) was more common than complete lactation failure(5.3%). An attempt at relactation was successful in 69.3% cases, failed in 4% cases and the remaining were lost to follow up.

LACTATION MANAGEMENT CLINIC-POSITIVE REINFORCEMENT TO HOSPITAL BREASTFEEDING PRACTICES by Nanavti and Mondkar78.1% mothers practised EBF on subsequent visits, 21.2% were partially successful in lactation and only 3 mothers had lactation failure.

ConclusionSupportive breastfeeding policies in hospital

constitute the foundation for initiation of successful breastfeeding by mothers, constant reinforcement and support to all lactating mothers is essential to maintain lactation.

REFERENCESRelactation: review of experience and

recommendation for practice, WHOIAP textbookBreast feeding in practice: a manual for health

workersTraining manual on breast feeding

management(UNICEF)Breast feeding medicine, vol 4(ABM protocols)Avery’s diseases of newbornMeherban singh for newborne

thank you....