LACTATION Physiology, Nutrition, and Breast-Feeding

LACTATION Physiology, Nutrition, and Breast-Feeding

Edited by

Margaret C. Neville and

Marianne R. Neifert UnilJersi~ oj Colorado Sclwol oj Medicine DenIJeT, Colorado

PLENUM PRESS. NEW YORK AND LONDON

Library of Congress Cataloging in Publication Data

Main entry under title:

Lactation: physiology, nutrition, and breast-feeding.

Bibliography: p. Includes index. 1. Lactation. 2. Breast-feeding. 3. Infants- Nutrition. I. Neville, Margaret C.,

date- . II. Neifert, Marianne R. QP246.L33 1983 ISBN-13: 978-1-4613-3690-7 DOl: 10.1007/978-1-4613-3688-4

©1983 Plenum Press, New York

612'.664 e-ISBN-13: 978-1-4613-3688-4

Softcover reprint of the hardcover 1 st edition 1983

A Division of Plenum Publishing Corporation 233 Spring Street, New York, N.Y. 10013

All rights reserved

83-17652

No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher

Contributors

Jonathan C. Allen, Ph.D. • Department of Physiology, University of Col­orado School of Medicine, Denver, Colorado 80262

SaUy E, Berga, Ph.D. • Department of Physiology, University of Colorado School of Medicine, Denver, Colorado 80262

Watson A. Bowes, Jr., M.D. • Department of Obstetrics/Gynecology, Uni­versity of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27514

Clare E. Casey, Ph.D. • Department of Pediatrics, University of Colorado Health Sciences Center, Denver, Colorado 80262

Janice E. Errick, Ph.D. • Department of MCD Biology, University of Colorado, Boulder, Colorado 80309

Stanley F. Gould, M.D., Ph.D • Departments of Obstetrics and Gynecology and Anatomy, University of Colorado School of Medicine, Denver, Colorado 80262

K. Michael Hambidge, M.D. • Department of Pediatrics, University of Colorado Health Sciences Center, Denver, Colorado 80262

Anthony R. Hayward, M.D. • Department of Pediatrics, University of Col­orado School of Medicine, Denver, Colorado 80262

Kathryn B. Horwitz, Ph.D • Departments of Medicine and Biochemistry, Biophysics, and Genetics,. University of Colorado Health Sciences Center, Denver, Colorado 80262

James A. McGregor, M.D., CM., F.A.C.O.G. • Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Denver, Colorado 80262

Mary B. Mockus, Ph.D. • Departments of Medicine and Biochemistry, Biophysics, and Genetics, University of Colorado Health Sciences Center, Denver, Colorado 80262

Marianne R. Neifert, M.D. • Department of Pediatrics, University of Col­orado School of Medicine, Denver, Colorado 80262

v

vi Contributors

Margaret C. Neville, Ph.D. • Department of Physiology, University of Colorado School of Medicine, Denver, Colorado 80262

Robert G. Peterson, M.D. • Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada K 1 H 8Ll

Robin Dee Post, Ph.D. • Department of Psychiatry, University of Colorado School of Medicine, Denver, Colorado 80262

Rhoda Singer, M.D. • Department of Psychiatry, University of Colorado School of Medicine, Denver, Colorado 80262

Tamiko Kano-Sueoka, Ph.D. • Department of MCD Biology, University of Colorado, Boulder, Colorado 80309

Christopher Watters, Ph.D. • Department of Biology, Middlebury College, Middlebury, Vermont 05753

Preface

This book had its genesIs In the frustrations of the editors in locating authoritative, up-to-date material for an interdisciplinary graduate course in mammary gland biology, lactation, and breast-feeding. As we turned to the original literature several reasons for the dearth of usable material became clear: (1) In the areas of mammary gland biology and physiology, particularly as they relate to the human, reviews simply have not kept up with current research, which has in the last two decades provided tremendous insight into the mechanisms of milk secretion and its control. (2) The lack of interest in human milk as infant food inhibited researchers until very recently from investigating human lactation. (3) Much of the relevant clinical information remains anecdotal with little scientific basis.

In this book we have tried to present the fundamentals of mammary gland physiology at the organismic and cellular levels in a form readily understood by physicians, scientists, and other professionals. This basic information is accompanied by authoritative reviews of the nutritional and immunological properties of human milk and by clinically relevant chapters designed to help health care professionals deal with the medical problems of the breast-feeding mother and her infant. We have strived in these chapters for up-to-date, authoritative, but readable accounts. In so far as possible we have avoided areas where much of our understanding rests on speculation. In the clinical domain this was not always possible because of a lack of solid, scientific information about breast-feeding.

In dedicating this book to our families, we wish to express our appre­ciation for their support throughout the seemingly endless task of writing and editing these chapters. We would also like to thank George Tarver, Julie Blish, and Pat Allen for their expert illustrations, Brian, Mike, and Dorothy for manhandling the references, Joy Seacat for helping us get it all together at the end, and Kirk Jensen of Plenum Press for his patient encouragement.

Denver, Colorado

vii

Margaret C. Neville Marianne R. Neifert

Contents

I. Introduction

1. An Introduction to Lactation and Breast-Feeding

Margaret C. Neville and Marianne R. Neifert

Evolution and Lactation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Historical Perspectives on Milk Secretion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Historical Perspectives on the Hormonal Control of Lactation. . . . . . . . . . . . . . . . . . . . . . 7

Placenta versus Ovary in Mammary Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 A Role for the Pituitary Gland .............................................. 8 The Hypothesis of Meites and Turner. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Multiple Hormonal Control.... .. .............................. ..... .. ...... 10 The Role of the Placenta. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Historical Perspectives on Breast-Feeding. . . . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . . 12 Historical Alternatives to Breast-Feeding. . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . . . . 12 The Decline of Breast-Feeding. .. .. .. . . . . . . . . . . . . .. . . . . . . . . . .. . . . . . . . . . . . . . . 13 Third-World Issues in Breast-Feeding. . . . . . . . . . .. .. . . . . . . .. . . . . . . . . . . . . . . .. . . 15

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

II. The Scientific Basis of Lactation

2. Anatomy of the Breast

Stanley F. Gould

Anatomical Features of the Breast.............................................. 23 Surface Anatomy, Supporting Structures, and General Relationships. . . . .. .. . . . . 23 The Nipple and Areola. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . 24 Vessels and Nerves. . .. . .. . .. . . .. ... . . . . . . . . . .. ... . . . . . .. . . . . . . . . . . . . . . . . .. . 25 Lymphatic Drainage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Content,

Embryologit:td Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Normal Development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Anomalous Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Structure of the Mammary Gland. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 General Features........................................................... 27 Inactive or Resting Stage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Proliferative or Active Phase .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Lactation or Secretory Phase. . . . . . . . . . . . . . . .. .. . . .. .. ... .. . . .. .. . . . .. .. . . . . . 37 Regression. Involution. or Atrophy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Summary.................................................................... 47 Refereru:es .................................................................. 47

3. The Mechanisms of Milk Secretion

Margaret C. Neville,Jonathan C. Allen, and Christopher Watters

Introduction and Overview. . . . .. .. . . . . . .. . .. ... . . .. .. .. .. .. . . . .. . .. .. . . . . . .. .. 49 Cellular Mechanisms for Milk Synthesis and Secretion. . . . . . . . . . . . . . . . . . . . . . . . . 51 Changes in Milk Composition at Parturition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 The Secretion of Cells into Colostrum and Milk............................... 57 Suckling and the Ejection of Milk from the Breast ............................ 58 Mammary Blood Flow. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Protein Syntheris, Processing, and Secretion in the Mammary Gland. . . . . . . . . . . . . . . . 59 Properties of Milk Proteins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Protein Precursors-The Transport of Amino Acids into Mammary Alveolar Cells...................................................................... 62 Synthesis and Processing of Milk-Specific Proteins. . .. .. .. .. . .. . .. .. .. . . . .. .. . . 62 Regulation of Milk Protein Synthesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Immunoglobulin Secretion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

The Syntheris of Mille Sugars. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Glucose Utilization in the Mammary Gland. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Lactose Synthesis. . .. . . . .. . . . .. . . . . . .. .. .. .. . . . .. .. .. .. . .. . . . .. .. .. .. .. . . . .. 69 Regulation of Lactose Synthesis. . .. . . .. .. .. ... . . . . .. .. .. . .. .. .. . .. .. . . . .. .. .. 71 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Secretion of Cakium, Phosphate, and Citrate into Mille ........................... 72 The Role of the Golgi Secretory Vesicles in Calcium Secretion.................. 73 Possible Regulatory Activities of Calcium in the Mammary Gland.. .. .. .. .. . .. .. 74

The Secretion of Mille Lipid . ... '. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 The Composition of Milk Fat. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Fatty Acid Synthesis in the Mammary Gland. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Lipoprotein Lipase and the Extraction of Lipids from Plasma. . . .. . ... .. .. .. .. . 81 Triglyceride Synthesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Cholestrol Secretion into Milk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Phospholipids ............................................................. 83 Milk Lipases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Conclusions ............................................................... 84

The Secretion of Monovalent Ions and Water into Mille. . . . .. ... .. .. .. .. .. .. .... .. . 84 Transcellular Ion Transport . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Paracellular Ion Transport. . .. .. .. .. . . .. . . . .. ... . .. ... .. .. .. .. . . .. .. .. .. .. .. 87 Conclusions ............................................................... 88

Trace Element Secretion into Mille. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Iron...................................................................... 88 Zinc...................................................................... 89

Contents xi

Iodine.................................................................... 89 Selenium ................................................................. 90 Sulfur.................................................................... 90 Cobalt ............................................. , ... .. . .. . . . . . .. . . . .. . . 91 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Milk Secretion-Questions for the Future. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 References .................................................................. 92

4. Regulation of Mammary Development and Lactation

Margaret C. NeviUe

Stages in the Development of Mammary FUllction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Mammogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Lactogenesis .............................................................. 108 Lactation ................................................................. 113 Involution ................................................................ liS

Prolactin Secretion through the Life Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Milk Ejection and Oxytocin .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Oxytocin Synthesis and Release. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Interaction of Oxytocin with Myoepithelial Cells ....................... , . .. .. . 123 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Lactation and Postpartum Infertility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Relation between Duration of Postpartum Amenorrhea and Breast-Feeding.. ... 125 Reproductive Hormone Levels during Lactation .... '" .. ... .. .. .. . . .. .... .. .. 126 The Mechanism of Postpartum Amenorrhea.. .... . ..... .. . .. .. .. .... .. .. .. ... 129 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130

Interactions between Food Intake and Lactation ................................. 131 A Forward Look .. ....... " .. . .. .. .. .. .. ..... .. .. ...... ..... ... . .. .. .. .. .. ... . 132 References .................................................................. 133

5. CeUular and Molecular Aspects of the Hormonal Control of Mammary Function

Margaret C. NeviUe and SaUy E. Berga

Lactogenic Hormones ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Regulation of Prolactin Synthesis and Release. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Cellular Actions of Prolactin .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Placental Lactogen .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

The Role of Steroid Hormones in the Control of Mammary Function. . . . . . . . . . . . . . . . 151 Estrogens ................................................................. 151 Progesterone ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Glucocorticoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

The Role of Insulin in Mammary Function. '" ................ , ... ,. .. .. ... .... .. 160 The Role of Insulin in Mammary Growth ............................ , .. .. . .. 160 The Role of Insulin in Lactogenesis and Lactation ............. ,. ..... ..... .. . 161 Effects of Insulin on Lipid Synthesis ...... ,. ... .. ...... ........ .. . ..... .. .. .. 161 Conclusion .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

Thyroid Hormones ... ................... '" ........................... ,. .. ... . 162 Prostaglandins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Cyclic AMP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

xii

Conclusion References

Contents

164 165

6. In Vitro Model Systems for the Study of Hormonal Control of Mammary Gland Growth and Differentiation

Janice E. Errick and Tamiko Kano-Sueoka

Introduction ................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Whole Gland Culture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Explant Cultures............. .............................................. ... 183 Primary Culture . ......................... , ......... " .. . . . . .. . . . . . .. .. . .. . . . . 186 CeU Culture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 General Conclusions............................................. .............. 194 References .................................................................. 194

111. The Nutritional and Immunologic Significance of Mammary Secretions

7. Nutritional Aspects of Human Lactation

Clare E. Casey and K. Michael Hambidge

Introduction ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 Technical Difficulties in the Measurement of Milk yield........................... 199 Composition of Human Milk................. .......................... ........ 201

Gross Composition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 ,Protein ................................................................... 202 Fat....................................................................... 204 Lactose ................................................................... 205 Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Minerals .................................................................. 206 Trace Elements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

Nutritional Requirements for Lactation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 Recommended Daily Allowances............................................. 209 Energy ................................................................... 210 Protein ................................................................... 212 Calcium .................................................................. 213 Iron..................... ..................... ............................ 214 Vitamins.................. ................................................ 215

Maternal Nutrition and Lactation Performance . . . . . . . . . . . . . . . . . . . . . .. . . . . . .. . .. . 216 Volume................................................................... 216 Composition .............................................................. 219 Incidence and Duration of Lactation ........................................ 225 Influence of Lactation on Maternal Nutritional Status. . . . . . .. . . . . . .. . . . . . .. . . . 226 Other Maternal Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . •. . . . . . . . . . . . 228

Human Milk in Infant Nutrition........... ..................................... 230 Growth................................................................... 230 Biochemical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Dietary Supplementation.................................................... 236 Premature Infants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236

Conclusions ................................................................. 238 References .................................................................. 239

Contents xiii

8. The Immunology of Breast Milk

Anthony R. Hayward

Introduction.. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . 249 Antibodies ................................................................ 249 Cellular Aspects of the Specific Immune Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 Phagocytes and Complement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 The Secretory Immune System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

ImmunologicaUy Active Constituents of Breast Milk . .......... " . . . . .. . . . . . . . . . . . . 257 Nonspecific Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 Cells in Milk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258 Functional Responses of Breast Milk Lymphocytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

Immunologic Consequences of Breast-Feeding for the Baby. . . . . . . . . . . . . . . . . . . . . . . . . 261 Protection from Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 Protection from Allergic Reactions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264 Breast-Feeding and Immunization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266

Conclusions ................................................................. 266 References .................................................................. 266

IV. Medical Management of Breast-Feeding

9. Routine Management of Breast-Feeding

Marianne R. Neifert

Introduction.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . 273 Prenatal Period... ......................................................... .. 274

Role of the Health Professional in Breast-Feeding Education. . . . .. . . . . . . . . . . . . . 274 Prenatal Examination..................... ... ....................... ..... ... 275 Management Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Nipple Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278 Support Groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278

Intrapartum Period .......................................................... 279 Hospital Policies .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 Initiation of Nursing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 Common Early Problems .......................... . . . . . . . . . . . . . . . . . . . . . . . . . 283

The Normal Co"rse of Lactation........................................ ........ 287 First Two Weeks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 Two Weeks .............................................................. " 288 Two Months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 Four Months ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290 Six Months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294 Nine Months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295 Twelve Months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295 Late Nursing... .......... ................................................. 296 Nursing through Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296

Conclusion .................................................................. 297 References .................................................................. 298

10. Infant Problems in Breast-Feeding

Marianne R. Neifert

Contents

The Premature or Sick Newborn ........ '........................................ 304 Advantages of Human Milk in Feeding Preterm Infants....................... 304 Initiating Breast-Feeding in the Premature Infant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 Methods of Expressing Milk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306 Maintaining the Milk Supply. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308 Surveillance and Storage of Milk ............................................ 309 Transition to the Breast. . . . .. .. .. . . .. .. .. .. .. .. .. . .. . .. ..... . . .. . .. . .. .. .. . 311 Follow-Up ................................................................ 312

F aUure to Thrive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313 Etiologies of Lactation Failure-Maternal Factors............................. 313 Etiologies of Lactation Failure-Infant Factors................................ 316 Evaluation of Failure to Thrive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317 Assessment and Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323

Cleft Lip and Palate .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323 Nursing Infants with Cleft Lip .............................................. 324 Nursing Infants with Cleft Palate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324

Multiple Births. . . . . . . . .. . . .. . .. .. . . . . .. . . .. .. . . .. .. .. .. . . . .. . .. .. .. .. .. . . .. .. 325 Breast Milk Jaundice. . .. . ... . . .. .. .. . . .. .. .. .. .. .. .. .. .. .. . .. .. . .. .. .. .. .. . . .. 326 Phenylketonuria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326 Hoapitalization of the Infant or Mother . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327 Conclusion .................................................................. 328 References .................................................................. 328

11. Maternal Problems in Lactation

James A. McGregor and Marianne R. Neifert

Lactation and Infectious Disease.. .. . . . . . . . . . . . . . . ... ... .. ..... .. . . . . . .. .. .. .... 333 Mastitis ................................................................... 334 Painful Nipples and Candida albicans ......................................... 337 Tuberculosis .............................................................. 338 Herpes Viruses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338 Rotaviruses ............................................................... 340 Hepatitis B Virus .......................................................... 340

Chronic Maternal Illness ...................................................... 342 Psychiatric Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 Cystic Fibrosis ............................................................. 343

Mammoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343 Relactation and Induced Lactation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344 Conclusion .................................................................. 346 References .................................................................. 346

12. Psychological Implications of Breast-Feeding for the Mother

Robin Dee Post and Rhoda Singer

Breast or Bottle' The Decision-Making Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349 Psychodynamic Factors in the Decison Not to Breast-Feed.. .. .. .. .. . . . .. .. .. .. 349

Contents xv

The Influence of Significant Others .................................... . . . . . 351 The Time for Decision . . . . . . . . . . . . .. .. .. . . . . . .. . . . .. . .. .. . .. . . . . . . . . . . . . . . . 352

Attihules aM Personality Charaeteristics of Breast· and Bottle.Feeding Mothers ..... 353 Mother-Infant Attach_t: The Importance of the Earl, Po,tpartum Period for the

Mother-Infant Bond aM the Establishment of Laetation ........................ 354 Psychological and Hormonal Interaetion in Breast·Feeding . .. .. . .. . . . . .. . . . .. . . . . . 355

Psychological Factors in Milk Secretion. . . . . .. . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . 355 Postpartum Blues............................... ........................... 357 Sexuality of Breast·Feeding Women..... ............................. .... ... 357

Support Systems for Nursing WOfM1I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359 Breast.Feeding and Family Life. .. . . . . . . . . . . . .. .. . . .. .. . .. . . . . . . . . . . . .. .. . . . 359 Medical Support Systems for the Expectant and New Mother . . . . . . . . . . . . . . . . . . 359 La Leche League International. . . . .. . . .. .. . . . . . . . . .. . .. . . . .. . . . . . . . . . . . . . . . . 360

Psychological Considerations in Weaning aM Exteruled Nursing. .. . . .. . . . . . . . . . . . . . 361 Conclusions ................................................................. 362 References .................................................................. 363

13. Drugs, Toxins, and Environmental Agents in Breast Milk

Robert G. Peterson and Watson A. Bowes,jr.

Introduction ................................................................ . 367 Drug Distribution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368 Propertie' of Sub,tance, That Affect Their Distribution into Milk. . .. .. . . . . . . .. . .. . 372 Quantitative Delivery of Pharmacologic Agent. to the Newborn. ... .. . . . . . . . . . . . . . . . 375

Oral Drug Absorption by the Infant................................ ......... 375 Recognizing Drug Toxicity in the Infant. . . . . . . .. . . . . .. . . . . . . . . . . . . .. . . . . . . . . 376 Idiosyncratic and Allergic Drug Reactions.................................... 377 Selective Drug Toxicity in Infants........................................... 378 Neonatal Drug Accumulation............................................... 379 Potential for Masking Medical Conditions.................................... 379

Over·the-Counter Medications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380 Environmental Agents in Breast Milk ........................................... 381 Summary of Quantitative Considerations . .. . . . . . .. . . . . . . .. . . . . . .. .. . . . . . . . . . . . . . 382 Review of Pharmaeologic Classes of Drugs in Breast Milk. . . . . . . . . . . . . . . . . . . . . . . . . 383

Antimicrobial Drugs. . .. . . . .. . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . . . . . . . 383 Analgesics and Psychotherapeutic Drugs ..................................... 385 Methylxanthenes .......................................................... 386 Cardiovascular and Diuretic Agents. . . .. . . . .. . . . .. . . .. .. . . . . . . . .. . . . . . . . . . . . . 387 Rubella Vaccination........................................................ 388 Antithyroid Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388 Anticoagulants ....................•....................................... 388 Anticonvulsants ........................................................... 389 Radio·Pharmaceuticals for Diagnostic Procedures. . . . . . . .. .. . . . . . . . . . . . . . . . . .. 389 Recreational Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390

Insecticide, aM Polychlorinated Biphen,ls (PCB,) in Breast Milk ............... . . . 390 Summary of Clinical Considerations..................................... ........ 391 Drug. That Affect Laetation ................................................... 393

Introduction .............................................................. 393 Drugs That Inhibit Lactation.. .. .. . . . . . . .. . . . .. . . . . . .. . .. . . . . . . . . . .. .. . . . . . . 393 Drugs That Enhance Lactation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396 Summary ................................................................. 397

Reference, .................................................................. 398

xvi Contents

14. Lactation and Contraception

James A. McGregor

Methodoligic Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405 The Effects of Lactation on Fertility. . . . . . . .. .. . . . . . . . .. .. . . . . .. .. .. .. . . . . . .. .. . . 406

Endocrine Basis of Lactational Amenorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406 Conception and Lactation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407 Summary ................................................................. 408

Contraception during Lactation . .............................. " .. . . .... . . .. .. . 409 Abstinence ................................................... . . . . . . . . . . . . . 409 Barrier Methods........................................................... 410 Rhythm or Natural Family Planning......... ................................ 410 Postpartum Sterilization .................................................... 411 Intrauterine Devices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 Steroid Contraceptives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412 Summary of Contraceptive Usage in Lactation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417

References .................................................................. 418

15. Pregnancy, Lactation, and Breast Cancer

Mary B. Mockus and Kathryn B. Horwitz

Introduction. .. . . . . . . . . . . . .. . . . .. . .. .. .. . . . . . . . .. . . . . . .. .. . .. .. .. .... .. .. . . . . 423 Epidemiology................................................................ 423 Steroid Hormones and Breast Cancer........................................... 426 Viruses and Breast Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429 Pregnancy, Lactation, and Breast Cancer: The Clinical Picture. .. . .. . . . . . . . .. .. . . . 430 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433 References .................................................................. 434

Index ............ ........................... ........ ............. ....... .... ... 441

LACTATION Physiology, Nutrition, and Breast-Feeding