’

The Nuts and Bolts of Breastfeeding:

Anatomy and Physiology of Lactation
Natasha K. Sriraman, MD, MPH, FAAP, FABM

Breastmilk is the physiologic norm for infant nutrition. Despite
recommendations from major health organizations, many women
in the U.S. are not achieving this metric. Understanding breast
anatomy and lactation physiology will allow physicians to gain
knowledge of the processes, which control lactation enabling
physicians to appropriately manage the breastfeeding dyad. The
interplay of hormones involved in lactation and milk management
affect milk initiation, as well as ongoing milk production (gal-
actopoesis). The unique components of breastmilk that provide
protection against infection and chronic diseases also change
between and during feeds. Colostrum and the importance of
early skin-to-skin after delivery will also be discussed.
Curr Probl Pediatr Adolesc Health Care 2017;47:305-310

reastmilk is the physiologic norm for infant breastfeeding.9 Breastfeeding education is neither
B nutrition. Despite recommendations from
major health organizations, such as the Centers
mandatory nor provided within many pediatric or
family medicine residencies. Over 71% of both prac-
for Disease Control (CDC), American Academy ticing pediatricians and OB-
of Pediatrics (AAP), American Gyns felt they had little or no
College of Obstetrics and Gyne- breastfeeding education or
cology (ACOG), American
Many seasoned practicing
training. Due to lack of knowl-
Academy of Family Practice physicians, who take care of edge and training, many physi-
(AAFP), UNICEF, the World infants, were trained when only cians lack confidence in
Health Organization (WHO) and 20-25% of new mothers were counseling their patients on
National Public Health Service
initiating breastfeeding. Some infant feeding choices. Even
(NPHS) which all state that an though 90% of physicians
infant, without a medical contra- pediatricians still recommend endorsed that they have a role
indication, should exclusively that mothers discontinue in breastfeeding promotion,
breastfed for the first 6 months breastfeeding for conditions that only half felt that they could
of life, followed by combining are compatible with effectively counsel patients
breastmilk and solid foods until breastfeeding about breastfeeding.10
a baby is at least 12 months of The lack of knowledge and
age.1–7 Unfortunately, many comfort is not surprising con-
women in the U.S. do not achieve this metric. 8 sidering that in medical school, students do not learn
Many seasoned practicing physicians, who take care about lactation anatomy and physiology. Some trainees
of infants, were trained when only 20–25% of new and physicians may ‘learn on the job’ whether during
mothers were initiating breastfeeding. Some pediatri- their own experience and/or during internship and
cians still recommend that mothers discontinue breast- residency. However, unless a physician seeks out
feeding for conditions that are compatible with additional learning and training, many physicians lack
the knowledge to properly counsel breastfeeding
From the Division of General Academic Pediatrics, Children’s Hospital of mothers in those early days, which, as this article will
The King’s Daughters, Eastern Virginia Medical School, Norfolk, VA. describe, is essential to establishing milk supply and
Curr Probl Pediatr Adolesc Health Care 2017;47:305-310
1538-5442/$ - see front matter
thus allowing mothers to not only initiate breastfeed-
& 2017 Elsevier Inc. All rights reserved. ing, but to exclusively breastfeed for as long as they
http://dx.doi.org/10.1016/j.cppeds.2017.10.001 and their babies desire.

Curr Probl Pediatr Adolesc Health Care, December 2017 305

Embryology important to remember as poor drainage of the breast can
result in increased and size and pain of the axillary lymph
In the 20-day-old embryo, the precursors of the breasts nodes. Intercostal nerves IV, V and VI supply nerve
begin initially as milk streaks or lines that eventually inervation to the breast. Due to the nerve distribution, the
develop in the mammary ridges. At week 6, the nipple areola is most sensitive. Physicians must keep this in
and areola begin to form, along with proliferation of the mind when counseling women with a history of breast
milk ducts. This process continues until birth. At week surgery, as the 4th intercostal nerve lies more super-
28, placental sex hormones induce canalization. At ficially close to areola at the outer lower quadrant, which
birth, maternal hormones can induce inflammation that is primarily responsible for nipple sensation.
can cause that newborn to secrete ‘witch’s milk.’ This is Since it is usually unknown how the surgery was
considered a normal physiological occurrence and no done, these women may be unable to exclusively
treatment or testing is necessary. Until puberty, the breastfeed due to a decreased milk supply.
mammary glands remain inactive in females. The size of the breasts do not determine the amount of
Breast bud development, known as thelarche is the milk that will be synthesized. Pre-conception breast size
1st sign of puberty (range 8–13.5 y/o). Hormones has no relation to the degree of increase in breast size
such as estrogen, progesterone, during pregnancy. The storage
corticosteroids, and thyroxine capacity of the breast is not
influence the growth and prolif- The size of the breasts do not determined by breast size, but
eration of the ducts and alveolar
buds, which continue to grow determine the amount of milk the adipose tissue determines
visible breast size. Also there is
with each successive menstrual that will be synthesized. no relation between the growth
cycle. Connective tissue (Coop- Pre-conception breast size has of the breast during pregnancy
er’s ligaments) and protective no relation to the degree of and the amount of milk the
fatty tissue are also a part of breasts produce during the 1st
the breast architecture.11
increase in breast size during
pregnancy. month of lactation.
While the alveolar cells store
Breast Anatomy the milk that is produced, the
maximum volume of milk stored in the breast covers a
So how does the breast change during pregnancy and wide range (80–600 ml). Breast capacity is not a
lactation? During the 1st trimester, there is rapid growth limiting factor to total daily milk production. However,
of the ductural-lobular-alveolar system in the breasts. As smaller capacity breasts will be emptied more quickly
the alveoli proliferate, distinct lobules are formed. For with faster breastmilk synthesis as compared to larger
each woman and each pregnancy, there is variation in the capacity breasts.13,14
timing and degree of glandular growth. While there is
extensive growth during the 1st trimester, there is gradual
growth throughout the pregnancy. Glandular luminal Lactation Physiology
cells begin actively synthesizing milk fat and proteins
near term, however only small amounts are released into There are various stages of lactogenesis (milk
lumen. However, there is no growth until just before and production).
after the birth of the baby. With postpartum withdrawal Lactogenesis I occurs at 15–20 weeks gestation. This
of luteal and placental sex steroids and placental lacto- stage is hormonally driven. All women, at this stage of
gen, prolactin is able to induce full secretory activity of pregnancy, will be able to synthesize milk components.
alveolar cells and the release of milk into alveoli and Colostrum production begins midway through the
smaller ducts.12 pregnancy.
Regarding blood supply the internal mammary artery Lactogenesis II occurs 30–40 hours after birth. It is
supplies the majority (60–70%) of the blood supply to initiated by the birth of infant plus removal of the
the breast, while the remainder is supplied by the placenta. Any functional placental tissue (progester-
lateral thoracic artery (30–40%). Lymphatic drainage one) will inhibit or compromise the effective initiation
of the breast drains to the axillary lymph nodes. This is of lactogenesis II. The key hormone during this stage is

306 Curr Probl Pediatr Adolesc Health Care, December 2017

TABLE 1. Hormones Involved with Lactation of women of child-bearing age (20–44%) have a BMI
Hormone Response ≥ 30.15
Prolactin Growth: nipple and areola So how does a woman’s BMI affect her ability to
Human placental lactogen
Estrogen Proliferation and differentiation:
breastfeed her child?
ducts and glandular system Women with BMI ≥ 30 are less likely to initiate
Progesterone Growth: lobes, lobules, alveoli breastfeeding and breastfeed for a shorter duration.16
Inhibition of lactation and milk
secretion
Research shows that obesity before pregnancy coupled
Decrease of estrogen and Prolactin uninhibited with excessive gestational weight gain show negative
progesterone (placenta removal) effects on breastfeeding duration.17
Increase of prolactin Milk synthesis When counseling obese women about breastfeeding,
Oxytocin (milk suckling) Milk ejection reflex (MER)
Myoepithelial cell contraction
it is important to start the discussion early on,
preferably during pregnancy. These women are at
particular risk of a delay in lactogenesis II, which
prolactin, other hormones (insulin, cortisol, thyroxin, can adversely affect breastfeeding initiation as well as
and oxytocin) are also involved. This stage is also duration. Also, obese women may need counseling
under endocrine control and will occur in all women regarding the mechanics of breastfeeding which can be
immediately after birth. Most women will feel difficult to large breast/areola size. Compromised onset
increased breast fullness after Lactogenesis II, gener- of Lactogenesis II needs to be managed appropriately
ally anywhere between 50 and 73 hours. and early in the hospital since women experience
Since lactogenesis I and lacto- delayed lactogenesis II may
gensis II are hormonally driven, be less able to sustain any
as long as the hormones are Women with BMI ≥ 30 are less and/or exclusive breastfeeding
normal, these 2 stages will occur
regardless of whether breastfeed-
likely to initiate breastfeeding in the18 early postpartum
period.
ing is initiated.13,14 and breastfeed for a shorter That 1st hour after the birth
Lactogenesis III occurs and duration. Obesity before preg- of the baby is often referred to
continues only with ongoing milk nancy coupled with excessive as the Magical Hour. For
production (galactopoesis). gestational weight gain show many reasons, the 1st hour is
Unlike the first two stages, lacto- a strong determinant of breast-
genesis III is under autocrine negative effects on breastfeed- feeding success. Colostrum,
control, and is driven by milk ing duration. which is rich in antibodies, is
removal (Table 1). the first milk. Although low
However, for many women, lactogenesis II can be volumes are produced in those first few days, colos-
delayed or adversely affected by various medical trum is of high nutritional value. Mothers should be
conditions, including obesity, diabetes, after having a counseled that the colostrum is sufficient to meet the
caeserean section or giving birth to a premature baby. newborn’s nutritional needs, and to counteract the
A delay in lactogenesis II, unfortunately, is becoming mother’s perception that she ‘doesn’t have enough
increasingly common as rates of obesity continue to milk.’ Skin-to-skin within the 1st hour after birth, if
rise. In the United States, more both mom and baby are
than 1/3 (37.5%) of adults are healthy after the delivery is
obese (BMI ≥ 30). In 2010, in Lactogenesis III occurs essential, not only for mother–
36 states, over 25% of the state’s and continues only with ongoing baby bonding, but for the
population are classified obese. In milk production (galactopoesis). baby to use his olfactory sense
2000, there were no states who to properly latch onto mom’s
had such a high prevalence of Unlike the first two stages, lac- breast. As mentioned in the
obesity. NHANES data shows togenesis III is under autocrine lactation physiology section,
that BMI rates skyrocketed from control, and is driven by milk removal of the milk continues
17–18 to 26–27 during this same removal. milk production, as lactogen-
time period. Data shows that 32% esis III is under autocrine

Curr Probl Pediatr Adolesc Health Care, December 2017 307

 60.20 The single-most predictor of any breastfeeding or
exclusive breastfeeding at 8 weeks postpartum was
having been fed only breastmilk prior to hospital
discharge.21 Pediatricians can assess the need for
supplementation, and if medically needed, the primary
goals to feed the infant while optimizing and main-
taining mother’s milk supply.22

FIG. Lactogenesis hormones.

Hormones
control, i.e., local control at the breast. It is truly a
supply–demand issue. As the milk is removed from the Prolactin, which is secreted by the anterior pituitary,
breast, this signals to the hypothalamus that more milk responds to nipple stimulation and infant suckling.
needs to be produced.13,14 Expression (manual/electric pump) of breastmilk
As long as the milk continues also stimulates prolactin.
to be removed from the breast, Receptors for prolactin are
lactation will continue. Lacto- The 1st hour is a strong deter- found on the basal membrane
genesis III will be adversely minant of breastfeeding success. of the alveolus and its secretion
affected by ineffective and/or Colostrum, which is rich in anti- depends on the intensity, dura-
infrequent milk removal. This tion and the frequency of nip-
is the mechanism of how moth-
bodies, is the first milk. Although ple stimulation. Theories show
ers’ milk supply decreases when low volumes are produced in that early lactation stimulates
formula supplementation is those first few days, colostrum is the development of more pro-
added to the infant’s feeding of high nutritional value. lactin receptors which may
regimen (Fig).19 enhance the potential of future
During the 1st days in the breastmilk production. Serum
hospital, it is essential to teach mothers to feed their prolactin levels do NOT control milk synthesis,
newborns on demand, follow the baby’s hunger cues infant suckling and nipple stimulation do. This is
(sucking on their hand, rooting) and feed at least 10–12 the theory behind skin-to-skin (S2S).
times/day. Mothers should be instructed that there is no
time-based feeding schedule and they should expect
their babies to cluster feed. It is expected that newborns Feedback Inhibitor of Lactation (FIL)
will lose 5–10% of their birth weight in the first 10–14 This is believed to be a whey protein in breastmilk
days. However, breastfed babies can initially have a which is controlled by a local negative feedback
slower growth velocity and may regain their birth mechanism. With large amounts of breastmilk in the
weight at a slower pace than breast, there are increased lev-
formula-fed babies. els of FIL, thereby slowing
As described above, the issue Why not just one bottle? Once a down breastmilk synthesis.
of ‘why not just one bottle?’ can
adversely affect breastmilk pro-
mother begins supplementation The opposite is true with
decreased levels of FIL.
duction. Studies show that once with infant formula in the hospi-
a mother begins supplementa- tal, even among women intend-
tion with infant formula in the ing to exclusively breastfeed, this Milk Ejection Reflex (MER)
hospital, even among women
was associated with a 2-fold
intending to exclusively breast- The MER is essential to
feed, this was associated with a greater risk of not fully breast- establish and maintain milk
2-fold greater risk of not fully feeding 30-60 days later and a production. Also known as the
breastfeeding 30–60 days later nearly 3-fold risk of breastfeed- ‘let down reflex’ the MER is a
and a nearly 3-fold risk of ing cessation by day 60. neuro-endocrine reflex, which is
breastfeeding cessation by day elicited by the stimulation of the

308 Curr Probl Pediatr Adolesc Health Care, December 2017

TABLE 2. Hormones involved with breast development
Stage Stimulus
Mid-pregnancy HPL: alveolar and ductal growth
Prolactin rising
Estrogen and progesterone present
Birth Withdrawal of pregnancy hormones
30–40 hours post birth High prolactin
Falling progesterone
Lactose moving into breast secretion
Ongoing breastfeeding Effective removal of milk
Removal of FIL
Presence of PRL receptor sites on lactocytes
Weaning Milk removal reduced
nipple and areola. Due to negative mechanical pressure
induced by an infant’s suck, the 4th intercostal nerve
signals to the hypothalamus to release oxytocin. Some
women experience overactive or forceful let down. As a
result, babies can exhibit gassiness, choking, clamping
down on the nipple or have a nursing ‘strike,’ and may
have watery stools.
Oxytocin is released from the posterior pituitary via a
neurosensory mechanism. It is released in a pulsatile
manner causing myoepithelial cells surrounding each
alveolus to contract forcing milk into the ductal system
towards the nipple. Oxytocin release can be enhanced by
things such as hearing a baby crying, thinking about the
baby or preparing to breastfeed, while it can be inhibited
by fear, pain, embarrassment, or anxiety by the mother.
The composition of breastmik is very dynamic.
Colostrum contains high amounts of secretory IgA,
lactoferrin, and oligosaccharides. Mature milk usually
comes in between days 3 and 5 with increasing levels
of lactose. Once breastmilk production is established, it
is important to counsel mothers that while the amount
of breastmilk synthesized is regulated by the frequency
of removal, the composition of the milk changes
during the feed. The foremilk at the beginning of the
feed contains more starch while the hindmilk, at the
end of the feed, contains more fat. By fully emptying
each breast during nursing, the baby will feel fuller by
consuming the fat-enriched hindmilk.13,14
Primary Lactation Failure
One to five percent of women can experience
primary lactation failure. These women have insuffi-
cient glandular tissue and they may have absence of
breast growth during the pregnancy. Breast hypoplasia
Curr Probl Pediatr Adolesc Health Care, December 2017
Event
Lactogenesis I (endocrine control of milk synthesis)
Lactogenesis II
(endocrine control of milk synthesis)
Lactogenesis III
(autocrine control of milk synthesis)
Involution of breast and lactation
may also be associated with a wide intramammary
space. An intramammary space of 1.5 in or greater was
clearly associated with insufficient lactation when the
breasts appeared to be hypoplastic (Type 4).23
Recommendations
Lactation anatomy and physiology has become
increasingly important within the health care field.
For pediatricians, it is essential to have a basic under-
standing to help counsel mothers who are breastfeed-
ing with evidence-based information so each mother is
able to reach her breastfeeding goals. Human milk is
the epitome of individualized medicine—each mother
makes milk that is specific to her baby’s needs at any
particular time. Understanding the interplay of hor-
mones on the development of breast tissue and
breastmilk production will help guide pediatricians in
giving mothers accurate information tailored to each
mother–baby dyad (Table 2).
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