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AIMS:
Breastfeeding; the
1. Describe the hormonal interplay that regulates human breastmilk production
physiology that
2. Relate breastfeeding physiology to breastfeeding establishment and support
underpins the
3. Describe the physiological underpinnings of early breastfeeding challenges
support
4. Appreciate the importance of a sound knowledge of breastfeeding physiology when
supporting women to breastfeed
N I C K I H A R T N E Y

R N , R M , M P R O F E D & T R N G

1 2

HORMONE RECAP:
• Physiology focus
• Acknowledging that anatomy and physical and
Human Placental Lactogen (HPL):
psycho-social influences are integral to • produced in placenta
• alveolar development in
assessment and support pregnancy
• prolactin inhibitor in pregnancy
• A sound understanding of breastfeeding
INTRODUCTION: physiology is a fundamental requirement when
Oestrogen:
supporting women Progesterone: • ductal development in pregnancy
• produced by ovaries, adrenals • inhibits milk production
• Breastfeeding hormones in play, an instructional and placenta • prolactin stimulant
• puberty- breast development
animation forms the foundation of this
• pregnancy- alveolar/ lobular
presentation formation
• withdrawal required for milk
secretion

3 4

Oxytocin:
• produced by hypothalamus
• secreted by posterior pituitary
gland
• ‘milk ejection’ reflex
Prolactin:
• synthetised by lactotrophs Feedback Inhibitor of Lactation (FIL):
in the anterior pituitary gland • locally produced whey protein
• negative control by Prolactin inhibitory in breast • Insulin is required for cellular differentiation during pregnancy preparing for secretory activation
factor (PIF) from the hypothalamus • produced by acini cells
• accelerates breast changes • Induction of milk synthesis requires insulin induced cell division and presence of Cortisol
• local control of milk volume • Breast contains insulin-sensitive tissue and requires insulin to initiate milk production
• milk secretion from 16 weeks • active in involution
• ongoing milk secretion
• withdrawal required for involution

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BREAST CHANGES AND

L AC TO G E N E S I S 1
LACTOGENESIS 1-
• Rapid development of the lobular / alveolar system of the
PRACTICAL
breast – results in extensive branching and the development
of highly differentiated secretory alveolar cells at the end of
these ductal branches.
I M P L I C AT I O N S
• Under influence of prolactin a colostrum like substance is
present from 16 weeks
• Copious milk production is suppressed by both
progesterone and human placental lactogen
• Oestrogen stimulates prolactin but inhibits its milk P R E M A T U R I T Y

production influence
A N T E N A T A L E X P R E S S I N G
• Lactogenesis 1 starts approximately 12 weeks before birth.
P R I M A R Y B R E A S T H Y P O P L A S I A A N D B R E A S T S U R G E R Y
Image from: Lawrence, R. A. . 1924-author., & Lawrence, R. M. (2016). Breastfeeding : a guide for the medical profession (Eighth edition.). Elsevier. • Composition of pre- birth secretion is constant.
• Increased nipple sensitivity at birth lasting several days

7 8

Birth before 28 weeks

• Delayed onset lactogenesis II
AN EXPRESSING
• Milk volumes significantly lower D10
Antenatal corticosteroids • Physiologically the composition of colostrum is unchanged in pregnancy

• Transitory activation of secretory activity in

• Wide variation in amount of colostrum women collect

P R E M AT U R I T Y
breast • Conditional safety established (DAME trial, Forster et al 2017)
• Occurred as early as 24 weeks • May increase confidence ( Dimerci et al , 2019)
• Timing influenced effect of betamethasone on
lactation PN.

Henderson et al 2008 & 2009

9 10

• Varies in timing of onset 32- 96 hours

P R I M A RY B R E A S T
• Major changes in milk composition continue to day 10
HYPOPLASIA &
B R E A S T S U R G E RY • Progesterone key inhibitor and decline is the trigger for
stage II lactogenesis
• Breasts do not undergo normal growth and
• Heralded by a physiological change in milk composition of
development during pregnancy
increased lactose, glucose and citrate and decrease in
• May be asymmetrical
LACTOGENESIS II
protein, nitrogen, sodium, chloride due to closure of gaps
• Characterized by widely spaced breasts, tubular between milk secreting cells.
shape • Gradual change – sensation of ‘milk coming in’ post dates
the change in milk composition
• Breast Augmentation
• “full feeling” is an overshoot of milk supply which then
• Reduction mammoplasty
often needs to down regulate to match need
• Supply increases to an average of 500ml over 24 hrs at 4
Image: Dessy, L. A., De Santo, L., Onesti, M. G., Fallico, N., & Mazzocchi, M. (2018). Tuberous breast and predisposition to breast deformity in consanguineous. Breast Journal, 24(1), 51–54.
days.

11 12

2

LACTOGENESIS II
13
SUPPORTING NORMAL PHYSIOLOGY
Initiation of breastfeeding
15
D E L AY S I N L A C T O G E N E S I S I I - C A U S E S
MEDICAL INTERVENTION
• Prolactin increase less on D2
following C/S
• Oxytocin reduced following C/S
• Similar oxytocin effect from
epidural
• Synthetic oxytocin potentiates
prolactin release
(M oberg, 2020, Kelly et al 2020)
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• Will occur regardless of milk removal in the first 3 days
• However, milk removal is critical for progression to
Lactogenesis III
• Regular milk removal will facilitate normal progression
LACTOGENESIS II-
of lactogenesis II and will ‘prime’ the breast by
increasing the number and sensitivity of prolactin P R A C T I C A L I M P L I C AT I O N S
receptors
• Nipple stimulation causes an increase in serum
prolactin
• Oxytocin induced ‘milk ejection reflex’ must occur for S U P P ORT I NG NOR MA L P HYS I OLOG Y
milk removal, without this minimal milk can be EXPRESSING
removed from the breast D E L AY S : C A U S E S A N D M A N AG E M E N T
14
EXPRESSING
• Early initiation within 1 hr of birth is influential on longer term volumes (Parker et al,2012)
• skin to skin contact, higher number of expressing episodes per day predictive of higher
volumes of milk on D10 (Fewtrell et al, 2016)
• Comfort and ease of use also influenced volume of milk on D10 (Fewtrell et al, 2016)
• Simultaneous expressing (with electric pump) increased volume over shorter time and
expressing reported as ‘easier’ (Koroglu et al, 2019)
Feeding frequency Normalising early breastfeeding How to work with FIL • Pumps that mimic infant sucking patterns improved milk yield that mimicked that of BF
infants and maintained volume through to the end of the 2nd week. (Meier et al 2012)
• Individualised approach accounting for purpose and individual woman and infant (Cochrane
review, 2016)
16
LACTOGENESIS II AND DIABETES
• Glucose metabolism impairment degree unknown what level triggers lactation effect
• Insulin influence throughout lactation phases
RETAINED PLACENTAL FRAGMENTS OBESITY
• Women with diabetes a delay of 24 hours of onset of lactogenesis II (Hartmann, 2001)
• Minimal literature – case based • Strong links with obesity and altered
glucose metabolism / insulin • More recently delay linked more closely to women with poor glycaemic control (DeBortoli & Amir,
• Retained placenta continues to resistance 2016)
secrete progesterone
• Delay aligned with grade of obesity • Women with tight glycaemic control demonstrated onset of Lactogenesis II in line with women
• Inhibits onset of Lact II • Multiple risks increases incidence of with no diabetes (Achong et al., 2017)
• A story to illustrate delay
• Modifiable management strategies must be considered
• Prolactin response to suckling
reduced at 48 hrs but not at 7 days
• Metformin use ?
Nom m sen-Rivers (2016 )
18
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• Maintenance of established milk supply ( D10

onward)
M A N A G I N G D E L AY E D L A C T O G E N E S I S I I • Oxytocin and Prolactin remain integral to lactation
• Milk produced in response milk removal
• FIL down regulates milk synthesis when breasts fill
• Milk synthesis increases when breast is drained and
Maximise breast slows as breast fills
stimulation L AC TO G E N E S IS III • Breast storage capacity 80-600 ml
Risk Factors - Determine cause
Ensure adequate • 24hr milk production remains constant @ 1-6
Identify and – this will drive months 708 – 742gm +/- 54-74 gm.
Frequent infant intake • Increased binding capacity for prolactin explains
close follow up Mx plan
effective breast maintenance despite reducing prolactin levels
• Highest volume of milk removed in the morning
drainage • Milk synthesis highest in late evening when breasts
most drained
• Oxytocin decreases activity of sympathetic nervous
system and facilitates social interaction and
decreases anxiety
• Oxytocin release related to BF = increased thirst and
absorption of nutrients – assist mothers to adapt to
nutrition and fluid demands of BF.

19 20

• Down regulation of supply – what women should

expect
LACTOGENESIS III- • How supply / demand works
P R A C T I C A L I M P L I C AT I O N S SUPPORTING
• Breast capacity and its influence on feeding
NORMAL
frequency
PHYSIOLOGY
• How to know if baby ‘getting enough’
S U P P O RT IN G T H E P H Y S IO LO G Y

G A L AC TAG O G U E S

L AC TAT IO N A L A M E N O R R H E A A N D H O R M O N A L C O N T R AC E P T IO N

W E A N IN G - IN VO L U T IO N

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G A L A C TA G O G U E S HORMONAL CONTRACEPTION LACTATIONAL AMENORRHEA

• Progesterone does not affect the lactating • Nipple stimulation impact on anterior pituitary
breast hormones

• Evidence: most studies conducted in early
stages of lactation
• Progesterone only pill not demonstrated to
have effect on supply or infant growth
• Combined pill – some inhibitory effects
• Cochrane review recommends further studies
• Frequency and intensity of suckling dictates
lactational amenorrhea
• Variation not well explained
• May be due to higher sensitivity to the breast-
hypothalamus-pituitary system
• Timing of solid introduction strongly related to
duration of amenorrhea

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WEANING - INVOLUTION IN CONCLUSION

PHYSIOLOGY • The hormonal interplay of lactation is very specific and relies on all
• Increase in protein, chloride and sodium and decrease in lactose.
normal physiological hormonal responses to prepare the breast,
commence early lactation and maintain lactation
• Volume falls below 400 ml / day
• Early initiation, stimulation and milk removal is vital for the success
Post lactational involution is 2 phase: of ongoing lactation, despite lactogenesis II occurring irrespective of
• 1. Secretory cell apoptosis and death begins within 2 days breastfeeding being initiated

• 2. Base membrane undergoes degradation • Milk volumes at one week are predictive of long-term milk supply
PRACTICE POINTS:
• Alveolar remodeling • Involution begins if feeding not initiated • Ongoing milk supply relies on regular, effective milk removal
• Delay of days to initiate will impact on reaching lactation potential
• Reconstruction to pre pregnancy state • Protein increase post lactation protective immune factors
• Understanding the physiology of lactation and lactation challenges
• Re-lactation to full capacity – time constrained
ensures appropriate targeted response to support women to
• Possible beyond time parameters but may not reach full potential succeed.
• Many areas of breastfeeding remain under researched
• Breastfeeding Hormones in Play is freely available on YouTube

25 26

REFERENCES Köroğlu, Ö. A., Can, N., Atıkan, B. Y., Tanrıverdi, S., Yalaz, M., Akısü, M., & Kültürsay, N. (2017). Efficacy and Maternal Comfort of Sequential versus Simultaneous Breast Expression by Mothers
of Critically III Newborns. Journal of Pediatric Research, 4(4), 211–215.

Achong, N., Duncan, E. L., M cIntyre, H. D., & Callaway, L. (2018). The physiological and glycaemic changes in breastfeeding women with type 1 diabetes mellitus. Diabetes Research and Clinical Practice, 135, 93–101.
Bahadori, B., Riediger, N. D., Farrell, S. M ., Uitz, E., & M oghadasian, M . F. (2013). Hypothesis: smoking decreases breast feeding duration by suppressing prolactin secretion. M edical Hypotheses, 81(4), 582–586.
Becker GE, Smith HA, Cooney F. M ethods of milk expression for lactating women. Cochrane Database of Systematic Reviews 2016, Issue 9.
Brownell, E., Howard, C. R., Lawrence, R. A., & Dozier, A. M . (2012). Delayed Onset Lactogenesis II Predicts the Cessation of Any or Exclusive Breastfeeding. The Journal of Pediatrics, 161(4), 608–614.
Cregan, M . D., M itoulas, L. R., & Hartmann, P. E. (2002). M ilk prolactin, feed volume and duration between feeds in women breastfeeding their full-term infants over a 24 h period. Experimental Physiology, 87(2), 207–214.
De Bortoli, J., & Amir, L. H. (2016). Systematic Review or M eta-analysis Is onset of lactation delayed in women with diabetes in pregnancy? A systematic review. Diabetic M edicine, 33(1), 17.
Lawrence, R. A. . 1924-author., & Lawrence, R. M. (2016). Breastfeeding : a guide for the medical profession (Eighth edition.). Elsevier.
Lepe, M., Bacardi Gascón, M., Castañeda-González, L. M., Pérez Morales, M. E., & Jiménez Cruz, A. (2011). Effect of maternal obesity on lactation: systematic review. Nutricion Hospitalaria,
26(6), 1266–1269.
Lopez LM, Grey TW, Stuebe AM, Chen M, Truitt ST, Gallo MF. Combined hormonal versus nonhormonal versus progestin-only contraception in lactation. Cochrane Database of Systematic
Reviews 2015, Issue 3. Art. No.: CD003988.
Meier, P. P., Engstrom, J. L., Janes, J. E., Jegier, B. J., & Loera, F. (2012). Breast pump suction patterns that mimic the human infant during breastfeeding: greater milk output in less time spent
pumping for breast pump-dependent mothers with premature infants. Journal of Perinatology, 32(2), 103–110.

Demirci, J. R. ( 1 ), Glasser, M . ( 1 ), Fichner, J. ( 2 ), Caplan, E. ( 3 ), & Himes, K. P. ( 4 ). (2019). “It gave me so much confidence”: First-time U.S. mothers’ experiences with antenatal milk expression. M aternal and Child Nutrition, 15(4). Neville, M. C., Webb, P., Ramanathan, P., Mannino, M. P., Pecorini, C., Monks, J., Anderson, S. M., & MacLean, P. (2013). The insulin receptor plays an important role in secretory differentiation
in the mammary gland. American Journal of Physiology (Consolidated), 5, 1103.
Donovan TJ, Buchanan K. M edications for increasing milk supply in mothers expressing breastmilk for their preterm hospitalised infants. Cochrane Database of Systematic Reviews 2012. Issue 3.
Nommsen-Rivers, L. A. (2016). Does Insulin Explain the Relation between Maternal Obesity and Poor Lactation Outcomes? An Overview of the Literature. Advances in Nutrition (Bethesda,
Falkland, M . (2018.). Galactagogues to increase milk supply in breastfeeding mothers. Australian Journal of Pharmacy, 99(1171), 76–79.
Md.), 7(2), 407–414.
Fewtrell, M . S., Kennedy, K., Ahluwalia, J. S., Nicholl, R., Lucas, A., & Burton, P. (2016). Predictors of expressed breast milk volume in mothers expressing milk for their preterm infant. Archives of Disease in Childhood -- Fetal & Neonatal Edition,
101(6), F502. Nommsen-Rivers, L., Thompson, A., Riddle, S., Ward, L., Wagner, E., & King, E. (2019). Feasibility and acceptability of metformin to augment low milk supply: a pilot randomized controlled
trial. Journal of Human Lactation, 35(2), 261–271.
Forster, D. A., M oorhead, A. M ., Jacobs, S. E., Davis, P. G., Walker, S. P., M cEgan, K. M ., Opie, G. F., Donath, S. M ., Gold, L., M cNamara, C., Aylward, A., East, C., Ford, R., & Amir, L. H. (2017). Advising women with diabetes in pregnancy to express
breastmilk in late pregnancy (Diabetes and Antenatal M ilk Expressing [DAM E]): a multicentre, unblinded, randomised controlled trial. Lancet (London, England), 389(10085), 2204–2213. Parker, L. A., Sullivan, S., Krueger, C., Kelechi, T., & Mueller, M. (2012). Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth
weight infants: a pilot study. Journal of Perinatology, 3, 205.
Grzeskowiak, L. E. (n.d.). No evidence that fenugreek is more effective than placebo as a galactagogue. Phytotherapy Research.

Soni, M. (2014). Sheehan Syndrome: a Rare Complication of Post-partum Hemorrhage. Nepal Journal of Obstetrics & Gynaecology, 9(2), 61–63.
Grzeskowiak, L. E., Wlodek, M . E., & Geddes, D. T. (2019). What Evidence Do We Have for Pharmaceutical Galactagogues in the Treatment of Lactation Insufficiency?-A Narrative Review. Nutrients, 11(5).

Hartmann, P., Cregan, M ., & Labarre, C. (2001). Lactogenesis and the effects of insulin-dependent diabetes mellitus and prematurity. (Symposium: Human Lactogenesis II: M echanisms, Determinants and Consequences). The Journal of Nutrition, 11.
Henderson JJ, Newnham JP, Simmer K, & Hartmann PE. (2009). Effects of antenatal corticosteroids on urinary markers of the initiation of lactation in pregnant women. Breastfeeding M edicine, 4(4), 201–206.
Henderson, J. J., Hartmann, P. E., Newnham, J. P., & Simmer, K. (2008). Effect of preterm birth and antenatal corticosteroid treatment on lactogenesis II in women. Pediatrics, 121(1), e92–e100.
Tuberous breast image: Dessy, L. A., De Santo, L., Onesti, M. G., Fallico, N., & Mazzocchi, M. (2018). Tuberous breast and predisposition to breast deformity in consanguineous. Breast Journal,
24(1), 51–54.
Uvnäs Moberg, K., Ekström-Bergström, A., Buckley, S., Massarotti, C., Pajalic, Z., Luegmair, K., Kotlowska, A., Lengler, L., Olza, I., Grylka-Baeschlin, S., Leahy-Warren, P., Hadjigeorgiu, E.,
Villarmea, S., & Dencker, A. (2020). Maternal plasma levels of oxytocin during breastfeeding-A systematic review. PloS One, 15(8), e0235806.

Hurst, N. M . (2007). Recognizing and Treating Delayed or Failed Lactogenesis II. Journal of M idwifery and Women’s Health, 52(6), 588–594. Walker, M. (2014). Breastfeeding management for the clinician : using the evidence (Third edition.). Jones and Bartlett Learning.
Kelly, N. M ., Smilowitz, J. T., Cagney, O., Flannery, R. L., & Tribe, R. M . (2020). Delayed onset of lactogenesis and reduced breastfeeding frequency in mothers who give birth by caesarean section. Proceedings of the Nutrition Society, 79(OCE2), 1.

27 28

5
 References:

Achong, N., Duncan, E. L., McIntyre, H. D., & Callaway, L. (2018). The physiological and glycaemic changes in
breastfeeding women with type 1 diabetes mellitus. Diabetes Research and Clinical Practice, 135, 93–101.
https://doi.org/10.1016/j.diabres.2017.11.005
Bahadori, B., Riediger, N. D., Farrell, S. M., Uitz, E., & Moghadasian, M. F. (2013). Hypothesis: smoking
decreases breast feeding duration by suppressing prolactin secretion. Medical Hypotheses, 81(4), 582–586.
Becker GE, Smith HA, Cooney F. Methods of milk expression for lactating women. Cochrane Database of
Systematic Reviews 2016, Issue 9.
Brownell, E., Howard, C. R., Lawrence, R. A., & Dozier, A. M. (2012). Delayed Onset Lactogenesis II Predicts
the Cessation of Any or Exclusive Breastfeeding. The Journal of Pediatrics, 161(4), 608–614.
Cregan, M. D., Mitoulas, L. R., & Hartmann, P. E. (2002). Milk prolactin, feed volume and duration between
feeds in women breastfeeding their full-term infants over a 24 h period. Experimental Physiology, 87(2), 207–
214.
De Bortoli, J., & Amir, L. H. (2016). Systematic Review or Meta-analysis Is onset of lactation delayed in
women with diabetes in pregnancy? A systematic review. Diabetic Medicine, 33(1), 17.
Demirci, J. R. ( 1 ), Glasser, M. ( 1 ), Fichner, J. ( 2 ), Caplan, E. ( 3 ), & Himes, K. P. ( 4 ). (2019). “It gave me
so much confidence”: First-time U.S. mothers’ experiences with antenatal milk expression. Maternal and Child
Nutrition, 15(4).
Donovan TJ, Buchanan K. Medications for increasing milk supply in mothers expressing breastmilk for their
preterm hospitalised infants. Cochrane Database of Systematic Reviews 2012. Issue 3.
Falkland, M. (2018.). Galactagogues to increase milk supply in breastfeeding mothers. Australian Journal of
Pharmacy, 99(1171), 76–79.
Fewtrell, M. S., Kennedy, K., Ahluwalia, J. S., Nicholl, R., Lucas, A., & Burton, P. (2016). Predictors of
expressed breast milk volume in mothers expressing milk for their preterm infant. Archives of Disease in
Childhood -- Fetal & Neonatal Edition, 101(6), F502.
Forster, D. A., Moorhead, A. M., Jacobs, S. E., Davis, P. G., Walker, S. P., McEgan, K. M., Opie, G. F., Donath,
S. M., Gold, L., McNamara, C., Aylward, A., East, C., Ford, R., & Amir, L. H. (2017). Advising women with
diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing
[DAME]): a multicentre, unblinded, randomised controlled trial. Lancet (London, England), 389(10085), 2204–
2213.
Grzeskowiak, L. E. (n.d.). No evidence that fenugreek is more effective than placebo as a galactagogue.
Phytotherapy Research.
Grzeskowiak, L. E., Wlodek, M. E., & Geddes, D. T. (2019). What Evidence Do We Have for Pharmaceutical
Galactagogues in the Treatment of Lactation Insufficiency?-A Narrative Review. Nutrients, 11(5).
Hartmann, P., Cregan, M., & Labarre, C. (2001). Lactogenesis and the effects of insulin-dependent diabetes
mellitus and prematurity. (Symposium: Human Lactogenesis II: Mechanisms, Determinants and
Consequences). The Journal of Nutrition, 11.
Henderson JJ, Newnham JP, Simmer K, & Hartmann PE. (2009). Effects of antenatal corticosteroids on
urinary markers of the initiation of lactation in pregnant women. Breastfeeding Medicine, 4(4), 201–206.
Henderson, J. J., Hartmann, P. E., Newnham, J. P., & Simmer, K. (2008). Effect of preterm birth and
antenatal corticosteroid treatment on lactogenesis II in women. Pediatrics, 121(1), e92–e100.
Hurst, N. M. (2007). Recognizing and Treating Delayed or Failed Lactogenesis II. Journal of Midwifery and
Women’s Health, 52(6), 588–594.
Kelly, N. M., Smilowitz, J. T., Cagney, O., Flannery, R. L., & Tribe, R. M. (2020). Delayed onset of lactogenesis
and reduced breastfeeding frequency in mothers who give birth by caesarean section. Proceedings of the
Nutrition Society, 79(OCE2), 1.
 Köroğlu, Ö. A., Can, N., Atıkan, B. Y., Tanrıverdi, S., Yalaz, M., Akısü, M., & Kültürsay, N. (2017). Efficacy and
Maternal Comfort of Sequential versus Simultaneous Breast Expression by Mothers of Critically III Newborns.
Journal of Pediatric Research, 4(4), 211–215.
Lawrence, R. A. . 1924-author., & Lawrence, R. M. (2016). Breastfeeding : a guide for the medical profession
(Eighth edition.). Elsevier.
Lepe, M., Bacardi Gascón, M., Castañeda-González, L. M., Pérez Morales, M. E., & Jiménez Cruz, A. (2011).
Effect of maternal obesity on lactation: systematic review. Nutricion Hospitalaria, 26(6), 1266–1269.
Lopez LM, Grey TW, Stuebe AM, Chen M, Truitt ST, Gallo MF. Combined hormonal versus nonhormonal
versus progestin‐only contraception in lactation. Cochrane Database of Systematic Reviews 2015, Issue 3. Art.
No.: CD003988.
Meier, P. P., Engstrom, J. L., Janes, J. E., Jegier, B. J., & Loera, F. (2012). Breast pump suction patterns that
mimic the human infant during breastfeeding: greater milk output in less time spent pumping for breast
pump-dependent mothers with premature infants. Journal of Perinatology, 32(2), 103–110.
Neville, M. C., Webb, P., Ramanathan, P., Mannino, M. P., Pecorini, C., Monks, J., Anderson, S. M., &
MacLean, P. (2013). The insulin receptor plays an important role in secretory differentiation in the mammary
gland. American Journal of Physiology (Consolidated), 5, 1103.
Nommsen-Rivers, L. A. (2016). Does Insulin Explain the Relation between Maternal Obesity and Poor
Lactation Outcomes? An Overview of the Literature. Advances in Nutrition (Bethesda, Md.), 7(2), 407–414.
Nommsen-Rivers, L., Thompson, A., Riddle, S., Ward, L., Wagner, E., & King, E. (2019). Feasibility and
acceptability of metformin to augment low milk supply: a pilot randomized controlled trial. Journal of Human
Lactation, 35(2), 261–271.
Parker, L. A., Sullivan, S., Krueger, C., Kelechi, T., & Mueller, M. (2012). Effect of early breast milk expression
on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: a pilot
study. Journal of Perinatology, 3, 205.
Soni, M. (2014). Sheehan Syndrome: a Rare Complication of Post-partum Hemorrhage. Nepal Journal of
Obstetrics & Gynaecology, 9(2), 61–63.
Tuberous breast image: Dessy, L. A., De Santo, L., Onesti, M. G., Fallico, N., & Mazzocchi, M. (2018).
Tuberous breast and predisposition to breast deformity in consanguineous. Breast Journal, 24(1), 51–54.
Uvnäs Moberg, K., Ekström-Bergström, A., Buckley, S., Massarotti, C., Pajalic, Z., Luegmair, K., Kotlowska,
A., Lengler, L., Olza, I., Grylka-Baeschlin, S., Leahy-Warren, P., Hadjigeorgiu, E., Villarmea, S., & Dencker, A.
(2020). Maternal plasma levels of oxytocin during breastfeeding-A systematic review. PloS One, 15(8),
e0235806.
Walker, M. (2014). Breastfeeding management for the clinician : using the evidence (Third edition.). Jones
and Bartlett Learning.