Definition of lactation

Lactation is describes the production of breast milk and its secretion

from the mammary gland after delivery
Anatomy of breast
PHYSIOLOGY OF LACTATION
Lactation can be divided into 5 stages:
1. Mammogenesis- Development of breasts to a functional state
2. Lactogenesis- Synthesis and secretion of milk from the breast
alveoli
3. Galactokinesis- Ejection of milk outside the breast
4. Galactopoiesis- Maintenance of lactation
5. Involution- regression and atrophy post lactation 6
Mammogenesis
Growth of ducts and lobuloalveolar systems
 This starts from birth to puberty and continues in pregnancy
 Ductal sprouting predominates in 1st trimester and lobular sprouting
occurs more in 2nd trimester hence the breast will contain more
glandular epithelial cells than stroma .
Hormonal influence during mammogenesis
Pre-pubertal growth-
 depends on estrogen and progesterone.
 Secretion of prolactin and somatotropin by the pituatory gland
results in mammary growth.
 Adrenocorticotrophic hormone(ACTH) and thyroid stimulating
hormone(TSH) acting on the adrenal gland and thyroid gland also play
a minor role in growth of the mammary gland
During pregnancy
In early pregnancy a marked increase in ductular sprouting, branching
and lobular formation is evoked by luteal and placental hormones.
Progesterone: causes increased growth of alveoli size and lobes
Estrogen: Stimulates milk duct system to grow and differentiate,
deposition of fat.
Prolactin: contributes to increased growth and differentiation of the
alveoli and ductal structures
LACTOGENESIS
The alveolar cells are the principal sites for production of milk.
Though some secretory activity is evident (colostrum) during
pregnancy and accelerated following delivery, milk secretion actually
starts on 3rd or 4th postpartum day.
Around this time, the breasts become engorged, tense, tender and
feel warm.
 Inspite of a high prolactin level during pregnancy, milk secretion is
kept in abeyance.
Probably, steroids — estrogen and progesterone circulating during
pregnancy make the breast tissues unresponsive to prolactin.
 Contd..
When the estrogen and progesterone are withdrawn following
delivery, prolactin begins its milk secretory activity in previously fully
developed mammary glands. Prolactin, insulin, growth hormone and
glucocorticoids are the important hormones in this stage.
The secretory activity is also enhanced directly or indirectly by growth
hormone, thyroxine and insulin. For milk secretion to occur, nursing
eff ort is not essential.
Galactokinesis:
Oxytocin is the major galactokinetic hormone.
 Discharge of milk from the mammary glands depends not only on
the suction exerted by the baby during suckling but also on the
contractile mechanism which expresses the milk from the alveoli into
the ducts.
Oxytocin is liberated from the posterior pituitary, produces
contraction of the myoepithelial cells of the alveoli and the ducts
containing the milk.
 This is the “milk ejection” or “milk let down” reflex whereby the milk
is forced down into the ampulla of the lactiferous ducts, where from it
can be expressed by the mother or sucked out by the baby.
 Contd..
Presence of the infant or infant’s cry can induce let down without
suckling.
A sensation of rise of pressure in the breasts by milk experienced by
the mother at the beginning of sucking is called “draught”.
This can also be produced by injection of oxytocin.
 The milk ejection reflex is inhibited by factors such as pain, anxiety,
breast engorgement or adverse psychic condition (depression).
The ejection reflex may be deficient for several days following
initiation of milk secretion and results in breast engorgement
During suckling, a conditioned reflex is set
up:
Ascending impulses from the nipple and areola thoracic sensory (4, 5
and 6) afferent neural arc paraventricular and supra optic nuclei of the
hypothalamus stimulate to release Oxytocin from the posterior
pituitary produces contraction of the myoepithelial cells of the alveoli
and the ducts containing milk. ("milk ejection" or "milk let down"
reflex) Milk is forced down into the ampulla of lactiferous ducts, where
from it can be expressed by the mother or sucked by The baby.
Galactopoiesis:
Prolactin appears to be the single most important galactopoietic
hormone.
For maintenance of effective and continuous lactation, frequency of
suckling (>8/24 hours) is essential.
 Distension of the alveoli by retained milk is due to failure of suckling.
This causes decrease in milk secretion by the alveolar epithelium.
Ductal and alveolar distension due to failure of milk transfer
(suckling) is a cause of lactation failure.
 Milk pressure reduces the rate of production and hence periodic
breastfeeding is necessary.
Involution
lactogenic hormone deprivation and local signals to undergo regression
and atrophy
MILK PRODUCTION:
A healthy mother will produce about 500–800 mL of milk a day to
feed her infant.
This requires about 700 Kcal/day for the mother, which must be made
up from diet or from her body store. For this purpose a store of about
5 kg of fat during pregnancy is essential to make up any nutritional
deficit during lactation
Stimulation of lactation:
Mother is motivated as regard the benefits of breastfeeding since the
early pregnancy.
No prelacteal feeds (honey, water) are given to the infant.
 Following delivery important steps are:
(i) to put the baby to the breast at 2–3 hours interval from the 1st day,
(ii) plenty of fluids to drink
(iii) to avoid breast engorgement
(iv) Early (½ – 1 hour) and exclusive breastfeeding in correct position is
encouraged.
Inadequate milk production (lactation
failure):
It may be due to infrequent suckling or due to endogenous
suppression of prolactin (ergot preparation, pyridoxin, diuretics or
retained placental bits).
 Pain, anxiety and insecurity may be the hidden reasons.
 Unrestricted feeding at short interval (2–3 hours) is helpful.
Drugs to improve milk production (galactogogues):
Metoclopramide (10 mg thrice daily)
Increases milk volume (60–100%) by increasing prolactin levels.
Sulpiride (dopamine antagonist),
domperidone has also been found effective by increasing prolactin
levels.
 Intranasal oxytocin contracts myoepithelial cells and causes milk let
down
 Contd..
Medications that reduce lactation-
 Bromocryptine(dopamine agonist)
 Progesterone, estrogen- OCP
 Clomiphene citrate
ergotamine
 pseudoephedrine(in cough syrups)
 Pyridoxine
 Prostaglandins- PGE/F2alpha
 Levodopa/carbidopa.
Advise to the mother to improve lactation
 Good health
Early and sufficient treatment of illnesses
 Proper balance between rest and exercise
 Freedom from worry
 Care of the breast /nipples during pregnancy
Post natally frequent breast feeding
Avoid breast engorgement
Plenty of fluids
Adequate nutrition
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