BREAST PROBLEMS AND INFANT FEEDING
 

Physiology of lactation

• High levels of progesterone during pregnancy inhibit the action of prolactin on milk production.
• After delivery, both prolactin and progesterone levels fall but the rapid fall in progesterone compared to prolactin allows the full lactogenic action of the residual prolactin to come to effect and milk secretion begins.
• Suckling also stimulates a rise in prolactin levels with resultant effects on milk production.
• Suckling stimulates milk ejection by increasing oxytocin release - this stimulates contraction of the myoepithelial cells around the breast alveoli and ducts.
• Successful breastfeeding depends on a well mother and infant, motivation by mother to breastfeed and support from healthcare professional to encourage breastfeeding.
• Poor technique and separation of mother and baby have a significant impact on establishment of breastfeeding.

Suppression of lactation

• Pharmacologic methods for lactation suppression are available e.g. bromocriptine and carbegolline but are not in routine use
• Symptoms will usually subside with the use of simple analgesia

Breastfeeding vs Bottle-feeding

Advantages of breastfeeding

• Free and contains all the nutrients that a baby requires to grow and develop healthily.
• Improves maternal-child bonding by encouraging a sense of closeness between mother and baby.
• Breast milk is available at the perfect temperature and there is no need for any special equipment to heat it to the correct temperature.
• Protects baby against illnesses such as diarrhoea, vomiting, chest, ear and urine infections, eczema and wheezing
• May help a child's mental development as it has been shown that children who were breastfed were able to achieve more, and had higher IQ (Intelligence Quotient) scores than those who were given formula milk.
• It may help mothers lose weight by getting rid of any excess fat that was stored whilst pregnant.

Disadvantages of breastfeeding

• If the mother has a blood-borne virus, such as HIV, or taking certain types of medication, they may be transmitted or passed from mother to baby
• In about 2% of cases, mothers are not able to produce enough breast milk to feed their baby.

Advantages of bottle feeding

• The baby may sleep for longer in between feeds
• The mother can ask someone else, such as the partner, or a family member, to feed the baby if she needs a break.
• Formula milk has added vitamin k which helps the clotting process. The neonate’s ability to store vitamin k is low and in rare cases (1:10,000) vitamin K deficiency causes haemorrhaigic disease of the newborn. Risk increased in mothers taking anticonvulsant drugs. If breastfeeding, babies should be given additional vitamin k with theirs parents consent.

Disadvantages of bottle feeding

• Expensive. It has been estimated that it costs about £450 a year to feed a baby using formula milk.
• Formula fed babies are at increased risk of obesity at least up to the age of six
• Formula fed babies are more likely to develop illnesses such as diarrhoea, chest or urine infection. There is also an increased risk of premature babies who are bottle fed developing necrotising enterocolotis
• Time consuming to prepare food. Equipment needs to be sterilised and it can be difficult to get the right mixture for the baby.  

Specific Breast Conditions

Breast engorgement

• Breasts may become distended with visible dilated veins and firm during the first day or two after delivery.
• Factors associated with breast engorgement include delayed initiation of feeds, infrequent feeds and partial breastfeeding.
• May be accompanied by a fever in 10-15% of women. This is however a diagnosis of exclusion and infection should be excluded
• Treatment – encourage to continue breastfeeding and offer simple analgesia.

Acute Mastitis

• Second most common cause of discontinuation of breastfeeding by women in UK.
• Irritation from lactation causes local skin inflammation and swelling; this causes obstruction to milk flow. Bacterial infection causees mastitis.
• Commonest organism is Staph aureus – 90% of cases.

Clinical features

• Symptoms – pain, (may be worse with breast feeding), swelling, shivering & chills
• Signs – redness, swelling, oedema and tenderness of breast; pyrexia, tachycardia, lymphadenopathy
• Investigations - Empirical treatment is usually undertaken without investigations

Consider

1. FBC, CRP, blood cultures if septic
2. Ultrasound scan if abscess suspected
3. Milk culture if failure to respond

• Treatment

Antibiotics to cover staph aureus. e.g. flucloxacillin
Continued expression of breast milk or breastfeeding.
Analgesia / antipyretics. AVOID aspirin.

• Complications

Breast Abscess - usually confined to one segment or quadrant and may become fluctuant on examination. Signs and symptoms of acute mastitis may still be present. Suspect an abscess if not responding to antibiotics. An ultrasound scan may help in the diagnosis.
Treatment – antibiotics + open or US guided drainage.