1. Lactation PhysiologyLactation Physiology
and Managementand Management
Alison Stuebe, MD, MSc
astuebe@med.unc.edu

2. ObjectivesObjectives
• Review public health impact of
breastfeeding
• Understand physiology of lactation
• Identify the differential diagnosis and
treatment for common breastfeeding
problems
» Low milk supply
» Mastitis
» Breast abscess

3. Health Impact ofHealth Impact of
Not BreastfeedingNot Breastfeeding
INFANTINFANT MOTHERMOTHER
IllnessIllness OROR IllnessIllness OROR
DiarrheaDiarrhea 2.82.8
PremenopausalPremenopausal
breast cancerbreast cancer
1.41.4
Otitis mediaOtitis media 2.02.0 Ovarian cancerOvarian cancer 1.31.3
PneumoniaPneumonia 3.63.6 Type 2 DiabetesType 2 Diabetes 1.21.2
SIDSSIDS 1.61.6
AsthmaAsthma 1.41.4
LeukemiaLeukemia 1.21.2
Formula-feeding vs. breast-feeding: risk of adverse outcomes.
Breastfeeding and Maternal and Infant Health Outcomes in
Developed Countries. AHRQ Evidence Report Number 153. April 2007.

4. AAP RecommendationsAAP Recommendations
• Exclusive
breastfeeding for
the first six months
of life
• Continued
breastfeeding for
at least one year,
‘As long as is
mutually desired
by mother and
child’
American Academy of Pediatrics (2005). "Breastfeeding and the Use of
Human Milk." Pediatrics 115(2): 496-506.

5. ContraindicationsContraindications
• HTLV-1 and HTLV-2
• HSV with lesion on
the breast
• Active tuberculosis
• Medications that
contraindicate
breastfeeding
• Newborn with
galactosemia
• Maternal HIV
» US: not recommended
» UNICEF: When
replacement feeding is
acceptable, feasible,
affordable, sustainable
and safe, avoidance of
all breastfeeding is
recommended;
otherwise, exclusive
breastfeeding is
recommended during
the first months of life.

6. Milk
production
Milk
ejection
PIF
How Does Lactation Happen?How Does Lactation Happen?
Prolactin Oxytocin
Anterior
pituitary
Posterior
pituitary
Hypothalamus
Paraventricular
nucleus

7. Where does milk come from?Where does milk come from?

8. OxytocinOxytocin
• Moves milk from
lobules to sinuses,
so baby can eat
• Inhibited by stress,
pain, anxiety
• Triggered by sound,
smell, sight of infant
Let Down: Ejection, not suction,
moves milk to the areola.

9. Stress and Milk VolumeStress and Milk Volume
J. Pediatr 1948; 33:698-704.

10. Milk TransferMilk Transfer
• Infant grasps most
of the areola in his
mouth
• Tongue “milks”
milk to the back of
the mouth prior to
swallowing.
Latch: The baby’s tongue moves
milk from areola to nipple.

11. Negative feedbackNegative feedback
• Milk in lobules contains
whey protein called
Feedback Inhibitor of
Lactation (FIL)
• If milk is not removed,
and lumen is full,
production will decrease
• Goal: 10-12 feeds in 24
hours, until baby is done.
Moving Milk:
Demand drives supply.

12. Evidence-based early careEvidence-based early care
Latch
Moving
Milk
Let
Down
Breastfeeding
Success
Start out right: establish
normal physiology

13. Low Milk SupplyLow Milk Supply
• Primary lactation failure
» Anatomic abnormality
» Sheehan’s syndrome
• Disruption of normal physiology
» Infrequent or inadequate milk removal
» Postpartum depression
• First line therapy:
» Lactation consultation
» Mechanical expression after breastfeeding
• If needed:
» Supplement after breastfeeding as indicated
» Continue pumping during supplementation
» Consider metoclopramide

14. MastitisMastitis
• Definition: tender, swollen, wedge-shaped
area of breast, usually unilateral, with fever,
malaise, chills, and systemic symptoms
• Incidence: 3 to 20%
• Treatment
» Rest, fluids
» Antibiotics – Dicloxicllin 500mg QID x 10-14d
» Empty the breast
• Evaluate latch
• Continue frequent breast feeding
• Milk is not harmful to healthy, term infant
• Abrupt weaning slows maternal recovery
• Poor response requires further evaluation
Academy of Breastfeeding Medicine. ABM Clinical Protocol #4: Mastitis.
Breastfeeding Medicine 3(3); 2008.

15. Breast abscessBreast abscess
• 3% of women with mastitis
• Diagnosis
» Hard, red, tender mass after appropriate
treatment
» Diagnostic ultrasound
• Treatment
» Needle aspiration for culture / treatment
» Surgical drainage for large or multiple
abscesses
• Follow-up care
» Antibiotics
» Continue breastfeeding

16. For more informationFor more information
• American Academy of Pediatrics (2005).
Breastfeeding and the Use of Human Milk.
Pediatrics 115(2): 496-506.
• American Academy of Family Physicians.
(2001, 2/26/2007). Breastfeeding (Position
Paper).
• American College of Obstetrics and
Gynecology (2007). Breastfeeding: Maternal
and Infant Aspects. Special Report from
ACOG. ACOG Clinical Review 12(1
(supplement)): 1S-16S.
• Academy of Breastfeeding Medicine
www.bfmed.org