Physiology of

Lactation

Adapted from the course on Breastfeeding : Advocacy & Practice Malaysia 2008

Stages of Lactation
(Criteria devised by Peter Hartman )

Mammogenesis Lactogenesis Lactogenesis I Lactogenesis II Galactopoiesis Lactogenesis III Involution

Lactogenesis
Lactogenesis I

starts at 28 weeks pregnancy

Substrate for milk production collect in breast tissue Early secretion production of colostrum starts

Lactogenesis II
starts at 3-4 days after delivery

- removal of placenta, progesterone &estrogen = stimulates milk synthesis Blood flows to breast increases
Transition milk comes in Copius production of mature milk starts

Lactogenesis II

Retained placenta inhibits

Initiation of milk production

depends on changed hormone levels

----- NOT on early suckling

Continuation of milk production

after 3-4 days DOES depend on infant suckling

Lactogenesis III or Galactopoiesis

from 10 days after delivery Mature milk is produced Production sustained if baby continues to breastfeed Volume depends on the amount baby

removes

Lactogenesis III or Galactopoiesis

Single baby 750 mls / 24 hrs

For Twins - 1500 mls / 24 hrs

Involution
When other feeds / foods satisfy appetite baby suckle less, production decreases milk cells die Milk in the breast is reabsorbed. Last milk produced is more like colostrum with many protective bodies

Role of Hormones
(primes mammary glands)
Estrogen growth of ducts
Progesterone growth of alveoli Placental Lactogen - growth of milk producing cells in the alveoli Prolactin helps growth of ducts and alveoli /stimulates alveoli cells to produce milk

: Prolactin Reflex

Sensory impulses from nipples

Prolactin in blood

Baby suckling

More prolactin secreted at night Suppresses ovulation

Secreted during and after feed to produce next feed

Prolactin Levels
Prolactin blood levels: Menstruating woman: End of pregnancy: ng /ml 8 14 200 500

Baseline during lactation: - From delivery to 10 days: - 10 90 days: - 90 180 days: - 180 days 1 year:

200 60 100 50 30 40

Oxytocin reflex

Oxytocin in blood

Sensory impulses from nipples

Baby suckling

Makes uterus contract

Works before or during feed to make milk flow

help reflex

hinder reflex

Thinks lovingly of baby Sounds / sight of baby Touching baby Confidence

Worry
Stress Pain Doubt

Helping and hindering of oxytocin reflex

NEUROENDOCRINE PATHWAYS INITIATED BY SUCKLING

Milk production

First 4 6 weeks after delivery

is very variable At 5 days = 200 900 ml / 24 hours At 4 6 weeks = 400 1100 ml/24 hours

Milk production

Milk production starts: low and increases (up-regulation) in most women high and decreases (down-regulation) in some women until it adjusts to the needs of the baby.
Milk production at this time is not related to size of baby

Milk production
(Ingram 99, Allen 91,Neville 88)

By 4 6 weeks, production adjusts to babys needs Milk production is now related to size of baby

- regulated by babys demand - babys fat or calorie intake controls appetite and hence demand
If supplements are given appetite is satisfied demand is less

Milk Production From Birth

Babys Age Day 1 (0-24 hrs) mls per day Range 7 123 Day 2 (24-48 hrs) 44 335 Day 3 (48-72 hrs) 98 775 Day 4 (72-96 hrs)
Day 5 (96-120 hrs)
mls per feed

Average On Average 37 84 266 385 500 750 7 14 38 58 70

3 months

6 months

800

Establishing a good milk supply

To establish adequate breastmilk production, the most important factor is:

Efficient and effective removal of breastmilk

To remove milk efficiently, a baby must:

Suckle effectively
To suckle effectively a baby must be:

Optimally attached and positioned at the breast

Storage of milk in the breast

Milk is made and stored in the breast between feeds - Storage capacity

to breast size.

varies , maybe related

Women with small breast can produced plenty of milk.

- If storage capacity low, baby may need

to feed more often.

Feedback Inhibitor of Lactation (FIL) It is chemical inhibitor Is an autocrine or local regulator of breastmilk synthesis Is a protein made in the breast itself If not removed it collects in the alveoli and blocks milk secretion in the mammary cells

Factors that impair milk production 1. Inefficient milk removal due to: - Poor attachment - Insufficiently suckling - Addition of supplements - Infrequent feeds - Short feeds - No night feeds

Factors that impair milk production

2. Impaired ejection anxiety, pain

(temporary)

3. Retained placenta products

(hormones inhibit prolactin)

4. Oestrogens (e.g., in combined

hormonal contraceptives) 5. Pregnancy

Factors that impair milk production

6. Lack of prolactin
- Sheehans syndrome (after postpartum haemorrhage) - Primary deficiency - (very rare) - Smoking (nicotine may lead to lower prolactin levels) 7. Physical abnormality (breast agenesis) 8. Severe malnutrition

INVOLUTION
Breastmilk output continues at about the same level while baby breastfeeds exclusively and on demand When other foods are given, the babys appetite are satisfied and he may suckle less. Breastmilk production decreases, milk cells die Milk which remains in the breast is reabsorbed.

Involution

The last milk produced is more like colostrum, with many protective factors, which may continue to help protect baby against some infection.