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Breast feeding & Lactation (Breast feeding (Contraindications (other…
Breast feeding & Lactation
Breast feeding
Breast anatomy
alveoli -> small duct -> large duct -> lobules -> lobes -> breast (has 15-25 lobules)
Myoepithelial fibers
that surround the outside of the uppermost alvelous: :<3: muscle that respond to
sucking reflex
Changes of breast during preg
First weeks: เจ็บ / ชา เต้านม
After 2 months
เต้านมขยาย + เห็นเส้นเลือดดำ :eight_pointed_black_star: + Bigger, blacker, ชี้ขึ้น of nipples
นวด nipples เบาๆ -> may มี thick, yellowish fluid (colostrum) ไหล
Areolae: broader + blacker
Bigger breast may hv striations
rare: gigantomastia -> need Sx Rx
:star: Size and Volume of breast
not related
to Amount of milk production
on Areolae has
Hypertrophic sebaceous glands
(aka glands of Montgomery)
Contraception
As Ovulation may happens as fast as 3 weeks after คลอด and varies invidually
Progesterone-only contraceptives (mini-pills), Depot medroxyprogesterone, Progestin implants
HAS NO EFFECTS ON
Amount and quality of milk
Estrogen-Progestin contraceptives :arrow_down: amount and quality of milk
1st Mense after คลอด: 2 months is fastest - 18 months is slowest
PROs
for BABY
:heavy_minus_sign: Rotavirus infection (half of reason of AGE in baby)
:arrow_down: Atopic dermatitis in ช่วงแรกของชีวิตเด็ก
:arrow_down: Wheezing in ช่วงแรกของชีวิตเด็ก
:star2: Baby got
Immunological experience of Mom
Milk got both
T
and B lymphocytes
T lymphocytes in milk is different
from in blood
T lymphocytes got 'specific mb antigens + LFA-1 high-memory T-cell phenotype
:arrow_down: Enteric infection (as got secretory IgA)
in Long term
:arrow_up: IQ of baby ตอนโต
for MOM
in Long term
:arrow_down: CA breast incidence
:arrow_down: BW ที่ค้างคลอดของแม่
if Breastfeeding for at least 2 yrs -> :arrow_down: Coronary heart disease risks by 23%
In terms of Nutritional, Immunological, Developmental, Psychological, Social, Economical, Environmental, Optimal Growth and development, and Decrease risks for acute and chronic diseases
10 steps to successful Breast Feeding (WHO 1988)
must latch-on correctly to prevent breast fissure :warning:
Position
Cradle hold
Cross-cradle hold
Lying on your side
Football hold
Laid-back
Contraindications
Drugs/Alcohol abuse mom
Newborn with Galactosemia
HIV mom
Active untreated TB
eating SOME Meds
currently treating CA breast (chemo)
other Virus infection is not C/I
Maternal CMV infection
Hepatitis B virus that baby alrdy got hepatitis B Ig
Hepatitis C
Herpes simplex
NO lesion at breast
Care of breasts
Clean nipple
Looks for Skin Fissure
Why?
Painful during BF
Affect milk production
Path for pyogenic bacteria to go in
Rx
Change breast side for BF
May use Topical Lanolin + Nipple shield for 24 hrs
Severe fissure :cry:
Avoid that side with fissure + Change to BF other side
Pump breast milk from fissure side ออกให้หมดเสมอ จนกว่าจะหายดี
Clean areola with water and light soap
before & after
BF as dry milk may เกาะ and irritate
Advice appropriate
Position
for BF including mom and baby posture and
latch-on
of baby during BF
(ท่าดูด + ลิ้นดูด)
Drug selection in BF
Chara. that should be considered to Decrease infant exposure
Short half life
Poor absorption
Low lipid solubility
How to take drugs?
many meals/day
each type should take
after latest BF asap
one meal/day
should take
immediately before the time baby will sleep the longest in that day
C/I
drugs during BF
Cytotoxic drugs
as affect cellular metabolism
Examples: cyclosphosphamide, cyclosporine, doxorubicin, and methotrexate
Effects
Immune suppression/neutropenia
Affected growth
:arrow_up: childhood cancer
Radioactive isotopes
consult nuclear medicine specialist before doing diagnostic study using these isotopes
Purpose: uses Radionuclide that hv Shortest excretion time in milk
Pump enough milk for before and after study -> Freeze in fridge
Pump milk during study to maintain milk production level -> trash those milk until Radioactivity is gone (between 15 hr to 2 week depends on each type of isotope)
:staff_of_aesculapius: affect ovulation
Slow
freq
and
return
of Ovulation than Non-BF mom
usu. not found in first 10 wks after คลอด -> we should give P contraceptive anyway
ให้นมลูกใช่ว่าจะ contraceptive ได้
Lactation
Timeline ให้นมลูก
First 6 mo yrs old: still no teeth -> need breast feeding
After 6 mo yrs old: เริ่มให้กินอย่างอื่น + encourage ให้กินนมกล่อง
Hormones related to Lac
maternal plasma lvl "Prolactin"
Hormone/NT that affects PRL lvl
TRH -> :arrow_up: PRL in preg -> then it :arrow_down: responds to PRL as GA เพิ่ม
Serotonin will :arrow_up: PRL
Dopamine (PRL-inhibiting factor) :no_entry: PRL
Concentration
After preg: :arrow_down:
Sucking reflex: intermittent :arrow_up: in response to sucking
During preg: :arrow_up: conc x10 of normal (as high as 150 ng/ml)
Function
Milk production in beginning of preg
Mechanism
DNA synthesis
mitosis of glandular epithelial cells & presecretory alveolar cells of breast
:arrow_up_small: Estrogen & Prolactin receptors in those cells
supports Mammary alveolar cell RNA synthesis
support Galactopoiesis
support production of Casein, Lactalbumin, Lactose and Lipids
:!: Isolated PRL def: can't produce milk
after preg for 2 times
meaning = PRL is for milk production
NOT for pregnancy
P, E, placental lactogen, PRL, cortisol and insulin related to :heavy_plus_sign: growth and deve of milk-secretory apparatus
Mechanism
After คลอด
:arrow_down: P and E immediately
:arrow_down: Progesterone (P) effect of :heavy_minus_sign:
Alpha-lactalbumin production
at RER
:arrow_up: Alpha-lactalbumin will :heavy_plus_sign: Lactose production in Milk
:arrow_down: P will allow PRL to :heavy_plus_sign: Alpha-lactalbumin production
Although :arrow_down: PRL (lower than during preg)
Each
sucking
:arrow_down: Dopamine (aka PRL-inhibiting factors)
:arrow_down: Dopamine fr hypothalamus (ลดตัวยับยั้ง PRL)
:arrow_up: PRL production
Milk ejection (letting down)
Sucking reflex (stimulate fr sucking)
stimulate Oxytocin release fr neurohypophysis
Contracts Myoepithelial cells (surround alveoli) in Alveoi and Small milk ducts
pulsatile stimulation lactation fr breast
also can stimulate fr Baby cries
inhibited by Stress and Frustration fr mom
Duration & amount of milk can be control (mostly caused by Repetitive stimulation of Breast feeding)
Milk
Milk production rate~600cc/day
depends on mammary glands (
NOT
size of breast)
Increased BW during preg has little effect on milk production
Found
After Colostrum
Components: Sugar + Fat + Protein
Proteins :star2:
Non-essential amino a got from blood :red_circle: and Mammary gland :glass_of_milk:
Essential amino a got from blood :red_circle:
special ~ got Alpha-lactalbumin, Beta-lactoglobulin and Casein
Fat (Fatty acids)
Produce in Alveoli by using Glucose and then release by Apocrine-like process
Vitamins
ALL
except
Vitamin K (varied amount in milk) and few Vitamin D (22 IU/ml) :warning:
Whey (milk serum)
Many IL-6
that closely related to production of Local IgA of breast
Prolactin
Epidermal growth factors
won't get destroyed by Gastric proteolytic enz -> mayb absorbed these factors ->
promote growth and maturation of intestinal mucosa in newborn
(so no NEC)
Def: Suspension of fat and protein in Carbohydrate-mineral solution
As นมแม่ ลูกจะดูดซึมไปใช้หมด เลยจะหิวบ่อย + ไม่ค่อยถ่าย
นมชง มีกาก so ถ่ายบ่อย
Colostrum
Deep lemon-yellow liquid :lemon:
Found @
D-2
after คลอด
Components
in compared to Mature milk
More of: Minerals, Amino a, Protein and Globulin
Less of: Sugar and Fat
Duration ไหล for
5 days
-> Then
ค่อยๆ change
into Mature milk in duration of
4 wks
Other components consist of
Immunoglobulin A
(IgA)
for newborn
protection
against 'enteric pathogen' eg E.coli
not usu. found Diarrhea as lower enteric infection :arrow_left:
Resistance factors
including Complement, Macrophages, Lymphocytes, Lactoferrin, Lactoperidase and Lyzozymes
not usu. found Infection :arrow_left:
Breast engorgement
Found along with milk leakage, breast pain
Found mostly @ Day 3-5 after คลอด
Mx
Support breast with Bras ที่ฟิตพอดี
Not rec uses Drugs / Hormones that inhibit milk production
Ice packs + Analgesics (แก้ปวด) 12-24 hr
Some institute says uses 'Breast binder' or 'Sport bra'
causing Puerperal fever
found after คลอด: มี high fever (37.8-39 deg C) may last 4 - 16 hrs
Breastfeeding will :arrow_down: :arrow_down: incidence, severity and fever
:warning:
must rule out Infection first
Diseases
Mastitis
incidence
before คลอด: little
after คลอด: 1/3 of BF mom
def: parenchymatous infection of mammary glands
S&S found at end of 1st wk หลังคลอด - ไม่เกิน 3-4 wk
usu. Unilateral
Breast engorgement มากกกก -> then Inflammation
Chills/Actual rigor -> later Fever and Fast pulse
Breast: Hard, red and painful
10% found: abscess (PE found fluctuation which is hardly to PE so U/S helps in Dx abscess)
Etio
S. aurues 40% :fireworks:
may even cause Toxic shock syndrome
Coagulase-neg staphylococci
Viridans streptococci
Treatment
should treat before suppuration happens
*Abscess usu caused by S. aureus
Dicloxacillin 500 mg oral 1x4 daily for 10-14 days OR Erythromycin OR Vancomycin/anti-MRSA antimicrobial
Should continue BF
cuz :arrow_down: abscess
some paper shown 'just Vigorous milk expression only' is adequate Rx for mastitis
Let baby sucks 2 sides: start fr normal side as aiming for let down reflex -> then suck at mastitic side (นมจะออกง่ายขึ้น)
48 - 72 hr after not adequate mastitic treatment
#
Breast abscess
Rx
Sx drainage under GA (scapel along Langer skin lines -> pack
loosely
with gauze
Sonographic-guided needle aspiration under Local anes
Galactocele
Def: Obstruction of milk ducts by Thick secretion
Start off: Limited amount -> Later: Fluctuant mass (galactocele) causing pressure symptoms like abscess
Rx
May spontaneous gone
May need aspiration
Accessory Breast Tissue
Polymastia (extra breasts)
Polythelia (extra nipples)
Embryonic mammary ridge (milk line)
Nipple ds
Depressed nipple
try ดึงก่อน ถ้าไม่ได้ผลค่อยใช้เครื่องช่วยดึง
**must always check nipple at ANC every time
Short nipple
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