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sleep. Forcing the infant to the breast might abolish the rooting reflex and disturb placement of the tongue (Widstrom & Thingstrom-Paulsson, 1993).

Consistent breastfeeding assessment and identification of early problems so that they can be resolved before they worsen is essential. Several breastfeeding assessment tools have been developed over the last decade. While there is not yet general agreement on which is the most valid tool in predicting how well breastfeeding will progress, an evidence-based tool undoubtedly will be developed (Riordan & Koehn, 1997). The more popular breastfeeding assessment tools are discussed in Chapter 20. The PIBBs breastfeeding tool, developed for assessing preterm infants, can be found as an appendix to Chapter 13.

Summary

Knowledge of maternal breast anatomy and the physiology of lactation are necessary antecedents to clinical practice. The fundamental biological principles of lactation discussed in this chapter are used, although not always consciously, in almost every clinical situation in which lactation is involved. Knowledge of the structure and function of the normal breast and of infant suckling are necessary for assessment; knowing what is normal must precede recognizing the abnormal and recommending actions designed to support an optimal breastfeeding experience. Enabling the natural physiological mechanisms to function optimally is more likely to lead to an uncomplicated breastfeeding experience; interference with these mechanisms can result in difficulty with breastfeeding for mother and infant. For example, restrictive policies in breastfeeding for preterm babies are commonly based on bottle-feeding studies, not on knowledge about the early development of infants' capacity for suckling at the breast (Nyqvist, Sjoden, & Ewald, 1999).

At the same time, anatomy and physiology are the building blocks in a larger picture of the breastfeeding and lactation experience. Most women are physiologically equipped to produce sufficient milk for their infant or infants. Yet the most commonly cited problem in breastfeeding worldwide is the mother's perception that she has insufficient milk (Hill & Humenick, 1989). Social and cultural influences play a major role in the mother's perceptions of her ability to nourish her infant from her breasts. Succeeding chapters build on the anatomy and physiology of lactation and address the clinical implications as well as its social and cultural aspects.

Key Concepts

• Breastmilk removal (through feeding or pumping) in the first two days postpartum is not necessary for lactogenesis II to occur; however, milk removal must begin by day 3 after birth or the likelihood of successful establishment of lactation is decreased.

• Three factors are necessary for lactation: (1) oxytocin released from the posterior pituitary, (2) removal of breastmilk by the infant or pump, and (3) prolactin release from the anterior pituitary, which stimulates lactogenesis and initiates milk secretion.

• Lactogenesis occurs earlier if breastmilk is removed by feeding or pumping within the first 2

to 3 days after birth. Early breastfeeding or pumping is associated with higher milk volume by day 5.

• Short-term rate of milk synthesis is considerably higher when most of the available milk has been removed from the breast.

• Frequency of breastfeedings varies widely; however, exclusively breastfed term infants (living in a country where breastfeeding is the norm) feed a median of 8 times per day (6 times during the day, and twice during the night).

• Mammary ducts do not widen into sinuses behind the nipple as previously thought.

• Suspensory ligaments of the breast are called Cooper's ligaments.

• Each breast of an adult woman weighs, on average 150 to 200 gm. It doubles in weight to 400 to 500 gm (about 1 pound) during lactation.

• Nerves that supply the breast are from the intercostal nerves of the fourth, fifth, and sixth intercostal spaces. The fourth intercostal nerve, which penetrates the left breast at 4 o'clock and right breast 8 o'clock, supplies the greatest amount of sensation to the nipple and areola.

• If the lowermost nerve branch of the fourth intercostal nerve is severed, the mother loses sensation to the nipple and areola.

• Breast asymmetry is common; the left breast is often larger than the right.

• Marked asymmetry and breast hypoplasia may indicate problems with breastmilk production.

• Areola and nipple color vary according to complexion: pink in blonds, brown in brunettes, and black in dark-skinned women.

• Supernumerary breasts (polymastia) and/or an accessory nipple may occur in about 1 to 2 percent of the population at any point along the milk line from the axilla to the groin.

• Poor nipple protractility occurs in 10 to 35 percent of women during their first pregnancy.

• Nipple inversion is found in about 3 percent of women, and it is bilateral in 87 percent of these women. Only 4 percent of nipple inversion is "true" inversion.

• Prolactin influences nipple growth; areolar growth is related to serum placental lactogen; the ductal system proliferates and differentiates under the influence of estrogen; progesterone promotes enlargement of the lobes, lobules, and alveoli.

• Lactogenesis, stage I occurs mid- to late pregnancy when breast size increases as epithelial cells of the alveoli differentiate into secretory cells for milk production.

• Lactogenesis II (days 2 to 8 postpartum) is the onset of copious milk secretion after birth when milk volume increases rapidly and then abruptly levels off.

• Before lactogenesis II large gaps occur between the alveolar epithelial cells. These gaps close suddenly after 3 to 4 days via a gasketlike structure (the tight junction) and trigger the onset of copious milk secretion.

• Maternal conditions that can delay or impair lactogenesis include cesarean birth, type I diabetes, labor analgesia, obesity, polycystic ovary syndrome, placental retention, and stress.

• The developmental cycle of the mammary gland has four phases: (1) mammogenesis, (2) lactogenesis, (3) galactopoiesis, and (4) involution.

• After delivery, progesterone levels drop and prolactin levels rise; both act synergistically with cortisol, thyroid-stimulating hormone, prolactin-inhibiting factor, and oxytocin to establish and maintain lactation.

• Following lactogenesis II, milk production shifts from endocrine to autocrine control. When the nipple is stimulated and milk removed from the breast, the hypothalamus inhibits dopamine, which in turn stimulates the release of prolactin and causes milk production.

• The basic unit of the breast is the alveoli which is surrounded by a contractile unit of myoep-ithelial cells responsible for ejecting milk into the ductules. Each ductule merges into a larger duct. The ducts are lined with epithelium and highly vascular connective tissue.

• Milk is secreted into the alveolar lumina where it is stored until the posterior pituitary hormone oxytocin causes the milk-ejection reflex or letdown, a contraction of the myoepithelial cells surrounding the alveoli.

• Oxytocin plays a major role in lactation. Blood levels rise within 1 minute of suckling, remain elevated during the feeding, and return to baseline levels within 6 minutes.

• Oxytocin contracts the mother's uterus, which help to control postpartum bleeding and to aid in uterine involution.

• The supply-demand response is a feedback control that regulates the production of milk to match the intake of the infant.

• Galactorrhea is the spontaneous secretion of milk from the breast from unexpected or unknown circumstances.

• Before lactogenesis, lactation is driven hor-monally (endocrine control); after, it is driven by suckling and milk removal (autocrine control).

• Suckling and milk removal is not a major factor for the initiation of lactation but is essential for its continuation.

• If the frenulum—a fold of mucous membrane midline on the undersurface of the baby's tongue—is too short or is too far forward, it can interfere with an infant's ability to suckle.

• The suckling reflex is present at 24 weeks gestation. By 28 weeks preterm, babies can coordinate the suckle/swallow/breathe cycle; by 32 weeks, they can suckle in repeated bursts.

• Forcing a crying baby to the breast evokes a defensive response (tongue to palate) that inhibits suckling and disturbs the rooting-tongue reflex system.

• Nutritive suckling is intake of continuous flow of liquid nutriment; nonnutritive suckling is suckling in the absence of liquid nutriment being introduced into the baby's mouth.

• Breastfeeding infants suckle more times per day and maintain a higher level of oxygen pressure (tcPO2) and skin temperature compared with bottle-fed infants.

• Babies suckle and swallow at a frequency of about once per second. When milk flow increases, the rate of suckling decreases; when milk flow is low, the rate of suckling increases.

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