00:00
hello and welcome to this aapko basic
00:02
science objective video on lactation the
00:04
objectives for this aapko basic science
00:06
video are recognize normal anatomic and
00:09
physiologic changes to breast tissue in
00:11
pregnancy and lactation explain
00:12
pathophysiology of milk synthesis milk
00:15
regulation and milk ejection and to
00:17
understand the composition of human milk
00:19
this is Nina and Lisa they’re happily
00:22
enjoying getting ready for their new
00:24
baby as Nina is learning about how to
00:26
breastfeed her new baby let’s see what
00:27
her body is already started to do in
00:29
order to prepare for the big day breast
00:32
architecture is a dynamic process that
00:34
has been evolving since puberty each
00:36
breast is composed of fifteen to twenty
00:38
five lobes each lobe contains multiple
00:41
lobules which are each made up of
00:42
alveoli the alveoli have secretory
00:45
epithelium and are responsible for milk
00:47
production the alveoli formed ducks that
00:50
coalesce into a single duct from each
00:51
lobe these lactiferous ducts open into
00:54
the nipple and their pinpoint openings
00:56
can be seen in lactation from birth
00:58
through puberty breast development
00:59
occurs in the volume and differentiation
01:01
of the structures of the mammary glands
01:03
final maturation past the state only
01:06
takes place with pregnancy in pregnancy
01:09
progesterone differentiation continues
01:12
to the point where the breast is mostly
01:13
glandular secretory units called a sin I
01:16
fully differentiate these changes begin
01:18
in pregnancy and continue until
01:20
lactation is complete after a beautiful
01:23
delivery Nina and baby Z have already
01:25
started the process of breastfeeding
01:26
while they’re getting settled what’s
01:29
considered the three basic concepts of
01:30
milk synthesis milk regulation and milk
01:33
composition exocytosis is the first
01:36
mechanism for milk synthesis it involves
01:38
the golgi complex forming vesicles that
01:40
transport protein and lactose to the
01:42
alveolar lumen water and electrolytes
01:44
follow the lactose into the vesicle and
01:46
are also secreted into the lumen the
01:49
second mechanism is reversed pinocytosis
01:50
and is the main pathway for lipids and
01:53
phospholipids to be added to the breast
01:55
milk this process occurs in the mammary
01:57
glands lipids formed in the smooth ER
02:00
combined to form large droplets that get
02:02
pushed out into the lumen the third
02:05
mechanism involves trance i ptosis
02:07
this mechanism allows immunoglobulins
02:09
albumin and hormones to bind to the
02:11
basement membrane of alveolar cells and
02:13
get transported to the apical membrane
02:15
where they are released apical transport
02:18
the fourth mechanism allows small
02:20
molecules such as sodium potassium and
02:22
water to move into the lumen the exact
02:25
mechanism is not well understood finally
02:28
in the fifth mechanism para cellular
02:30
movement allows components such as
02:31
immune cells to move between alveolar
02:33
cells across the type Junction these
02:36
tight junctions are more leaky during
02:38
specific times such as pregnancy and
02:40
mediate postpartum period and during
02:42
mammary involution now let’s pause think
02:45
and apply think fast
02:47
what were the five cellular mechanisms
02:50
associated with the transport of breast
02:51
milk components into the alveolar lumen
02:54
of the breast lobules the answer is
02:57
exocytosis pinocytosis trans cytosis
03:01
apical transport and para cellular
03:03
movement milk synthesis is regulated
03:06
through a combination of processes the
03:09
most important regulatory factor is
03:10
emptying the breast either through
03:12
infant suckling or mechanical breast
03:14
pump we will not discuss the clinical
03:17
components of milk production here
03:19
instead let’s focus on the cellular
03:21
level and how milk production is
03:23
regulated to create and maintain a
03:25
breast milk supply the breasts must be
03:28
emptied on a regular basis the frequency
03:31
with which the breast needs to be
03:33
emptied and the time needed will vary
03:34
with each dyad if breast milk is not
03:38
emptied eventually there will be a
03:39
reduction in involution of the memory
03:41
glands the increased milk in the breast
03:44
causes increased intro memory pressure
03:46
which decreases stimulatory hormones and
03:49
disrupts the tight junctions between
03:50
cells thereby decreasing milk synthesis
03:54
the increased pressure also increases
03:57
feedback inhibitor of lactation or fil a
04:00
polypeptide which accumulates in the
04:02
breast milk causing a down regulation of
04:04
cell surface prolactin receptors
04:07
through a positive feedback loop breast
04:10
stimulation via suckling or mechanical
04:12
stimulation also leads to spikes and
04:14
prolactin release which aids in
04:15
regulation
04:16
the level of the spike is not correlated
04:18
to the amount of milk produced finally
04:21
it is important to remember that milk
04:23
ejection is controlled by a different
04:25
pathway and requires oxytocin to trigger
04:27
the myoepithelial cells to contract
04:29
enforce milk out of the electa first
04:32
ducts
04:32
now let’s pause think and apply a
04:36
postpartum patient complains of
04:38
significant cramping associated with
04:40
breastfeeding episodes she thinks
04:42
something is wrong how do you counsel
04:44
her here’s the answer you tell her that
04:49
this is normal and explained that
04:50
suckling triggers oxytocin release from
04:53
the anterior pituitary the oxytocin has
04:56
a dual mechanism it triggers
04:58
myoepithelial cells in the breast to
05:00
contract and force milk from the
05:01
electives ducts and it stimulates the
05:04
smooth muscle in the uterus to contract
05:05
allowing the uterus to involute it is
05:09
important to note that the composition
05:10
at volume of breast build changes to
05:12
meet the demands of the baby
05:14
the first secretions after delivery are
05:16
called colostrum this is a thick yellow
05:18
secretion that is seen by post part of
05:21
day 2 it contains many immunological
05:23
components and has more minerals and
05:26
amino acids than mature milk there’s
05:28
also more protein unless fats and sugars
05:30
mature milk usually does not appear
05:33
until at least 3 to 7 days after
05:34
delivery mature milk secretion can be
05:38
delayed by c-section in Prime members
05:40
women placental retention diabetes or
05:44
stressful partition the composition of
05:47
mature milk changes daily with the age
05:49
of the infant and between feeds to meet
05:51
the ever-changing needs of the infant on
05:53
average a woman makes about 600
05:56
milliliters per day but this can be
05:57
highly variable based on the infant’s
05:59
needs and with multiple gestation ‘z
06:01
milk is composed of fats proteins
06:04
carbohydrates bioactive factors minerals
06:08
vitamins and hormones vitamin K is
06:10
virtually absent from breast milk hence
06:12
the need for injection at birth also
06:14
iron and vitamin D is very low and thus
06:18
and is often recommended for moms to
06:19
supplement babies with both
06:21
it is important to note that there are
06:23
many changes that continue to happen to
06:25
the press after lactation the mammary
06:27
glands will involute due to a pop tonic
06:29
cell death mediated by the lack of lacta
06:31
genic hormones and local autocrine
06:33
signals in menopause there’s further
06:36
atrophy of the glandular elements and
06:38
loss of the lobules adipose tissue
06:40
displaces the fibers connective tissue
06:42
the breast as well now let’s pause think
06:45
and apply a patient is ready for
06:49
discharge after an uncomplicated vaginal
06:51
delivery you discuss birth control
06:53
options and she states she will be
06:55
breastfeeding so should not need any
06:57
other methods how would you counsel her
06:59
in a lactating woman elevated prolactin
07:02
levels provide a negative feedback on
07:04
the hypothalamus suppressing ovulation
07:07
in order for this to be effective a
07:09
mother must be exclusively breastfeeding
07:11
otherwise any drop in prolactin levels
07:14
will release negative feedback and
07:16
resume ovulation it is important to
07:19
remind patients that they will ovulate
07:21
before their first menstrual cycle
07:22
indicating return of fertility Mina Lisa
07:27
and baby Z are growing together as a
07:28
family the ability of Mina to
07:31
exclusively breastfeed will depend on a
07:32
host of factors from biological
07:34
considerations and milk production and
07:36
regulation to social and environmental
07:38
cues from babies II and the support of
07:40
the community around the family for more
07:43
information on the clinical aspects of
07:45
breastfeeding please see aapko clinical
07:47
video 14 on lactation that concludes the
07:51
app Co basic science video on lactation
07:53
you should be able to recognize the
07:55
normal anatomy and physiological changes
07:57
to the breast tissue in pregnancy and
07:59
lactation understand the composition of
08:01
human milk and explained the
08:03
pathophysiology of milk synthesis
08:05
regulation and ejection

00:06
hello everybody this is Chris Morosky
00:08
and this is a short video on the
00:10
benefits of breastfeeding the content of
00:13
this video was taken exclusively from an
00:15
article written by Alison Stubbe from
00:17
the University of North Carolina at
00:19
Chapel Hill
00:19
the title of our article is the risks of
00:22
not breastfeeding for mothers and
00:23
infants it was published in reviews and
00:25
obstetrics and gynaecology in 2009 for
00:28
those who enjoy reading articles and
00:30
prefer that over video and PowerPoint
00:32
slides
00:32
I do recommend checking out this article
00:34
it is very well-written detailed and has
00:37
a lot more information than is found in
00:38
the video the goals and objectives of
00:41
this video are to review the national
00:43
guideline recommendations for postpartum
00:45
breastfeeding to correlate the transfer
00:47
of specific components of breast milk
00:48
from the mother to the infant with
00:50
improved health outcomes for the infant
00:52
to describe the improved health outcome
00:55
seen in mothers who breastfeed their
00:56
infants and to understand the importance
00:59
of physician support of breastfeeding
01:00
and its impact on women’s decisions to
01:03
choose breastfeeding for their infants
01:06
first moving on to the national
01:07
guidelines the American College of
01:10
Obstetricians and Gynaecologists
01:11
recommends that women exclusively
01:13
breastfeed their infants 6 months
01:15
following delivery the American Academy
01:18
of Pediatrics and American Academy of
01:21
Family Physicians take this one step
01:22
further
01:23
they also recommend six months of
01:25
exclusive breastfeeding but they also
01:27
recommend continued breastfeeding while
01:28
introducing complementary foods until
01:31
twelve months or longer following
01:33
delivering the question is how are we
01:36
doing and the answer really is that we
01:38
are falling far short of these guideline
01:40
recommendations only approximately 75%
01:43
of all infants are ever breastfed one
01:45
since delivery only 31.5%
01:48
are exclusively breastfed at three
01:50
months and only 12% are exclusively
01:53
breastfed at six months what we can see
01:56
is that the variations in breastfeeding
01:57
rates are closely tied to physician and
02:00
hospital messaging practices and support
02:02
related to breastfeeding what are some
02:06
of the improved health outcomes for
02:08
infants we’ll review these in the next
02:10
few slides
02:12
increased protection from infectious
02:14
disease seen with breastfeeding plasma
02:17
cells from the mothers bronchial tree in
02:19
intestines migrate to the mammary
02:21
epithelial and produce iga antibodies
02:24
specific to the antigens and the mother
02:26
infant diods
02:27
immediate surroundings is actually
02:29
pretty cool this provides specific
02:32
protection against pathogens in the
02:34
mother’s environment also
02:36
oligosaccharides in breast milk prevent
02:38
attachment of common respiratory
02:39
organisms including Hamas Phylis
02:42
influenza and streptococcus pneumoniae
02:44
to the respiratory epithelium
02:47
glycoproteins and breast milk prevent
02:49
binding of intestinal pathogens
02:51
including Vibrio cholera ecoli and
02:54
rotavirus glycosaminoglycans and breast
02:57
milk prevent binding of HIV gp120 to the
03:01
cd4 receptor thus decreasing
03:03
transmission of HIV and human milk
03:07
lipids contribute innate immunity with
03:09
activity against Giardia lamblia
03:11
Pamela’s influenza Group A streptococcus
03:15
staff at the dermis respiratory
03:17
syncytial virus and herpes simplex virus
03:20
type one looking at some of the
03:25
infections and some of the research
03:27
clinically that documents this immunity
03:30
first otitis media approximately 44
03:34
percent of infants will have one episode
03:35
of otitis media in their first year of
03:37
life the risk of otitis media among
03:40
formula-fed infants is doubled compared
03:43
to infants who are exclusively breastfed
03:45
human milk oligosaccharides in
03:48
antibodies to common respiratory
03:49
pathogens in the infant’s environment
03:52
are thought to provide protection from
03:53
infection next lower respiratory tract
03:58
infection in a meta-analysis of seven
04:01
cohort studies of healthy term infants
04:03
Bachrach at all in 2003 showed that
04:06
infants who were not breastfed faced a
04:08
3.6 fold increased risk of
04:10
hospitalization for lower respiratory
04:12
tract infection in the first year of
04:14
life compared to infants who are
04:15
exclusively breastfed for more than four
04:17
months the majority of respiratory
04:20
hospitalizations were from RSV have you
04:23
done your pediatric rotation during the
04:25
winter time you can
04:26
see plenty of RSV interestingly lipids
04:29
in human milk appeared to have antiviral
04:31
activity against RSV gastrointestinal
04:35
infections and a meta-analysis of 14
04:38
tolbert studies Chen and Holly in 2001
04:41
showed that infants who were formula fed
04:43
or fed a mixture of formula and breast
04:45
milk were two point eight times more
04:47
likely to develop GI infection than
04:51
those who are exclusively breastfed in a
04:54
study of over 17,000 infants Kramer at
04:57
all in 2001 showed that infants in the
04:59
control group which had a 6.4 percent
05:02
exclusive breastfeeding rated three
05:04
months so is low these infants were 1.7
05:07
times more likely to develop GI illness
05:10
than those in the intervention group and
05:13
the intervention group had a 43.3%
05:17
exclusive breastfeeding rate at three
05:19
months so again showing the impact of
05:21
exclusive breastfeeding on decreasing GI
05:23
illness in terms of necrotizing
05:27
enterocolitis among preterm infants not
05:31
being breastfed is associated with a 2.4
05:34
fold risk of necrotizing enterocolitis
05:36
with an absolute risk difference of 5
05:38
percent the case fatality rate of neck
05:42
is 15% so this absolute risk difference
05:45
of five percent is clinically
05:46
significant and I can tell you with all
05:48
the neonatologist that I work with
05:50
nowadays focusing on mothers milk and
05:53
breast milk decreasing necrotizing
05:55
enterocolitis is very very important in
05:57
this premature population there is also
06:02
improved immunity for babies with
06:05
prolonged and exclusive breastfeeding
06:08
formula-fed infants have a higher ph of
06:10
their stools and a greater colonization
06:13
with e-coli Clostridium difficile and
06:15
Bacteroides fragilis bioactive factors
06:19
in human milk appear to facilitate a
06:20
more favorable gut colonization in
06:22
breastfed infants oligosaccharides
06:25
cytokines and immunoglobulins regulate
06:28
gut colonization and development of gut
06:30
associated lymphoid tissue and govern
06:33
differentiation of T cells that play a
06:35
role in host defense and tolerance and
06:37
it’s these differences in the
06:39
immune system differentiation which may
06:42
underlie the higher incidence of
06:43
allergic disease and formula-fed
06:46
children and looking at asthma and a
06:49
meta-analysis by if at all in 2007
06:52
formula-fed children with a family
06:54
history of asthma or a2p had a one point
06:57
seven risk of developing asthma compared
07:00
with those who were breastfed for three
07:01
months or more and another separate
07:04
study exclusive breastfeeding for less
07:06
than three months compared to exclusive
07:08
breastfeeding for three months or more
07:10
was associated with a one point nine
07:13
fold risk of developing asthma among
07:16
those with a family history of asthma or
07:17
a Sabine and in terms of atopic
07:21
dermatitis infants with the family
07:23
history of a2p who are exclusively
07:25
breastfed for less than three months
07:27
have a one point seven fold increased
07:29
risk of atopic dermatitis compared with
07:31
infants who are exclusively breastfed
07:33
and infants who were delivered in
07:35
hospitals with decreased breastfeeding
07:38
were one point nine times as likely to
07:40
develop atopic dermatitis compared to
07:43
those who delivered in hospitals with
07:44
increased breastfeeding rates again
07:47
prolonged breastfeeding appears to be
07:49
associated with decreased rates of
07:51
atopic dermatitis and finally looking at
07:55
obesity and metabolic disease in terms
07:57
of breastfeeding and two separate
07:59
meta-analysis formula-fed infants were
08:01
1.1 to 1.3 times more likely to become
08:04
obese compared to children who had ever
08:07
been breastfed and being formula-fed in
08:09
infancy is associated with a 1.6 fold
08:12
risk of type 2 diabetes compared with
08:14
being breastfed the proposed mechanisms
08:17
are that human milk contains edible
08:19
kinds which may play a role in
08:21
regulating energy intake in long-term
08:23
obesity rescue also long-chain
08:26
polyunsaturated fatty acids found in
08:29
breast milk may improve blood pressure
08:31
and insulin resistance later in life
08:33
certainly there are also differences in
08:35
composition of breast milk versus
08:37
formula associated lifestyle factors and
08:40
self-regulation of intake by the infant
08:42
which may play a role in changing
08:44
metabolic disease associated and around
08:47
breastfeeding a quick transition to
08:51
improved health outcomes
08:53
for mothers who exclusively breastfeed
08:56
or breastfeed for longer durations of
08:58
time there is a known and decreased risk
09:01
of certain malignancies for women who
09:04
breastfeed lactation suppresses
09:06
ovulation and leads to a left ational
09:08
amenorrhea decreased ovulatory cycles
09:11
are associated with a decreased risk of
09:13
ovarian cancer by tation also causes
09:16
terminal differentiation of breast
09:17
tissue which following involution
09:20
removes these cells from the long-term
09:22
effects of malignant transformation in a
09:25
large longitudinal follow-up study
09:27
called the Nurses Health Study – it was
09:31
found that never breastfeeding was
09:32
associated with a 2.4 fold increase in
09:34
the incidence of premenopausal breast
09:36
cancer compared to having had ever
09:38
having breastfed also never
09:41
breastfeeding was associated with a 1.5
09:43
fold increase in the incidence of
09:45
ovarian cancer compared to women who
09:47
breastfed for greater than 18 months
09:50
there was also a large impact of
09:52
lactation on maternal metabolism
09:54
breastfeeding poses a 500 kilo calorie
09:57
per day metabolic burden on mothers this
09:59
can contribute to an increased pregnancy
10:02
weight loss for mothers who breastfeed
10:05
breastfeeding also is associated with
10:07
more favorable glucose levels and the
10:09
mother live at metabolism and blood
10:11
pressure in 1993 do-it-all showed that
10:14
women who breastfed for more than one
10:16
year lost on average four point four
10:18
pounds more than women who breastfed
10:20
less than three months and this
10:22
difference persisted for two years
10:24
postpartum again returning to the nurse
10:26
health study – the risk of type 2
10:29
diabetes 15 years since birth was 1.7
10:33
fold higher among Paris women who never
10:35
breastfed compared to those who
10:37
breastfed for a lifetime total of two
10:39
years and more and the risk of
10:42
myocardial infarction 15 years since
10:44
birth was 1.3 fold higher among Paris
10:47
women who never breastfed compared to
10:49
those who breastfed for a lifetime total
10:51
of two years or more and just to end on
10:55
one small point about the role of the
10:57
physician in promoting breastfeeding the
11:00
things that physicians can do to promote
11:02
breastfeeding include providing
11:04
education and counseling during prenatal
11:06
care
11:07
avoid participating in Formula marketing
11:09
campaigns and programs physicians can
11:12
also encourage immediate skin-to-skin
11:14
contact
11:15
feeding on demand and rooming in with
11:17
the infant following delivery and
11:19
finally in a leadership role physicians
11:22
can support a hospital culture that
11:24
promotes breastfeeding all of these
11:26
actions have been shown to greatly
11:28
increase the likelihood that women will
11:30
choose breastfeeding for their infants
11:31
and exclusively breastfeed their infants
11:34
for longer durations of time which as
11:36
we’ve shown improves health outcomes for
11:39
both the moms and their peas and that
11:42
brings us to the end of the video as you
11:44
can see we did review the national
11:46
guideline recommendations for postpartum
11:48
breastfeeding we also correlated the
11:50
transfer of specific components of
11:52
breast milk from the mother to the
11:53
infant with improved health outcomes for
11:55
the infant we described the improved
11:57
health outcome seen and mothers who
11:58
breastfeed their infants and there was
12:01
an understanding of the importance of
12:03
physician support of breastfeeding and
12:05
its impact on women’s decisions to
12:07
choose breastfeeding for the infants
12:08
thank you for taking the time to watch
12:10
this video I hope you found it
12:12
educational go luck with your studies
12:14
and we’ll see you soon in class
12:16

hello everyone this is Chris mirage key
00:08
and this is a short video on
00:10
breastfeeding complications the goals
00:12
and objectives of this video are to
00:14
review some of the common infectious and
00:16
non-infectious complications of
00:17
breastfeeding to discuss the risk
00:19
factors for and management of these
00:21
conditions and to describe the impact
00:24
that these complications can have on
00:25
both the lactating mother and the
00:27
nursing infant there are obvious health
00:30
benefits for both the mother and the
00:32
baby for breastfeeding the American
00:33
Academy of pediatricians recommend that
00:35
moms breastfeeding for the first six
00:38
months of the baby’s life and continue
00:40
breastfeeding while introducing
00:41
complementary foods up to one year of
00:44
life or longer there are some common
00:47
minor complications of breastfeeding
00:49
unfortunately major complications are
00:51
more rare we’re going to review some of
00:53
these minor and major complications in
00:56
this video breast engorgement usually
00:59
happens about three to seven days
01:01
following birth and this is more likely
01:04
in first-time mothers with the increase
01:07
in blood supply to the breasts the
01:09
accumulation of milk and the breasts and
01:11
swelling there is increased pain and
01:13
tissue damage the cause of breast
01:16
engorgement is not getting enough of the
01:18
breast milk out this happens with the
01:22
lays and breastfeeding poor infant latch
01:25
and not feeding on infant cues but
01:29
trying to stick to more of a schedule
01:31
breast engorgement can be treated with
01:33
regular breastfeeding breast pumping or
01:35
hand expression and when we can also
01:38
gently massage the breast and use warm
01:40
compresses prior to breastfeeding and
01:42
then use cool compresses in Tylenol in
01:45
between the breast feedings low milk
01:47
supply is a major cause of stopping
01:50
breastfeeding women will commonly feel
01:52
like they are not producing enough milk
01:53
due to your irritability of the baby or
01:57
feeling their breasts aren’t as
01:59
encouraged as I continue to breastfeed
02:01
and most of the time their milk supply
02:04
actually is normal low milk supply is
02:07
caused by a decreased emptying of the
02:09
breast milk when this happens there are
02:12
increased amounts of
02:13
feedback inhibitor of lactation this
02:16
peptide can build up in the breast and
02:17
then this actually inhibits ciation the
02:20
causes here are poor latch breast
02:22
engorgement use of formula and pacifiers
02:25
and then trying to stick to more a timed
02:28
feeding schedule rather than feeding
02:31
when the baby requests to be fed there’s
02:35
also changes in infant growth and
02:38
feeding patterns babies will tend to
02:39
cluster feed and eat while they’re
02:41
growing rapidly
02:42
sometimes they grow a little more slowly
02:44
and they’ll eat differently mothers will
02:48
sometimes believe that this is a supply
02:50
problem when really it’s just a change
02:51
in the baby’s growth and feeding the
02:54
treatment is to increase skin-to-skin
02:55
time with the mother to also increase
02:58
breastfeeding with pumping right after
03:00
if you look to the right you can see
03:03
here’s a nice schedule for a mother who
03:06
wants to try to increase her milk supply
03:08
which combines nursing and pumping
03:10
throughout the day any type of increased
03:13
nipple stimulation nipple massage is
03:15
helpful treating nipple pain is also
03:18
very important there are some
03:20
medications called Galacta gags the one
03:23
most commonly known and studied which is
03:25
proven to be effective is domperidone it
03:27
is a selective dopamine d2 receptor
03:30
antagonists also metoclopramide can be
03:33
used but this is off-label there are
03:35
some herbal therapies including
03:37
fenugreek and milk thistle sometimes
03:40
called blessed and oak thistle it’s not
03:42
entirely sure and studies how these
03:44
medications work there may be simple
03:45
SIBO effects but you will commonly see
03:47
these being prescribed and taken by
03:49
women to increase their low milk supply
03:51
on the other end of things is oversupply
03:54
of milk now for a lot of mothers who
03:56
have low milk supply this seems like a
03:58
good problem to have
03:59
but actually it’s not the reason it’s
04:02
not is that there’s an increased risk
04:03
for a gorge meant an increased risk for
04:05
block ducks and mastitis also what ends
04:09
up happening in these situations is that
04:11
there is a lot more for milk being
04:13
produced rather than hind milk for milk
04:16
is more watery it’s higher in lactose
04:18
and it’s lower in fat as compared to
04:21
hind milk which is thicker and has
04:23
higher fat so what ends up happening
04:24
with these moms are making a lot more
04:26
quantity of milk
04:27
is that the babies getting more for milk
04:29
and therefore the baby is less satisfied
04:31
it’s more fussy it’s wanting to feed
04:33
more often and surprisingly these babies
04:36
actually can have trouble gaining weight
04:38
because they’re not getting that higher
04:40
fat thicker hind milk the way to treat
04:43
this is to breastfeed on only one breast
04:46
for two-hour block period of time
04:49
whenever the baby wants to feed so that
04:51
you can get to the hind milk in that
04:52
breast the other option is to pump some
04:56
of the four milk
04:57
prior to breast feeding the infant and
05:00
if you’re sticking with one breast
05:02
during that two-hour block period the
05:04
other contralateral breast may become
05:06
more engorged and hand expression and
05:08
pumping of the contralateral breast can
05:10
help if the mom is having too much
05:12
discomfort while trying to stay without
05:14
one breast for the baby during that
05:16
two-hour block period overactive milk
05:19
letdown is the overly forceful ejection
05:21
of breast milk this can cause difficulty
05:24
for the baby feeding because too much
05:26
breast milk is pushed into the mouth the
05:29
babies can be fussy they can ingest a
05:31
lot of air and then it can be very
05:33
colicky this is caused by a very strong
05:35
milk letdown reflex and as well as
05:38
increased sensitivity of the
05:40
myoepithelial cells to oxytocin the
05:43
treatment here is to use hand expression
05:45
or pumping prior to the infant latching
05:48
also gentle compression on either side
05:51
of the nipple can decrease some of the
05:53
flow of the breast milk right after the
05:54
baby is latched one of the things that’s
05:57
very helpful is to avoid engorgement and
05:59
to have regular milk emptying and there
06:02
are certain positions to hold the baby
06:03
that reduced gravity to the nipple these
06:06
would include sidelines or the football
06:08
hold nipple pain is common it can happen
06:13
really in the first few days after
06:16
initiating breast feeding but this
06:18
really should resolve by five to seven
06:19
days
06:20
the woman has nipple pain a week out
06:22
from delivery then really need to look
06:26
into why this is happening the most
06:28
common cause is um poor latch of the
06:31
baby latching directly onto the nipple
06:34
or even biting down on the nipple rather
06:36
than the areola an improper release
06:39
where the baby sort of pulled off the
06:41
breast
06:41
and the nipple is stretched and that
06:43
sort of snaps back this can all lead to
06:47
cracking bleeding cellulitis and
06:49
mastitis well and the treatment really
06:51
is to focus on first a good latch so to
06:54
make sure that the baby has the whole
06:55
nipple on the back of their mouth and
06:56
that sort of suckling of the gums is on
07:01
the areola rather than the nipple also
07:04
massaging a little bit of breast milk at
07:07
the end of the feeding into the nipple
07:08
can help and then lanolin cream which
07:11
can be obtained over the counter can be
07:13
used to hydrate the nipple and keep it
07:15
protected and this is done following
07:17
feeding the cream isn’t wiped off before
07:19
the next feeding also it’s important to
07:22
allow the nipple to be completely dry
07:24
following feeding after rubbing in the
07:26
breast milk or some lanolin cream and to
07:28
change breast pads regularly women will
07:31
want to avoid tight-fitting bras
07:32
tight-fitting clothes and also avoid
07:35
using any harsh soaps or fragrances on
07:38
the breast or the nipple a blocked milk
07:41
duct will present as a tender or sore
07:44
lump in the breast and it’s important to
07:46
make sure that there’s no signs of an
07:47
infection because that’s a whole
07:48
different thing but they’ll have no
07:50
redness or really fever or anything like
07:53
that just a tender sore lump in the
07:54
breast what’s happened here is that
07:56
there’s a blockage of the lactiferous
07:58
duct with milk building up behind it the
08:01
treatment here is actually to keep the
08:03
breast milk flowing through the like
08:05
Tiferet duct and hopefully undo that
08:07
blockage moms will want to frequently
08:10
feed on the involved breast and also of
08:13
some gentle massage from behind the mask
08:15
pushing towards the nipple can push the
08:17
breast mucked out and hopefully open up
08:18
that blockage when we can also use heat
08:21
and it’s important to avoid here and
08:24
underwire or tight-fitting bra one of
08:27
the other long-term consequences of
08:29
these bot ducts is something called a
08:31
Galactus seal which is a retention cyst
08:33
with milk this can be during breast
08:36
feeding this can also happen after
08:37
breast feeding these can sometimes
08:40
resolve on their own but if they’re
08:42
persistent and tender they either can be
08:44
aspirated with the fine needle or
08:46
completely excised as these pockets of
08:50
breast milk can predispose to secondary
08:52
infection or even rupture
08:54
mastitis is an infection of the breast
08:56
this presents with fever pain and
08:58
redness it usually happens in the first
09:00
two to three weeks postpartum and is
09:03
associated with milk stasis the most
09:06
common bacterial agents here that cause
09:09
mastitis are Staphylococcus species
09:11
streptococcus species and e-coli
09:15
the treatment is to continue
09:17
breastfeeding similar to the block milk
09:19
duct to pull that breast milk out from
09:22
the breast breastfeeding and pumping is
09:24
important the baby still can drink this
09:26
milk it is okay for the baby even though
09:28
there is an infection the baby’s stomach
09:31
acid will kill the infection of the
09:33
breast milk massage again towards the
09:36
nipple is helpful to keep that breast
09:37
milk coming out and then these patients
09:39
are often started on broad-spectrum
09:41
antibiotics like dicloxacillin unless
09:43
they have an allergy and these patients
09:45
need to be followed up closely to make
09:47
sure that they don’t develop an abscess
09:50
breast abscess is a rare complication of
09:52
breast feeding but it can be pretty
09:54
serious and it presents in point five
09:56
percent of breastfeeding mothers it will
09:58
present with a painful swelling and
10:00
persistent systemic symptoms of fever
10:02
and chills and body aches despite
10:04
antibiotics on physical exam there can
10:07
either be a palpable sort of squishy
10:09
flexure mass and this can be confirmed
10:12
on ultrasound with a hypoechoic
10:15
collection of fluid in the breast tissue
10:18
once the breast abscess is developed
10:20
this needs to be treated with aspiration
10:22
or incision and drainage as antibiotics
10:24
alone are not sufficient that said the
10:26
antibiotics are important to help treat
10:28
of any overlying cellulitis and to treat
10:31
any systemic symptoms fungal infection
10:35
of the breast is also common this can
10:39
happen and present with sore nipples
10:41
despite a good latch it’s always
10:43
something to think about when a woman
10:44
has continued sore nipples despite a
10:46
good latch on physical exam she may have
10:49
flaky shiny itchy nipples or cracked
10:52
nipples and she can even have these
10:54
small little blisters like you see in
10:55
the photograph this is caused by a
10:57
candida species and Candida loves warm
11:00
and wet environments breast milk also
11:02
has a lot of sugar and Canada loves that
11:05
the treatment here is a topical
11:07
antifungal cream
11:08
that has put on in between the breast
11:10
feedings and wiped away so the baby can
11:13
breastfeed these creams are safe for the
11:15
baby for these women they’re gonna want
11:18
to thoroughly wash all of their clothes
11:20
including their bras and their shirts
11:21
and to make sure that the pumping
11:23
supplies are clean because the Canada
11:25
that can stick around on all this stuff
11:26
and it’s important to have a new clean
11:29
and dry bra daily and really the
11:31
important thing to do here is to keep
11:33
the breasts dry inverted flat or
11:37
enlarged nipples can be an issue for
11:39
infant feeding this can either be
11:42
something that’s congenital especially
11:43
the enlarged nipples or secondary due to
11:47
engorgement so when we can have totally
11:49
normal nipples and then with breast
11:50
engorgement have them become more flat
11:52
or even become an inverted nipple
11:56
massage nipple stimulation and
11:57
stretching can draw the nipple out with
12:01
just a little bit of exposure of the
12:03
nipple infants can often latch on the
12:05
areola with a good effect and be able to
12:08
breastfeed there are these small suction
12:11
devices and nipple shields that can help
12:12
pull the nipple out more these moms also
12:15
sometimes need to use hand expression
12:17
and pumping to get milk flowing and get
12:19
them up out of the nipple and then with
12:22
that little bit of milk there the infant
12:23
is more likely to latch on finally I
12:27
wanted to talk a little bit about
12:28
Raynaud’s of the nipple this is an
12:30
uncommon condition but it can be seen
12:33
it’s caused by vasospasm leading to
12:36
decreased blood supply to the nipple
12:38
this causes very intense nipple pain
12:41
with the latch and then in between
12:43
breastfeeding you’re going to seem to
12:44
pile blanching like you see in the
12:46
picture this is either caused by early
12:48
trauma to the nipple from initiating
12:50
breastfeeding so things like nipple
12:53
cracks and bleeding or again Candida
12:57
infection can predispose to Raynaud’s of
12:59
the nipple this is treated with nipple
13:02
massage avoiding cold and sometimes
13:05
nedeth nifedipine which can be used for
13:07
Reynaud so the hand is also helpful with
13:09
Raynaud’s at the nippon all right
13:12
everybody well that’s about it you can
13:15
see we covered some of the common
13:17
infectious and non-infectious
13:18
complications of breastfeeding
13:20
we discussed the risk factors for
13:21
management
13:22
these conditions and we describe the
13:24
impact that these complications can have
13:26
on both a lactating mother and the
13:28
nursing infant I hope you found this
13:30
video educational good luck with your
13:32
studies and we’ll see in class
13:35
[Music]
Up next

00:06
hello everybody this is Chris murasky
00:09
and this is a brief video on drugs and
00:11
breastfeeding the majority of the
00:13
content for this video was obtained from
00:16
Neil hotham and Elizabeth Hoffman and
00:19
their article titled drugs and
00:20
breastfeeding this was published an
00:22
Australian prescriber in 2015 I highly
00:24
recommend checking it out it’s a short
00:26
article it’s a great review and it
00:28
includes all the details of this video
00:30
plus more the learning goals and
00:32
objectives of this video are to review
00:33
the contraindications to breastfeeding
00:35
according to the Centers for Disease
00:37
Control to describe the effect of drug
00:39
pharmaceutical properties on the
00:41
concentration of the drug in the breast
00:43
milk to understand what influences the
00:45
risks of adverse effects of a particular
00:48
drug on the baby and share available
00:50
resources for more information on drug
00:52
safety in breastfeeding at the end of
00:56
the day most medications are safe and
00:58
breastfeeding most drugs themselves are
01:00
actually safe for the baby
01:02
most lactating women rarely take
01:04
medications in fact and those that do
01:07
usually only take them intermittently
01:09
although almost every drug is
01:12
transferred somewhat to the breast milk
01:14
the amount is usually small and not
01:16
enough to affect the baby so at the end
01:19
of day the big question is what are the
01:20
actual contraindications to
01:22
breastfeeding according to the Centers
01:25
for Disease Control there are a few rare
01:28
contraindications to breastfeeding to
01:31
begin there are certain mothers who
01:33
should not breastfeed or feed their
01:35
express milk to their infants in the
01:38
setting where the infant is diagnosed
01:40
with khalaqtu C Mia this is true
01:41
if the mother is affected with human
01:44
immunodeficiency virus they should not
01:46
breastfeed or provide the v with express
01:49
milk this really does depend on the
01:50
country in countries like America where
01:53
there’s safe access and ready access to
01:55
safe formulas moms with HIV are
01:58
recommended not to breastfeed in other
02:01
countries where formula is not readily
02:03
available those mothers are still
02:05
recommended to breastfeed their babies
02:06
moms were infected with human t-cell
02:08
infant row flu virus type 1 & 2 if the
02:11
mother is using illicit street drugs
02:13
such
02:13
just PCP or cocaine they should not
02:15
breastfeed the exception here are
02:17
mothers who have an opiate use disorder
02:20
when who are on maintenance opioids with
02:22
negative HIV screening and mothers with
02:25
suspected or confirmed Ebola virus
02:27
should not breastfeed the next class are
02:29
mothers who should temporarily not
02:31
breastfeed or feed express milk this
02:34
include mothers that are infected with
02:35
untreated brucellosis mothers taking
02:38
certain medications and we’re going to
02:40
go over those in this video specifically
02:43
mothers that are undergoing diagnostic
02:45
imaging with certain radio
02:47
pharmaceuticals we’ll talk about that
02:49
later but those are radioactive
02:50
medications that are injected into
02:52
mothers and mothers who have active
02:55
herpes simplex virus infection with
02:57
lesions present on the breast finally
03:00
there are mothers who should temporarily
03:02
not breastfeed but it’s okay for them to
03:05
provide the baby with expressed breast
03:07
milk if the mother has untreated active
03:10
tuberculosis and if the mother has
03:13
active varicella infection that
03:14
developed within five days prior to
03:16
delivery up to the two days following
03:18
delivery these are mostly respiratory
03:21
precautions and it’s okay for the
03:22
expressed breast milk to be given to the
03:24
baby although they should temporarily
03:26
not be breastfeeding until these
03:27
infections have cleared
03:29
okay returning back to drugs the big
03:32
question is what affects the
03:33
concentration of drugs in the breast
03:35
milk there are several factors on the
03:37
role of them individually the first is
03:40
the maternal plasma concentration drugs
03:43
enter the milk from the maternal serum
03:44
through passive diffusion the time
03:47
course of milk drug concentration is
03:49
concordant with the maternal plasma drug
03:51
concentration the plasma concentration
03:53
is also affected by the drugs’
03:55
distribution in two different tissues a
03:57
high volume of distribution will
03:59
contribute a lower maternal plasma
04:01
concentration and therefore subsequent
04:04
lower concentration in the breast milk
04:06
maternal plasma protein binding drug
04:10
binding the plasma proteins influences
04:12
the extent of transfer into the breast
04:13
milk free unbound drugs diffuse readily
04:17
highly protein bound drugs are unable to
04:19
diffuse in significant amounts size of
04:23
the drug molecule most drug molecules
04:25
are small enough to enter the milk for
04:27
ample alcohol nicotine caffeine small
04:30
enough go right in
04:31
some have higher molecular weights and
04:33
will not enter the milk examples of
04:36
these are heparin and insulin degree of
04:40
ionization drugs cross membranes in an
04:43
onion iced form milk is generally more
04:46
acidic with a pH around 7.2 compared to
04:49
the mothers plasma which has a pH of 7.4
04:52
therefore the milk attracts weak organic
04:55
bases
04:56
conversely weak organic acids tend to be
04:59
held in the maternal plasma lipid
05:01
solubility in addition to passive
05:04
diffusion into the aqueous phase lipid
05:06
soluble drugs have Co secretion by
05:09
dissolution in the fat droplets of milk
05:12
the fat content of milk also varies
05:14
according to the age of the infant and
05:16
the phase of the feed for example for
05:19
milk versus hind milk with hind milk
05:21
having more fat content
05:24
finally maternal pharmacogenomics
05:27
there’s a growing knowledge about the
05:28
influence of pharmacogenomics a classic
05:31
example of this is coding coding is very
05:34
oblique metabolized to morphine by
05:35
cytochrome p450 enzyme sip to DES
05:39
ultra-rapid metabolizers can produce
05:42
significant amounts of morphine with
05:44
repeated doses of codeine rapid transfer
05:47
of the morphine and the maternal serum
05:48
to the breast milk can result in
05:50
neonatal CNS depression and potentially
05:52
fetal death it is recommended to avoid
05:54
codeine while breastfeeding now
05:57
balancing this out the question also is
06:00
what influences the effects on the baby
06:02
there are again several components to
06:04
this we’ll take them one by one the
06:07
first is the timing of the dose feeding
06:09
the baby prior to taking a drug results
06:11
in the baby receiving the lowest
06:13
possible dose of the drug this does not
06:15
apply however to drugs with longer
06:17
half-life so caution is still needed
06:19
here
06:20
toxicity premature babies have a lower
06:23
capacity to metabolize and excrete drugs
06:26
also if a baby has just been exposed to
06:29
a drug in utero further exposure in the
06:31
breast milk will augment the existing
06:33
concentration this is used as an
06:35
advantage with infants experience in
06:37
opiate withdrawal the mothers of infants
06:40
undergoing open
06:41
withdrawl are recommended to breastfeed
06:43
as long as they have no other
06:44
contraindications the baby then obtained
06:46
some of the opiate in the breast milk
06:48
and this helps with the withdrawal the
06:51
following is a list of drugs that are
06:52
actually contraindicated in
06:53
breastfeeding examples of drugs country
06:56
ended in breastfeeding including
06:57
amiodarone which has a long half-life
06:59
and may affect thyroid function
07:02
antineoplastic s’ which can cause
07:04
leukopenia and bone marrow suppression
07:06
gold salts can cause rash nephritis and
07:09
hematological abnormalities iodine and
07:12
high doses can lead to infant
07:13
hypothyroidism lithium is really not
07:16
recommended in breastfeeding and it’s
07:18
really only feasible with rigorous
07:19
monitoring as mentioned earlier radio
07:22
pharmaceuticals can be a problem as the
07:24
radiation can be put into the breast
07:27
milk coming into the baby
07:28
retinoids are also associated with
07:30
serious adverse effects back to things
07:34
that influence the effects on the baby
07:35
another one is oral bioavailability just
07:39
because a drug is present in the breast
07:40
milk does not mean that it will lead to
07:42
a significant exposure to the infant for
07:44
example the infant gut may very well
07:46
destroy or degrade the drug and some
07:49
drugs are not particularly absorbed well
07:51
through the infant gut volume of breast
07:54
milk the amount of breast milk a baby
07:56
receives also varies for example a baby
07:59
exclusively breastfeeding at two months
08:01
is going to be getting a lot more breast
08:02
milk than an eleven month old baby who
08:05
is mostly nursing at night for comfort
08:06
and bonding relative infant dose the
08:11
relevant infant dose is equal to the
08:12
dose received in the breast milk to the
08:14
baby relative to the mother’s dose the
08:17
formula for this is relative infant dose
08:19
equals the infant dose which is
08:21
milligrams per kilogram weight of the
08:24
baby per day divided by the maternal
08:26
dose which is milligrams per kilogram of
08:29
the mom per day this is expressed as a
08:32
percent and it keeps in mind two
08:34
different weights of the mom and the
08:35
baby a relative dose of ten percent or
08:37
above is a notable level of concern
08:39
although it’s pretty rare also the age
08:42
of the infant most averse effects of
08:45
drugs and breast milk occur in newborns
08:46
under two months and rarely occur in
08:49
those older than six months in infants
08:52
metabolism and excretion capacity at
08:54
birth is all
08:55
one third of what it is it’s seven to
08:57
eight months the following is not
09:00
complete but good list of resources that
09:03
are readily available on the Internet
09:04
the first is lactMed or toxnet from the
09:07
National Institutes of Health and the US
09:08
National Library of Medicine another
09:11
great resource is mother to baby which
09:13
is put out by the nonprofit organization
09:15
of teratology information specialists
09:18
alright that about wraps it up I believe
09:21
if we go back to our learning goals and
09:22
objectives they were all met review the
09:25
contraindications to breastfeeding
09:26
according to the Center for Disease
09:27
Control described the effect of drug
09:30
pharmaceutical properties on the
09:31
concentration of the drug in the breast
09:33
milk understand what influence is the
09:35
risk of adverse effects of a particular
09:37
drug on the baby and share available
09:40
resources for more information on drug
09:41
safety and breastfeeding thanks for
09:44
taking the time to watch this video I
09:45
hope that you found it informative and
09:48
educational good luck with your studies
09:50
and we’ll see you in class