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Stages of Lactogenesis and
Why Newborn Babies Suck so Much
“I DON’T HAVE
ENOUGH MILK”
OR …
WHY DO BABIES
SUCK “SO MUCH?”
Gini Baker, RN, MPH, IBCLC
UC San Diego Lactation Programs
Thanks to …
USLCA
YOU
!!!
My
grand
babies for
being role
models ….
Gini Baker RN, MPH, IBCLC
Gini Baker, RN, MPH, IBCLC
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1
Stages of Lactogenesis and
Why Newborn Babies Suck so Much
Disclosures & Conflicts of Interest
Program Coordinator
UCSD Perinatal Health Programs
Lactation Specialist
Baby Friendly Hospital Training’s
Lactation Educator
Lactation Consultant
Lactation Consultant
Sharp Mary Birch Hospital
Private Consulting/Lecturing
Web Site
www.breastfeeding--education.com
www.breastfeeding
Objectives
Review the stages of lactation
Relate the information to the practice of
lactation consulting
Vocabulary changes necessary for consistency
within our practices
Outline the pathophysiology of “Why newborns
suck so much ???”
Gini Baker RN, MPH, IBCLC
Gini Baker, RN, MPH, IBCLC
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2
Stages of Lactogenesis and
Why Newborn Babies Suck so Much
http://nojan.wor
dpress.com/2008
What
happens
when
Folks
come to
the
USA ?
Gini Baker RN, MPH, IBCLC
Why do babies suck so much?
Aka: I don’t have any milk?
How old is the baby ?
What is the physiologic
expectation for DOL?
Glandular Tissue
Growth Spurts
Role of prenatal
Education ??
Gini Baker RN, MPH, IBCLC
Gini Baker, RN, MPH, IBCLC
DO NOT COPY Copyrighted Materials
http://www.wikicover.com/World
3
Stages of Lactogenesis and
Why Newborn Babies Suck so Much
STAGES
OF
LACTATION
Gini Baker RN, MPH, IBCLC
**Stages of Lactation**
Mammogenesis
(Milk making … In the beginning)
Breasts grow: Size & weight
Ducts & glands proliferate
Estrogen and progesterone
Shannon April 2006
From: Breastfeeding & Human Lactation
Jan Riordan
Gini Baker RN, MPH, IBCLC
Gini Baker, RN, MPH, IBCLC
DO NOT COPY Copyrighted Materials
4
Stages of Lactogenesis and
Why Newborn Babies Suck so Much
Stages of Lactogenesis
Mamogenesis
Lactogenesis
Stage 1
Transition
Lactogenesis
Stage 2
Galactopoesis
Involution
(Milk making …
In the
beginning)
a. Breasts grow:
Size & weight
b. Ducts &
glands grow
c. Influences of
Estrogen and
progesterone
Part of Menses
Hyperactivity
during
Pregnancy
Gini Baker RN, MPH, IBCLC
**Stages of Lactation**
Lactogenesis Stage 1
About 1010-14 weeks gestation
Milk secretion accelerates
Alveoli distend
Accumulation of colostrum
WHY there is milk at delivery !
Supply
& Demand
Rule of BF:
“If you can’t handle the answer, don’t ask the question”
Gini Baker RN, MPH, IBCLC
Gini Baker, RN, MPH, IBCLC
DO NOT COPY Copyrighted Materials
5
Stages of Lactogenesis and
Why Newborn Babies Suck so Much
Stages of Lactogenesis
Mamogenesis
Lactogenesis
Stage 1
(Milk making …
In the
beginning)
a. Breasts grow:
~ 10-14 Wks
Gestation
a. Milk
secretion starts
b. Alveoli
distend
c. Accumulates
in breast
Size & weight
b. Ducts &
glands grow
c. Influences of
Transition
Lactogenesis
Stage 2
Galactopoesis
Involution
Estrogen and
progesterone
Part of Menses
Hyperactivity
during
Pregnancy
WHY there is
MILK at
delivery
Supply
And
Demand !
Gini Baker RN, MPH, IBCLC
**Stages of Lactation**
Lactogenesis Stage 2
3-4
days after birth
Can be delayed by “third spacing”
spacing” of fluids
Placenta Delivery Triggers:
Fall progesterone/estrogen
Milk “coming in” (Change Vocabulary)
Decreased milk levels sodium, chloride, protein
Rise in lactose and milk lipids
Gini Baker RN, MPH, IBCLC
Gini Baker, RN, MPH, IBCLC
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6
Stages of Lactogenesis and
Why Newborn Babies Suck so Much
Stages of Lactogenesis
Mamogenesis
Lactogenesis
Stage 1
Transition
Lactogenesis
Stage 2
(Milk making …
In the
beginning)
a. Breasts grow:
~ 10-14 Wks
Gestation
a. Milk
secretion starts
b. Alveoli
distend
c. Accumulates
in breast
Delivery of
Placenta
To
Mil k
Increasing in
Volume
3-4 days after
delivery
Placenta
WHY there is
MILK at
delivery
Note: Milk
does NOT
come in !
Supply
And
Demand !
It increases in
volume !
Size & weight
b. Ducts &
glands grow
c. Influences of
Galactopoesis
Involution
Milk “In”
Increased in
volume to meet
infant demands
Estrogen and
progesterone
Part of Menses
Hyperactivity
during
Pregnancy
Delayed by 3rd
Spacing !
(3rd spacing seems
to resolve
~ DOL 4)
Reverse
Pressure
Softening
Gini Baker RN, MPH, IBCLC
3rd Spacing
Orders
1000cc fluid load before procedure
Rationale:
for epidural
Maternal: Maintain maternal blood pressure
Infant: Oxygenation of the fetus
Maintenance IV at 125cc125cc-ml/hour
UNLESS Maternal BP drops
Increase fluid rate as necessary to maintain maternal BP
Add Pitocin to IV after delivery
Potential 10 hour epidural
1000 + (125 X 10 hours) 1250 + pp pitocin 500 = 2750cc/ml
Gini Baker RN, MPH, IBCLC
Gini Baker, RN, MPH, IBCLC
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7
Stages of Lactogenesis and
Why Newborn Babies Suck so Much
3rd Spacing …. Reality
1000+ cc fluid load
Maternal BP drops .. Open the IV
Average in 10 hours = 300300-700cc/hr
Common 35003500-5000 cc fluid
Supposed Rationale:
Client is “dry” needs the fluids
No consideration to postpartum fluid shift
What about the baby?
www.gnuron.net
Raise your hand if you have seen “sleepy babies” after 10 hour epidural
Do epidurals effect infant instinctive behaviors ?
Of course !!!!!!
Gini Baker RN, MPH, IBCLC
3rd Spacing … Postpartum
8-10 hours later ..
Fluid shifts
1st
Space: IV
2ndSpace: Intracellular
3rd Space: Extra Cellular
Path of least resistance:
Any part that ”hangs down”
Feet – Bottom
– Hands – Breasts
http://www.uct.ac.za/depts/ich/teaching/temp/tb_scenarios/case%205/tbs_c05.html
Gini Baker RN, MPH, IBCLC
Gini Baker, RN, MPH, IBCLC
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8
Stages of Lactogenesis and
Why Newborn Babies Suck so Much
Pituitary
Breast stimulation: Suckling
Sends message to pituitary to secrete
oxytocin and prolactin
Oxytocin
Prolactin
Third Spacing:
Due to fluid load
1st space – Intravenous
2nd space – Intracellular
3rd space – Extra cellular
Delayed mammary cell response:
Delayed onset
Lactogenesis II
Fluid Creates “lake” effect
Reduces hormonal influence
Diuresis: “Lake dries up”
Takes about 4-5 days
Gini Baker RN, MPH, IBCLC
Third Spacing
* Fluid load of 3000ml+
* Edema: 8-10 hours after delivery
-Feet
-Hands
-Bottom -Breasts
Delays:
* Hormonal response
at breast cellular level
*Onset of lactogenesis II
“Milk coming in”
Gini Baker RN, MPH, IBCLC
Gini Baker, RN, MPH, IBCLC
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9
Stages of Lactogenesis and
Why Newborn Babies Suck so Much
Reverse Pressure Softening
Jean Cotterman at Kellymom.com
Two handed, oneone-step method
Fingernails short, fingertips curved,
each one touching the side of nipple
Two handed, twotwo-step method
Using 2 or 3 straight fingers on each
side, first knuckles touching nipple.
Move ¼ turn, repeat above &
below nipple
Gini Baker RN, MPH, IBCLC
Reverse Pressure Softening
Jean Cotterman at Kellymom.com
Two handed, twotwo-step method
(step 1) Using straight thumbs, base
of thumbnail even with side of
nipple.
Two handed, twotwo-step method (step
2)
2)Move
Move ¼ turn, repeat above & below
nipple
Gini Baker RN, MPH, IBCLC
Gini Baker, RN, MPH, IBCLC
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10
Stages of Lactogenesis and
Why Newborn Babies Suck so Much
Reverse Pressure Softening
Jean Cotterman at Kellymom.com
One handed “flower hold”
Fingernails short, fingertips
curved,placed where baby’s tongue
will go. (Use a hand mirror to see
areola)
Soft ring method
Cut off bottom half of an artificial
nipple to place on areola to press
with fingers
Mirror
Gini Baker RN, MPH, IBCLC
Other Products
Reverse Breast Shell with silicone nipple
Gini Baker RN, MPH, IBCLC
Gini Baker, RN, MPH, IBCLC
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11
Stages of Lactogenesis and
Why Newborn Babies Suck so Much
Gini Baker RN, MPH, IBCLC
3rd Spacing vs. Engorgement
How old is the baby?
How does the breast feel to
touch?
3rd Spacing = 88-10 hours
Engorgement = 33-5 days
3rd Spacing = pliable (Fluid
moves)
Engorgement = firm – hard
Treatment?
3rd Spacing = Reverse pressure
softening
Engorgement = Cold, expression
of milk
Gini Baker RN, MPH, IBCLC
Gini Baker, RN, MPH, IBCLC
DO NOT COPY Copyrighted Materials
12
Stages of Lactogenesis and
Why Newborn Babies Suck so Much
Stages of Lactogenesis
Mamogenesis
Lactogenesis
Stage 1
Transition
Lactogenesis
Stage 2
(Milk making …
In the
beginning)
a. Breasts grow:
~ 10-14 Wks
Gestation
a. Milk
secretion starts
b. Alveoli
distend
c. Accumulates
in breast
Delivery of
Placenta
To
Mil k
Increasing in
Volume
3-4 days after
delivery
Placenta
WHY there is
MILK at
delivery
Note: Milk
does NOT
come in !
Supply
And
Demand !
It increases in
volume !
Size & weight
b. Ducts &
glands grow
c. Influences of
Galactopoesis
Involution
Milk “In”
Increased in
volume to meet
infant demands
Estrogen and
progesterone
Part of Menses
Hyperactivity
during
Pregnancy
Delayed by 3rd
Spacing !
(3rd spacing
seems to ~
DOL 4)
Reverse
Pressure
Softening
Gini Baker RN, MPH, IBCLC
**Stages of Lactation**
Galactopoesis
About 9 days
Maintenance established milk
secretion
Supply – Demand vs.
Demand -- Supply
Involution
Approx 40 days after last
breastfeeding
Gini Baker RN, MPH, IBCLC
Gini Baker, RN, MPH, IBCLC
DO NOT COPY Copyrighted Materials
13
Stages of Lactogenesis and
Why Newborn Babies Suck so Much
Stages of Lactogenesis
Mamogenesis
Lactogenesis
Stage 1
Transition
Lactogenesis
Stage 2
Galactopoesis
Involution
(Milk making …
In the
beginning)
a. Breasts grow:
~ 10-14 Wks
Gestation
a. Milk
secretion starts
b. Alveoli
distend
c. Accumulates
in breast
Delivery of
Placenta
To
Mil k
Increasing in
Volume
3-4 days after
delivery
Placenta
Maintenance of
Established
Milk Supply
Return of
uterus and
breasts to prepregnant state
~ 40 days
Lots of
choices based
on this …
WHY there is
MILK at
delivery
Note: Milk
does NOT
come in !
Demand
and
Supply !
Are ya
sure?
Supply
And
Demand !
It increases in
volume !
Size & weight
b. Ducts &
glands grow
c. Influences of
Milk “In”
Increased in
volume to meet
infant demands
Estrogen and
progesterone
Part of Menses
Hyperactivity
during
Pregnancy
Delayed by 3rd
Spacing !
(3rd
spacing seems
to resolve
~ DOL 4)
Reverse
Pressure
Softening
FIL Factor
Feedback
Inhibitor of
Lactation
Gini Baker RN, MPH, IBCLC
http://www.kellymom.com/bf/supply/milkproduction.html
Shift from Endocrine to Autocrine System
Gini Baker RN, MPH, IBCLC
Gini Baker, RN, MPH, IBCLC
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14
Stages of Lactogenesis and
Why Newborn Babies Suck so Much
**Stages of Lactation**
Mammogenesis
Lactogenesis
Stage 1
Lactogenesis Stage 2
Galactopoesis
Involution
Gini Baker RN, MPH, IBCLC
Lactogenesis Stage II
Sucking DOES NOT = Hunger
DOL 3-4
High Suck need
Infant Goal: Clean out meconium
Maternal Goal: Prolactin receptor sites
High prolactin levels at birth
Low Milk Volume
Baby born full
Prolactin levels reduce over time
Gini Baker, RN, MPH, IBCLC
Gini Baker, RN, MPH, IBCLC
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30
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Stages of Lactogenesis and
Why Newborn Babies Suck so Much
Gini Baker RN, MPH, IBCLC
Bibiliography
Epidemiol. 2002 Oct;16(4):355
Oct;16(4):355-Aksit S, Ozkayin N, Caglayan S. Effect of sucking characteristics on breast milk creamatocrit.
creamatocrit. Paediatr Perinat Epidemiol.
60.
Butte NF, Garza C, Smith EO, Nichols BL. Human milk intake and growth in exclusively breastbreast-fed infants.
infants. J Pediatr
Pediatr.. 1984 Feb;104(2):187Feb;104(2):18795.
Cregan MD, Hartmann PE. Computerized breast measurement from conception to weaning: clinical implications.
implications. J Hum Lact
Lact.. 1999
Jun;15(2):89--96.
Jun;15(2):89
Daly SEJ, DiRosso A, Owens RA, Hartmann PE. Degree of breast emptying explains changes in the fat content, but not fatty acid
composition, of human milk.
milk. Exp Physiol 1993;78:7411993;78:741-55.
Hamosh M. Breastfeeding: Unraveling the Mysteries of Mother's Milk.
Milk. Medscape Women's Health eJournal 1996;1(5).
Hamosh M, Dewey, Garza C, et al: Nutrition During Lactation.
Lactation. Institute of Medicine, Washington, DC; National Academy Press 1991. This
book is available free from the HRSA Information Center (look under Nutrition publications).
Jelliffe DB, Jelliffe EFP. Human milk in the modern world: psychosocial, nutritional and economic significance. Oxford: Oxford University
Press, 1978.
Lawrence R and Lawrence R. Breastfeeding: A Guide for the Medical Profession
Profession,, 5th ed. St. Louis: Mosby, 2005.
Mitoulas LR, Gurrin LC, Doherty DA, Sherriff JL, Hartmann PE. Infant intake of fatty acids from human milk over the first year of lactation
lactation..
Br J Nutr
Nutr.. 2003 Nov;90(5):979Nov;90(5):979-86.
Mitoulas LR, Kent JC, Cox DB, Owens RA, Sherriff JL, Hartmann PE. Variation in fat, lactose and protein in human milk over 24 h and
throughout the first year of lactation.
lactation. Br J Nutr
Nutr.. 2002 Jul;88(1):29Jul;88(1):29-37.
Stutte PC, et al. The effects of breast massage on volume and fat content of
human milk. Genesis 1988; 10:2210:22-25.
van der Westhuyzen J, Chetty N, Atkinson PM. Fatty acid composition of human milk from South African black mothers consuming a
traditional maize diet.
diet. Eur J Clin Nutr 1988 Mar;42(3):213
Kellymom.com
Gini Baker RN, MPH, IBCLC
Gini Baker, RN, MPH, IBCLC
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