Clinical:Case Study: Breastfeeding Essentials

Original materials created in September 2000 by Francesca Taylor, M.D.

History

JK is a 33 year old married Caucasian woman, Gravida 3 Para 2 Ab 1, presenting to my office 2 days post-partum for a lactation follow up visit. She tried breastfeeding her first child but gave up after a week because her milk “didn’t come in”. She wanted very much to make another attempt with this baby. At this visit she is still concerned about not producing enough milk.

The baby was asleep at the beginning of the visit and so I used the time to elicit a more detailed history. After her first delivery she’d had little support for breastfeeding and a friend had even frightened her, saying that “babies wake up more often at night when they are breastfed”.

I asked about sensations of letdown. She said she did have a mild sort of “pins and needles” feeling. She had never had mastitis in the past. She did not feel engorged, but noted that her nipples were quite sore.

Her home environment was generally peaceful. Her mother-in-law had come to help her and her husband with house chores and baby care. No one in the home had any objection to breastfeeding and her husband was very supportive of it. Everyone in our clinic was proactive for lactation and she felt she had been given good resources during her prenatal care. She had made her first attempt to breastfeed right in the delivery room as she had learned in a lactation class. She had also set up a special chair with a side table and foot stool at home to be for breastfeeding only.

I asked how the baby was doing? She noted he seemed to be hungry every 2 to 4 hours, around the clock, and had made about 5 wet diapers daily with 1 to 2 of these containing yellow, seedy stool.

Exam

After this conversation I asked her to undress from the waist up and put on a gown and a towel beneath her breasts in case of leakage. Her breasts were rounded, and fairly firm though not engorged. The areolae and nipples were average in size and there were no nipple inversions or other variants.

JK had been using a hand operated breast pump, and we connected this to the electric pump kept in our clinic for lactation teaching. I started the pump at the lowest suction and slowest frequency, and she tolerated this well. Small amounts of milk flowedfrom each nipple, colostrum mixed with more mature milk. We were able to increase the flow of her milk by turning up the pump a little. She was relieved to see that she was actually making more milk than she initially believed.

I then examined the baby, checking mouth size, jaw, lips, gums, tongue and palate. The baby had no notable abnormalities, no frenulum of the tongue, and by a digital check had a normal sucking reflex.

I asked the mother to place the baby on a breast to see how they functioned as a maternal-infant dyad. The baby latched with minimal difficulty. From time to time he would doze on the breast but would re-initiate suckling on his own within 1 to 2 minutes. I showed JK how to jiggle her breast gently and tickle the baby’s cheek to stimulate him to resume. She also remarked that the baby would fall fast asleep sometimes after feeding from only one breast.

Discussion

Significant milk synthesis and secretion begins after parturition when prolactin secretion by the anterior pituitary is triggered by a fall in maternal progesterone. Progesterone decreases directly following removal of the placenta. An abrupt increase in milk production occurs about 3 days after delivery and is referred to as lactogenesis or, more colloquially, as the milk “coming in”. By this time suckling or pumping should be well established. Removing milk from the breast by suckling or by pumping stimulates prolactin. Lactogenesis occurs whether or not the mother initiates breastfeeding, but if the breast is not emptied maternal prolactin falls and the mammary gland will involute.(1)

In traditional cultures women learn about breastfeeding from childhood as they notice lactation by their mothers and other women of the tribe or village. Even in western cultures prior to the development of infant formula, women either had to breastfeed or utilize wet nurses and thus many female networks would be assembled to assist in lactation.

In our era, women’s reproductive lives have changed; women have fewer children, space children further apart, and/or are childbearing at older ages. Family structures have also changed, and women may live far from families of origin and do not always have female relatives or even friends nearby who can guide them. The most frequently cited concern is “inadequate milk”.(2)

Varied problems can arise during breastfeeding. Some are complex (baby with congenital clefts, mother with previous breast surgery, twin pregnancy, etc.), but many are common and simple.

In JK’s case, her fears needed to be addressed with education about breastfeeding physiology and assistance with a session of pumping and actual feeding observation. Her baby was not a highly demanding one (and some aren’t) and she benefited from simple coaching to stimulate the baby more. Another piece of advice was to undress her son completely if he fell fast asleep, as a non-intrusive way of re-awakening him to resume feeding.

To build her milk supply during that crucial first week I instructed her to offer the breast to the baby frequently – since the baby is the best pump. She was to do this every 2 hours during the day and every 3 to 4 hours at night.

When using the pump I instructed her to pump each breast for about 7 minutes, then massage, rub and shake her breasts and repeat pumping on each side for 5 minutes. For more stimulation I suggested yet another pumping using a smaller size pump shield as it would put different pressure on the areolar tissue and nipple.

At a follow up visit 2 days later JK reported that her milk had noticeably “come in” and that her baby was generating 4 diapers with stool each day and more wet diapers than before. She commented that she had not perceived her breasts as dynamic and productive organs and felt a new pride in them now. We planned to follow up again at her 6 week postpartum check, and told her to call between times if she had any further questions.

References

(1) Principles and Practice of Pediatrics, 2nd Edition. F Oski, C DeAngelis, R Feigin, J McMillan, J Warshaw. P. 598. J.B. Lippincott Co., Philadelphia.c. 1994

(2) Lactation Forms: a Guide to Lactation Consultant Charting. C Marmet and E Snell. Lactation Institute, Publishers, Encino, California. C. 1986 and 1989