BREAST-FEEDING AND MATERNAL-CHILD HEALTH 3 CE hours Learning objectives Discuss issues pertinent to breast-feeding. Review the anatomy of the breast. Describe the physiological functioning of the breast. Identify breast changes that occur during pregnancy. Explain how to deal with mastitis and breast engorgement. Discuss the benefits of breast-feeding for mother and child. Identify the economic benefits of breast-feeding. Identify the societal benefits of breast-feeding. Discuss the barriers to breast-feeding. Describe strategies for successful breast-feeding. Offer suggestions for successful breast-feeding in public. Introduction Chris is 32 years old and gave birth to her second child late last night. This morning, she tells Karen, her hospital roommate, that she is looking forward to breast-feeding her baby. Chris had a very positive experience breast-feeding her first child and she tells her roommate, in great detail, about the benefit to both mother and child of breast-feeding. As Chris is speaking, a visitor arrives. The visitor’s name is Lisa and she and Chris have been close friends for years. Karen hesitantly tells both women that she had a very difficult time trying to breast- feed her first child. “My breasts were so sore and I developed a terrible infection in them. I finally had to stop trying to breast-feed, so I don’t know if I should try again.” Both Chris and Lisa express their disapproval, telling Karen that she “had” to breast-feed, and if she cared about her baby, she would not hesitate. Karen becomes tearful. At this point, a nurse arrives and gently but firmly puts an end to the confrontation. The nurse helps Karen to her office and they have a lengthy discussion about breast-feeding and other feeding options. After the conversation, Karen asks the nurse for her help in breast-feeding the baby. “I really do want to try again, but I don’t need someone pressuring me and making me feel guilty.” __________ Breast-feeding provides a multitude of benefits to both mother and baby. However, it is important to provide mothers with support, assistance and adequate education so the experience is positive for both mother and child. This includes discussing not only the benefits but also possible complications and how to deal with them. Persons involved in facilitating breast-feeding must remain objective and nonjudgmental. Although most women can successfully breast-feed, there are some exceptions. Consider the following scenario: Angela is a registered nurse who works on the obstetrics unit of a large community hospital. She loves her work, especially the patient/family education aspects of the job. Despite this, Angela sometimes 1 feels a bit wistful when she helps new mothers to breast-feed. Angela was not able to breast-feed her own child, something she desperately wanted to do. Angela has had a life-long struggle with serious depression, and the medications she needs have the potential to harm babies during breast-feeding. After much discussion with her physician and husband, it was decided that the risk of stopping or changing her medications outweighed the need to breast-feed. Angela had not taken medications during her pregnancy, and it proved to be extremely difficult. In fact, it was so difficult that she and her husband decided not to have any more children. Because of her own problems, Angela has developed a knack for helping women who have problems breast-feeding. __________ The preceding example shows that there are some circumstances that make it dangerous for mother and child if breast-feeding occurs. These kinds of circumstances can have devastating effects on women who want to breast-feed. Health care professionals need to provide empathy and support in such cases. Empathy and support are also needed as women make the choice to breast-feed in public places. Women may experience both support and disapproval if they choose to breast-feed in public. Marlene is the mother of a 6-week-old baby girl. She is breast-feeding her new baby as she did with her first child, a little boy who is now 4 years old. With her first child, Marlene was not comfortable breast-feeding in public. Today, she is more confident and comfortable in her role as mother, and she often discretely breast-feeds her daughter in public. This afternoon, Marlene is with both children at McDonalds. She begins to breast-feed her daughter. An elderly woman passes by and says, “What a lovely family you have.” A few minutes later, a woman about Marlene’s age stops and tells her, “You should be ashamed doing that in public and in a place where children can see you.” __________ The preceding scenario shows that breast-feeding in public can trigger a variety of emotions and behaviors, not all of them productive or appropriate. This education program deals with both the physiological and psychological issues pertinent to breast- feeding. It also addresses the emotions breast-feeding can trigger in family members and friends of the nursing mother and her baby, and even strangers. Anatomy and physiology of the breasts The breasts are paired mammary glands located on either side of the anterior chest wall over the greater pectoral and anterior serratus muscles. They are composed of glandular, fatty (adipose), and fibrous tissues. The breasts are supported by connective tissue. Fibrous bands called Cooper’s ligaments attach the breast to the chest wall and prevent breasts from sagging. The breasts of males and females are similar until puberty, at which time female breast tissue enlarges due to hormonal influences. Normally, the mammary glands function only in the female.2,8,13 2 The areola is the pigmented area of the center of the breast and contains elevated sebaceous glands called Montgomery glands. In the center of the areola is the nipple, which contains erectile tissue that responds to sexual stimulation, friction, and cold.2,13 Each breast contains 15 to 25 lobes that are separated by fat and connective tissue. These lobes branch out around the nipple. The lobes are composed of clusters of acini, very small sac-like duct terminals that are responsible for the secretion of milk during lactation (secretion or production of milk by the mammary glands). 2,13 The ducts that drain the lobules come together to form the lactiferous excretory ducts and sinuses called ampullae. The ampullae store milk during lactation. The ducts drain onto the surface of the nipple through 15 to 20 pores.2,8,13 The female breast undergoes age-related changes in response to hormonal changes. At puberty, the pituitary gland, ovaries, and hypothalamus secrete hormones that stimulate the buildup and shedding of the endometrium during the menstrual cycle. These hormones are estrogen, progesterone, follicle stimulating hormone (FSH), and luteinizing hormone (LH). At puberty, the female breasts enlarge and mature in order to produce milk.2,8,13 The female breasts and reproductive structures are dependent on estrogen. As a woman ages, reduced levels of estrogen and progesterone lead to significant changes in these structures. The fatty, glandular, and supporting tissues of the breast atrophy. Cooper’s ligaments lose elasticity, causing the breasts to become pendulous. Over time, the nipples become smaller and flat and ridges of the breasts become more obvious.2 Breast changes during pregnancy During pregnancy, the female breasts undergo changes in preparation for breast-feeding. During the first trimester of pregnancy, the amount of fatty tissue in the breasts increases as does blood flow to the breasts. These changes occur to promote growth of the mammary glands and the milk ducts. 2,9 As the breasts grow, they generally become tender and heavier. The nipples and veins of the breast become more prominent and the areola become larger and darker. Breasts may have a tingling sensation with changes in temperature. Women may find relief from some of the discomfort by wearing a less constricting bra and limiting sodium intake to reduce water retention.6, 9 Cotton bras allow the skin to “breath” and are usually more comfortable than those made from synthetic material. A maternity bra not only provides some relief from breast tenderness but includes extra rows of hooks so that size can be adjusted as breasts enlarge.6 Patient education alert! Although breast changes can cause discomfort, women should be advised not to take analgesic medications, even over-the-counter preparations, while pregnant unless specifically told to do so by their physicians. Medications have the potential to pass to the baby and adversely affect him or her. 9 During the second and third trimester, the breasts continue to enlarge but breast discomfort generally decreases. Stretch marks may appear on the breasts, and the Montgomery glands of the areola enlarge. There may be some leaking of colostrum, the precursor to breast milk, from the breasts. This leakage is normal. Disposable breast pads may be worn if leaking occurs. As the skin of the breasts stretch, it may become itchy. To reduce the itching, women may use a moisturizer after bathing and at bedtime. The breasts should be allowed to dry thoroughly after bathing and prior to applying moisturizer. Women should avoid using soap on the nipples and over the areola because soap can dry out skin and increase itching.6,9 3 Patient education alert! Females should be educated about the various changes in their breasts throughout the life cycle and during and after pregnancy. They need to know what is normal and what is abnormal. Knowledge of these issues will help women to implement proper breast self-examination. Physiology of lactation Breast milk is widely believed to be the best form of nutrition for neonates and infants.11 Lactogenesis, commonly referred to as milk production, involves all necessary steps for the production and excretion of milk from the mammary glands.11 The first stage takes place about the middle of a woman’s pregnancy.