UNIT 9 WEEK 6

Physiology of Lactation
Mammogenesis 1,4 Before puberty, there is not much of an internal glandular structure. At puberty, breasts start to develop due to stimulation of mammary glands by oestrogens as well as deposition of fat which provides an increased mass. The oestrogen however does not really affect the development of the alveoli. The increased secretion of progesterone during the luteal phase of the menstrual cycle causes growth of the alveoli. Terminal end buds start to form. During pregnancy when oestrogen levels are even higher, growth occurs at a greater rate and it is only at this time that the glandular tissue becomes developed enough to produce milk (under the influence of various hormones); terminal end buds start to become actual alveoli.
Image showing: (A) the breast & its secretory lobules, alveoli and lactiferous (milk) ducts these make up the mammary gland (B) a lobule (C) milk-secreting cells of an alveolus
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Hormones and lactation 1,2 ,3 Oestrogen, progesterone and human prolactin (hPr) are all involved in the development of the lactiferous ducts and the alveoli. Oestrogen causes an increase in the size & number of the lactiferous ducts Progesterone causes an increase in the number of alveoli Human placental lactogen (hPL) also stimulates development of the alveoli, & can be involved in the alveolar synthesis of casein, lactalbumin and lactoglobulin

hPr is secreted from the anterior pituitary gland of the mother, and continues to increase gradually from 5 weeks gestation onwards (at birth, levels are around 10-20 times that of a nonpregnant woman). hPr has lactogenic properties so stimulates alveolar cells to secrete milk. The placenta also secretes large amounts of human chorionic somatomammotropin which also has lactogenic properties, which helps to promote secretion of prolactin from the anterior pituitary. However, although hPr levels rise throughout pregnancy, its action is inhibited due to the high levels of oestrogen & progesterone which occupy alveolar binding sites, and therefore the alveoli cannot respond to the lactogenic properties of hPr. Soon after birth, the sudden reduction of these hormones allows hPr to act, so lactation can begin. In late pregnancy, colostrum can be expressed from the breast, which is a thick yellowish protein-rich fluid (containing immune antibodies), and soon after birth will be replaced by the production of milk. Lactogenesis 1,4 There are 3 stages that correspond to the production of milk. Lactogenesis I leads to the formation of colostrum as a result of activity of secretory cells due to the action of the aforementioned hormones. Lactogenesis II is when copious milk secretion occurs, which starts off with endocrine control and then changes to autocrine control, for example by suckling of the infant. Lactogenesis III is maintenance of lactation every time the mother feeds there is secretion of prolactin which helps to maintain milk production, which is stimulated by suckling (nipple receptors send afferent input to the hypothalamus to inhibit dopamine release from hypothalamic neurons, allowing prolactin to be released.

Image showing the changes in the breast structure at different stages Image showing changes in secretion of oestrogens, progesterone & prolactin. Taken from 1

UNIT 9 WEEK 6

Physiology of Lactation
There is also a protein known as FIL (feedback inhibitor of lactation) and it is involved in slowing the synthesis of milk when the breast is already full (i.e. FIL increases when breast is full) via a feedback mechanism that causes prolactin to be secreted when FIL levels are low.

Milk-ejection reflex 2
This reflex is initiated by suckling and is mediated by the hypothalamus & pituitary gland which release oxytocin into the blood. Oxytocin causes contraction of the myoepithelial cells so that milk is ejected from the alveoli and small ducts into the large ducts and the subareolar reservoir. It can also inhibit dopamine release to further aid the secretion of milk. NB. Negative emotions can reduce this reflex so mother must be reassured and advised to feel confident about breastfeeding

Pros & Cons of Breast-feeding 3 Advantages

Can protect the child against GI illness fewer GI infections are seen in infants that are breastfed Breast milk can protect against UTIs

Potential problems
Inadequate milk supply - <1% of women produce an inadequate supply. Can treat by ensuring that the mother consumes enough fluids, good nutrition, stays in a secure environment, dopamine antagonists, thyrotropin-releasing hormone, oxytocin Milk flow problems can be caused by: breast engorgement, mastitis, breast abscess, sore/cracked nipples these can all affect the positioning of the baby on the breast, and can themselves be caused by incorrect attachment to the breast. The mother is advised to continue breastfeeding nevertheless. After breast cancer treated breast will not enlarge (or only slightly) but untreated breast will remain normal. Tamoxifen can be used to inhibit milk production is the woman does not wish to breastfeed. Drugs some drugs can reduce production of milk, e.g. progestins, oestrogens, ethanol, bromocriptine, ergotamine, cabergoline, pseudoephedrine.

Less likely to get chest infections and/or atopic illnesses Reduced risk of childhood leukaemias Not clear as to whether breast-feeding affects intelligence, however it is still the best way to provide ideal nutrition Helps in uterine involution (for the mother) so protecting from post-partum haemorrhage Full breastfeeding can be 99% as effective as contraception lactational amenorrhoea Can protect the mother against premenopausal breast and ovarian cancer, & osteoporosis

Breast-milk Substitutes 2
These include formula milks which are based on cows milk but are modified to have similar nutritional values as human breast milk, such as protein, fat, carbohydrates, vitamins and minerals. As long as they are prepared in the way that is stated by the manufacturer, these should allow the infant to thrive however the baby will not be as protected against infection as a breastfed one.

References
1 2

Guyton and Hall; Llewellyn-Jones; Fundamentals of Obstetrics and Gynaecology. 9th edition. Edinburgh: Elsevier. 2010. 3 Collins, Arulkumaran, Hayes, Jackson & Impey; Oxford Handbook of Obstetrics and Gynaecology. 2nd ed. New York: Oxford University Press. 2008. 4 Seminar Physiology of Lactation Margaret Bunting