Physiology of Lactation

Adapted from the course on

Breastfeeding : Advocacy & Practice
Malaysia 2007
Stages of Lactation

Mammogenesis
Lactogenesis
Lactogenesis I
Lactogenesis II
Galactopoiesis
Lactogenesis III
Involution
 Mammogenesis -

“priming”- growth and

development of ducts & alveoli in
the first 12 weeks of pregnancy

The breast is prepared for

lactation by 16 weeks
 Lactogenesis
Lactogenesis I

starts at 28 weeks pregnancy

Substrate for milk production

collect in breast tissue

Early secretion – production of

colostrum starts
Lactogenesis II

–starts at 3-4 days after delivery

of placenta, progesterone &
estrogen = stimulates milk
synthesis
–Blood flows to breast increases
–Production of transition milk
starts milk “comes in”
 Lactogenesis II

Retained placenta – inhibits

Initiation of milk production
depends on changed hormone
levels -----NOT on early
suckling
Continuation of milk
production after 3-4 days DOES
depend on infant suckling
Lactogenesis III or Galactopoiesis

– From 10 days after delivery

– Mature milk is produced
– Production sustained if baby
continues to breastfeed
– Volume depends on the amount
baby removes
 Lactogenesis III or Galactopoiesis

Single baby – 750 mls / 24 hrs

for Twins - 1500 mls / 24 hrs
As baby grows and weight
increases, milk need per kilo of
body weight decreases
So total milk needs remains
about the same from 6 weeks to
6 months despite growth
Involution

When other feeds / foods satisfy

appetite baby suckle less
production decreases
milk cells die Milk in the
breast is reabsorbed.

Last milk produced is more like

colostrum with many protective
bodies
 Role of Hormones
(primes mammary glands)

Estrogen – growth of ducts

Progesterone – growth of alveoli
Placental Lactogen - growth of milk
producing cells in the alveoli
Prolactin – helps growth of ducts
and alveoli /stimulates alveoli cells
to produce milk
: Prolactin Reflex
Sensory impulses
from nipples

Prolactin
in blood

• More prolactin
secreted at night
Baby
suckling • Suppresses
ovulation

Secreted during and after

feed to produce next feed
Prolactin Levels

Prolactin blood levels: ng /ml

Menstruating woman: 8 – 14
End of pregnancy: 200 – 500

Baseline during lactation:

- From delivery to 10 days: 200
- 10 – 90 days: 60 – 100
- 90 – 180 days: 50
- 180 days – 1 year: 30 – 40
 Prolactin level

Each breastfeeding causes a

rise in Prolactin
x 5 baseline in early
lactation,
x 2 in late lactation.

Prolactin rise is maximum 30

minutes after feed.
 Oxytocin reflex

Sensory impulses
Oxytocin from nipples
in blood

Baby Makes uterus

suckling contract

Works before or during

feed to make milk flow
 help reflex hinder reflex

• Worry
• Thinks lovingly of baby
• Stress
• Sounds / sight of baby
• Pain
•Touching baby
• Doubt
•Confidence

Helping and hindering of

oxytocin reflex
NEUROENDOCRINE PATHWAYS
INITIATED BY SUCKLING
 Milk production

First 4 – 6 weeks after delivery

is very variable
At 5 days = 200 – 900 ml / 24
hours
At 4 – 6 weeks = 400 – 1100
ml/24 hours
 Milk production

Milk production starts:

low and increases (up-regulation) –
in most women
high and decreases (down-
regulation) - in some women
until it adjusts to the needs of the
baby.

Milk production at this

time is not related to
size of baby
 Milk production

By 4 – 6 weeks, production adjusts to

baby’s needs

Milk production is now related to size of baby

- regulated by baby’s demand

baby’s fat or calorie intake controls
appetite and hence demand

If supplements are given appetite is

satisfied demand is less
 Milk Production From Birth
Baby’s Age mls per day mls per feed

Range Average On Average

Day 1 (0-24 hrs) 7 – 123 37 7
Day 2 (24-48 hrs) 44 – 335 84 14

Day 3 (48-72 hrs) 98 – 775 266 38

Day 4 (72-96 hrs) 385 58
Day 5 (96-120 hrs) 500 70
3 months 750
6 months 800
 Hartmann et al (1993) – a study
found that babies removed an
average of only 76% of the
available milk from their mothers’
breast in a 24-hr period.

Wilde 1995 – a special protein in

human milk called feedback
inhibitor of lactation (FIL)
regulates milk production.
Feedback Inhibitor of Lactation (FIL)

It is chemical inhibitor
Is an autocrine or local regulator
of breastmilk synthesis
Is a protein made in the breast
itself
If not removed it collects in the
alveoli and blocks milk secretion
in the mammary cells
Volume, frequency, fat content
Study by Kent, Ramsay et al (2006)

Result:
Left and right breast volume differ
Fat inversely related to 24hr volume from
that breast
No relationship between # of BFs and 24
hour milk production
Night breastfeeding has important
contribution to volume
Encourage on demand
feeding
Factors that impair milk production

1. Inefficient milk removal due to:

- Poor attachment
- Insufficiently suckling
- Addition of supplements
- Infrequent feeds
- Short feeds
- No night feeds
 Factors that impair milk production

2. Impaired ejection – anxiety, pain

(temporary)
3. Retained placenta products
(hormones inhibit prolactin)
4. Oestrogens (e.g., in combined
hormonal contraceptives)
5. Pregnancy
 Factors that impair milk production

6. Lack of prolactin
- Sheehans syndrome (after
postpartum haemorrhage)
- Primary deficiency - (very rare)
- Smoking (nicotine may lead to lower
prolactin levels)

7. Physical abnormality (breast

agenesis)

8. Severe malnutrition
 Factors that impair milk production

6. Lack of prolactin
- Primary deficiency - (very rare)
- Smoking (nicotine may lead to lower
prolactin levels)

7. Physical abnormality (breast

agenesis)

8. Severe malnutrition