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Prolactin cycling and the management of breast-feeding failure.


 Various studies (Tyson et.al.; Frantz; Aono et.al.) show that cycling of prolactin is critical to the establishment of successful lactation in the first 60 to 80 days postpartum, and that a 2-hour nursing interval is associated with a statistically significant earlier onset of milk production (Salarija et.al.). However, in the patient with a lactational insufficiency, efforts to increase the frequency of nursing more often than every 2 hours may be counterproductive, as experimental evidence shows that prolactin exerts a negative feedback upon itself, and the patient with a breastfeeding problems may experience increased episodes of anxiety and fatigue. The patient with breast milk insufficiency can be managed by ensuring that a sucking stimulus of 30 minutes (15 minutes bilaterally) be present and repeated every 2-3 hours to provide adequate stimulation for prolactin release. Maternal anxiety about milk supply can be relieved by using the Lact-Aid nursing supplementer, a device which provides an additional source of milk to the infant at the breast. Nursing should be carried out in a sheltered situation to provide an uninterrupted sucking stimulus devoid of distraction. The mother should be directed to focus on pleasant associations while nursing to keep her from worrying about whether she will have enough milk. Symptoms of lactational insufficiency can be corrected with proper hormonal regulation. Evaluation of a breastfeeding disorder depends upon a careful physical examination of the breast, preferably to be done prior to and during infant nursing. Observation of infant nursing has not been a standard part of physical examination, although it is critical to making a diagnosis of the problem. The principles of breastfeeding management are illustrated in 3 cases in this chapter. In cases where there is no response to treatment, additional evaluation of the patient's developmental (e.g., adolescent attitude towards the breast) attitude and sexual function history should be done.
