Hypogalactia is a complication of the postpartum period, in which the level of milk excretion does not meet the child’s needs for nutrients necessary for normal development. A decrease in lactation is manifested by the restless behavior of the baby, a slowdown in body weight gain. To make a diagnosis, a control weighing of the child is carried out after feeding, breast ultrasound, the level of sex hormones and prolactin is determined. In order to restore lactogenesis, the feeding regime is optimized, lactogenic drugs and physiotherapeutic methods that enhance lactation are prescribed, and concomitant pathology is treated.
ICD 10
O92.4 Hypogalactia
Meaning
Taking into account the special importance of breastfeeding in the physical and mental development of children, the formation of their immunity, one of the most important tasks of modern medicine is to maintain normal lactation in a nursing woman. The results of various studies indicate that hypogalactia is observed in 26-80% of mothers. A decrease in milk secretion is more often observed in patients who have reached 35 years of age, the degree of violations increases as the age of the woman increases. Disorders of lactogenesis in primiparous women are 2.1-2.5 times more common than in repeated childbirth. The probability of hypogalactia is increased in single women, which is most likely due to significant physical and psycho-emotional stress associated with independent care of a newborn.
Causes
Reducing the amount of milk and shortening the lactation period is a polyethological disorder. Only in 2-5%, the disorder occurs immediately after childbirth and is due to anatomical reasons or a violation of neurohumoral regulation. Often, lactogenesis worsens some time after childbirth under the influence of external factors and diseases of the nursing mother. The main causes of hypogalactia are:
- Congenital pathology. The secretory function of the breast is impaired due to the insufficient development of its glandular parenchyma during sexual infantilism and hypogonadism. In a number of patients, genetic defects lead to malfunctions in the enzyme systems involved in ensuring lactogenesis, or are manifested by a reduced number of membrane receptors reacting to prolactin.
- Neuroendocrine disorders. Hypogalactia occurs in dishormonal conditions associated with impaired secretion of estrogens, progestogen, prolactin, LH, FSH. Similar disorders develop with ovarian lesions (oophoritis, adnexitis, tumors) and hypothalamic-pituitary region, diabetes mellitus, thyrotoxicosis, adrenal diseases.
- Age over 35 years. Breast involution, which usually begins at the age of 35-40 years, is accompanied by a gradual replacement of glandular tissue with fat cells. As a result, the breast’s ability to lactation decreases due to a decrease in the number of active lactocytes. In addition, such patients are more likely to have endocrine disorders.
- Somatic and infectious diseases. Significantly more often, a decrease in lactogenesis is detected in the presence of urogenital infections, iron deficiency anemia. The secretion of milk is suppressed with the development of acute infectious diseases in the nursing mother, which are accompanied by feverish conditions, transient hypovolemia and are a stressful load for the body.
- Pathological pregnancy and childbirth. The risk of hypogalactia increases during pregnancy, preeclampsia of various degrees of severity, premature birth, severe injuries, significant blood loss. Lactation also depends on the method of delivery. With cesarean section, the probability of inhibition of lactogenesis increases by an average of 3-3.2 times.
- Pathology of the mammary glands. Cracks and eczema of the nipple, mastalgia, postpartum mastitis limit the possibilities of feeding. In the presence of such diseases, a woman usually experiences pain that increases when sucking. The detection of pathological microorganisms in milk is an indication for the temporary cessation of feeding, which complicates the qualitative emptying of the breast.
- Violation of feeding rules. According to the observations of mammologists and neonatologists, hypogalactia is provoked by the rare application of the baby to the breast, characteristic of strict feeding regimes by the hour, unreasonable introduction of additional feeds and insufficient pumping after feeding. To maintain secretory function, it is recommended to apply to the breast on demand.
The child factor. Incomplete emptying of the breast, leading to a decrease in milk secretion, occurs with insufficiency of the sucking reflex, characteristic of premature infants, aerophagia (ingestion of air during feeding), some developmental abnormalities (defects of the upper lip, hard and soft palate).
Lactation disorders are often caused by significant physical and psycho-emotional stress, fatigue caused by a change in the usual way of life, lack of sleep, constant worries about caring for a newborn. Hypogalactia develops with a low-calorie diet, insufficient fluid intake and an unbalanced diet.
Pathogenesis
The specific mechanism of deterioration of lactogenesis is associated with the immediate causes that caused the pathological condition. With hypoplasia of parenchymal tissue, the number of active glandular cells is not enough to secrete the volumes of milk needed by the child. Failure of hormonal regulation is usually accompanied by low stimulation of parenchymal cells. In cases where hypogalactia develops due to insufficient emptying of the breast, the mechanisms of reverse regulation with a decrease in the production of prolactin, the main hormone regulating lactogenesis, become the basis for the deterioration of lactation. Similar processes are observed in various diseases, stress, insufficient water intake and low-calorie nutrition. In such cases, the suppression of lactation due to hypoprolactinemia often plays a protective role to preserve the basic vital functions of the mother.
Classification
The identification of various forms of hypogalactia is based on taking into account factors such as the causes and timing of the disorder, the degree of its severity. The classification of lactation disorders plays a key role in choosing the optimal therapeutic tactics to restore the normal secretory function of the mammary glands. Specialists in the field of mammology distinguish the following variants of hypogalactia:
By the time of occurrence:
- Early. The secretory function of the mammary glands is disrupted within 10 days after delivery.
- Late. Signs of lactation depression appear later than the 10th day after childbirth.
For reasons:
- Primary. It is caused by the functional failure of the glandular tissue of the mammary glands, neuroendocrine and other disorders that exist before pregnancy or occurred during gestation and childbirth. It is rarely observed.
- Secondary. It manifests itself after a period of normal lactation under the influence of factors that disrupted lactogenesis in the postpartum period — violations of feeding rules, inflammatory processes in the breast, acute infections, poisoning, etc.
According to the degree of severity:
- Easy. The deficiency of daily milk secretion does not exceed 25%.
- Moderate. The daily decrease in lactation is no more than 50%.
- Average. Milk secretion deficiency reaches 50-75% per day.
- Heavy. The excretion of breast milk is reduced by more than 75%.
In addition to true hypogalactia, manifested by a real decrease in the secretory function of the mammary glands, there is a false form of the disease in which a woman is convinced that the baby lacks the milk produced. However, in fact, the volume of secretion is sufficient, and the restless behavior of the baby is caused not by malnutrition, but by other reasons.
Symptoms
A woman with reduced milk secretion usually does not have a feeling of its rush, the breast gland seems soft to the touch almost all the time. If the baby constantly lacks nutrients, in the period between feedings he shows anxiety, cries, sleeps very little and continues to actively search for the breast. The feeding time usually increases, it is difficult to take the baby away from the breast, with such attempts he begins to cry. With pronounced hypogalactia, the baby may completely refuse to suck the “empty” breast. After feeding, milk from the breast is practically not expressed.
The suppression of lactation can be suspected not only by the changed behavior of the child, but also by violations of some parameters of his vital activity and development. Insufficient fluid intake leads to a decrease in urine formation and less frequent urination. The child urinates no more than 6-7 times a day. Concentrated urine is released, which has an intense color and a pungent odor. Defecation is rare, the consistency of the stool is dense. The rate of weight gain is uneven, the increase in the baby’s weight during weekly weighing does not exceed 125 g, the daily increase is less than 15-20 g.
Complications
When applied to the breast, secreting little milk, the child makes more active attempts at sucking, which, combined with an increased feeding time, leads to skin irritation in the nipple-areolar region. As a result, with hypogalactia, the skin is more easily macerated and cracks of the nipple appear. Against the background of such injuries, decreased immunity and the presence of foci of chronic infection in women with an allergic predisposition, the risk of eczema of the nipple increases. Insufficient consumption of mother’s milk, which is the main source of nutrients for the baby, leads to the development of hypotrophy of the newborn. Inadequate therapy of impaired lactogenesis provokes the development of agalactia.
Diagnostics
The objectives of the diagnostic search in hypogalactia is to verify the reduced secretion of milk and identify the causes that have disrupted lactation. For an objective assessment of the level of lactogenesis, a control weighing of the baby is carried out during the day before and after each feeding, after which the data obtained on the weight difference is summed up with the amount of expressed milk. The results are compared with calculated indicators of nutritional needs for children of different ages. To assess the ability of the mammary glands to secrete and detect possible disorders of neuroendocrine regulation, the patient is prescribed:
- Ultrasound of the breast. Sonographic examination makes it possible to assess the structure of the mammary gland, the development of the parenchyma, to identify possible focal and involutive changes. The detection of focal pathology of the mammary glands during ultrasound is the basis for the appointment of mammography and cytological examination of the material obtained by puncture biopsy.
- Hormonal studies. The greatest diagnostic value in hypogalactia is the determination of the concentration of prolactin, estradiol, progesterone, FSH, LH in the blood.
- Additional diagnostics. If lactation depression is suspected due to damage to cerebral structures, CT and MRI of the pituitary gland may be performed. However, in most cases, a thorough history collection and control measurements are sufficient to confirm the diagnosis.
Differential diagnosis of hypogalactia is carried out with lactostasis, lactation crisis due to a temporary decrease in milk secretion due to high motor activity or overwork and a hungry crisis caused by the rapid growth of the baby. If necessary, the patient is examined by an endocrinologist, gynecologist, surgeon, oncologist, infectious disease specialist.
Treatment
Medical tactics with reduced lactogenesis are aimed at eliminating the causes that disrupted the formation of milk, and increasing the secretory function of the breast. Complex therapy of hypogalactia involves the use of both pharmaceutical preparations and hardware methods, as well as special measures to establish breastfeeding. The lactation recovery scheme usually includes:
- Optimization of breastfeeding. It is recommended to regularly apply the baby to both breasts, observing an interval no longer than 1.5-2 hours, and even more often at the request of the child (in general — up to 10-12 times a day). At the same time, night feeding is provided, in response to which prolactin is best produced. After each application to the breast, the mammary glands must be pumped to further stimulate their secretion.
- Drug stimulation of lactogenesis. With insufficient prolactin levels, both its replacement with analogues (lactin, etc.) and stimulation of synthesis with deaminooxytocin and other drugs with oxytocin-like action are used. Vitamin E, which affects hormone secretion, and nicotinic acid, which improves blood supply to the breast, also have a lactostimulating effect.
- Physiotherapy techniques. In the absence of contraindications, compresses, acupuncture, hardware physiotherapy are used to improve lactation — ultrasound exposure, nicotinic acid electrophoresis, ultraviolet irradiation, darsonval, magnetic acupuncture, vibration massage, inductothermy, etc. The advantage of physical methods is their harmlessness and effectiveness.
When accurately determining the causes of hypogalactia, antibacterial and hormone therapy, immunocorrectors, antifungal drugs, eubiotics are used to treat the underlying disease and correct possible complications, and other surgical interventions are performed according to indications. Sufficient sleep and rest, correction of the diet in order to increase its caloric content play a greater role in normalizing lactogenesis.
Prognosis and prevention
Most forms of secondary hypogalactia with adequate etiopathogenetic therapy respond well to treatment. In accordance with WHO recommendations, the prevention of breastfeeding disorders involves the observation of a pregnant woman by an obstetrician-gynecologist for the timely treatment of concomitant diseases, prevention of complications of pregnancy and childbirth. After childbirth, early application of the baby to the breast is shown, ensuring round-the-clock joint stay of the mother and child, establishing a feeding regime on demand. An important role in supporting lactation is played by a rational diet and a nursing mother’s daily routine, a ban on breast imitators (pacifiers, nipples), and the reasoned appointment of supplementary feeding.
Literature
- Hale TW, Hartmann PE. Hale & Hartmann’s Text book of Human Lactation. 1st ed. Hale Publishing, L.P., Amarillo, TX, USA: 2007.
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