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    <meta name="author" content="Denise Fisher" />
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    <title>Breastmilk transfer</title>
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      <h1 id="top">5.2 Breastmilk transfer</h1>
      <div>
    <p> Obviously the goal of breastfeeding is to achieve milk transfer from mother to baby. </p>
    <p class="listTitle">Breastmilk transfer occurs by:</p>
    <ol>
      <li>positive pressure as the milk ejection reflex (MER) forces milk from storage in the alveoli towards the nipple, and</li>
      <li>negative pressure, created in the baby's mouth, drawing the milk from the breast into the oro-pharynx.<sup><a href="#note1">1</a></sup></li>
    </ol>
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      <div class="section" id="Understanding_the_anatomy"><h2>Understanding the anatomy</h2>
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        <div class="captionBox"><img width="380" height="380" src="images/breast_anatomy.gif" alt="" /><p> <br />&copy; Health e-Learning</p></div>
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          <p>
					Imagine the functional tissue of the breast as like a large bunch of grapes. The grapes are linked by thin stalks to thicker stalks and thicker stalks again as more sections of grapes join it, until there is one thick stalk.
				</p>
          <p>
					A grape represents an alveolus (<span class="aside">pl. alveoli</span>) which holds the breastmilk. The stalks are the ductules and lactiferous ducts through which the milk passes, and the whole bunch of grapes represents one lobe of functional breast tissue. Each breast contains about nine lobes.
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          <p> The lactocytes, <dfn>columnar epithelial cells</dfn> that make up the alveolus, synthesise the breastmilk which is then stored in the lumen. </p>
          <p> Each alveolus is surrounded by a basket-like weave of myoepithelial cells, <dfn>muscle cells</dfn>. Contraction of the myoepithelial cells constricts the alveoli, forcing the breastmilk into the ducts and towards the nipple where the baby can remove it. </p>
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        <div class="captionBox"><img width="380" height="253" src="images/alveolus.gif" alt="" /><p> <br />&copy; Health e-Learning</p></div>
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      <div class="section" id="Positive_pressure_transfer"><h2>Positive pressure transfer</h2>
    <div>
      <p> The hormone <strong>oxytocin</strong> causes the milk ejection reflex and the contraction of the myoepithelial cells. A surge of oxytocin is released from the posterior pituitary gland in response to stimulation of the nerves around the nipple. It travels via the blood stream to both breasts causing the myoepithelial cells surrounding the alveoli to contract. Sometimes this can be so forceful as to cause the milk to drip or even squirt from the nipple. </p>
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        <div class="captionBox"><img width="300" height="352" src="images/MER_graphic.gif" alt="" /><p> <br />&copy; Health e-Learning</p></div>
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        <div class="captionBox"><img width="225" height="347" src="images/MERactive_BI.gif" alt="Note the breastmilk squirting from the unused breast while the baby suckles on the other breast." /><p>Note the breastmilk squirting from the unused breast while the baby suckles on the other breast. <br />&copy; B.Ingle, IBCLC</p></div>
      </div></div><br style="clear: both" />
    <div>
      <p class="listTitle">When the MER has been stimulated mothers may describe the sensation as</p>
      <ul>
        <li>a sharp, momentary pain in the breast, or</li>
        <li>a fullness or tightness of the breasts, or</li>
        <li>a tingling sensation inside the breast, or</li>
        <li>there may be no sensation at all.</li>
      </ul>
      <p> It can be seen to be functioning when milk drips or squirts from the breast. If the baby is suckling at the time you'll notice a change in suck pattern to a suck / swallow / breathe / suck / swallow / breathe pattern with swallows about every second. This vigorous sucking from increased milk flow may last 1.5 - 2 minutes. You may hear the baby gulping the larger volume of milk too.</p>
      <p>As the effect of oxytocin wears off the alveoli and ductal system, milk which is not removed by the infant (or by expressing) moves back up the ductal system to the alveoli once more. </p>
      <p>
        <br />
      </p>
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      <div>
        <p>Milk transfer is dependent on milk ejection! No MER = Hungry baby </p>
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      <div>
        <p> Many mothers do not feel the milk ejection at all, and rarely is it felt in the first few days postpartum despite it functioning quite well. Prior to the milk 'coming in' the change in the baby's suckling is also not noticeable. </p>
        <p> In multiparous women involution pain is felt more acutely during milk ejection. <span style="font-style: italic;">(Why?)</span><br /></p>
      </div>
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  </div>
      <div class="section" id="Negative_pressure_transfer"><h2>Negative pressure transfer</h2>
    <div>
      <p> The mouth of the newborn is ideally suited to suckling at the breast. The tongue grasps the breast tissue and the lips create a seal around the areola. Negative pressure in baby's mouth draws the breast into position and maintains it there forming a teat of soft breast which completely fills the mouth. The small mandible fits closely against the breast, allowing the baby's nose to be free for breathing, while the buccal fat pads in their cheeks prevent the cheek from 'collapsing' in during suckling. </p>
      <p> Negative pressure is created in the sealed mouth when the back of the tongue drops in response to the increased milk flow at milk ejection. There is a coincident lowering of the soft palate. The intra oral vacuum is at its greatest when the tongue is fully lowered prior to swallowing. It is this negative pressure which draws the breastmilk from the nipple into the baby's mouth.</p>
    </div>
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              <h3>Workbook Activity 5.5</h3>
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      <div class="section" id="What_should_I_remember_"><h2>What should I remember?</h2>
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      <div>
        <ul>
          <li>The two mechanisms which are required for milk transfer during breastfeeding - describe each.</li>
          <li>The hormone which stimulates the milk ejection reflex.</li>
          <li>The mechanism and function of the milk ejection reflex.</li>
          <li>The changes which occur in the mother and the infant during MER.</li>
        </ul>
      </div>
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      <div class="section" id="Self-test_Quiz"><h2>Self-test Quiz</h2>
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      <div></div><div class="activity" id="activity_m">
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	new MCQ('Breastmilk is made by the lactocytes. Where is it stored?', [{text:'in the lumen of the alveoli',feedback:'Yes, that\'s correct.',score:1},{text:'in the lumen of the areola',feedback:'No, the areola is the darker colored area that surrounds the nipple',score:0},{text:'in the ducts near to the base of the nipple',feedback:'No. These ducts remain empty until the milk moves out of the storage area',score:0},{text:'breastmilk is made in the breast as the baby suckles, storage is not required',feedback:'No. Minimal amounts of milk are made while the baby is suckling.',score:0}]),
	new MCQ('What is the function of the myoepithelial cells?', [{text:'they produce breastmilk',feedback:'No. That\'s not their function.',score:0},{text:'when they contract they cause the nipple to become erect facilitating latching',feedback:'No. They\'re not found near the nipple.',score:0},{text:'when they contract the alveoli is constricted forcing the breastmilk out',feedback:'Yes. That\'s right.',score:1},{text:'provide innervation to the breast',feedback:'No. These are not nerve cells.',score:0}]),
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	new MCQ('Which of the following best describes the negative pressure transfer of breastmilk to the baby?', [{text:'stimulation of the nerves around the nipple causes oxytocin to be released into the blood stream, which causes the myoepithelial cells to contract moving the milk out of the alveoli.',feedback:'This is actually positive pressure, not negative pressure.',score:0},{text:'it is created in the sealed mouth when the back of the tongue drops prior to swallowing',feedback:'Yes, that\'s right.',score:1},{text:'it is created in the baby\'s mouth as the baby\'s cheeks are sucked in prior to swallowing',feedback:'No, the cheeks should never be seen to be \'sucked in\'.',score:0},{text:'stimulation of the tip of the tongue causes a rolling movement of the tongue which removes the milk from the breast',feedback:'No. This doesn\'t happen.',score:0}])
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    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
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      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#rams04a" title="See full details">#</a> Ramsay D et al. (2004-09-10) Ultrasound imaging of the sucking mechanics of the breastfeeding infant</li>
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      <h1>Breastfeeding Essentials</h1>
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        <li>1.0 <a href="topic_1-0.html">Why Breastfeeding is Important</a><ol><li>1.1 <a href="topic_1-1.html">Biochemistry</a></li><li>1.2 <a href="topic_1-2.html">Immunology</a></li><li>1.3 <a href="topic_1-3.html">Relative risks</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Communication Skills</a><ol><li>2.1 <a href="topic_2-1.html">Non-verbal</a></li><li>2.2 <a href="topic_2-2.html">Listening skills</a></li><li>2.3 <a href="topic_2-3.html">Building confidence</a></li><li>2.4 <a href="topic_2-4.html">An example</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Pregnancy Care</a><ol><li>3.1 <a href="topic_3-1.html">The feeding decision</a></li><li>3.2 <a href="topic_3-2.html">The barriers</a></li><li>3.3 <a href="topic_3-3.html">Physical preparation</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">The Birth Experience</a><ol><li>4.1 <a href="topic_4-1.html">The first hours</a></li><li>4.2 <a href="topic_4-2.html">Labor interventions</a></li><li>4.3 <a href="topic_4-3.html">Postnatal interventions</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Breastfeeding the Baby</a><ol><li>5.1 <a href="topic_5-1.html">Positioning Principles</a></li><li class="current">5.2 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_5-2.html">Breastmilk transfer</a></li><li>5.3 <a href="topic_5-3.html">Assessing breastfeeding</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">A time to learn</a><ol><li>6.1 <a href="topic_6-1.html">Practical skills</a></li><li>6.2 <a href="topic_6-2.html">Breastfeeding messages</a></li><li>6.3 <a href="topic_6-3.html">Normal growth</a></li><li>6.4 <a href="topic_6-4.html">Sleep</a></li><li>6.5 <a href="topic_6-5.html">Psychological support</a></li><li>6.6 <a href="topic_6-6.html">Discharge planning</a></li></ol></li>
        <li>7.0 <a href="topic_7-0.html">Infant Challenges</a><ol><li>7.1 <a href="topic_7-1.html">Late preterm infant; Non-latching</a></li><li>7.2 <a href="topic_7-2.html">Hypoglycemia; Jaundice</a></li><li>7.3 <a href="topic_7-3.html">Supplementation</a></li><li>7.4 <a href="topic_7-4.html">Crying baby</a></li><li>7.5 <a href="topic_7-5.html">Inadequate weight gain</a><ol><li>7.5.1 <a href="topic_7-5-1.html">Feeding-line device at the breast</a></li><li>7.5.2 <a href="topic_7-5-2.html">Cup feeding</a></li><li>7.5.3 <a href="topic_7-5-3.html">Finger Feeding</a></li><li>7.5.4 <a href="topic_7-5-4.html">Bottle feeding</a></li></ol></li></ol></li>
        <li>8.0 <a href="topic_8-0.html">Maternal Challenges</a><ol><li>8.1 <a href="topic_8-1.html">Engorgement</a></li><li>8.2 <a href="topic_8-2.html">Nipple Pain</a></li><li>8.3 <a href="topic_8-3.html">Breast Problems</a></li><li>8.4 <a href="topic_8-4.html">Insufficient breastmilk</a></li><li>8.5 <a href="topic_8-5.html">Medical, Surgical Issues</a></li></ol></li>
        <li>9.0 <a href="topic_9-0.html">Promotion, Protection and Support</a><ol><li>9.1 <a href="topic_9-1.html">The International Code of Marketing of Breastmilk Substitutes</a></li><li>9.2 <a href="topic_9-2.html">The Baby Friendly Initiative</a></li><li>9.3 <a href="topic_9-3.html">Young Child Feeding</a></li><li>9.4 <a href="topic_9-4.html">Local initiatives</a></li><li>9.5 <a href="topic_9-5.html">Infant feeding in emergencies</a></li></ol></li>
        <li>10.0 <a href="topic_10-0.html">Closing session</a><hr /></li>
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