Characterization of Three Cases of Primary Hypogalactia in Jalisco, Mexico

INTRODUCTION

Human lactation should be taken into account as an important issue for the international agenda. Despite advances in lactation information and knowledge, insufficient milk production is still a concern for mothers and health practitioners, including International Board Certified Lactation Consultants and others. Primary hypogalactia, or insufficient milk production is uncommon, but should be considered when there is poor weight gain and decreased urine output in infants despite good latch-on and suckling, or anatomic differences in the physical exam of the lactating breast.

MAIN ISSUE

This case series presents three cases illustrating insufficient milk production resulting in infants who experienced significant dehydration and poor weight gain.

MANAGEMENT

Primary hypoplasia was diagnosed by means of a thorough interview and physical examination that entailed a consultation with a physician who was also an International Board Certified Lactation Consultant.

CONCLUSION

Awareness of an infant's feeding needs and proper evaluation of a child's health status is paramount if health care providers are to identify the important factors contributing to breastfeeding problems. In some instances, breastfeeding goals cannot be achieved, and then the provider's role becomes support in coming to terms with persistent insufficient milk production, and coordinating appropriate supplementation to meet each baby's nutritional needs.

Psychological Distress and Milk Volume in Lactating Mothers

The purpose of this article is twofold: (a) to compare psychological distress as measured via self-reported perceived stress, sleep, and fatigue levels in lactating mothers of a term infant and mothers of a preterm infant and(b) to determine whether the addition of psychological distress to a previous model predicts milk volume at Postpartum Week 6 by gestation group. The convenience sample of 95 mothers of a preterm infant (31 weeks) and 98 mothers of a term infant completed the Perceived Stress Visual Analogue Scale, Richards-Campbell Sleep Questionnaire, and the Fatigue Visual Analog Scale. Stress, sleep difficulty, and fatigue levels decreased during the 6-week study period for mothers of a term but not for mothers of a preterm infant. Perceived stress, sleep difficulty, and fatigue during the first 6 weeks postpartum were not related to milk volume; thus, the mother’s perceived psychological distress had no apparent effect on lactation.

ABM Clinical Protocol #20: Engorgement, Revised 2016

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Sheehan's syndrome in Xinjiang: Clinical characteristics and laboratory evaluation of 97 patients

OBJECTIVE

To evaluate the clinical and hormonal characteristics of patients with Sheehan's syndrome in Xinjiang, China.

METHODS

97 cases diagnosed as Sheehan's syndrome in our hospital from 1999 to 2013 were retrospectively reviewed. The medical history, physical examination findings and hormonal profiles were documented and analyzed.

RESULTS

The mean age at diagnosis was 43.7±12.4 years, with a mean diagnostic delay of 9.1±9.5 years (range, 1 month-35 years). 10 of our patients (10.3%) had a home birth. 96 of our patients (99.0%) had a history of obstetric hemorrhage. The most common clinical presentation included amenorrhea (80/97, 82.5%), agalactia (2/97, 74.2%) and loss of axillary or pubic hair (83/97, 85.6%). Seventy two of our patients (74.2%) failed to lactate and 80 of our patients (82.5%) failed to resume menstruation. Hypothalamic dysfunction included the hypothalamic-pituitary-gonadal axis (HPG) (LH deficiency: 77/83 patients, 92.8%; FSH deficiency: 73/83 patients, 88%; E2 deficiency: 62 of 82 patients,75.6%), the hypothalamic-pituitary-thyroid (HPT) axis (TSH deficiency: 77/93 patients, 82.8%, TT3 deficiency: 70/ 87 patients, 80.5%, TT4 deficiency: 72/87 patients, 82.8%) and the hypothalamus-pituitary-adrenal (HPA) axis (ACTH deficiency: 19/37 patients, 51.4%, cortisol deficiency: 49/64, 76.6%).

CONCLUSIONS

Sheehan's syndrome is still common in Xinjiang, especially in rural areas. Long diagnosis delay in most of the patients indicates that women might be lacking correct diagnosis and treatment. Physicians need to be aware of the most important clues for diagnosis such as lack of lactation in the postpartum period and failure to resume menstruation.

Breastfeeding is natural but not always easy: intervention for common medical problems of breastfeeding mothers - a review of the scientific evidence

Natural processes do not always function perfectly. In breastfeeding, problems are encountered in up to 80% of mother-infant dyads. Altogether, in Western societies, the difficulties reduce the breastfeeding rate within the first months drastically. To deal with the problems of breastfeeding efficiently requires a profound understanding of its physiology, as well as of its psychological and social determinants. This review focuses on the current knowledge of breastfeeding physiology, only touching the psychosocial factors, which are included in the promotion strategies. Subsequently, it scrutinizes definitions, incidences, prevention, and treatment of breastfeeding problems faced most frequently by nursing mothers and their consultants. Not all measures used in counseling mothers and not all treatments for the most common medical problems withstand a careful evaluation on the basis of current scientific data. However, applying proven prevention strategies will significantly improve the well being of mothers and their infants, and may contribute to an affective attitude that increases the success, frequency, and duration of breastfeeding.

Delayed diagnosis of Sheehan's syndrome in a developed country: a retrospective cohort study

BACKGROUND

Little is known about Sheehan's syndrome (SS), even though it is believed that its incidence is low. The aims of this study were to determine the clinical features and diagnostic delay of SS and to ascertain whether early signs could have allowed earlier diagnosis.

SUBJECTS AND METHODS

All patients with SS diagnosed in reference units in the southeast of France between 1980 and 2011 were recruited for this study. Data on obstetrical history, clinical symptoms suggestive of hypopituitarism, early signs, hormone analysis, and magnetic resonance imaging were collected.

RESULTS

Of the 40 women found to have SS, 39 were studied. Mean delay in the diagnosis of SS was 9 ± 9.7 years. We found that four of the 35 assessable patients were diagnosed with agalactia, 16 of the 29 assessable ones with amenorrhea, 19 of the 39 with hypothyroidism, eight with acute adrenal insufficiency, and 15 with asthenia. Among the patients for whom there was a diagnostic delay of more than 1 year (n=28), seven had headaches during the postpartum period, all assessable patients had agalactia, six of the 22 assessable ones had amenorrhea, seven of 28 had hypothyroidism, and 12 of 28 had asthenia.

CONCLUSION

Most signs of SS are aspecific and classical signs such as agalactia and amenorrhea are often difficult to detect, which can explain the long diagnostic delay. We suggest that all women failing to lactate after postpartum hemorrhage (PPH) should be evaluated by measuring prolactin levels and women with signs such as amenorrhea and asthenia, even several years after PPH, should undergo a blood test including assessment of thyroxine, TSH, 0800  h ACTH-cortisol, and IGF1 levels.

Cabbage leaves vs hot and cold compresses in the treatment of breast engorgement

This study was conducted to evaluate the effect of cold cabbage leaves and alternate hot and cold compresses in decreasing breast engorgement and pain in post-natal mothers admitted in AIIMS, New Delhi.

A case of prolactin deficiency with familial puerperal alactogenesis accompanying impaired ACTH secretion

We report here the case of a 34-year-old female with puerperal alactogenesis. Her menstrual cycle was regular and breast development normal. She had delivered a healthy boy but could not breast-feed after parturition. Endocrinological studies disclosed that the cause was a prolactin (PRL) deficiency. In addition, she showed accompanying impaired ACTH secretion that was believed to be triggered by encephalitis, although her plasma levels of GH, TSH, LH and FSH remained intact. Pituitary MRI showed no specific findings and anti-pituitary antibody tests were negative. Interestingly, both her mother and grandmother also reported puerperal alactogenesis. The sequences of all five exons of the PRL gene, including promoter region and transcription initiation point, were surveyed in order to examine for certain genetic disorders, but no mutations were identified. Although it cannot be definitively concluded that this PRL deficiency was not a genomic DNA disorder, in our case at least, her PRL gene was normal and, therefore, was not directly responsible for the patient's impaired PRL secretion. This evidence suggests that familial puerperal alactogenesis and PRL deficiency can be induced by other causes such as via disorders of unknown transcription factors or molecules that contribute to translation of PRL gene.

Severe hypernatremic dehydration secondary to undetected lactation failure: usefulness of sodium levels in breast milk

There is a concern that lactation failure and neonatal morbidity might be more common than previously thought. Maybe the early discharge, the lack of timely follow-up, or poor information during pregnancy or after delivery play important roles. A case of severe hypernatremic dehydration secondary to lactation failure is reported and we analyze recent recommendations.

Teat endoscopy (theloscopy) for diagnosis and therapy of milk flow disorders in dairy cows

Teat endoscopy (theloscopy) is a useful technique for diagnosis and therapy of covered teat injuries. Minimal invasive theloscopic surgery may help to restore milk flow, milk yield, and SCC of the affected quarter. Infection with pathogens may not change significantly, however. Cows treated as described may yield as much milk as their herdmates at a slightly increased udder SCC and stay as long in the herd as their herdmates. Theloscopy also may be used for diagnosis and therapy of various other teat disorders.

A controlled trial of a new treatment for galactocele

BACKGROUND

Needle aspiration, followed by excision should it recur, is the standard method of treating galactocele. Villagers in Northeast Thailand traditionally treat galactocele by probing the obstructed duct with double strands of pleated human hair. The aim of the study was to mimic this method in order to scientifically assess its effectiveness.

PATIENTS AND METHOD

Sixteen patients were consecutively enrolled between 1995 and 2001. They elected either standard needle aspiration (Group A) or treatment by 6-0 nylon probing (Group B). The results were compared using the Fisher's exact and Mann-Whitney tests at p-value < 0.05.

RESULTS

The two groups were similar regarding the children's age, first para, mass size, and duration of symptoms, but patients in the aspiration group were considerably younger than the nylon probing group. Both methods reduced the symptoms completely. Pain from treatment was reported by all patients in the aspiration method while there were none in the nylon probing method (p < 0.001). The aspiration method took 14.8 minutes less time than the nylon probing method (p < 0.001). Recurrence was found in 2 out of 5 patients in the aspiration method, whereas there was none in the 11 patients with the nylon probing method (difference = 40%; 95% CI: -3% to 83%; p = 0.083).

CONCLUSIONS

The new treatment of galactocele by nylon probing took longer than aspiration but removed the protein plug that caused obstruction of the duct without pain and had a tendency to reduce the recurrence rate.

An unusual cause of breast enlargement in a 5-year-old boy

A 5-year-old male developed painless enlargement of the left breast and was found to have a soft, mobile, and nontender swelling that was excised. Histological examination revealed a galactocele, which is a very rare cause of breast enlargement in male infants and children.

How to assess slow growth in the breastfed infant. Birth to 3 months

Pediatricians must monitor early breastfeeding to detect and manage breastfeeding difficulties that lead to slow weight gain and subsequent low milk production. Infant growth during the first 3 months of life provides a clear indication of breastfeeding progress. Healthy, breastfed infants lose less than 10% of birth weight and return to birth weight by age 2 weeks. They then gain weight steadily, at a minimum of 20 g per day, from age 2 weeks to 3 months. Any deviation from this pattern is cause for concern and for a thorough evaluation of the breastfeeding process. Evaluation includes history taking and physical examination for the mother and infant. Observation of a breastfeeding session by a skilled clinician is crucial. A differential diagnosis is generated, followed by a problem-oriented management plan. Special techniques may be used to assist in complicated situations. Ongoing monitoring is required until weight gain has normalized. In most cases, early intervention can restore promptly infant growth and maternal milk supply. Underlying illness of the infant or mother must be considered if weight gain and milk supply do not respond to the earlier-mentioned interventions as expected. Physicians are responsible for knowledge about additional resources and for coordination of breastfeeding care. Pediatricians have a pivotal role in achieving the goals of optimal breastfeeding and appropriate infant growth.

Prevention of breastfeeding tragedies

Although successful breastfeeding confers compelling advantages to infants and mothers, inadequate breastfeeding can result in critical infant failure-to-thrive and hypernatremic dehydration. Potential catastrophic infant outcomes can occur when enthusiastic promotion of breastfeeding outpaces necessary support services and management. Such cases often involve underlying maternal and infant breastfeeding risk factors, made deadly by parental and professional misconceptions and knowledge deficits or health care system failures. An early follow-up visit a few days after discharge allows at-risk infants to be identified before they lose excessive weight and at a time when intervention can easily correct most breastfeeding problems before they become complicated by insufficient milk. Those who enthusiastically promote breastfeeding for its many health benefits must confront the reality of breastfeeding failure and implement necessary changes in medical education and support services to foster successful outcomes in breastfed infants.

Prenatal, intrapartum, and postpartum support of the lactating mother

Physicians must continue to improve their knowledge regarding lactation. Improved education will allow for alterations in standard practices that may deter breastfeeding. Presently known influences on successful breastfeeding should direct changes in clinic and hospital practices. Continued research into various aspects of care in and out of the hospital must be pursued to improve maternal-infant care and breastfeeding.

A lactation management rotation for family medicine residents

Lack of knowledge about the practical aspects of breastfeeding management is one of the major barriers to physician support of the breastfeeding dyad. Few physicians receive any training in lactation management during medical school. Because family physicians see both mothers and babies and often attend deliveries, they are in a unique position to care for breastfeeding mothers. This article describes a lactation management rotation for family medicine residents to prepare them to manage breastfeeding problems.

Assessing infant suck dysfunction: case management

Based on this more thorough assessment, the lactation consultant may be able to identify all of the factors contributing to this complex case. In some situations, her skilled interventions will suffice once the underlying problem is addressed. Occasionally, she will identify a factor that falls outside of her area of expertise; when this happens, she must make the appropriate referrals. For example, a referral to a physician for a frenotomy or suspected neurological or other medical problem is appropriate. It is clear that because Baby E's problems were not resolved after 6 weeks of concerned effort, something was missed. It would certainly be appropriate for the lactation consultant to refer the dyad to another lactation consultant who has more expertise in handling clinically challenging breastfeeding problems. If possible, the referring lactation consultant should accompany the dyad so that she can improve her clinical skills. Assuming Baby E does not have underlying medical problems, the most likely causes of Baby E's difficulties are anatomical variation and/or sucking dysfunction. Because the baby is so fussy, it also would be wise to consider the possibility of allergies or food tolerance. Our first rule is " Feed the baby." The second rule is " Correct or work on correcting the problem or problems." Our goal is to achieve exclusive breastfeeding or as close an approximation as possible. We almost never give up on this goal, but we do educate the mother and work professionally with her choices. Until the baby is breastfeeding well, the lactation consultant will probably need to instruct the mother to continue using a pump ( preferably a hospital-grade, electric, bilateral pump). The mother should use the pump physiologically, pumping as many times a day as the baby would breastfeed. As soon as the situation improves, the mother should be instructed to wean gradually from the pump and any other breastfeeding equipment she is using. The goal should always be to help the mother and baby acheive a breastfeeding relationship, preferably without the use of any devices. We usually suggest that the mother avoid all rubber nipples and pacifiers during this learning period. Babies have a strong need to suck. Correct sucking helps the baby organize and be soothed. Whenever possible, we prefer infants to use their mother's breasts for pacification, warmth, love, smell, and food rather than artificial nipples and devices. Mothers almost always want to know how much work and time is involved before committing to following suggested treatment plans. As a general rule, we have found that it will take approximately the same number of weeks as the baby's age to solve the problems completely. In this case, it will probably take about 6 weeks until mother and baby graduate from "breastfeeding school." The first 2 weeks would most likely be very intense for the whole family, with the mother getting very little sleep. VJ is likely to cry when talking to the lactation consultant during this period of intense change. It is helpful during these times to listen to the mother, reinforce that you know how hard she is working and that what she is feeling is normal. Giving the mother a hug and complimenting her mothering efforts go a long way toward encouraging her to continue. It is not a time to give up. The second 2 weeks typically are easier, as everybody is used to the workload and required skills. The focus becomes refining skills. The last 2 weeks is usually a time to reduce and then wean off the equipment and exercises. This timing is just a guideline and must always be individualized. Although it is a tremendous amount of work for the mother, baby, family, and lactation consultant to correct well-established but incorrect breastfeeding behaviors, we have never met a mother who was sorry that she chose to tackle the problem. Even if she tries and then gives up or achieves only a partial milk supply or partial breastfeeding relationship, she can take pleasure in knowing that she left no stone unturned. Unfortunately, mothers and babies with presentations similar to that of VJ and Baby E all too often fail to establish an exclusive breastfeeding relationship. Not only are patience, dedication, time, and skills needed, but there are often multiple underlying problems that need to be solved. With a thorough assessment and appropriate use of skills and equipment by the lactation consultant, success is much more likely. This particular dyad should be able to acheive an exclusive breastfeeding relationship.

[Seven years of experience at a specialized breast feeding clinic. Incorrect breast feeding technique and milk stasis are the most common problems]

Breastfeeding is internationally important, providing benefits both immunologically and emotionally. A specialized breastfeeding-unit at the hospital Södersjukhuset in Stockholm has evolved continually since its inception in 1993. Attendance figures for 1994-1998 are shown, and the treatments for the most frequent diagnoses are described. The most common complications in breastfeeding seen at this unit are 1) problems in breastfeeding technique, e.g. nipple wounds cause breastfeeding difficulties; 2) breast engorgement, both with and without bacterial infection; and 3) pain of unknown etiology and infections without mastitis, including Candida and bacterial infections. The most important strategy for treatment is to observe the moment of breastfeeding and give individual advice (the procedure is described).

New bilateral microcalcifications at mammography in a postlactational woman: case report

A 33-year-old woman with a strong family history of breast cancer who was referred for mammography 5 weeks after completing lactation was found to have new diffuse bilateral microcalcifications in the breast ducts. Contrast material-enhanced magnetic resonance imaging of the breast showed bilateral patchy areas of abnormal enhancement. Large-core needle biopsy showed diffuse calcifications within expanded benign ducts in a background of lactational change, without evidence of malignancy. To the authors' knowledge, these calcifications have not been previously reported and are possibly related to milk stasis or apoptosis associated with lactation.

Slow weight gain and low milk supply in the breastfeeding dyad

There are a large number of women who perceive a reduction in milk supply. With appropriate, knowledgeable advice, most are able to continue breastfeeding successfully. If an infant is not gaining weight normally, the mother's milk production must be assumed to be low (usually a secondary phenomenon); meanwhile, consider the possibility of an organic problem in mother or infant. The complex interactional nature of the problem requires attention to history, physical examination, differential diagnosis, and thoughtful problem solving. There are situations that require infant supplementation for optimal growth; when this is the case, supplementation should be provided in a way that best supports continued breastfeeding to the fullest extent possible. Anticipatory guidance, early detection of problems, and prompt intervention are the keys to ensuring copious milk production and normal infant growth.

[Failure of milk ejection reflex in primiparous cows from the differential diagnostic and therapeutic aspects]

A particular failure of the milk-ejection reflex in dairy cows is described on the base of own experiences in farms and reports from literature. Four cases are reported more in detail. Quantity and fat content of cisternal, alveolar and residual milk fractions, oxytocin content in blood serum, milk-ejection after manual teat stimulation, after massage of the clitoris or rectal stimulation of the vagina and cervix were investigated. This failure of the milk-ejection is observed mostly in primiparous cows and always at the begin of the lactation period. It is complete and permanent unless successfully treated, and seems to be based on an central inhibition of the oxytocin release. Treatment consists of thorough udder stimulation and milking followed by an i.v. application of oxytocin in order to remove the residual milk portion. The condition has a good prognosis, if the treatment is carried out regularly for some days and even weeks. Acute Mastitis is the main differential diagnosis.

Contagious agalactia of small ruminants: current knowledge concerning epidemiology, diagnosis and control

Contagious agalactia of small ruminants is a syndrome which principally affects the mammary glands, joints and eyes. The main causal agents are Mycoplasma agalactiae in sheep, and M. agalactiae, M. mycoides subsp. mycoides large colony type and M. capricolum subsp. capricolum in goats. In addition, M. putrefaciens can produce a similar clinical picture, particularly in goats. Contagious agalactia occurs on all five continents and is often enzootic. The evolution of the infection tends to be chronic in affected animals and herds. Symptomless shedding of mycoplasmas, mainly in the milk, may persist for a long time. These insidious infections, associated with carriage in the ears of healthy animals, are difficult to diagnose and to control. The main mode of transmission between flocks is related to the sale of carrier animals and contact during transhumance, whereas transmission within a flock occurs through contact, suckling and milking. This review discusses the clinical features, epidemiology, treatment, prevention and control of the disease.

Determinants and utility of the anion gap in predicting hyperlactatemia in cattle

The objectives of this study were to investigate the determinants of the anion gap (AG) in cattle and to evaluate the utility of AG in detecting hyperlactatemia in sick neonatal calves and adult cattle. The AG was calculated as AG = ([Na+] + [K+])-([Cl-] + [HCO-3]), with all values in mEq/L. The AG of healthy neonatal calves (n = 16) was 29.6 +/- 6.2 mEq/L (mean +/- SD), and the blood L-lactate concentration ranged from 0.5 to 1.2 mM/L. The AG was significantly (P < .05) correlated with serum phosphate (r = .66) and creatinine (r = .51) concentrations. The AG of neonatal calves with experimentally induced diarrhea (n = 16) was 28.6 +/- 5.6 mEq/L, and the blood L-lactate concentration ranged from 1.1 to 2.9 mM/L. The AG was significantly correlated with blood L-lactate concentration (r = .67), serum phosphate concentration (r = .63), creatinine concentration (r = .76), and blood pH (r = -.61). The AG of adult cattle with abomasal volvulus (n = 41) was 20.5 +/- 7.8 mEq/L, and the blood L-lactate concentration ranged from 0.6 to 15.6 mM/L. The AG was significantly correlated with blood L-lactate concentration (r = .60), serum phosphate concentration (r = .71), creatinine concentration (r = .65), albumin concentration (r = .47), total protein concentration (r = .54), blood pyruvate concentration (r = .67), and blood pH (r = -.41) but not plasma beta-OH butyrate concentration. The results indicate that the AG in cattle is only moderately correlated with blood L-lactate concentration and is similarly correlated with serum phosphate and creatinine concentrations in neonatal calves and adult cattle, as well as with serum albumin and total protein concentrations in adult cattle. Anion gap determination is of limited usefulness in predicting blood L-lactate concentration in sick cattle, whereas the correlation between AG and serum creatinine concentration in sick cattle suggests that an increased AG should alert the clinician to the potential presence of uremic anions.

[Contagious agalactia of small ruminants: epidemiology, diagnosis and control]

Contagious agalactia of small ruminants is a syndrome which affects mainly the mammary glands, joints and eyes. The principal causal agents are Mycoplasma agalactiae in sheep and M. agalactiae, M. mycoides subsp. mycoides large colony type and M. capricolum subsp. capricolum in goats. In addition, M. putrefaciens can produce a similar clinical picture, particularly in goats. Contagious agalactia occurs on all five continents and is often enzootic. These infections are chronic in animals and in flocks. Symptomless shedding of mycoplasmas, mainly in the milk, may persist for a long time. Associated with carriage in the ears of healthy animals, these insidious infections are difficult to diagnose and control. The sale of carrier animals and contact during transhumance are the main modes of transmission between flocks, while transmission within a flock occurs through contact, suckling and milking. This review discusses clinical features, epidemiology, treatment, prevention and control.

Too much of a good thing. Maternal and infant hyperlactation syndromes

Milk stasis, blocked ducts, inflammatory or infectious mastitis, and breast abscess represent the spectrum of maternal hyperlactation syndrome. Management includes decreasing the rate of milk synthesis, improving milk removal out of the breast, and antibiotic therapy for ascending lactiferous duct infections and mastitis. Thriving infants who choke and splutter at the breast, feed frequently, are colicky, and have explosive, watery bowel movements have infant hyperlactation syndrome and are managed by decreasing quantity and increasing quality of breast milk drunk.

The clinical usefulness of breast milk sodium in the assessment of lactogenesis

OBJECTIVE

A study was undertaken to assess the value of breast milk sodium concentration (BM [Na+]) during early lactogenesis in predicting nursing outcome.

METHODS

Samples of breast milk from 130 nursing mothers were obtained between the 3rd and 8th postpartum day for analysis of BM [Na+]. Approximately half the mothers were referred for nursing problems, although no problems were anticipated in the other primiparous mothers. A BM [Na+] of < or = 16 mmol/L was considered normal. For women with normal BM [Na+], follow-up was scheduled at 1 month, whereas those with high [Na+] were evaluated more frequently with repeated [Na+] determinations.

RESULTS

Of the 65 women with normal BM [Na+] (excluding five mothers who had experienced breast surgery), 95.4% were exclusively and successfully breast-feeding at 1 month without intervention. Of 60 women with high BM [Na+], all of whom received intervention, 55% were ultimately successful. In general, those who failed tended to have higher initial [Na+] determinations; additionally, the longer the [Na+] remained elevated, the lower the success rate. Infant weight gain was greater if the initial BM [Na+] was normal. Infants of mothers with normal BM [Na+] gained an average of 994 g above birth weight by 1 month in contrast to the average weight gain of 818 g in infants of mothers with initially elevated [Na+].

CONCLUSION

This study suggests that a normal drop in [Na+] is highly predictive of successful lactation, although a prolonged elevation of [Na+] signifies impaired lactogenesis with a high risk of failure. The clinical usefulness and limitations of this determination are discussed.

[A physiological validation for the early diagnosis of hypogalactia in women]

Colostrum cell composition observed during the first 24 hrs following delivery objectively reflects the degree of prelactation preparation of the breast. The state of neutrophilic leucocytes appeared to be the most informative in this respect. In normal lactation, maximal number of neutrophilic leucocytes was found during the first 24 hrs after delivery. The leucocyte inflow to the colostrum is highly increased in hypogalactia. Leucocytes aggregation which is the most characteristic for normal lactation did not occur in hypogalactia. The activity of alkaline phosphatase and myeloperoxidase of leucocytes is much higher in normal lactation and much lower in hypogalactia. The evaluation of alkaline phosphatase activity and sudanophilic lipids content shows no differences related to the lactation level.

The influence of breast surgery, breast appearance, and pregnancy-induced breast changes on lactation sufficiency as measured by infant weight gain

We conducted a prospective study of the associations between several biologic and surgical breast factors and the onset of lactation in 319 healthy, motivated, primiparous women who were breastfeeding term, healthy, appropriate for gestational age or large for gestational age infants. During the last trimester of pregnancy subjects' breasts were examined for surgical incisions, size, symmetry, and nipple protuberance, and women estimated their prenatal breast enlargement. At two visits in the first two weeks postpartum, infants were weighted naked, and mothers reported the magnitude of postpartum breast engorgement when their milk came in. Breastfeeding was evaluated at each visit, and interventions were recommended for problems, with emphasis on maximizing milk yield. Lactation was deemed sufficient when an exclusively breastfed infant achieved an average weight gain of 28.5 g or more per day between the two visits. Infants gaining less than 28.5 g per day with breast milk exclusively, and those requiring formula supplement returned for a third visit at or before 21 days of age, when final lactation outcome was assessed based on weight gain between the second and third visits. Within three weeks postpartum 85 percent of the mothers achieved sufficient lactation, whereas 15 percent had persistent milk insufficiency despite intensive intervention. Of the study population, 6.9 percent had undergone previous breast surgery. Women with periareolar breast incisions were nearly 5 times more likely to have lactation insufficiency than were those without surgery (relative risk [RR] = 4.55; 95 percent confidence interval [CI] = 2.21-9.43; P less than 0.001). Insufficient lactation was significantly associated with minimal prenatal breast enlargement (P less than 0.02) and minimal postpartum breast engorgement when milk came in (P less than 0.001). Although not statistically significant, women with inverted nipples were more likely to have lactation insufficiency compared with those with normal nipples (RR = 2.94; 95% CI 1.05-8.20; P = .07). The findings from this study indicate that certain biologic and surgical breast variables are associated with lactation insufficiency.

[The metoclopramide test in the differential diagnosis of various forms of galactorrhea-amenorrhea syndrome]

The results of the metoclopramide test in 24 patients with the lactorrhea-amenorrhea syndrome were presented. It was shown that the metoclopramide test could be used for differential diagnosis of various types of disease. The blood prolactin concentration was raised only in the patients with the functional type of the lactorrhea-amenorrhea syndrome and changed insignificantly in the patients with pituitary microadenoma as well as in the patients with a noticeable increase in the prolactin basal level but without x-ray signs of a pituitary tumor. The presence of pituitary microadenoma could be suspected in the patients of the 3rd group.

Bromocriptine therapy in normoprolactinemic women with unexplained infertility and galactorrhea

Forty-three women with unexplained infertility and 16 women who ovulated with clomiphene citrate therapy, yet failed to conceive, were evaluated because of the presence of expressible galactorrhea and normal random prolactin levels. The overall mean duration of infertility for these women was 5.68 +/- 0.33 years (mean +/- standard error) and their mean age was 30.20 +/- 0.46 years. Fifty-two of these women had primary infertility. Three treatment protocols were evaluated. Twenty-five women with unexplained infertility (Group A) received low-dose bromocriptine (1.25 to 2.5 mg) at bedtime for the first 18 days of the cycle; 18 women with unexplained infertility (group B) received 100 mg of pyridoxine continuously; and 16 women receiving clomiphene citrate (group C) also received bromocriptine in a manner similar to that for group A. All subjects were followed for six treatment cycles or until pregnancy occurred. The estimated cumulative pregnancy rate after six treatment cycles was 65% for groups A and C, which is significantly higher than the 22% rate for group B (Lee-Desu statistic = 4.66, P = 0.03). Women treated with bromocriptine were 2.3 times more likely to conceive than women treated with pyridoxine. Furthermore, those infertile galactorrheic women whose random prolactin level was greater than or equal to 15 ng/ml were most likely to conceive. Expressible galactorrhea in women with unexplained infertility and high normal prolactin concentrations may serve as a clinical sign indicating those women who may benefit from low-dose bromocriptine treatment administered at bedtime.