Lactation and Breastfeeding

1. Lactation and Breastfeeding Obstetrics and Gynecology

2. Breastfeeding Infant Health Benefits • COLOSTRUM • Small amount for the immature digestive system • ‘paints’ the digestive tract • Low fat for easy digestion • Contains mothers antibodies which boost infants’ immune system • Acts as a laxative to ease passage of meconium

3. Breastfeeding Infant Health Benefits • The milk comes in • Transitional milk for up to 2 weeks • May still have yellow appearance • Amounts increase quickly as infant hungers and digestive system matures • Mother's" milk making” changes from endocrine to autocrine system • Mature milk • Supply/demand system engorgement decreases • Properties of fore milk and hind milk present

4. Breastfeeding Infant Health Benefits • Lower risk of • Diarrhea • Constipation • Infections • Ear, respiratory, meningitis, urinary tract • SIDS • Allergic diseases • Chronic digestive diseases • Juvenile onset diabetes • Acute leukemia • Adult obesity

5. Breastfeeding Infant Health Benefits • Provides immunologic protection while the infant’s immune system is maturing • Antimicrobial agents • Anti-inflammatory agents • Immunomodulating agents

6. Breastfeeding Infant Health Benefits • Preterm Infants • Decreased necrotizing enterocolitis • Decreased ROP • Decreased infection rates • Better able to tolerate feedings • Increased IQ rates • Contains long chain polyunsaturated fatty acids that help the infant’s brain develop – these are normally provided by the mother in late pregnancy, therefore preterm infants miss this

7. Breastfeeding Mother Health Benefits • Less postpartum bleeding • More rapid uterine involution • Weight loss • Decreased premenopausal breast cancer rates • Decreased ovarian cancer rates • Lactational amenorrhea • Should still use progesterone only contraceptives • Combined contraceptives dry up milk

8. Colostrum is a milky fluid that comes from the breasts of humans, cows, and other mammals the first few days after giving birth, before true milk appears. It contains proteins, carbohydrates, fats, vitamins, minerals, and proteins (antibodies) that fight disease-causing agents such as bacteria and viruses. Antibody levels in colostrums can be 100 times higher than levels in regular cow’s milk.

9. Colostrum is a milky fluid that comes from the breasts of humans, cows, and other mammals the first few days after giving birth, before true milk appears. It contains proteins, carbohydrates, fats, vitamins, minerals, and proteins (antibodies) that fight disease-causing agents such as bacteria and viruses. Antibody levels in colostrums can be 100 times higher than levels in regular cow’s milk.

10. People originally got interested in bovine colostrum because of the high antibody levels. They thought that the antibodies might prevent intestinal infections in people, but they seem to be wrong.

11. Some athletes use bovine colostrum to burn fat, build lean muscle, increase stamina and vitality, and improve athletic performance. Bovine colostrum is not on the banned drug list of the International Olympic Committee.

12. Bovine colostrum is also used for boosting the immune system, healing injuries, repairing nervous system damage, improving mood and sense of well being, slowing and reversing aging, and as an agent for killing bacteria and fungus.

13. Bovine colostrum is used in the rectum to treat inflammation of the colon (colitis).

14. Researchers have created a special type of bovine colostrum called “hyperimune bovine colostrum.” This special colostrum is produced by cows that have received vaccinations against specific disease-causing organisms. The vaccinations cause the cows to develop antibodies to fight those specific organisms. The antibodies pass into the colostrum. Hyperimmune bovine colostrum has been used in clinical trials for treating AIDS-related diarrhea, diarrhea associated with graft versus host disease following bone marrow transplant, and rotavirus diarrhea in children.

15. How does it work? • Colostrum is collected from cows that have been vaccinated to produce antibodies that fight the bacteria that cause diarrheal disease. These antibodies appear in the colostrum that is collected as medicine. Though the hope is that these cow antibodies will help fight human disease, the cow antibodies do not seem to be very active in humans.

16. The undeveloped intestinal tract of a newborn allows the growth factors present in colostrum to pass freely through the intestinal wall for absorption. However, fully-developed adult mammal intestines will break down the beneficial compounds before they can be absorbed into the blood stream. Though digestive enzymes prevent colostrum growth factors from affecting muscles, they will still exert a local effect, which increase intestinal integrity. This prevents inflammation, like the kind that can be caused by prolonged, intense exercise, like competitive cycling. Outside of intense exercise, supplementing colostrum will have an effect similar to supplementing whey protein or casein protein.

17. Dosing • Bovine colostrum is a difficult preparation to standardize because its antibody content may vary widely. Some clinical studies have been performed with hyperimmune colostrum, which may have a specific antibody titer; however, most products do not meet this criterion. Studies administering 25 to 125 mL of liquid formulations or 10 to 20 g of dry powder have been reported.

18. Bovine colostrum side effects, safety, long term useNo significant bovine colostrum side effects have yet been reported in the medical literature. Since it is rich in calories, one would guess that drinking excess amounts could add on some pounds. But most people are not likely to drink more than an ounce or two a day.

19. Breastfeeding Parent Benefits • Saves money • Saves time • Babies love it

20. Lactation Anatomy and Physiology • Breast enlargement • During pregnancy and lactation indicates the mammary glands are becoming functional • Breast size before pregnancy does not determine the amount of milk a woman will produce

21. Lactation Anatomy and Physiology • Hormones during pregnancy • Estrogen stimulates the ductile systems to grow, then estrogen levels drop after birth • Progesterone increases the size of alveoli and lobes • Prolactin contributes to increasing the breast tissue during pregnancy

22. Lactation Anatomy and Physiology • Alveoli secrete milk and contract when stimulated • Oxytocin stimulates milk secretion and is released during the ‘let down’ or milk ejection reflex • After let down, milk travels into the ductules, then to the larger – lactiferous or mammary ducts

23. Lactation Anatomy and Physiology • Hormones during breastfeeding • Prolactin levels rise with nipple stimulation • Alveolar cells make milk in response to prolactin when the baby sucks • Oxytocin causes the alveoli to squeeze the newly produced milk into the duct system

24. Lactation Anatomy and Physiology Latch On and sucking Oxytocin Release Releases Milk Infant Empties Breast Production Increases Milk Production Occurs Interference with this cycle decreases the milk supply.

25. Breastfeeding Barriers • Early breastfeeding failures deprive infants of the benefits, and leave many mothers disappointed • It is a natural process, but many mothers need a lot of help

26. Breastfeeding Barriers • Must educate mothers regarding: • Positioning the baby • Latching on • Normal nipple soreness • Cramping with breastfeeding • How often to feed the baby • Need to wake the baby • Alerting techniques • Rooting • Sucking • Listening for swallows • Preventing engorgement • Nutrition • Supply and demand • Infant cues

27. Breastfeeding Barriers • Breast Pathology • Flat/inverted nipples, breast reduction surgery that severed milk ducts, previous breast abscess, extremely sore nipples (cracked, bleeding, blisters, abrasions) • Hormonal pathology • Failure of lactogenesis, hypothyroidism • Overall health • Smoking, anemia, poor nutrition, depression • Psychosocial • Restrictive feeding schedules, mother without support system, not rooming in with baby, bottle supplementing when not medically required • Other • Previous breastfed infant who failed to gain weight well, perinatal complication (hemorrhage, htn, infection

28. Breastfeeding Teaching methods • With infant in mother’s arms • Consistent information • Repeat information in a variety of ways • Watch the mother feed the baby and help • Let the mother know she may have difficulties at first • Remind mom that baby is learning with her • Praise the mother’s progress, help build confidence • Provide discharge support

29. Breastfeeding The Results • Baby gains weight • No more than 7% weight loss • Back to birth weight in 2 weeks • 1oz per day weight gain for the first three months • Mother is comfortable and satisfied • If baby is still loosing weight on the 4th day of life: • Get feeding evaluation • Remember to: • 1. fed the baby • 2. maintain the milk supply • 3. continue breastfeeding

30. Breastfeeding Complications • Infants at risk for poor weight gain • Premature (less than 38 weeks) • Difficulty latching on • Ineffective or unsustained sucking • Oral anatomic abnormalities (cleft lip/palate, short frenulum, receding chin) • Multiples • Jaundice • Cystic fibrosis • Infection • Cardiac disorders • Neurologic problems – downs, hypo or hypertonia • Poor apgars • Long labor • Sleepy, nondemanding, passive temperament • Separation from mother early after delivery • Infants less than 5 lbs

31. Breastfeeding Hospital Discharge Support • Mother breastfeed longer if they: • Are confident at hospital discharge • Have a good support system after discharge • Receive follow up after discharge • Upon discharge • Give written information • Recommend mom to keep breastfeeding record • Give mom phone number for a telephone helpline • Lactation consultant follow-up

32. Breastfeeding Hospital discharge support • Support the mothers breastfeeding efforts • Provide accurate current breastfeeding information

33. Breastfeeding Resources for Mothers • Books: • The Womanly Art of Breastfeeding – LeLeche League • So that’s what they’re for! Breastfeeding Basic by Janet Tamaro • The Breastfeeding Book by Martha and William Sears • Nursing Mother Companion - Huggins Howard Common Press • The Breastfeeding Answer Book – LeLeche Legue • Medication and Mothers Milk – Thomas Gele PhD., a manual of lactational pharmacology 9th Ed. • Breastfeeding and Human Lacation – 2nd Ed. Jan Rioden and Kathleen G. Auerbach • Breastfeeding Triage Tool - Sanie Jollay and Ellen Phillips-Angeles, M.S. Ches 4th Ed. • Websites • LeLecheLeague.org • Medela.com • Parents.com • CBI@illi.org • Groups • LeLeche League • WIC – Public Health Department • Carle’s Breast Feeding Clinic • Twin clubs

34. References • Slusser Wndelin, Ms, MD and Powers Nancy G MD; Breastfeeding Update 1:Immunology, Nutrition and Advocacy; Pediatrics Review Vol 18 No. 4 • Neifert, Marianne M.D., Early Assessment of Breastfeeding Infant, Contemporary Pediatrics Oct. 1996 • The Breastfeeding Answer Book, LeLeche League International • AWHONN – Association of Women’s Health, Obstetric and Neonatal Nurses Independent Study Module for the Clinical Management of Breastfeeding for Health Professionals 1999

35. Clinical Case • You are seeing a 22 yo G1 P0 woman in your office for her first prenatal visit at 12 weeks gestation. When you ask her if she intends to breastfeed her baby, she replies that she is concerned that she will not be able to due to the fact she is a chronic Hepatitis B carrier. • She is also concerned about the fact that her friend told her that, if she breastfeeds, she will need to do so every hour and thus will be unable to do anything else.

36. Clinical Case • Prenatal Labs • Hct 33% • WBC 5600/cmm (normal differential) • Plt 224,000/cmm • Blood type A + • Antibody screen: negative • Rubella titer: immune • UA and Cx – negative • Varicella-zoster titer: immune • VDRL test: negative • HBsAg: positive

37. Clinical Case • How would you counsel this patient? • What infant and maternal benefits are there to breastfeeding.

38. Clinical Case • Counseling the patient: • Prevalence of HBV infection in pregnancy • Symptomatic – 1 to 1:1000 • Asymptomatic – 5 to 15:1000 • Perinatal transmission of HBV without intervention • Seropositive for HBsAg only – 15-20% risk • Seropositive for HBsAg and HBeAg – 85-90% risk

39. Clinical Case • Counseling the patient: • Immunoprophylaxis for prevention of perinatal transmission of HBV • Treat neonates immediately after birth with HBIG and HBV vaccine (must give HBIG within 12 hrs of birth) • Reduces the risk of transmission to <5% • First dose of HBV vaccine prior to hospital discharge, 2nd and 3rd doses administered at 1 and 6 months of age • CDC recommends universal vaccination of all infants

40. Clinical Case • Counseling the patient: • Breastfeeding is not contraindicated in chronic Hep-B carriers if the infant receives the HBIG and is vaccinated

41. Clinical Case • Based on your advice, the pt decides to breastfeed. She and her infant have now been successfully nursing for over 3 weeks. One morning she wakes to discover a red, wedge-shaped area in her right breast. She also has a fever to 101 degrees. • What is the most likely diagnoses? • How would you treat her?

42. Clinical Case • Treating the patient: • Most likely diagnosis = Mastitis • Give antibiotics that cover S. aureus – antistaphylococcal penicillin or first-generation cephalosporin, continue treatment for 10 days • Patient should continue breastfeeding

43. Review Question #1 • 1. How many calories should a lactating woman increase above her non-pregnant baseline calorie consumption?

44. Answer #1 • 400 calories

45. Review Question #2 • Match the following response associated with the following conditions • i. May breast feed • ii. Breastfeeding not encouraged • iii. Breastfeeding contraindicated • A. Acute mastitis • B. HSV infection • C. CMV infection • D. two alcoholic beverages consumed per day • E. Tetracycline • F. Clindamycin • G. Smoking two packs of cigarettes per day • H. Use of sub 50mg oral contraceptives • i. HTLV 1 infection • J. HBeAg + hepatitis

46. Answer #2 • A – i • B – i • C – i • D – i • E – iii • F – i • G – i • H – i • I – iii • J - ii

47. Answer #2 • Breastfeeding is contraindicated in very few situations. Most viral infections are not considered contraindications. CMV has been transmitted in breast milk, but the effect on the healthy term neonate is relatively minor if breastfeeding is allowed to continue. Active acute hepatitis B (particularly if the E antigen is present), HIV, HTLV 1, cyclophosphamide, tetracycline, oral metronidizole, lithium carbonate, and radioactive agents are considered to be contraindicated during pregnancy. Puerperal mastitis is not a contraindication to breastfeeding.

48. Review Question #3 • Select the 3 correct statements comparing human mature breast milk to cow’s milk • i. Calories are increased • ii. Proteins are decreased • iii. Fat is increased • iv. Carbohydrate is increased • v. Iron is increased

49. Answer #3 • i, iii, iv • Human milk is significantly different from both cow’s milk and formula with iron. Human milk has 75 calories per 100ml as compared to 69 calories for cow’s milk. The protein content is approximately one third more than cow’s milk. The fat is increased by one third in human milk. Carbohydrate levels 100% increased. Although the concentration of iron I slow in human’s milk, it is more efficiently absorbed.

50. Review Question #4 • The principle function of prolactin is? • A. Ensure lactation • B. Sensitize the pituitary to LRH • C. Increase the number of estrogen and prolactin receptors in alveolar cells