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

9. 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

10. 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

11. 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

12. 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

13. 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.

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

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

22. 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

23. 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

24. 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.

25. 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

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

27. 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

28. 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

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

30. 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?

31. 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

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

33. Answer #1 • 400 calories

34. 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

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

36. 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.

37. 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

38. 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.

39. 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

40. Answer #4 • A. • LRH causes an increase in the serum prolactin level greater in pregnancy than in nonpregnancy. Prolactin insures lactation by promoting DNA synthesis in the glandular epithelial cells of the breast. It also increases the number of estrogen prolactin receptors in those cells. Prolactin promotes galactopoiesis and the production of casein and other breast products. The concentration of prolactin is approximately 10 times greater in pregnancy than it is in nonpregnancy. High concentrations of prolactin in the fetus and in amniotic fluid may have a role in preserving fetal fluid balance, preventing fetal dehydration.