BreastfeedingUNC School of Medicine

Obstetrics and Gynecology ClerkshipCase Based Seminar Series

Alison Stuebe, MD, MSc

astuebe@med.unc.edu

Objectives for Breastfeeding

List the reasons why breast feeding should be encouraged

List the normal physiologic and anatomic changes of the breast during pregnancy and postpartum

Describe the common challenges in the initiation and maintenance of lactation

Describe the resources and approach to determining medication safety during breast feeding

Recognize and know how to treat common postpartum abnormalities of the breast

What have you heard about breastfeeding?

Risks of Not Breastfeeding

INFANT INFANT MOTHERMOTHER

IllnessIllness OROR IllnessIllness OROR

DiarrheaDiarrhea 2.82.8Premenopausal Premenopausal

breast cancerbreast cancer1.41.4

Otitis mediaOtitis media 2.02.0 Ovarian cancerOvarian cancer 1.31.3

PneumoniaPneumonia 3.63.6 Type 2 DiabetesType 2 Diabetes 1.21.2

SIDSSIDS 1.61.6

AsthmaAsthma 1.41.4

LeukemiaLeukemia 1.21.2

Formula-feeding vs. breast-feeding: risk of adverse outcomes.

Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. AHRQ Evidence Report Number 153. April 2007.

Risks of Not Breastfeeding

Burden of suboptimal breastfeeding

Bartick, M. and A. Reinhold (2010). "The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis." Pediatrics 125(5): e1048-1056.

Burden of Suboptimal Breastfeeding

AAP Recommendations

Exclusive breastfeeding for the first six months of life

Continued breastfeeding for at least one year, ‘As long as is mutually desired by mother and child’

American Academy of Pediatrics (2005). "Breastfeeding and the Use of Human Milk." Pediatrics 115(2): 496-506.

AAP Recommendations

Adapted from “Racial and Ethnic Disparities in Child Health: North Carolina 2008” Reported July 2009, CHAMP data

Health People 2010 Goals

Breastfeeding in North Carolina

Ahluwalia, I. B., B. Morrow, et al. (2005). "Why Do Women Stop Breastfeeding? Findings From the Pregnancy Risk Assessment and Monitoring System." Pediatrics 116(6): 1408-1412.

Why Mothers Wean

Taveras, E. M., R. Li, et al. (2004). Pediatrics 113(4): e283-90.

How confident are providers about solving problems?

Objectives for Breastfeeding

List the reasons why breast feeding should be encouraged

List the normal physiologic and anatomic changes of the breast during pregnancy and postpartum

Describe the common challenges in the initiation and maintenance of lactation

Describe the resources and approach to determining medication safety during breast feeding

Recognize and know how to treat common postpartum abnormalities of the breast

35 yo G1 with a family history of breast cancer presents for 28 week visit, concerned about nipple discharge.

Case

Breast Development During Pregnancy

Distal ducts proliferate, creating more lobules and more alveoli within lobules.

Early pregnancy

Women experience breast tenderness and enlargement, which may be among first symptoms of pregnancy.

Lobular units begin to differentiate into secretory units.

In late pregnancy, lactocytes fill with fat droplets, and colostrum distends acini. Glandular changes replace fat and connective tissue.

Latepregnancy

Ongoing breast enlargement occurs due to distention of acini with colostrum and increased vascularity.

Many women report leakage of colostrum.

Postpartum With loss of estrogen and progesterone, secretory activation occurs.

At 2 to 3 days postpartum, milk ‘comes in,’ accompanied by swelling from increased vascular supply. Frequent nursing reduces engorgement.

1 to 3% of all breast cancers are diagnosed during pregnancy or lactation.

Prognosis is worse for women diagnosed in this time period, likely because of delays in diagnosis.

During pregnancy, dominant masses should be promptly evaluated, starting with a breast ultrasound.

Lactating women who identify a mass should be counseled to use massage, warm packs, and position changes to relieve a plugged duct. Areas that persist more than 2 weeks should be evaluated with ultrasound.

Breast biopsies may be performed during pregnancy and lactation, and milk fistula formation is rare. Women do not have to stop breastfeeding prior to a biospy.

Breast Masses During Pregnancy and Lactation

Objectives for Breastfeeding

List the reasons why breast feeding should be encouraged

List the normal physiologic and anatomic changes of the breast during pregnancy and postpartum

Describe the common challenges in the initiation and maintenance of lactation

Describe the resources and approach to determining medication safety during breast feeding

Recognize and know how to treat common postpartum abnormalities of the breast

Healthy 22 yo G1 presents for first prenatal visit. When do you ask about breastfeeding? How do you ask? What do you say?

Case: Counseling

3 Step Counseling

Are you planning to breastfeed or bottle feed?

What have you heard about breastfeeding?

You sound like you’re worried about what will happen when you go back to work.

Describe how to express milk, how to combine breast and formula feeding.

DiGirolamo et al. Birth 2003;30:94-100

Patients listen to what their doctor say…..

Only 8% of obstetricians thought their advice on duration of breastfeeding was very important.

Taveras et al. Pediatrics 2004;113:e405-11.

Very important Somewhat / not importantPatient opinion of OB advice:

…..even when their doctors don’t think they are listening.

34 yo G1P1 presents for 1 week post-partum visit for staple removal Pregnancy c/b type 2 diabetes, cesarean section for

arrest of dilation after 2-day induction. You ask: “How is breastfeeding going?” She says: “I don’t have enough milk”

Case: Not enough milk

Milk production

Milk ejection

PIF

Prolactin Oxytocin

Anterior pituitary

Posterior pituitary

Hypothalamus

Paraventricular nucleus

How Does Lactation Happen?

Speroff et al. Reproductive Endocrinology and Infertility.

How Does Lactation Happen?

How Does Lactation Happen?

Breastfeeding Success

How Does Lactation Happen?

Breastfeeding SuccessINCORRECT

CORRECT

Photos © Jane Morton, MD, FAAP

AAP Breastfeeding Residency Curriculum

Breastfeeding Success

How Does Lactation Happen?

Ejection, not suction, moves milk to the

areola

The baby’s tongue pulls milk from

areola to nipple

Demand drives supply

Breastfeeding Success

How Does Lactation Happen?

34 yo G1P1 presents for 1 week post-partum visit for staple removal Pregnancy c/b type 2 diabetes, cesarean section for

arrest of dilation after 2-day induction. You ask: “How is breastfeeding going?” She says: “I don’t have enough milk”

Case: Not enough milk

Infant Separation from mom

in hospital Hypoglycemia Hyperbilirubinemia “Mom needs to rest”

Supplementation Formula Pacifier use

Mother Delayed lactogenesis

Diabetes Long induction C-section Obesity

Supplementation with insufficient milk removal

What are her risk factors for breastfeeding difficulties?

‘My breasts feel empty’ Initial engorgement association with lymphatics, not

actual milk As milk supply comes in, mothers will feel less full, but

will still have plenty of milk ‘The baby isn’t growing’

Normal weight loss of up to 7 percent Growth curves used by many pediatric providers

standardized to formula-fed babies

Taking a history: Does mom have enough milk?

‘The baby is always hungry’ It’s physiologic to feed on demand Babies may “cluster feed” to increase milk supply Typical spurts: 2-3 weeks, 6 weeks, 3 months

Collaborate with the pediatric provider: Is there a real problem?

Does mom have enough milk?

Do you feel tingling sensation when baby is nursing? Do your breasts feel more full? If you pump, does production increase after the first few minutes?

Is it comfortable when the baby nurses? Are his lips

flanged out? Can you hear the baby swallow?

Are you feeding 8-12 times a day, until the baby is satisfied? Do your breasts feel softer after a feed? Are you away from your baby? Supplementing? Pacifiers?

Breastfeeding Success

Does mom have enough milk?

J. Pediatr 1948; 33:698-704.

Stress and Milk Volume

Breastfeeding difficulties may be a symptom – or a consequence – of postpartum depression.

Taveras EM et al. Clinician Support and Psychosocial Risk Factors Associated With Breastfeeding Discontinuation. Pediatrics. July 1, 2003 2003;112(1):108-115.

Breastfeeding and Depression

First line therapy: Lactation consultation Mechanical expression after breastfeeding

If needed: Supplement after breastfeeding as indicated Continue pumping during supplementation

Restore Normal Physiology

Medication Second line treatment Offer trial of

metoclopramide, 10 mg TID, and follow for side-effects

Kauppila et al. Lancet 1981;1(8231):1175-7.

Restore normal physiology, then consider metoclopramide as an adjunct.

Augmenting milk supply

Objectives for Breastfeeding

List the reasons why breast feeding should be encouraged

List the normal physiologic and anatomic changes of the breast during pregnancy and postpartum

Describe the common challenges in the initiation and maintenance of lactation

Describe the resources and approach to determining medication safety during breast feeding

Recognize and know how to treat common postpartum abnormalities of the breast

Maternal plasma Clearance

Drug entry

Breast milk

Infant plasma

Oral Ingestion

Clearance

Milk/plasma ratio

Relative infant dose

How do drugs get into milk?

≠

The placenta and the breast are not the same organ.

Drugs that are safe in pregnancy may not be safe in breastfeeding, and drugs that are safe in breastfeeding

may not be safe in pregnancy.

How do drugs get into milk?

39 yo, 6 weeks post-partum, with persistently elevated blood pressures and type 2 diabetes Her PCP prescribes Enalapril At CVS, the pharmacist tells her she can’t take Enalapril

when she is breastfeeding She calls your office and asks what to do

Case: Treatment for hypertension

Enalapril

Akus M, Bartick M. Lactation Safety Recommendations and Reliability Compared in 10 Medication Resources Ann Pharmacother. September 2007;41(9):1352-1360.

Not all resources are equal

http://lactmed.nlm.nih.govOr Google “LactMed”

Not all resources are equal

Active metabolite, enalaprilat, not orally bioavailable

Estimated exposure less than 0.2% of therapeutic dose

Four breastfed infants of mothers taking enalapril not affected

Eur J Clin Pharmacol. 1990;38:99.

Infant dose 0.51 g/kg/d

Relative dose 0.17%

AAP Usually compatible w/ breastfeeding

MMM L2

Briggs Limited Human Data – Probably Compatible

LactMed Not expected to cause adverse effects in infants

Enalapril

26 yo, 2 weeks postpartum, with seasonal allergies. She is breastfeeding, and asks if she can take Sudafed.

Case: Seasonal Allergies

Infant dose 39.6 g/kg/d

Relative dose 4.3%

AAP Usually compatible w/ breastfeeding

Briggs Limited Human Data – Probably Compatible

MMML3 for acute useL4 for chronic use

LactMed

May interfere with lactation – avoid if lactation not well-established

Aljazaf et al. British Journal of Clinical Pharmacology 2003;56:18-24.

Pseudoephedrine

Breastfeeding and Medications•Breastfeeding mother needs medication•No effective non-pharmacologic therapy available

Drug systemically absorbed?

no yes

Yes

Look up drug on LactMed http://lactmed.nlm.nih.gov

Good data re safety, effect

on milk supply?

no

Safer drug w/ similar

efficacy?no yes

Prescribe alternative medication

Prescribe originally selected drug

Discuss risks of drug exposure in milk vs. risks of not

breastfeeding, in conjunction with pediatric provider.

No risk to infant, reassure mother.

yes

With informed consent, choose a plan:1. Continue breastfeeding w/ medication.

2. Express and discard milk during treatment

3. Start medication and wean.

Counseling and follow-up

1.Print out LactMed monograph on the selected drug.

2.Review monograph with patient and discuss the risks of infant drug exposure vs. risks of formula feeding for both mother and infant.

3.When breastfeeding while taking medication:

a. Encourage mother to share the LactMed monograph with her pediatrician.

b. Review common or worrisome side effects for infant, if any

c. Alert her that pharmacies may instruct her not to use the drug during breastfeeding, despite the safety data that you are sharing with her.

d. Provide a contact number to call with questions.

4.Time dose to minimize exposure: After feeding or before prolonged infant sleep.

Breastfeeding and Medications

Objectives for Breastfeeding

List the reasons why breast feeding should be encouraged

List the normal physiologic and anatomic changes of the breast during pregnancy and postpartum

Describe the common challenges in the initiation and maintenance of lactation

Describe the resources and approach to determining medication safety during breast feeding

Recognize and know how to treat common postpartum abnormalities of the breast

24 yo G2P2, 14 wks postpartum, presents with fever, chills, and tender, red, wedge-shaped are on her right breast. She just returned to work, and has had difficulty finding time to express milk during the day.

Case

Definition: tender, swollen, wedge-shaped area of breast, usually unilateral, with fever, malaise, chills, and systemic symptoms

Incidence: 3 to 20% Treatment

Rest, fluids Antibiotics – Dicloxicllin 500mg QID x 10-14d Empty the breast

Evaluate latch Continue frequent breast feeding Milk is not harmful to healthy, term infant Abrupt weaning slows maternal recovery

Poor response requires further evaluation

Academy of Breastfeeding Medicine. ABM Clinical Protocol #4: Mastitis. Breastfeeding Medicine 3(3); 2008.

Mastitis

Mastitis

Workplace

American Academy of Pediatrics (2005). Breastfeeding and the Use of Human Milk. Pediatrics 115(2): 496-506.

American Academy of Family Physicians. (2001, 2/26/2007). Breastfeeding (Position Paper).

American College of Obstetrics and Gynecology (2007). Breastfeeding: Maternal and Infant Aspects. Special Report from ACOG. ACOG Clinical Review 12(1 (supplement)): 1S-16S.

Academy of Breastfeeding Medicinewww.bfmed.org

For More Information

Bottom Line Concepts Public health begins with breastfeeding

Never or curtailed breastfeeding is associated with increased acute and chronic disease risk for mothers and infants

There are substantial disparities in breastfeeding initiation and duration

Breast changes begin in early pregnancy Expression of colostrum during pregnancy is common

Masses detected during pregnancy or lactation should be evaluated promptly with ultrasound

Normal physiology depends on let down, latch and moving milk Encourage mothers to feed on demand, for as long as the infant is interested

Treatment of low milk supply begins with restoring normal physiology

The placenta and the breast are not the same organ Look up drug safety in lactation on LactMed

Continued breastfeeding is crucial for mastitis treatment Rest, fluids, empty the breast – and antibiotics as needed

References and Resources

APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 14 (p30-31).

Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 11 (p129-130).

Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 8 (p109-110).

Academy of Breastfeeding Medicine Protocolshttp://www.bfmed.org/protocols