Lactation and Breastfeeding

Obstetrics and Gynecology

BreastfeedingInfant 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

BreastfeedingInfant 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

BreastfeedingInfant 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

BreastfeedingInfant Health Benefits

Provides immunologic protection while the infant’s immune system is maturing Antimicrobial agents Anti-inflammatory agents Immunomodulating agents

BreastfeedingInfant 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

BreastfeedingMother 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

BreastfeedingParent Benefits

Saves money Saves time Babies love it

LactationAnatomy 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

LactationAnatomy 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

LactationAnatomy 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

LactationAnatomy 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

LactationAnatomy 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.

BreastfeedingBarriers

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

BreastfeedingBarriers

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

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

BreastfeedingTeaching 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

BreastfeedingThe 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

BreastfeedingComplications

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

BreastfeedingHospital 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

BreastfeedingHospital discharge support

Support the mothers breastfeeding efforts Provide accurate current breastfeeding

information

BreastfeedingResources 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 4 th 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

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

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.

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

Clinical Case

How would you counsel this patient?

What infant and maternal benefits are there to breastfeeding.

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

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

Clinical Case

Counseling the patient: Breastfeeding is not contraindicated in chronic

Hep-B carriers if the infant receives the HBIG and is vaccinated

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?

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

Review Question #1

1. How many calories should a lactating woman increase above her non-pregnant baseline calorie consumption?

Answer #1

400 calories

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

Answer #2

A – i B – i C – i D – i E – iii F – i G – i H – i I – iii J - ii

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.

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

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.

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

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.