BreastfeedingUNC School of Medicine
Obstetrics and Gynecology ClerkshipCase Based Seminar Series
Alison Stuebe, MD, MSc
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